Extending specialist palliative care to all?

How to extend palliative care services to all patients needing them is an issue currently exercising a range of bodies in contemporary Britain. This paper first considers the evidence regarding the needs of dying patients with long term conditions other than cancer and concludes that there is evidence to support their presumed need for palliative care. It then considers five potential barriers to extending specialist palliative care services to non-cancer patients in Britain. These are the skill base of current specialists in palliative care, difficulties in identifying candidates for specialist palliative care, the views of potential users of these services, resource implications and vested interests in present health service arrangements.     

Is it appropriate to screen palliative care patients for depression?

It is estimated that approximately 25 percent of palliative care patients have symptoms of depression, but much of this depression is not identified and therefore not treated. Reasons for nonidentification include the difficulties of distinguishing between what can be called "appropriate sadness" and depression at the end of life and also the nondisclosure by patients of their own mood. In an effort to improve the early detection of depression, patients of all age groups referred to a clinical nurse specialist team within a six-month period were invited to complete the Edinburgh Postnatal Depression Scale (EPDS); the scale was found in an earlier study to have a sensitivity and specificity of above 80 percent at a cutoff threshold of 13 or above. The present study found that 34 percent of patients scored at or above the previously validated threshold of 13, and that younger patients (under age 50) were twice as likely to score above the threshold than were older patients (over age 70). The scale was easy to complete by patients, and staff found it useful as part of their initial assessment of patients. It is suggested that such a tool may aid the early detection and treatment of depression in palliative care patients.     

Is there a place for sexuality in the holistic care of patients in the palliative care phase of life?

Being diagnosed with a life-limiting condition is a traumatic event. The journey to the moment of death is usually only done once--so it is a time of fears and uncertainty. Sexuality is particularly vulnerable at this time. It may be difficult for both patient and partner to deal with the changes in sexuality without professional assistance. It is "sexuality" rather than "sex" that defines the meaningful relationships people have with themselves and significant others. When sexuality is lost or changed, important benefits may be lost. Studies show that many patients do value sexuality and want assistance in making the best of their sexual potential during the palliative care phase. Health professionals regularly acknowledge the importance of sexuality for their patients but have difficulties acting on their beliefs. Sexuality, within the patient's functional ability and desire for it, must be acknowledged and included in holistic management. It is the health professional's responsibility to raise this issue.     

The Health Security Act and improving the quality of care: will the Clinton reforms help or hinder?

Maintaining and improving the quality of care is central to the Health Security Act, according to this in-depth analysis of the Act's intended quality reforms. The author reviews the proposal from several perspectives, including those of administrative law, hospital administration, health services research, and risk management. In the author's opinion, quality reforms involving the federal government as purchaser of medical care and as grader of the quality of its health care providers require close scrutiny. The establishment of a National Health Board and a National Quality Management Council further heightens concerns for quality standards and oversight. The article also evaluates the proposed health quality data super-highway, making several stops for contemplation and critical analysis.     

Death without distress? The taboo of suffering in palliative care

Medicine, Health Care and Philosophy - Palliative care (PC) names as one of its central aims to prevent and relieve suffering. Following the concept of “total pain”, which was first...     

Is the British diet improving?

The UK government's National Diet and Nutrition Survey report of Years 5 and 6 (2012/2013–2013/2014) of the Rolling Programme has just been published. By and large, the results are not encouraging. Compared to previous results from 2008/2009, little has changed and the national sample of children and adults continues to report eating too much saturated fat, non‐milk extrinsic sugars, too few fruit and vegetables and not enough oil‐rich fish, with certain groups of the population found to have low levels of some key vitamins and minerals. A glimmer of hope is that there are a couple of indicators of improvement, and overall, the UK population's diet has not got worse in the past 6 years.     

What do we owe the dying? Strategies to strengthen end-of-life care

More than 2.5 million Americans died last year, and a majority of these persons died within an inpatient hospital setting. The demand for inpatient hospital care at the end of life (EOL) will increase appreciably as the population continues to age; several leading bodies, including the Institute of Medicine, have called for an expansion of evidence-based, patient-centered EOL care. In an attempt to assist healthcare executives to meet the needs of the increasing number of dying patients, we reviewed four hospital-based, best-practice EOL programs. Following this review, we defined an operational planning process that yields three ways to improve EOL care programs. The improvement of EOL care programs should constitute a great benefit to those organizations concerned with improving the quality of patient care, reducing the costs associated with the treatment of dying patients, and responding to the standards of national credentialing bodies.     

Evidence of an environmental contribution to the aetiology of cryptorchidism and hypospadias?

Objectives Evidence suggests that there is geographical variation in the birth prevalence of both cryptorchidism and hypospadias. The aim was to determine if there is evidence of spatial heterogeneity in the prevalence of these conditions and to test the hypothesis that environmental factors may contribute to aetiology. Methods A population-based dataset of cryptorchidism and hypospadias cases was constructed from the hospital episodes statistics that covered the Northern Region of England and assigned to a small area based on the residential address at time of admission. Expected numbers of cases for each small area were computed. The ratio of observed to expected cases was determined for each small area and analysed with respect to both geographical heterogeneity and small area level socio-economic deprivation. The Potthoff–Whittinghill method was used to determine if there was localized spatial clustering of cases. Results There was statistically significant spatial clustering for cases of both cryptorchidism [estimated Extra-Poisson Variation (EPV) = 0.14; 95% CI, 0.03–0.25] and hypospadias (EPV = 0.17; 95% CI, 0.05–0.28). In addition, increased prevalence was associated with lower levels of deprivation for hypospadias (P = 0.06), but there was no such relationship for cryptorchidism (P = 0.61). Conclusions The finding of localized spatial heterogeneity in the prevalence of cryptorchidism and hypospadias is consistent with the involvement of a spatially varying environmental risk factor. The apparent social patterning of hypospadias is likely to reflect an association with lifestyle and other factors which underpin social variation in health. However, there also remains a possibility that these findings may be due to variability in ascertainment of cases.     

Is new drug prescribing in primary care specialist induced?

Background  

Medical specialists are often seen as the first prescribers of new drugs. However, the extent to which specialists influence new drug prescribing in primary care is largely unknown.     

Is universal health coverage the practical expression of the right to health care?

Background

Public stigma against family members of people with mental illness is a negative attitude by the public which blame family members for the mental illness of their relatives. Family stigma can result in self social restrictions, delay in treatment seeking and poor quality of life. This study aimed at investigating the degree and correlates of family stigma.

Methods

A quantitative cross-sectional house to house survey was conducted among 845 randomly selected urban and rural community members in the Gilgel Gibe Field Research Center, Southwest Ethiopia. An interviewer administered and pre-tested questionnaire adapted from other studies was used to measure the degree of family stigma and to determine its correlates. Data entry was done by using EPI-DATA and the analysis was performed using STATA software. Unadjusted and adjusted linear regression analysis was done to identify the correlates of family stigma.

Results

Among the total 845 respondents, 81.18% were female. On a range of 1 to 5 score, the mean family stigma score was 2.16 (±0.49). In a multivariate analysis, rural residents had significantly higher stigma scores (std. β?=?0.43, P?<?0.001) than urban residents. As the number of perceived signs (std. β?=?-0.07, P?<?0.05), perceived supernatural (std. β?=?-0.12, P?<?0.01) and psychosocial and biological (std. β?=?-0.11, P?<?0.01) explanations of mental illness increased, the stigma scores decreased significantly. High supernatural explanation of mental illness was significantly correlated with lower stigma among individuals with lower level of exposure to people with mental illness (PWMI). On the other hand, high exposure to PWMI was significantly associated with lower stigma among respondents who had high education. Stigma scores increased with increasing income among respondents who had lower educational status.

Conclusions

Our findings revealed moderate level of family stigma. Place of residence, perceived signs and explanations of mental illness were independent correlates of public stigma against family members of people with mental illness. Therefore, mental health communication programs to inform explanations and signs of mental illness need to be implemented.     

Do the organizational reforms of general practice care meet users’ concerns? The contribution of the Delphi method

Context  The debate over primary care reform in France, as in most OECD countries, centres on questions about efficacy and accessibility. Do these reforms actually respond to the users’ concerns?Objective  The objective of this study was to identify the importance that users attribute to different aspects of general practice (GP) care.Design  The method used was a variant of the classical Delphi approach, called Delphi ‘ranking‐type’. Between May and September 2009, 74 experts aged over 18 were recruited by ‘snowballing’ sampling. Three iterative rounds were required to identify the core aspects through a consensus‐building approach.Results  It is shown that users attribute a very high importance to the ‘doctor–patient relationship’ dimension. The following aspects ‘GP patient information about his/her illness’, ‘Clarity of communication and explanation’, and ‘Whether the GP seemed listen to the patient’ were evaluated by 96% of the experts as being of high importance. The coordination of GP was also considered as a very important aspect for 85% of the experts. In contrast, the aspects that belong to the organizational dimension appeared to be of relatively low importance for users.Conclusions  Our results support a comprehensive approach of care and argue in favour of care reorganization following the patient‐centred model. To promote organizational care reforms through the prism of the doctor–patient relationship could thus be a fruitful way to insure a better quality of care and the social acceptability of the reforms.     

What is 'best practice' in health care? State of the art and perspectives in improving the effectiveness and efficiency of the European health care systems

A framework for the classification of information on maintaining or improving effectiveness and efficiency in health care systems is proposed. Activities, disciplines and methods that are available to identify, implement and monitor the available evidence in health care are called 'best practice'. We reviewed the literature in order to (1) establish a definition for 'best practice' in the health sector, (2) develop a framework to classify relevant information, and (3) synthesise the literature on activities, disciplines and methods pertinent to the concept. Health care, public health activities and health policy should be advised by the best available evidence. Currently, the concept can be broken down into three activities (Health Technology Assessment (HTA), Evidence-Based Medicine (EBM), Clinical Practice Guidelines (CPGs)) by which evidence is synthesised either as an evidence base (EBM and most HTA) or in the form of recommendations (CPGs and some HTA) for different decision purposes in health care. These activities gain input mainly through four disciplines: clinical research, clinical epidemiology, health economics and health services research. The different disciplines are related to each other in three 'domains': (a) input, (b) dissemination/implementation and (c) monitoring/outcome. These provide evidence on (a) the (potential) effects of health care interventions and policies; (b) on ways to implement them; and (c) on ways to monitor their actual outcome. None of these separate approaches and activities exclusively forms a successful and all-embracing strategy to ascertain 'best practice'. A collective approach in the management of information is expected to add value to individual efforts. Resources should be devoted to increase quality and quantity of both primary and secondary research as well as the establishment of networks to synthesise, disseminate, implement and monitor 'best practice'.     

Does gender bias exist in the use of specialist health care?

OBJECTIVES: To investigate the evidence for the existence of gender bias (defined as care provided independently of clinical need) in the use of specialist services by critically appraising the literature. METHODS: A computer-assisted search of the bibliographic databases PubMed, Medline, EMBASE, Healthstar and Social Science Citation Index for English language papers published from 1966 until May 1999. In addition, four journals were handsearched and the reference lists of identified papers were explored. Retrospective studies were only used when there were insufficient prospective studies. RESULTS: One hundred and thirty-eight studies were identified covering five major topics: coronary artery disease; renal transplantation; human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS); mental illness; and other (mainly invasive) procedures. The majority (94) examined coronary artery disease. It appears that men are more likely to undergo non-invasive investigations than women, but that subsequent investigation and treatment shows no clear evidence of gender differences. Men are more likely to undergo renal transplantation and, for those with HIV and AIDS, to receive azidothymidine (zidovudine, AZT) than women. There are some indications that disparities in favour of men also occur for those suffering from cardiac arrhythmias and cerebrovascular disease, and for those undergoing vascular surgery, hip replacement and heart transplantation. In contrast, women are more likely to undergo liver transplantation and cataract surgery. Mental health services may be provided differently for men and women. All these findings are limited by a lack of accurate denominator information and insufficient ability to adjust for prognostic factors. CONCLUSIONS: Differences in health care use can be due to demand factors (e.g. differences in the prevalence and severity of disease or in patient preferences), supply factors (particularly clinical judgement), or both. There is a need to examine these explanations thoroughly for gender inequalities in order to ensure that equity (lack of bias) is achieved. There is also a need for higher quality studies if differences are to be attributed conclusively to bias or not.     

Is occupation missing from occupational therapy in palliative care?

Background/aim: The role of occupational therapists in palliative care is largely undocumented in Western Australia (WA). Little is known about the services occupational therapists provide or the needs of people who are dying and their carers in relation to these services. The aims of this study were as follows. First, to determine the number of occupational therapists employed and the range of services they provide in palliative care in WA. Second, with particular reference to self care, leisure, productive roles and occupations, to explore the daily experiences of people who were dying as well as their primary carers to determine the services that might be offered by occupational therapy to this population. Methods: Semi‐structured interviews were used to gather information from carers (n = 10 metro, n = 4 rural) and occupational therapists (n = 13 metro, n = 5 rural). Data were analysed qualitatively using grounded theory to develop categories. Themes were defined using the constant comparison method. Results: Four themes emerged that impacted people who were dying and their carers. These were; ongoing disengagement from usual activities with resultant occupational deprivation; disempowerment of both people who are dying and their carers within palliative care services; ‘occupation’ not being addressed adequately in palliative care and occupational therapists experience frustration with limited opportunities to contribute to the care of people who are dying. Conclusions: This paper highlights gaps in service provision in WA to people who are dying and their carers. It provides direction for occupational therapists to offer an occupation‐focussed approach to the care of this vulnerable group.