BackgroundIdentification of patients at risk of death from cancer surgery should aid in preoperative preparation. The purpose of this study is to assess and adjust the age-adjusted Charlson comorbidity index (ACCI) to identify cancer patients with increased risk of perioperative mortality.MethodsWe identified 156,151 patients undergoing surgery for one of the ten common cancers between 2007 and 2011 in the Taiwan National Health Insurance Research Database. Half of the patients were randomly selected, and a multivariate logistic regression analysis was used to develop an adjusted-ACCI score for estimating the risk of 90-day mortality by variables from the original ACCI. The score was validated. The association between the score and perioperative mortality was analyzed.ResultsThe adjusted-ACCI score yield a better discrimination on mortality after cancer surgery than the original ACCI score, with c-statics of 0.75 versus 0.71. Over 80 years of age, 70–80 years, and renal disease had the strongest impact on mortality, hazard ratios 8.40, 3.63, and 3.09 (P < 0.001), respectively. The overall 90-day mortality rates in the entire cohort varied from 0.9%, 2.9%, 7.0%, and 13.2% in four risk groups stratifying by the adjusted-ACCI score; the adjusted hazard ratio for score 4–7, 8–11, and ≥ 12 was 2.84, 6.07, and 11.17 (P < 0.001), respectively, in 90-day mortality compared to score 0–3.ConclusionsThe adjusted-ACCI score helps to identify patients with a higher risk of 90-day mortality after cancer surgery. It might be particularly helpful for preoperative evaluation of patients over 80 years of age.
We studied the effect of Age-Adjusted Comorbidity Index Score in colorectal cancer patients who underwent similarly aggressive treatment.Using the National Health Insurance Research Database of Taiwan, we identified 5643 patients with colorectal cancer who underwent surgical resection and chemoradiation from 2007 through 2011. We estimated survival according to Age-Adjusted Comorbidity Index Scores and 5-year survival using Cox proportional hazard regression analysis, adjusting for sex, oxaliplatin-based chemotherapy, socioeconomic status, geographic region, and hospital characteristics.In the cohort were 3230 patients with colonic cancer and 2413 patients with rectal cancer, who had undergone combined surgical resection and either neoadjuvant or adjuvant chemoradiation. After adjusting for patient characteristics (sex, oxaliplatin-based chemotherapy, socioeconomic status, geographic region, and hospital-characteristics), colonic cancer patients with age-adjusted Charlson (AAC) ≥6 had a 106% greater risk of death within 5 years (adjusted HR = 2.06; 95% CI, 1.66–2.56). In rectal cancer patients, patients with an AAC score of 4–5 had a 28% greater risk of death within 5 years (adjusted HR = 1.28; 95% CI, 1.02–1.61), and those with AAC ≥6 had a 47% greater risk (adjusted HR = 1.47; 95% CI, 1.15–1.90).Age and burden of comorbidities influence survival of patients with colonic or rectal cancer. Age-Adjusted Comorbidity Score remains an independent prognostic factor even after adjusting for the aggressiveness of treatment.
Background. The relationship between low socioeconomic status (SES) and aggressiveness of end-of-life (EOL) care in cancer patients of working age (older than 18 years and younger than 65 years) is not clear.We assessed the association between aggressiveness of EOL care and differences in SES among working-age terminal cancer patients from Taiwan between 2009 and 2011. Methods. A total of 32,800 cancer deaths were identified from the Taiwan National Health Insurance Research Database. The indicators of aggressive EOL care (chemotherapy, more than one emergency room [ER] visit or hospital admission, more than 14 days of hospitalization, intensive care unit [ICU] admission, and death in an acute care hospital) in the last month of life were examined. The associations between SES and the indicators were explored.
PurposeGastric cancer is a leading cause of death, particularly in the developing world. The literature reports individual socioeconomic status (SES) or neighborhood SES as related to survival, but the effect of both has not been studied. This study investigated the effect of individual and neighborhood SES simultaneously on mortality in gastric cancer patients in Taiwan.Materials and MethodsA study was conducted of 3,396 patients diagnosed with gastric cancer between 2002 and 2006. Each patient was followed for five years or until death. Individual SES was defined by income-related insurance premium (low, moderate, and high). Neighborhood SES was based on household income dichotomized into advantaged and disadvantaged areas. Multilevel logistic regression model was used to compare survival rates by SES group after adjusting for possible confounding factors.ResultsIn patients younger than 65 years, 5-year overall survival rates were lowest for those with low individual SES. After adjusting for patient characteristics (age, gender, Charlson Comorbidity Index Score), gastric cancer patients with high individual SES had 68% risk reduction of mortality (adjusted odds ratio [OR] of mortality, 0.32; 95% confidence interval [CI], 0.17–0.61). Patients aged 65 and above had no statistically significant difference in mortality rates by individual SES group. Different neighborhood SES did not statistically differ in the survival rates.ConclusionGastric cancer patients aged less than 65 years old with low individual SES have higher risk of mortality, even under an universal healthcare system. Public health strategies, education and welfare policies should seek to correct the inequality in gastric cancer survival, especially in those with lower individual SES.
Introduction. Although palliative chemotherapy during end‐of‐life care is used for relief of symptoms in patients with metastatic cancer, chemotherapy may lead to more aggressive end‐of‐life care and less use of hospice service. This is a population‐based study of the association between palliative chemotherapy and aggressiveness of end‐of‐life care. Patients and Methods. Using the National Health Insurance Research Database of Taiwan, we identified 49,920 patients with metastatic cancer who underwent palliative chemotherapy from January 1, 2009, to December 31, 2011. Patients who received chemotherapy 2–6 months before death were included. Aggressiveness of end‐of‐life care was examined by previously reported indicators. Cardiopulmonary resuscitation and endotracheal tube intubation were included as indicators of aggressive end‐of‐life care. The association between palliative chemotherapy and hospice care was studied. Results. Palliative chemotherapy was associated with more aggressive treatment. After adjustment for patient age, sex, Charlson Comorbidity Index score, cancer group, primary physician's specialty, postdiagnosis survival, hospital characteristics, hospital caseload, urbanization, and geographic regions, more than one emergency room visit (p < .001), more than one intensive care unit admission (p < .001), and endotracheal intubation (p = .02) during end‐of‐life care were significantly more common in patients receiving palliative chemotherapy. Patients who did not receive palliative chemotherapy received more hospice care in the last 6 months of life (p < .001). Conclusion. Although the decision to initiate palliative chemotherapy was made several months before death, this study showed that palliative chemotherapy was associated with more aggressive end‐of‐life care, including more emergency room visits and intensive care unit admissions, and endotracheal intubation. The patients who received palliative chemotherapy received less hospice service toward the end of life. Implications for Practice: Palliative chemotherapy is used for patients with incurable cancer toward the end of life (EOL). Aggressiveness of EOL care and hospice care are related to the quality of life of these patients. This study of data from the Taiwanese National Health Insurance Research Database found that palliative chemotherapy led to more aggressive EOL care and less hospice care. There is a need to provide patients with terminal cancer access to care information that best meets their needs, especially those patients who receive palliative chemotherapy.
This paper addresses a single-machine scheduling problem with simultaneous consideration of due-date assignment, generalised position-dependent deteriorating jobs, and deteriorating maintenance activities. It is assumed that the actual processing time of a job is a general non-decreasing function depending on the number of maintenance activities performed before it and its position in a sequence. Moreover, the machine may be subject to several maintenance activities up to a limit over the scheduling horizon. The maintenance activities do not necessarily restore the machine fully to its original perfect state and the duration of a maintenance activity depends on its start time. The objective is to find jointly the optimal job sequence, maintenance frequency and maintenance positions to minimise an objective function that includes the cost of due-date assignment, the cost of discarding jobs that cannot be completed by their due dates and the earliness of the scheduled jobs under the popular CON and SLK due-date assignment methods. We provide polynomial-time solution algorithms for various versions of the problem.
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