PATIENT CHARACTERISTICS, TREATMENT PROFILE AND RELATED MANAGERIAL PERSPECTIVES WHILE TREATING ONCOLOGY CASES IN A TERTIARY CARE ONCOLOGY CENTRE

PATIENT CHARACTERISTICS, TREATMENT PROFILE AND RELATED MANAGERIAL PERSPECTIVES WHILE TREATING ONCOLOGY CASES IN A TERTIARY CARE ONCOLOGY CENTRE�

1. PATIENT CHARACTERISTICS, TREATMENT PROFILE AND RELATED MANAGERIAL PERSPECTIVES WHILE TREATING ONCOLOGY CASES IN A TERTIARY CARE ONCOLOGY CENTRE S2-22_MBAZG623T: DISSERTAION   DR VIRENDER SUHAG   BITS ID: 2021HB28218 Command Hospital, Pune

2. Background The growing cancer burden has generated an unmet need to identify and address gaps in the healthcare system to enable access to affordable and quality cancer care for all in a manner that enhances the value of care. The oncology patients present with diverse characteristics including demographic profile, histopathological features, disease status, stage of disease etc. Every patient merits an individualized treatment plan as mandated by the clinical condition and in most cases the management is multimodal in nature. There is an unmet need to adopt a value-based care approach , to identify areas for enhancing the objectives of value-based care through multi-characteristic and multidimensional consideration of patient centricity and to devise health system strategies to improve comprehensive value-based care in India within the current context, especially in public sector which caters to a large number of lower and middle class Indian clientele. There is a need to align the concerns of the senior administrative staff with those of the treating clinicians for implementing best possible level of care despite the infrastructural and manpower challenges in a country like India.  

3. AIMS AND OBJECTIVES The aim of the research is to study patient characteristics and treatment profile of oncology cases in a tertiary care oncology center. The objectives of this project are as follows:   To correlate if there is sufficient infrastructure and human resources to provide comprehensive oncology care to these patients. To make recommendations about optimum utilization of existing resources. To forecast the need for future expansion and upgradation of resources .

4. STUDY-DESIGN It was an observational study that was carried out at the Oncology Centre of a tertiary care government hospital with research and academic interests, catering to the serving and retired personnel of Indian army and their dependents. For studying the infrastructure and manpower resources , relevant observations were made followed by analysis of pertinent data. The study period was from January 2023 (after the abstract was submitted) till March 2023 for collecting and documenting the observations . Based on these observations, certain strategic health care recommendations were made.

5. INCLUSION AND EXCLUSION CRITERIA Inclusion Criteria: Patients with histopathological confirmation of malignancy Patients who are fit for radical treatment Patients who are registered with institutional cancer registry Patients who are willing for treatment Exclusion criteria : Patients without histopathological confirmation of malignancy Patients who are unfit for radical treatment Patients who are for palliative care Patients who are unwilling for treatment

6. Methodology: to correlate if there is sufficient infrastructure and human resources A note was made of the waiting time (in days) before the start of chemotherapy and Radiotherapy. The main infrastructure in terms of type of machine, technology and other treatment resources available to give Radiotherapy and chemotherapy was evaluated . The number of Radiotherapy-trained technicians available to execute Radiotherapy and the number of Oncology-trained nurses available to administer chemotherapy as per the standard protocol was studied. Any delay in allotment of bed or implementing the protocol-based therapy due to shortage of HR resources or infrastructural constraints was studied .

7. Methodology: Recommendations on optimum utilization of existing resources The average number of chemotherapies administered per day was studied and compared with the number of beds available . Similarly, the number of patients executed Radiotherapy was calculated and the workload per machine was calculated . The average number of indoor patients allotted per nurse was calculated . A note would be made about the workload of the department and the utilization of HR and infrastructural resources. The availability of CAMC (comprehensive annual maintenance contract) and proper maintenance of log books was checked .

8. Methodology: Forecast the need for future expansion and upgradation of resources. This study was carried out in a tertiary-care government institute of armed forces where modernization sometimes takes time due to procedural delays. The facilities available would be compared with those being used in reputed civil oncology centers . If there are any gaps in the management of standard of car e, necessary recommendations would be made for future expansion and upgradation of resources . In case there is a delay in instituting the treatment noted due to scarcity of resources , a recommendation for the same would be made.

9. RESULTS The study was conducted from January to March 2023 in an Oncology center of a multispecialty tertiary-level government hospital of Indian Armed Forces which provides free treatment to its dependent clientele. For satisfying objective 1 regarding study of patient-related and therapy-related characteristics, 78 patients were included as selected by simple randomization. For the study of infrastructure, human resources, optimum utilization of resources and other such indices, all patients managed during the period of study on outpatient setting or indoor setting were included. The period of the study was from January 2023 to March 2023. Patients were enrolled from 09 Jan 2023 to upto 19 March 2023 for a period of 10 weeks.

10. OBSRVATIONS PERTAINING TO PATIENT CHARACTERISTICS AND TREATMENT PROFILE T he most common age-slab was in 6 th decade (23%) followed by 7 th decade (19%); thus 42% patents were in 6 th and 7 th decades cumulatively. Out of a total of 78 patients, 54 were male (69%) and 24 were female (31 %). (Fgure-1) The most common site of primary disease was abdomen and gastrointestinal tract; including lower esophagus, stomach, intestine, liver, gall bladder and pancreas; accounting for a total of over 20% of all primary sites of origin. About 40% patients presented in Stage IV and 37% patients presented in Stage III disease; remaining 23% patients presented in early stage disease. About 81% patients belonged to middle socio-economic status as this is a government hospital catering to a specific salaried clientele . ( Fgure-2) O nly 16 patients (21%) were treated with single modality therapy while the remaining 79% received surgery, chemotherapy and radiotherapy concurrently or sequentially due to advanced nature and stage of their disease. The average duration of treatment was about 7 weeks .

11. Figures 1 and 2

12. OBSRVATIONS PERTAINING TO INFRASTRUCTURE The most common waiting time-slab before start of definitive management was 4-6 days as seen in 22 patients followed by 7-9 days noted in 21 patients. (Table-1) The average delay after registration and start of CT/RT was 9 days . This was commonly due to time taken in special investigations including CT/ MRI, PET imaging, Immunohistochemistry etc. The average waiting time for allotment of bed for day-care patients of chemo-radiation and for chemotherapy was 3 days . This data during the study period is in consonance with the institutional data normally noted.   There are 50 beds for male patients and 20 beds for female patients; on an average 33 new male patients and 12 new female patients were admitted per week. There was no delay in allotment of beds. T he average bed occupancy during the period of study was 92% thereby indicating good utilization of resources . (Table-2)

13. Table-1: Average waiting time before start of definitive management (n=78) Sr No Waiting time (days) No. of patients Any remarks/common cause noted 1 1-3 7 Patients awaiting documentation and planning of treatment 2 4-6 22 Patients awaiting consultation by allied specialists 3 7-9 21 Patients undergoing workup 4 10-12 14 Patients undergoing nutritional buildup 5 13-15 10 Patients awaiting special investigations 6 >15 days 4 Patients recovering from surgery Table-1: Average waiting time before start of definitive management (n=78)

14. Table-2: Total average number of patients admitted (Number of beds=70) Sr No Week Males Females Total new /d Previous patients remaining Total beds occupied/day (%) 1 First 35 13 48 19 67 (95.7) 2 Second 42 11 53 12 65 (92.8) 3 Third 24 12 36 22 58 (82.8) 4 Fourth 43 19 62 8 70 (100) 5 Fifth 28 16 44 24 68 (97.1) 6 Sixth 40 17 57 13 70 (100) 7 Seventh 24 12 36 23 59 (84.2) 8 Eighth 35 9 44 13 57 (81.4) 9 Ninth 40 13 53 15 68 (97.1) 10 Tenth 26 6 32 30 62 (88.5) Total Av   33.7 12.8 46.5 17.9 64.4 (92) Table-2: Total average number of patients admitted (Number of beds=70)

15. OBSRVATIONS PERTAINING TO HUMAN RESOURCES The Oncology department is posted with 02 full-time Medical Oncologists, 02 Surgical Oncologists and 02 Radiation Oncologists on permanent basis . A total of 8 nurses per day on rotational basis are available to work in the 70 bedded male and female oncology wards. The average patient: nurse ratio for indoor patients in Oncology division was 8.05 which is comparable with that of other departments of the institute as well as other reputed Indian centers, though less than international standards . (Table-3) The average number of patients managed in the day care centre on weekly basis during the study period (total number of beds=10 and total oncology nurses=2) was 13.6 with patient:nurse ratio of 6.8 and bed occupancy of over 100% as more than one patient can be given infusion on a bed on rotational basis . (Table-4) The total average patients treated per day on the single Radiotherapy Machine was 53 , with one Radiotherapy Technician available for about 27 patients . (Table-5)  

16. Table-3: Distribution of nurse according to patient workload Sr No Week Total Av beds occupied/day Total nurses available/day Pt: Nurse Ratio 1 First 67 8 8.37 2 Second 65 8 8.12 3 Third 58 8 7.25 4 Fourth 70 8 8.75 5 Fifth 68 8 8.5 6 Sixth 70 8 8.75 7 Seventh 59 8 7.37 8 Eighth 57 8 7.12 9 Ninth 68 8 8.5 10 Tenth 62 8 7.75 Total Average   64.4 8 8.05 Table-3: Distribution of nurse according to patient workload

17. Table-4: Total average number of average patients in day care centre Sr No Week Number of chemo infused Other procedures Average patients treated /day Pt: Nurse Ratio 1 First 12 2 14 7 2 Second 10 2 12 6 3 Third 11 4 15 7.5 4 Fourth 8 2 10 5 5 Fifth 6 3 9 4.5 6 Sixth 10 5 15 7.5 7 Seventh 10 9 19 9.5 8 Eighth 9 7 16 8 9 Ninth 12 2 14 7 10 Tenth 11 1 12 6 Total Average   9.9 3.7 13.6 6.8 Table-4: Total average number of average patients in day care centre

18. Table-5: Average number of daily patients treated on the Telecobalt Unit   Sr No Week Males Females Total average patients/d Number of RT Technicians No. of pts per technician 1 First 42 13 55 2 27.5 2 Second 39 15 54 2 27 3 Third 41 9 50 2 25 4 Fourth 43 12 55 2 27.5 5 Fifth 38 15 53 2 26.5 6 Sixth 44 11 55 2 27.5 7 Seventh 43 10 53 2 26.5 8 Eighth 39 12 51 2 25.5 9 Ninth 44 11 55 2 27.5 10 Tenth 41 13 54 2 27 11 Total 41.4 12.1 53.5 2 26.75 Table-5: Average number of daily patients treated on the Telecobalt Unit

19. OBSERVATIONS: NEED FOR FUTURE EXPANSION AND UPGRADATION OF RESOURCES The Oncology Centre is functional with a conventional telecobalt Unit with a Simulator and treatment planning system and is capable of delivering conformal radiotherapy in selected cases. However, the technology has leaped forwards to modern Linear Accelerators compatible with delivering precision Radiotherapy including IMRT, IGRT, SBRT etc. Hence the hospital should upgrade its existing facilities by procuring a state-of-art Linear Accelerator. The Oncology Centre is equipped with only one machine and there is no fallback plan if this machine malfunctions. Though the machine is under CAMC and regular preventive maintenance is done, the hospital should have an alternate machine to meet any exigency. It can explore the feasibility of signing a MOU with other government set-ups nearby with Oncology facilities. There is no acute shortage of human resources in this center as to compromise quality of care ( though it still fall short of International standards ) , but they must keep themselves updated by undergoing short fellowship programs to keep them abreast with latest developments in the field of Oncology.

20. CONCLUSION: MANAGERIAL PERSPECTIVES In any oncology center of public or private sector, there should be adequate infrastructure and trained manpower to provide standard of care to the distressed needy patients and for optimum clientele satisfaction. Every center must have its own institutional protocols regarding patient admission and management which must broadly conform to the national and international guidelines . Since cancer care is a highly specialized field, the clinical managers and senior functionaries of the hospital should make all endeavors that the sophisticated electromedical equipment are compatible with providing the highly précised and individualized treatment which will not only improve the overall oncological outcome of the patients but will also provide a reasonably good quality of life at an effective cost. The highly skilled human resources may get fatigued and burnt out if there is too much workload, hence availability of adequate number of dedicated team members must be ensured at all time. In this study conducted in a government tertiary-care multi- speciality research hospital catering to armed personnel and their dependents clientele, there was no delay in instituting the treatment as this hospital caters to a specific clientele. Suitable number of oncologists, oncology-trained nurses and other paramedical staff was noted in the study which was comparable with most of the other reputed oncology centers in India.

21. STRATEGIC RECOMMENDATIONS All developing countries including India should use health care facilities judiciously and diligently. There is a gap in demand and supply of Oncological facilities across most cancer hospitals in India. Hence every institute should develop its individually-tailored protocols best suited for the need of its clientele. The backbone of any good specialized center is its trained and dedicated manpower, specially the nursing team . The clinical leaders must ensure proper recruitment, employability, training, motivation and welfare of oncology-trained nurses and paramedical staff. Upgradation and modernization is difficult in public sector due to too many administrative approvals, multiple channels of authority, bureaucratic hurdles and procedural requirements. This process of priority procurement should be fast tracked and expedited for optimal clientele satisfaction . Most of the centers in India follow NCCN, ESMO, ACMO and other such international guidelines. We should conduct our own research and promulgate guidelines best suited for our patients. All specialized centers should ensure proper collaboration and sharing of resources across various sub specialties and allied specialties so that there is optimal utilization of existing resources and no duplication of efforts. Ensure preventive maintenance of all sophisticated medical equipment. The senior functionaries of the hospital must ensure that every department practices a robust in-house quality assurance program.

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