Acute Care Use by Breast Cancer Patients on Adjuvant Chemotherapy in Alberta: Demonstrating the Importance of Measurement to Improving Quality

Round 1

Reviewer 1 Report

This is a very well-conducted retrospective study assessing acute care utilization of healthcare services (hospitalization and ED) within 180 days of adjuvant chemotherapy initiation for breast cancer treatment. It supports a very important theme in healthcare: the need for greater attention to ongoing monitoring and quality improvement activities and efforts. I have several comments/suggestions to improve and/or clarify the manuscript:

 

1. It is a bit confusing that the outcomes stated in the Methods include ED only, ED to hospital, and hospital direct, but the latter category is only mentioned/described in Fig 1 and then again in the discussion. Presumably this is because direct to hospital is actually defined as “planned acute care” and thus excluded but, if so, currently this is not defined and needs to be. If the direct to hospital were excluded as planned, then it’s unclear why they are included in Fig 1. Suggest they be excluded if, indeed, these are the planned events that were excluded. Would also suggest relabeling “Any ED” to “All unplanned acute care.” Alternatively, if they count as unplanned care then they need to be added to the results, in a meaningful way, even if combined with the ED to hospital group.
2. The manuscript would greatly benefit with a figure illustrating the description of acute care utilization given in the second paragraph: possibly an (a) and (b), one based on visits and one based on unique patients. It is hard to keep track of the story with just the existing written description, at least in part because the percentages change based on a changing denominator. For example: “…1607 patients (25%) experienced ED only and 1261 patients (20%) experienced ED→ Hence, the proportion of patients who presented to the ED and were subsequently admitted was 44%.”
3. Please modify the Discussion, to indicate that this is one of many studies published showing regional variation in care in Alberta across breast, CRC, and lung cancers as well as other conditions for more than a decade (See references below).
4. The single largest driver of ED to hospitalization was use of GCSF; that combined with the fact that approximately 40% of patients received it and that hospitalization due to neutropenia was high suggests these issues should collectively be given more attention in the Discussion. For instance, a deeper understanding may be needed as to risk factors for or control/prevention of severe neutropenia; perhaps closer monitoring of high risk patients is needed, etc.
5. Minor comment- suggest presenting percentages rounded to whole number as the decimal does not add to the reader’s understanding and makes tables and text busier than necessary.
6. Minor comment-In Table 2, ‘Community” should be bolded in the univariable analysis for consistency

 

Possible references for Comment #3

1. Sharma, V., Weir, D., Samanani, S., Simpson, S. H., Gilani, F., Jess, E., & Eurich, D. T. (2019). Characterisation of concurrent use of prescription opioids and benzodiazepine/Z-drugs in Alberta, Canada: a population-based study. BMJ open, 9(9), e030858. https://doi.org/10.1136/bmjopen-2019-030858
2. Kim J, Davis F, Butts C, Winget M. Waiting Time Intervals for Non-Small Cell Lung Cancer Diagnosis and Treatment in Alberta: Quantification of Intervals and Identification of Risk Factors Associated with Delays. Clinical Oncology, 28(12):750-9. doi:10.1016/j.clon.2016.06.010, 2016
3. Fisher S, Yasui  Y, Dabbs  K, Winget  M. Using multi-level models to explain variation in clinical practice: Surgeon volume and the surgical treatment of breast cancer. Annals of Surgical Oncology, 23(6), 1845-1851
4. McAlister, F. A., Tonelli, M., Wiebe, N., Lin, M., Svenson, L. W., & Dean, S. (2020). The ecology of medical care for adults in Alberta, 2002/03 to 2016/17: a retrospective cohort study. CMAJ open, 8(1), E169–E177. https://doi.org/10.9778/cmajo.20190188

 

Author Response

Please see attachment. 

Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you for the opportunity to review this manuscript. This is a study that examines emergency department and hospital use in patients with Stage 1-3 breast cancer undergoing adjuvant chemotherapy in the province of Alberta. Retrospective population-based cohort study. The authors aim to explore important clinical outcomes.

1. Can the authors please explain how the “planned” visits were identified?
2. The timeline of capturing outcomes within 180 days of first chemotherapy is quite long (I realize this decision was justified by the authors in the manuscript). Can the authors provide information on the distribution of time between starting adjuvant chemotherapy and first recorded emergency department visit or hospitalization? Are most of the events happening soon after initiation of chemotherapy or later (i.e. as side effects accumulate)?
3. Can the authors provide some information on reasons for acute care utilization not related to chemotherapy? If the premise of the paper is that patients undergoing chemotherapy are at increased risk of using acute care services, it would be important to know the proportion of visits directly related to chemotherapy versus not in order to determine whether systemic changes (i.e. in chemotherapy prescribing) are indeed warranted.
4. It would be valuable to know the reasons for chemotherapy-related visits. You specifically describe febrile neutropenia, but what were the others? You may choose to include this as a Table in the Appendix.
5. The results of urban center 2, I believe, are completely expected. Variation between centers is common, but what is more important is whether the variation is dangerous. The authors should provide additional text in the Discussion on reasons for variations, what other investigators have shown on other studies, and what interventions have been described to reduce dangerous variations in practice.

Again, thank you for the opportunity to review this work.

 

Sincerely,

 

Author Response

Please see attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Thank you for your edits--looks great!