Skip to main content

Advertisement

SpringerLink
Log in

Quality of life diagnosis and therapy as complex intervention for improvement of health in breast cancer patients: delineating the conceptual, methodological, and logistic requirements (modeling)

  • Original Article
  • Published:
Langenbeck's Archives of Surgery Aims and scope Submit manuscript

Abstract

Background and aims

A system for quality of life (QoL) diagnosis and therapy in breast cancer patients was developed according to the Medical Research Council (MRC) framework of complex interventions. Along MRC’s five phases in the continuum of evidence, the present paper deals with phase I: modeling (i.e., delineating the conceptual, methodological, and logistic requirements).

Basic elements

Theoretical background is a new conceptualization of QoL that provides a rational basis to diagnose “diseased” QoL. A care pathway as the central part of modeling is composed of the following interrelated structural elements: patients (n = 170), clinicians (n = 10), experts in a quality of life unit (n = 5), coordinating practitioners (n = 38), local opinion leaders (n = 12), and professional therapists for QoL enhancing therapies (n = 75). Networking of these structural elements was achieved by clinical algorithm. In the clinical center, the patient and doctor delivered a questionnaire (EORTC) and health status report. The QoL unit transformed it into a profile and experts’ report. The coordinating practitioner transformed the latter into a decision on QoL therapy and the care pathway ended with the professional therapists. Implementation of this system used a multifaceted strategy including educational outreach visits, local opinion leaders, and quality circles.

Conclusion

The suffering cancer patient is the main focus of this QoL diagnosis and therapy system. It will have to pass the rigorous test of a definitive randomized trial.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. Lorenz W, McKneally M, Troidl H et al (1998) Surgical research around the world. In: Troidl H, McKneally MF, Mulder DS et al (eds) Surgical Research: Basic Principles and Clinical Practice (3rd edn). Springer, Berlin Heidelberg New York, pp 637–654

    Google Scholar 

  2. MRC Health Services and Public Health Research Board (2006) A framework for development and evaluation of RCTs for complex interventions to improve health, http://www.mrc.ac.uk/pdf-mrc_cpr.pdf

  3. Bone R (1996) Why sepsis trials fail? JAMA 276:565–566

    Article  PubMed  CAS  Google Scholar 

  4. Lorenz W, Koller M, Ehret C et al (2006) Diagnose und Entscheidungsfindung: ein konzeptioneller Rahmen für prädiktive Pathologie. Verh Dtsch Ges Pathol 90:25–30

    PubMed  CAS  Google Scholar 

  5. Velikova G, Brown J, Smith A et al (2002) Computer-based quality of life questionnaires may contribute to doctor-patient interactions in oncology. Br J Cancer 86:51–59

    Article  PubMed  CAS  Google Scholar 

  6. Wulff H, Gotzsche P (2000) The disease classification. In: Wulff H, Gotzsche P (eds) Rational Diagnosis and Treatment. Evidence-based Clinical Decision Making. Blackwell, Oxford, pp 39–62

    Google Scholar 

  7. Koller M, Lorenz W (2002) Quality of life: a deconstruction for clinicians. J R Soc Med 95:481–488

    Article  PubMed  Google Scholar 

  8. Lorenz W, Troidl H, Solomkin JS et al (1999) Second step: Testing—outcome measurements. World J Surg 23:768–780

    Article  PubMed  CAS  Google Scholar 

  9. Klinkhammer-Schalke M, Koller M, Jakob C et al (2004) QL-diagnostics and QL-enhancing therapy for breast cancer patients: implementation of a clinical path in the Tumor Center Regensburg. Qual Life Res 13:1517

    Google Scholar 

  10. Klinkhammer-Schalke M, Koller M, Steinger B et al (2005) Implementing PDCA quality management for five quality of life specific therapies in breast cancer patients within a regional tumor center. Qual Life Res 14

  11. Klinkhammer-Schalke M, Lorenz W, Steinger B et al (2005) Enhancing the status of quality-of-life diagnostics in caring for breast cancer patients: Results from a multilevel implementation study in a regional tumor centre. JCO 23, Suppl. 165, 43s

  12. Koller M, Klinkhammer-Schalke M, Ehret C et al (2006) Diagnosis and therapy of illness-related quality of life in breast cancer patients. Protocol of a randomized clinical trial at the Regensburg Tumour Centre. Z Arztl Fortbild Qual Sich 100:175–182

    Google Scholar 

  13. Boulding K (1968) General system theory: the skeleton of science. In: Buckley W (ed) Modern systems research for the behavioral scientist. Aldine, Chicago, pp 3–10

    Google Scholar 

  14. Wulff H, Pedersen S, Rosenberg R (1986) The mechanical model. Philosophy of medicine. Blackwell, Oxford, pp 46–60

    Google Scholar 

  15. Gimmler A, Lenk C, Aumüller G (2002) Health and Quality of Life. LIT, Münster

    Google Scholar 

  16. West S, Wicklund R (1980) A primer of social psychological theory. Brooks, Monterey

    Google Scholar 

  17. Lorenz W, Koller M (2002) Empirically based concepts of outcome and quality of life in medicine. In: Gimmler A, Lenk C, Aumüller G (eds) Health and Quality of Life. Philosophical, Medical and Cultural Aspects. LIT-Verlag, Münster, pp 129–141

    Google Scholar 

  18. Wulff H (2002) The relationship between health, disease and quality of life. In: Gimmler A, Lenk C, Aumüller G (eds) Health and Quality of Life. Philosophical, Medical and Cultural Aspects. LIT-Verlag, Münster, pp 129–141

    Google Scholar 

  19. Wechsler A (1998) The Nature of Surgical Research: Phenomenology to Molecular Biology and Back. Springer, New York

    Google Scholar 

  20. Troidl H, Wechsler AS, McKneally M (1998) How to choose a relevant endpoint. In: Troidl H, McKneally M, Mulder DS, Wechsler AS, McPeek B, Spitzer WO (eds) Surgical Research – Basic Principles and Clinical Practice (pp. 303–319). New York: Springer

  21. Weinstein M, Fineberg H (1980) Clinical Decision Analysis. Saunders, Philadelphia, PA

    Google Scholar 

  22. Wulff H, Gotzsche P (2000) The clinical decision process. In: Wulff H, Gotzsche P (eds) Rational Diagnosis and Treatment. Evidence-based clinical decision making. Blackwell, Oxford, pp 6–19

    Google Scholar 

  23. Koller M, Klinkhammer-Schalke M, Lorenz W (2005) Outcome and quality of life in medicine: a conceptual framework to put quality of life research into practice. Urol Oncol 23:186–192

    PubMed  Google Scholar 

  24. Lorenz W, Rothmund M (1989) Theoretical surgery: a new specialty in operative medicine. World J Surg 13:292–299

    Article  PubMed  CAS  Google Scholar 

  25. Hofstädter F, Jauch K-W, Tyrra J et al (2004) Internetvernetzung, Benchmarking und Datendigitalisierung. Wird die flächendeckende onkologische Versorgung dadurch verbessert? Forum DKG 5:42–45

    Google Scholar 

  26. Wennberg J, Gittelson A (1973) Small area variations in health care delivery. Science 182:1102–1108

    Article  PubMed  CAS  Google Scholar 

  27. Hamm R (1988) Clinical intuition and clinical analysis: expertise and the cognitive continuum. In: Dowie J, Elstein A (eds) Professional Judgment. Cambridge University Press, Cambridge, UK

    Google Scholar 

  28. Lomas J, Murray E, Anderson G et al (1991) Opinion leaders vs audit and feedback to implement practice guidelines. JAMA 265:2202–2207

    Article  PubMed  CAS  Google Scholar 

  29. Grimshaw J, Shirran L, Thomas R et al (2001) Changing provider behavior: an overview of systematic reviews of interventions. Med Care 39(suppl 2):II-2–II-45

    CAS  Google Scholar 

  30. Albert U-S, Koller M, Lorenz W et al (2002) Quality of life-profile: from measurement to clinical application. Breast 11:324–334

    Article  PubMed  Google Scholar 

  31. Berwick D (1989) Continuous improvement as an ideal in health care. N Engl J Med 320:53–56

    Article  PubMed  CAS  Google Scholar 

  32. Margolis C (1992) Society for Medical Decision Making Comittee on standardization of clinical algorithms: proposal for clinical algorithm standards. Med Decis Mak 12:149–154

    Article  Google Scholar 

  33. Koller M, Kussmann J, Lorenz W et al (1996) Symptom reporting in cancer patients. The role of negative affect and experienced social stigma. Cancer 77:983–995

    Article  PubMed  CAS  Google Scholar 

  34. Middeke M, Bauhofer A, Kopp I et al (2004) Computerized visualization of quality of life data of individual cancer patients—the QoL-profiler. Inflamm Res 53(suppl 2):S175–S178

    PubMed  CAS  Google Scholar 

  35. Detmar S, Muller M, Schornagel J et al (2002) Health-related quality-of-life assessments and patient-physician communication. A randomized controlled trial. JAMA 288:3027–3034

    Article  PubMed  Google Scholar 

  36. Cartmill R, Thornton J (1992) Effect of presentation of partogram information on obstetric decision-making. Lancet 339:1520–1522

    Article  PubMed  CAS  Google Scholar 

  37. Wright P, Jansen C, Wyatt J (1998) How to limit clinical errors in interpretation of data. Lancet 352:1539–1543

    Article  PubMed  CAS  Google Scholar 

  38. Teutsch S, Berger M (2005) Evidence synthesis and evidence-based decision making: related but distinct processes. Med Decis Mak 25:487–489

    Article  Google Scholar 

  39. Kreienberg R, Kopp I, Lorenz W et al (2004) Interdisziplinäre S3-Leitlinie für die Diagnostik und Therapie des Mammakarzinoms der Frau. München, Zuckschwerdt

    Google Scholar 

  40. National Health and Medical Research Council NHMRC (2003) Clinical practice guidelines for the psychosocial care of adults with cancer. No. CP90. Canberra: NHMRC. Available at http://www.nhmrc.gov.au/publications/synopses/cp90syn.htm

  41. Gross PA, Greenfield S, Cretin S et al (2000) Optimal methods for guideline implementation. Conclusions from Leeds Castle meeting. Med Care 39(suppl 2):II-85–II-92

    Google Scholar 

  42. Margolis C, Cretin S (1999) Implementing clinical practice guidelines. AHA Press, Chicago

    Google Scholar 

  43. Davis D, Thomson M, Oxman A et al (1995) Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 274:700–705

    Article  PubMed  CAS  Google Scholar 

  44. Thomson O’Brien M, Oxman A, Davis D et al (2006) Educational outreach visits: effects on professional practice and health care outcomes. The Cochrane Database of Systematic Reviews 35

  45. Geertsma R, Parker R, Krauss Whitbourne S (1982) How physicians view the process of change in their practice behavior. J Med Educ 57:752–761

    PubMed  CAS  Google Scholar 

  46. Kanouse D, Jacoby I (1988) When does information change practitioners’ behavior? Int J Technol Assess Health Care 4:27–33

    Article  PubMed  CAS  Google Scholar 

  47. Avorn J, Soumerai S (1983) Improving drug-therapy decisions through educational outreach. N Engl J Med 308:1457–1463

    Article  PubMed  CAS  Google Scholar 

  48. Skevington S, Day R, Chisholm A et al (2005) How much do doctors use quality of life information in primary care? Testing the trans-theoretical model of behaviour change. Qual Life Res 14:911–922

    Article  PubMed  Google Scholar 

  49. Lorenz W, Koller M, Kopp I et al (2002) Lebensqualität trotz Krebs: Klischee und Mitgefühl sind zu wenig. Leben? Leben 3:10–14

    Google Scholar 

  50. Koller M, Lorenz W (2002) Ziele des Heilens und Konzepte von Outcome in der modernen Medizin. RPG 8:18–25

    Google Scholar 

  51. Hofstädter F (2003) Diagnose Krebs - was nun? Regensburg, Tumorzentrum Regensburg e.V

  52. Grol R, Lawrence M (1995) Quality improvement by peer review. Oxford University Press, Oxford

    Google Scholar 

  53. Gerlach F, Beyer M, Römer A (1998) Quality circles in ambulatory care: state of development and future perspective in Germany. Int J Qual Health Care 10:35–42

    Article  PubMed  CAS  Google Scholar 

  54. Bahrs O, Gerlach F, Szecsenyi J et al (2001) Ärztliche Qualitätszirkel. Köln, Deutscher Ärzte-Verlag

    Google Scholar 

  55. King M (1996) The interpretation of scores from the EORTC quality of life questionnaire QLQ-C30. Qual Life Res 5:555–567

    Article  PubMed  CAS  Google Scholar 

  56. Osoba D (2002) A taxonomy of the uses of health-related quality-of-life instruments in cancer care and the clinical meaningfulness of the results. Med Care 40:31–38

    Article  Google Scholar 

  57. Wyrwich K, Bullinger M, Aaronson NK et al (2005) Estimating clinically significant differences in quality of life outcomes. Qual Life Res 14:285–295

    Article  PubMed  Google Scholar 

  58. Lydick E, Epstein R (1993) Interpretation of quality of life changes. Qual Life Res 2:221–226

    Article  PubMed  CAS  Google Scholar 

  59. Bottomley A, Flechtner H, Efficace F et al (2005) Health related quality of life outcomes in cancer clinical trials. Eur J Cancer 41:1697–1709

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgement

The authors would like to thank Sabine Fleischmann for her careful management of the QoL profile data bank. Furthermore, we are indebted to Laura Wilkie and Monika Schöll for their editorial support. Supported by the program “Bayern aktiv” of the Bavarian Ministry of Health, grant no. 710 302.

Author information

Authors and Affiliations

  1. Tumor Center Regensburg, Josef-Engert-Str. 9, 93053, Regensburg, Germany

    Monika Klinkhammer-Schalke, Brunhilde Steinger, Christoph Ehret, Brigitte Ernst, Ferdinand Hofstädter & Wilfried Lorenz

  2. Center for Clinical Trials, University Hospital Regensburg, Franz-Josef-Strauss Allee 11, 93042, Regensburg, Germany

    Michael Koller

  3. Health Informatics Centre, University of Dundee, Dundee, United Kingdom

    Jeremy C. Wyatt

Authors
  1. Monika Klinkhammer-Schalke
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael Koller
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jeremy C. Wyatt
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Brunhilde Steinger
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christoph Ehret
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Brigitte Ernst
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ferdinand Hofstädter
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Wilfried Lorenz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Monika Klinkhammer-Schalke.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Klinkhammer-Schalke, M., Koller, M., Wyatt, J.C. et al. Quality of life diagnosis and therapy as complex intervention for improvement of health in breast cancer patients: delineating the conceptual, methodological, and logistic requirements (modeling). Langenbecks Arch Surg 393, 1–12 (2008). https://doi.org/10.1007/s00423-007-0210-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00423-007-0210-5

Keywords

Search

Navigation