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Holistic Integrated Care in Ovarian Cancer (HICO) - Reducing inequalities due to age, frailty, poor physical and mental health - Bath

Project Title: Holistic Integrated Care in Ovarian Cancer (HICO) - Reducing inequalities due to age, frailty, poor physical and mental health

Project Lead & Pilot location: Jonathan Frost - Consultant Gynaecological Oncologist & Project Lead Lead Centre: Royal United Hospitals Bath

Inequality Criteria: Age

Objective Criteria: Improve patient experience and quality of life

Improve physical functioning, nutritional status, and psychological wellbeing

Holistic Integrated Care in Ovarian Cancer (HICO) - Reducing inequalities due to age, frailty, poor physical and mental health

One-minute QI Project read:


This summary comprehensively captures the complexity and nuances of the HICO project, reflecting its aims, achievements, challenges, and lasting impact in the field.

Issue Focus, Aims, and Objectives
The HICO project targeted the treatment disparities faced by older women (aged 65 and over) with ovarian cancer in two healthcare trusts, focusing on a holistic approach to reduce inequalities. Through the integration of physiotherapy, psychological support, quality-of-life assessments, and management of nutritional risks, the project sought to improve physical function, mental well-being, and overall patient experience. Specific objectives included the use of optimal treatment regimens such as surgery and specialised chemotherapy, education for healthcare teams, cost-efficacy analysis, and sharing lessons with other cancer centres nationally and internationally.

Successes, Challenges, and Mitigations
The project's success was marked by full integration into patient pathways, evident improvement in quality of life, and a cultural shift in treatment. Online resources were developed, and the continuous HICO approach even after project cessation underscored its sustainable impact. Challenges such as limited stakeholder engagement, understaffing, recruitment difficulties, and data analysis were met with thoughtful mitigations, including more time for planning, support and funding, larger studies, and separate project managers. The failure to increase the surgery rate was recognised as an area for further investigation.

Conclusion and Broader Impact
Conclusively, the HICO project stands as a pioneering model in the treatment of older women with ovarian cancer, with a distinct focus on holistic healthcare. Achieving its aims and objectives, the project significantly enhanced patient well-being and established a new standard of care. Despite challenges, the lessons learned have shaped future practices and fostered collaboration and research. The HICO team's work now guides national discourse on prehabilitation in gynaecological cancers, with planned presentations at major conferences, journal submissions, and a collaboration for a national conference on prehabilitation, emphasising the project's far-reaching influence.

Key spillover effects resulting from participation in the IMPROVE UK programme

Formation of Collaborative Relationships:

The IMPROVE UK programme led to successful collaborations both within and across different trusts, engaging colleagues from various disciplines that might not have connected otherwise. There was an enhanced understanding of individual roles in patients' treatment pathways, and the success of the project served as a foundation for developing a long-term programme for patient benefit.

Value of Holistic Assessment and Integration into Clinical Practice:

The programme prompted the realisation of the importance of a comprehensive, holistic assessment of cancer patients. Principles of comprehensive geriatric assessment were embedded into routine clinical practice, and there was continued use of the holistic assessment tool from the HICO project. This had a positive impact on the understanding of patients' physical condition and psychosocial situation.

Development and Innovation through Collaborative Efforts:

Collaboration in the IMPROVE UK programme resulted in productive collaborations in the combined prehabilitation dataset project. This collaboration led to the creation of clinically meaningful outcomes and fostered opportunities to discuss and evaluate different approaches chosen by each centre. This facilitated development and innovation in individual programmes.

Support and Long-term Collaboration through IMPROVE UK:

The meetings for the prehabilitation project groups within the programme were instrumental in supporting collaborative efforts and keeping projects on track. These interactions also facilitated the cementing of long-term clinical collaborations between sites, showcasing the enduring and multifaceted benefits of the programme.

Overall, participation in the IMPROVE UK programme has led to a rich set of positive outcomes that extend beyond the specific aims of the project itself, demonstrating the multifaceted value of such a collaborative approach in healthcare innovation and patient care. It shows a blend of collaboration, holistic approach, developmental innovation, and support that resonates well with the overarching goals of the healthcare system.

Key Factors for success of HICO project

These successes highlight the multifaceted achievements of the HICO project, touching on patient care, clinical practices, education, and the broader medical community.

Holistic Approach Integration:

Successfully introduced and integrated a structured holistic care approach for older women with ovarian cancer in two trusts.

Improved Patient Experience:

Demonstrated a clear improvement in the patient experience and global health score, enhancing quality of life during treatment.

Enhanced Physical Functioning:

Achieved improvements in physical functioning through targeted physiotherapy, as evidenced by positive changes in the six-minute walk test and grip test.

Mental Well-being Support:

Successfully implemented routine mental well-being screenings and provided necessary support, including clinical psychology when required.

Increase in Combination Chemotherapy:

Observed an increase in the proportion of patients receiving combination chemotherapy, improving treatment options.

Multidisciplinary Team Education:

Successfully educated the multidisciplinary team, leading to increased confidence and competence in managing holistic care elements like nutrition and physical activity.

Cultural Shift in Treatment:

Facilitated a significant cultural shift in ovarian cancer treatment, considering patients' holistic healthcare needs, which continued beyond the project's end.

Resources for Replication:

Created resources that will be freely accessible online, enabling other UK NHS Trusts to replicate the project.

Conferences and Publications:

Scheduled presentations at national conferences and planned publications to share the project's learnings and findings, furthering the impact.

National Collaboration for Prehabilitation:

Established a working collaboration to run a national conference and work towards a national consensus on prehabilitation in gynaecological cancers.

The challenges and mitigations identified in the HICO project:

Lack of Engagement Time:
Mitigation: Allow enough time for clinical stakeholders' engagement in future projects, specifically the project lead.

Understaffing and Clinical Pressures:
Mitigation: Administrative support, dedicated project management days, and proper funding.

Difficulty in Recruiting Project Admin:
Mitigation: Clear future planning for role fulfilment.

Challenges with Data Analysis:
Mitigation: Arrange for regular BI support for data interrogation.

Excessive Project Management Time:
Mitigation: Explore separate project managers or more funded hours.

Difficulty Assessing Geriatric Intervention:
Mitigation: Consider assessment in a larger study

Subjective Fatigue Measurement:
Mitigation: Use more objective tools like the EORTC questionnaire.

Failure to Increase Cytoreductive Surgery Rate:
Mitigation: Continued analysis to understand underlying reasons.

Incomplete Patient Questionnaires:
Mitigation: Encourage completion in subsequent oncology clinics.

Holistic Integrated Care in Ovarian Cancer - Reducing inequalities due to age, frailty, poor physical and mental health

Full Case Study (10-15 minute read)


  • Brief outline – identify issue & significance
    • Aims & objectives
    • Issue & background information
  • Project design, planning and implementation
    • Intervention – set up
    • Referral criteria
    • PDSA cycle 1 & 2 details and modifications
  • Importance of Patient Engagement
    • Aims, methods, outcomes, summary
  • Data & Measures
    • Endpoints, QOL assessments
    • Detailed measures
    • Baseline measurements
    • Results to physical function tests
    • QOL assessments
  • Cancer Outcomes Summary
    • Patient level costing data
    • Discussion
  • Lessons Learned
    • Patient engagement
    • Project management
    • Clinical intervention
  • Key Limitations & recommendations
  • Conclusions


Focus of the Project:
Ovarian cancer predominantly affects older women with around half of all new diagnoses occurring in those aged 65 and over. It has repeatedly been demonstrated that older patients with ovarian cancer receive less intensive treatment, a key factor in the disproportionately poorer survival outcomes in older women with ovarian cancer in the UK and internationally. Older patients are more likely to have medical and functional comorbidities that can lead to relative under-treatment.


  1. Develop a holistic approach to care, addressing inequalities related to age, frailty, and other factors.
  2. Enhance patient experience and quality of life during and after treatment.


  • Enhance physical functioning through physiotherapy from baseline compared to end of treatment.
  • Provide support for mental wellbeing during and post-treatment.
  • Assess and enhance quality of life through standardised questionnaires - combined EORTC CLCQ30 OV28.
  • Identify and manage patients with medium and high nutritional risk using appropriate tools, such as MUST.
  • Identify and manage anaemia.
  • Increase the use of effective treatments, including specific surgeries and chemotherapies.
  • Educate the wider MDT on the assessment and management for older ovarian cancer patients.
  • Analyse cost-efficacy and develop a sustainable business case.
  • Share the lessons learned with other cancer centres.

Issues & Background Information:

Ovarian cancer mainly affects older women (65 and over), with various factors contributing to worse survival outcomes, including advanced disease and more comorbidities.

Older women often receive less intensive treatment, contributing to lower survival rates in the UK compared to other Western countries.

Research has shown that increasing age is linked with lower rates of standard care (35% for those over 80 years old versus 78% of 65–69-year-olds) and a decreased likelihood of completing planned chemotherapy.

Traditional assessments might underrate older patients' tolerance for treatment, and their needs are often neglected. Despite this, older women still desire active treatment, and certain treatments have been found superior for them.

International guidelines propose comprehensive geriatric assessments for those 65 and over for cancer therapy, but it's not standard in the UK.

Implementing this along with a supportive multimodal program could significantly improve quality of life and survival for older ovarian cancer patients.

Project design, planning and implementation:

The design and planning phase of the project, a joint effort between RUH and UHBW, ran from December 2021 to January 2022.

Key elements included the formation of a strategic HICO Project Board, an Implementation Group for day-to-day operations, regular project management meetings, collaborative working through Microsoft Teams, input from a Patient Advisory Group, and careful scheduling and planning.

These preparations laid the foundation for two subsequent Plan, Do, Study, Act (PDSA) cycles that took place from February 2022 to January 2023.

Intervention Set-up:
The intervention was centered around two 5-6 month 'plan, do, study, act' (PDSA) cycles. The Implementation group crafted an assessment package with clear inclusion criteria, initial questionnaires, structured assessment tools, quality of life assessments, and patient information resources for a holistic approach.

Specialist interventions in the HICO project were meticulously designed, considering several aspects including referral criteria and assumptions:

  • Physiotherapy: Required for all patients.
  • Dietetics and Clinical Psychology: Anticipated to be necessary for 50% of patients.
  • Geriatrics: Estimated to be required by 31% of patients.
  • Occupational Therapy: Projected to be needed for 25% of patients.

These projections guided resource allocation and planning for the interventions, ensuring tailored care. The team also considered a payment-by-results remuneration model, the MUST score for nutritional assessment, and organised cross-site data sharing.

Additionally, the Implementation Group created a patient information leaflet, provided training through webinars, handled funding agreements, developed Standard Operating Procedures, and facilitated the referral process for patient assessments, showcasing a comprehensive and thoughtful intervention setup.

PDSA Cycle 1 Summary:

The first Plan, Do, Study, Act (PDSA) cycle began on February 1, 2022, recruiting 46 patients and achieving 56% of the recruitment target. This cycle involved initial assessments, leading to individualised interventions, and used various support methods like face-to-face appointments and phone consultations. The Implementation Group monitored progress through monthly meetings.

Key Successes of PDSA Cycle 1:

  • Recruitment of 46 patients without any declinations.
  • Positive engagement with patients and valuable feedback.
  • Cross-functional collaboration among staff, emphasising a multidisciplinary approach.
  • Improved midpoint measurements and functional improvements.
  • Continuity in care, early problem detection, and addressing unmet needs.
  • Resource development, positive feedback on techniques, and skill enhancement across the medical team.

These successes contributed to the overall effectiveness of the cycle, highlighting areas for improvement and strengthening patient care.

Modifications Made After PDSA Cycle 1:

  • Patient Information/Engagement: Simplified patient information with a single care plan document, updated webpage, and aligned therapy appointments with chemotherapy.
  • Initial & Final Assessments: Streamlined assessments and updated care plan.
  • Physiotherapy: Introduced a tiered intervention approach and secured funding for new measures.
  • Occupational Therapy: Revised the assessment process, increased allocation, and created new videos.
  • Geriatrics: Improved triage and removed a memory function assessment.
  • Dietetics: Established funding for additional capacity, revised the MUST screening process, and ensured dietary advice.
  • Project Resourcing: Monitored time spent by clinical specialists and allocated more funding for management and support.

The significant change was the introduction of tiered levels of care, replacing the initial approach that was found to be too resource-intensive. These alterations reflect the adaptive nature of the intervention, driven by real-world experiences and feedback, and show an ongoing commitment to enhancing patient care and resource utilisation.

PDSA Cycle 2 Summary:

The second PDSA Cycle for the intervention started on August 1st, 2022, and included the implementation of several key changes. These refinements targeted improvements in patient care and collaboration across the healthcare team.

Key Developments in PDSA Cycle 2:

  • Dietetic Treatment Transition: UHBW transferred dietetic treatment for RUH patients back to RUH, primarily due to IT system issues.
  • Inclusion Criteria Modification: Clinical leads expanded the inclusion criteria to include a wider patient base.
  • Collaborative Assessments at UHBW: Initial assessments became more collaborative with additional staff involvement.
  • Patient Recruitment Growth: An additional 36 patients were recruited, bringing the total to 82.

Key Successes of PDSA Cycle 2:

  • Positive Reception of Patient Care Plan: The revised care plan was well received by patients.
  • Recruitment Target Exceeded: 82 patients were recruited, exceeding the target by 3%.
  • Effective Utilisation of the Website: The HICO webpage became a valuable tool for patient engagement and education.
  • Successful Implementation of Activity Monitors: Activity monitors were successfully integrated and well received.
  • Positive Impact of Early Nutritional Intervention: Early dietary information led to better symptom management.
  • Integration of Therapy During Chemotherapy Appointments: Therapists engaged with patients during chemotherapy, emphasising a multidisciplinary approach.
  • Reinforcement of Physiotherapy Importance: The vital role of physiotherapy was further emphasised with successful goal-setting and positive feedback.
  • Regular Communication Alleviated Patient Anxieties: Ongoing communication provided support and reassurance.

These successes showcase the effectiveness of the changes made during the second PDSA cycle, enhancing patient experience and reinforcing the value of a multifaceted, iterative approach to healthcare.

The Importance of Patient Engagement:

The importance of patient engagement in the HICO project was focused on enhancing the patient experience for older women with newly diagnosed ovarian cancer. It emphasised understanding patient needs and preferences to inform ongoing refinements in the program.


  • Improve the patient experience focusing on physical functioning, nutritional status, and psychological well-being.
  • Implement a patient-centered approach involving continuous feedback and consultation.
  • Utilise technology such as virtual consultations and electronic monitoring.


  • Identify the project's needs, form a Patient Advisory Group (PAG), and create an engagement activity plan.
  • Collaborate with patients, conducting interviews and focus groups.
  • Utilise the 'Ladder of engagement' framework to understand various methods and levels of involvement.
  • Conduct patient engagement in two improvement cycles and analyse the results.

Outcomes Identified

  • Overwhelming printed information led to the development of web pages.
  • Preference for videos over leaflets led to the inclusion of videos on the website.
  • Challenges in managing appointments led to the creation of a care plan booklet.
  • Desire for fewer follow-up appointments led to varied appointment formats.
  • Need for support for surgical menopause led to online information and specialised support.
  • Recognition of changing needs during treatment led to responsive pre-hab processes and specialist access.

What Worked Well

  • A patient-centered approach.
  • Flexibility through virtual meetings.
  • Rich qualitative feedback through in-depth telephone interviews.


  • Technical constraints hindered virtual participation.
  • Significant time commitment required.
  • Collaborative delays across different specialties.

Next Steps

  • Continued patient engagement, including more diverse patient groups.
  • Targeted interviews with non-referred patients.
  • Assessing the impact of key improvements on patient experiences.

The patient engagement in the one-year pilot project successfully integrated patient voices and needs, leading to tangible improvements. The challenges faced included technology limitations, time management, and collaboration. Future commitments are focused on sustaining and deepening patient engagement to continue enhancing the quality and responsiveness of care.

Data and Measures:


The effectiveness and impact of a prehabilitation project aimed at improving care for patients with newly diagnosed ovarian cancer were assessed through three primary ways, measures were selected before the start of the project:

  1. Clinically relevant endpoints
  2. Longitudinal functional and quality of life assessments and a
  3. Comprehensive qualitative assessment of patients' views.

Clinically Relevant Endpoints

  • Length of post-operative stay
  • Time from surgery to next chemotherapy
  • Proportion of patients who underwent surgery and carboplatin-based chemotherapy
  • Surgical post-operative complication rates
  • Transfusion demand
  • Reporting 1-year mortality when data is mature

Longitudinal Functional and Quality of Life Assessments

  • Assessment of Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLS)
  • 6-Minute Walk Test (6-MWT)
  • Grip Strength
  • 30 Second Sit to Stand Test
  • Maximum Inspiratory Pressure (MIP)
  • EORTC QLQ C30 and module ELD14

Comprehensive Qualitative Assessment

  • Patients' views and perceptions of project participation

Detailed Measures

• Rationale: Established clinical tool
• Comments: Replaced by EORTC QLQ C30 and ELD14
• Rationale: Assess aerobic capacity and endurance
• Comments: Difficult to implement in certain locations
Grip Strength
• Rationale: Screen for muscle strength and sarcopenia
• Comments: Requires a dynamometer
30 Second Sit to Stand Test
• Rationale: Assess lower limb strength in older adults
• Comments: Quick, easy, and can be done virtually
Maximum Inspiratory Pressure (MIP)
• Rationale: Measure global inspiratory muscle strength
• Comments: Requires strong instructions and individual mouthpieces
EORTC QLQ C30 with ELD14
• Rationale: Assess health-related quality of life in cancer patients
• Comments: Compliance with assessments was not complete

Planned Outcomes

  • Proportion of patients receiving chemotherapy or surgery
  • Chemotherapy-related toxicity
  • Surgical complications and post-operative length of stay

The summarised information provides an overview of the diverse measures used to assess the intervention and highlights the importance of both clinical and patient-centered evaluation. It also touches on the challenges encountered in implementing certain measures, reflecting the complex nature of healthcare intervention assessment.

Summarised baseline measurements for the HICO intervention involving 82 people with ovarian cancer:

The summary below presents a clear picture of the initial assessments, highlighting the age, BMI, lifestyle habits, psychological considerations, physical health, and specialist referrals. It also notes the unfortunate deaths and one instance of declined treatment during the intervention.

• Total Participants: 82
• Age: Mean 70, Range 49 – 88
• BMI: Mean 25.04, Range 16 to 47
• Deaths During Intervention: 4
• Declined Physiotherapy Element: 1

Lifestyle Factors

  • Smokers: 5 (6.09%), all referred for cessation advice
  • Patients with Audit C Score > 3: 14 (17.07%)
  • Referred for alcohol consumption advice: 6 (7.31%)

Psychological Factors

  • Patients with Hospital or Treatment Related Phobia: 4 (4.87%)
  • Patients with HADS > 10: 22 (26.8%)
  • Referred for clinical psychologist assessment: 100%
  • Reviewed by a clinical psychologist: 45%
  • Others awaiting assessment, declined, or were not well enough, or felt improved

Physical Health and Risks

  • Patients with G8 Frailty Score < 14: 48 (59.3%)
  • History of Falls in Last 6 Months: 11 (12.3%)
  • Referred for Geriatric Triage: 33 (40.7%)
  • Medium or High Risk of Malnutrition: 37 (45.7%), referred for specialist dietetic assessment
  • Seen by Physiotherapist: 74 (90.24%)
  • Seen by Occupational Therapist: 25 (30.8%)


Physical Function:

Here's a summary of the results related to physical function, broken down by each test conducted:
These results show improvement in the mean values across all metrics, with statistically significant improvement in the MIP. The proportions of patients who improved and deteriorated vary across the different tests, with the highest improvement observed in MIP and a balanced distribution between improvement and deterioration in the 6MWT.

6 Minute Walk Test (6MWT) - 33 Participants

  • First Observation (Mean): 391m
  • Last Observation (Mean): 410m
  • P-Value (paired t-test): 0.352
  • Improved: 48.5%
  • Deteriorated: 42.4%

Grip Strength - 37 Participants

  • First Observation (Mean): 22.3kg
  • Last Observation (Mean): 22.8kg
  • P-Value (paired t-test): 0.366
  • Improved: 56.8%
  • Deteriorated: 32.4%

Sit to Stand - 41 Participants

  • First Observation (Mean): 11.2
  • Last Observation (Mean): 12.5
  • P-Value (paired t-test): 0.05
  • Improved: 53.7%
  • Deteriorated: 36.6%

Maximum Inspiratory Pressure (MIP) - 19 Participants

  • First Observation (Mean): 49cmH20
  • Last Observation (Mean): 61cmH20
  • P-Value (paired t-test): 0.002
  • Improved: 78.9%
  • Deteriorated: 15.8%

ICIQ – Incontinence

  • Participants Reported: 6
  • Comments: No repeat readings; data not included in results.

Summary of the quality of life assessment for the HICO project:

The results suggest a positive change in the quality of life for over half of the patients involved in the HICO project, with a significant mean improvement from the baseline to the last observation. Some patients did not experience any change, and nearly a third reported a reduction in their quality of life.

Quality of Life Assessment - 42 Participants

Methodology: A comprehensive mixed-methods approach was used, including longitudinal quality of life assessments, semi-structured interviews, and questionnaires.

Global Health Score: This score ranged from 1 (worst) to 7 (best).

Baseline Mean Score: 4.4

Last Observation Mean Score: 5

Statistical Significance: p=0.048, indicating a statistically significant change over time.

Improvement: 54.8% of patients reported an improvement in global health.

No Change: 14.3% reported no change in global health.

Reduction: 31% experienced a reduction in their global health score.

Summary of the patient experience questionnaire for the HICO service:

These results indicate a generally positive response from patients regarding their experience with the HICO service.

  • Clarity of Information: 71% found the information clear and easy to understand.
  • Initial Assessment: 89% felt the initial assessment was straightforward to complete.
  • Managing Appointments: 79% found the number of appointments with HICO therapists easy to manage.
  • Improvement in Confidence: The team helped improve confidence in managing symptoms (89% for the consultant, 82% for CNS and physiotherapist, 79% for occupational therapists, etc.).
  • Physical Activity: 86% felt the physiotherapy team helped them become more physically active.
  • Preparation for Treatment: 75% felt better prepared for treatment and surgery.
  • Dietetic Assistance: 100% found the dietetic team's information useful, and all respondents felt more confident in diet choices.
  • Recommendation: 86% would recommend the HICO service to a friend with ovarian cancer.

Cancer Outcomes Summary

The data presented here is a first analysis of the outcomes of the HICO programme, as of the censor date of November 30th, 2022. This includes 166 patients, 58 from the current HICO programme, and 108 from a historical comparator cohort (from 1st October 2018 to 30th September 2019).

Some caution should be exercised in interpreting these results as missing data was excluded from the analysis, and differences in FIGO stage distributions between the cohorts may impact treatment outcomes.

Key Outcomes:

These outcomes provide insights into various aspects of cancer treatment, including the length of stay, time to chemotherapy, surgery rates, and chemotherapy completion among others. Significant difference is noted in the percentage receiving at least one cycle of carboplatin and paclitaxel, while other metrics show close alignment between the cohorts.

  • Age: Mean age was 71 (range 53-88) in the current cohort vs 65.5 (range 22-88) in the retrospective cohort.
  • FIGO Stage III/IV: 81.1% in the current cohort, compared to 65.7% in the retrospective cohort.
  • Length of Stay: Mean 6.9 days in the current cohort vs 6.3 days in the retrospective (p=0.5341).
  • Time from Surgery to Chemotherapy: Mean 36.6 days vs 40.3 days in the retrospective cohort (p=0.2521).
  • Surgery Rates: 76.9% underwent surgery in the current cohort vs 81.5% in the retrospective (p=0.5402).
  • Optimal Cytoreduction: 91.7% in the current cohort vs 93.8% in the retrospective (p=0.6692).
  • Post-operative Complications: 64.9% had zero complications in the current cohort vs 67.1% in the retrospective (p=0.8142).
  • Pre-operative Anaemia: 30% in the current cohort vs 13.7% in the retrospective (p=0.0532).
  • Chemotherapy Completion: 86.8% completed 6 cycles in the current cohort vs 80% in the retrospective (p=0.3602).
  • Carboplatin and Paclitaxel Treatment: 82.4% received at least one cycle in the current cohort vs 57.6% in the retrospective (p=0.0032).
  • Emergency Admissions: 41.9% had zero admissions in the current cohort vs 44.0% in the retrospective (p=0.8552).
  • Acute Oncology Contacts: Mean 1.9 contacts for RUH patients only in the current cohort vs 2.1 in the retrospective (p=0.7813).

Summary of insights related to the implementation of the HICO intervention:

Patient Level Costing Data:

The HICO intervention was analysed for its actual cost of care within the hospital, considering all hospital activities.

A comparison between the HICO cohort and the retrospective cohort showed the mean cost of care for 6 months after diagnosis was £18,037 prior to the intervention, and £17,783 after its introduction.

The data, based on 25 patients, suggests no increase in total care costs with the intervention and possibly a slight reduction, but this is subject to confounding factors.

Once the data is more mature and further patient costs are assessed by finance teams it will be possible to offer more accurate insight into the cost of care with and without the intervention.


The findings reflect a promising trend in cost-effectiveness and improvement in certain physical health measures, though further study and more extensive data are needed to fully assess the impact of the HICO intervention.

  • The project was a time-limited observational evaluation targeting an integrated holistic care approach for older ovarian cancer patients.
  • It aimed to improve the patient experience and quality of life during and after treatment.
  • The intervention was found acceptable by patients, with positive feedback, high concordance, and no significant burden of appointments.
  • Improvements in physical function measures like walk test, grip strength, etc., were observed, although the small cohort size precludes significant conclusions.
  • Global health scores also showed improvement, indicative of a trend toward better physical function.
  • A significant improvement was noted in the rate of patients receiving at least one cycle of carboplatin with paclitaxel in the HICO cohort.
  • There were no other significant differences in key cancer metrics, and more mature data is expected to offer more accurate insights in the future.

Lessons learned:

The following summary highlights the lessons learned from the project, focusing on three main areas: patient engagement, project management and organisation, and clinical intervention. The strengths and unique aspects of the approach are summarised under each subheading.

Patient Engagement:

Support from Patient Engagement Lead: Allocating time for an experienced patient engagement lead was crucial for a patient-centered approach.

Commitment from Patients: The involvement of dedicated patients provided valuable insights and consistent feedback for service improvement.
Recording Meetings: Transcripts of recorded virtual meetings helped retain the authenticity of patient vices.
Listening to Patients: Health professionals' open receptiveness to patient feedback led to constructive improvements in the HICO service.

Project Management and Organisation:

PDSA Cycles: Utilising two Plan-Do-Study-Act cycles helped in structured review and revision of the project.
Dedicated Project Manager: Having a separate project manager was essential for maintaining progress and meeting milestones.
Regular Implementation Meetings: Scheduled check-ins allowed timely resolution of issues and risk mitigation.
Teamwork and Collaboration: Face-to-face workshops and early engagement with Information Governance enhanced collaboration and prevented delays.

Clinical Intervention:

Tailored Solutions: The clinical intervention provided tailored solutions to significantly unwell patients, fostering positive patient involvement in treatment.
Small Cohort Limitations: While personalisation was a strength, the small number of patients limited potential economies of scale.
Education and Skills Development: The project led to an increase in knowledge and skills related to physical, psychological, and nutritional health.
Funding Complexity: Using payment by activity added unnecessary complexity without apparent benefits.

Overall Summary:

The project's strong emphasis on patient engagement and a structured approach to project management laid the groundwork for a personalised and effective clinical intervention. While the tailored solutions were well-received by patients, challenges such as the small cohort size and funding complexities also provided key learning points for future endeavours. The lessons learned and the strengths identified in this project may offer valuable insights for similar initiatives aimed at enhancing patient care and experience.

Key limitations:

The limitations of the project approach have been identified and analysed to understand the causes, effects, and possible recommendations for future projects.

Here's a summary of the key issues:

Lack of CNS Support at UHBW

  • Cause: Tight timelines for project bidding.
  • Effect: Surgical oncologist was burdened with extra responsibilities.
  • Recommendations: Engage all clinical stakeholders early; ensure sufficient time for bidding processes.

Missing Eligible Patients at UHBW

  • Cause: Absence of surgical oncologist; understaffing; lack of follow-up.
  • Effect: Missed opportunities to improve patient outcomes.
  • Recommendations: Adequate staffing and administrative support; dedicated days for engagement.

Data Challenges

  • Cause: Patient attrition; inadequate data maturity; limitations with HICO App data interrogation.
  • Effect: Impact on data/results; manual data handling.
  • Recommendations: Review data post-project; proper arrangements for regular BI support; use of more effective questionnaires.

Inadequate Staffing for Intervention

  • Cause: Economies of scale; lack of backfill for staff time; extreme clinical pressures.
  • Effect: Inability to deliver optimal service; delays in follow-ups.
  • Recommendations: Explore dedicated days per week; ensure adequate funding and support.

Overwhelming Patient Engagement Process

  • Cause: High volume of information; unstage process.
  • Effect: Patients overwhelmed.
  • Recommendations: Stage the process to avoid overburdening patients.

Project Admin and Management Challenges

  • Cause: Difficulty in recruitment; significant project management time; concurrent report writing and project closure activities.
  • Effect: Project manager overworked; expensive resources used; last-minute report finalisation.
  • Recommendations: Clear plans for admin roles; consider separate project managers or more funded hours; receive report template early.

Measuring Geriatric and OT Interventions

  • Cause: Too few patients; subjective questionnaires; difficulty in outpatient measurement.
  • Effect: Challenges in assessing the difference made.
  • Recommendations: Larger studies; use of the EORTC questionnaire.

Overall Recommendations:

The project faced several limitations, particularly around staffing, data management, project administration, and the measurement of specific interventions. A future approach should consider early stakeholder engagement, proper staffing and administrative support, well-planned data management tools, and early alignment on reporting requirements. By addressing these challenges head-on, subsequent projects could deliver more impactful results, more efficiently and effectively.


The HICO project has largely succeeded in achieving its aims, making substantial strides in implementing a holistic care model for older women with ovarian cancer. It has demonstrated improvements in patient experience, physical and mental well-being, and contributed to a broader cultural shift in the approach to treatment. Though there were some mixed results in altering treatment modalities, the project's overall success and future planning, including potential replication in other centres, indicate a significant contribution to the broader goal of reducing health inequalities in this patient population. The continuing efforts to share the learnings and collaborate nationally further underscore the project's impact and potential legacy.

Here is a summary of the extent to which these aims were achieved, contributing to the overall program goal of tackling systemic and regional health inequalities for women with ovarian cancer:

Introduction of Holistic Care: Achieved

  • The structured holistic approach was successfully integrated into the patient pathway in both trusts.
  • Result: Potential positive effect on reducing inequalities in care for older women with ovarian cancer.

Improvement in Patient Experience: Achieved

  • Clear improvement in patient experience was observed, with positive feedback from patients.
  • Result: Improved global health score and quality of life during treatment.

Improvement in Physical and Mental Well-Being: Achieved

  • Physiotherapy addressed physical functioning, and support for mental well-being was provided.
  • Result: Improvements in physical tests and proactive support for mental health.

Increase in Specific Treatments: Partially Achieved

  • An increase in patients receiving combination chemotherapy was seen, but no significant difference in the rate of cytoreductive surgery.
  • Result: Mixed success in changing treatment approaches.

Wider Education and Culture Shift: Achieved

  • The multidisciplinary team's education was a significant success, leading to increased confidence in managing care areas.
  • Result: A culture shift in treating ovarian cancer holistically, with ongoing commitment to the HICO approach.

Resource Generation and Replication: Achieved

  • Resources created are set to be freely accessible online, and the project can be replicated in other UK NHS Trusts.
  • Result: Broad impact and continued engagement through conferences and publications.

National Collaboration: Achieved

  • Collaboration to run a national conference and work towards a national consensus on prehabilitation in gynaecological cancers.
  • Result: Extended influence on a national level.

Project Outputs

We are considering using a separate box on the case study webpage rather than place within the main body text. Then we will link items listed below to the resource library.

Project Outputs:

Clinical Intervention
• Initial Assessment Package (including QoL questionnaire)
• Physiotherapy Tools:
• Triage tool for OT referrals
• Equipment report
• MUST flow chart
• Intervention Plans: Tiered intervention introduced in PDSA cycle 2
• Funding Plans: Draft business case for longer-term funding & costings
• Project Visuals: HICO Project Infographics

Patient Engagement
• Patient Advisory Group (PAG) Documents:
• Terms of Reference
• ‘You said we did’/thank you card
• Patient Resources:
• Patient experience questionnaire
• Patient information leaflet
• Patient care plan or workbook

Part 1 - Review of the Additional Project- Prehabilitation Joint Data Collection & Analysis :

Project Overview:

A detailed review of the IMPROVE UK Prehabilitation Joint Data Collection and Analysis Project, with a specific focus on women with particular diagnoses.


To evaluate the impact of prehabilitation on treatment tolerance and outcomes by comparing current and historical cohorts.


  • Collect and analyse data from various sites within the UK.
  • Identify the influence of prehabilitation on the quality of treatment.
  • Assess patient responses and tolerance to different prehabilitation programs.


  • Comparison of treatment tolerance between cohorts.
  • Analysis of the survival rate after 1 year.
  • Evaluation of patient quality of life and overall satisfaction with the treatment process.

Design and Planning:

  • Leadership by a Consultant Medical Oncologist at the RUH.
  • Collaboration with teams in Wales and Northern Ireland.
  • Phase One: Feasibility assessment, planning stage, analysis of datasets, and review of data protection.


  • Secure transfer of pseudonymised data.
  • Clear agreements on handling and storage.

Inclusion Criteria:

  • Patients diagnosed with a particular condition - Epithelial ovarian cancer (any stage) who received first line treatment.
  • Diagnosed between:
    a. Current cohort (patients recruited to local prehabiliation project)
    b. Retrospective cohort: 01-Oct-2018 to 30-Sep-2019

Exclusion Criteria:

1) Borderline serous tumours
2) Sex cord stromal tumours

Interim Report Details:

  • An interim readout planned for January 2023.
  • Further analysis in April 2023.
  • Final analysis with 1-year survival data in January 2024.

Limitations and Challenges:

  • Delays in signing off data sharing agreements.
  • Extensive time required to agree on a core data set.
  • Additional time spent on reviewing and validating data due to inconsistencies in definition.

Part 2: Novel/Alternative Prehabilitation Approaches within the Existing HICO Project


A summary of the results on novel and alternative approaches to prehabilitation introduced within the existing HICO project.

Activity Monitors/Trackers:

  • Distribution to 17 out of 20 patients.
  • Positive impact on setting and monitoring goals, tracking heart rate, and preventing fatigue.

Nordic Walking:

  • Participation by 1 patient.
  • Boosted confidence, with some deterrents like cold weather reported.

Supervised Hospital-Based Exercise:

  • Participation by 3 patients.
  • Positive feedback, helped with anxiety, and provided opportunities to engage in different exercises.


The novel approaches added value to the existing HICO project by introducing innovative means to support patients in their prehabilitation journey. While the uptake was limited, the feedback from the patients who did participate was generally positive, showing the potential benefits of these approaches. Future projects may further refine and expand these methods based on these initial findings.

If you are a patient, go to the Ovarian Cancer Action website