Palliative care at the end of life: comparing quality in diverse settings

There is growing awareness that pain and other symptoms are often poorly managed at the end of life. The purpose of this quality improvement project was to compare the quality of care provided to a convenience sample of 195 patients who died during a six-month period, using a retrospective chart review. Quality was defined by symptom documentation, use of diagnostic and therapeutic procedures in the final 48 hours of life, and determination of advance directives. Daily and total charges incurred by these patients were also captured. Symptom distress was common, and diagnostic and therapeutic procedures were widespread. These data suggest areas for improvement in clinical practice, in palliative care units, and in all settings where end-of-life care is provided. Also, the data can guide future research into the quality of care provided to dying persons.     

Lifestyle and quality of life in colorectal cancer survivors

Purpose  

As cancer survival rates improve, there is growing interest in the role of lifestyle in longer-term health and quality of life (QoL). This study examined the prevalence of health-related behaviours, and the associations between health behaviours and QoL, in colorectal cancer survivors.     

Health-related quality of life of breast and colorectal cancer patients undergoing active chemotherapy treatment: Patient-reported outcomes

Quality of Life Research - We sought to explore the Health-Related Quality of Life (HRQoL) of Breast Cancer (BC) and Colorectal Cancer (CRC) patients receiving active chemotherapy. A...     

Benefits of psychosocial oncology care: Improved quality of life and medical cost offset

The burden of cancer in the worldwide context continues to grow, with an increasing number of new cases and deaths each year. A significant proportion of cancer patients at all stages of the disease trajectory will suffer social, emotional and psychological distress as a result of cancer diagnosis and treatment. Psychosocial interventions have proven efficacious for helping patients and families confront the many issues that arise during this difficult time. This paper reviews the literature detailing the extent of distress in patients, the staffing needed to treat such levels of distress, and the efficacy of psychosocial treatments for cancer patients. This is followed by a summary of the literature on medical cost offset in mental health, other medical populations, and in cancer patients, which supports the notion that psychosocial interventions are not only effective, but also economical. Conclusions support taking a whole-person approach, as advocated by a growing number of health care professionals, which would not only help to treat the emotional and social aspects of living with cancer, but also provide considerable long-term cost savings to overburdened health-care systems.     

Palliative care: community nurses' perceptions of quality

OBJECTIVES: To identify community nurses' perceptions of quality care provision for patients requiring palliative care. DESIGN: Semi-structured interviews were conducted with community nurses working within the district nursing service. An adaptation of Flanagan's critical incident technique was employed to elicit factors associated with high or poor quality palliative care. Interviews were tape recorded and transcribed. Data were analysed using thematic content analysis, recurrent themes being agreed by the research team. SETTING: One community healthcare trust. SUBJECTS: 62 members of the district nursing team (grades B-H). RESULTS: Respondents recounted the context in which high quality palliative care could be provided, the actions required, and the indicators that suggested the desired level of care had been achieved. Key factors identified were: the early referral of patients to the district nursing service, family circumstances, the availability of time, the accessibility of services and equipment, and the relationship with other healthcare professionals and informal carers. There was a general view that a positive outcome had been achieved when patients retained control over their circumstances and died a peaceful death, in the place of their choice, supported by their family. CONCLUSIONS: Community nurses were able to articulate clearly the essential components of high quality care. Whilst these factors do not represent a comprehensive list, they are put forward as a useful starting point for standard setting and subsequent audit.     

Costs of treatment of colorectal cancer in different settings in Germany

The objective of this study was to evaluate the cost implications of different settings (inpatient, outpatient/day clinic, or office-based oncologists) for the administration of standard fluoropyrimidine therapies, i.e., Mayo Clinic and Arbeitsgemeinschaft Internistische Onkologie (AIO)/Ardalan regimen, and to compare the results with the cost of oral capecitabine in Germany. In total, 89 quarterly fee-listings from 26 patients provided by 5 office-based oncologists were analyzed. Physicians services, drug costs, pharmacy costs, and costs for implantable venous port systems and single-use pumps were considered. Findings were transferred to the hospital setting. A third-party payer perspective was applied. Quarterly treatment costs for the Mayo Clinic regimen varied between € 2,036 and € 10,569, and between € 1,294 and € 10,179 for the AIO/Ardalan regimen depending on the treatment setting. Projected costs for capecitabine were € 2,338. No hospitalization was considered to be necessary for capecitabine due to its oral administration route. The most expensive treatment options were the AIO/Ardalan protocol in the office-based setting and the Mayo Clinic protocol in the hospital setting. Capecitabine emerged as the cheapest option in the office-based setting. Overall, the cheapest option was the AIO/Ardalan protocol in municipal hospitals. However, municipal hospitals are unlikely to cover their costs in this situation. Substantial cost savings without incurring losses to providers may be realized if patients are transferred from the hospital setting to the office-based setting and treated with capecitabine.     

Predictors of health-related quality of life in patients with colorectal cancer

Background  

Most studies that have identified variables associated with the health-related quality of life (HRQL) of patients with colorectal cancer have been cross-sectional or included patients with other diagnoses. The objectives of this study were to identify predictors of HRQL in patients with colorectal cancer and interpret the clinical importance of the results.     

基于结直肠癌患者医生治疗质量指标评价

目的 通过单指标使用率及多指标综合得分进行医生结直肠癌治疗质量评价,为结直肠癌治疗质量的改善及医生的绩效考核提供依据。方法 收集哈尔滨市四家医院内出院时间为2011年6月-2013年6月的结直肠癌患者病历信息共1 559份;利用适合使用某评价指标的患者数为分母,适合该指标中实际使用的患者数为分子,计算某评价指标的使用率;利用潜变量模型及贝叶斯参数估计方法,整合多维评价指标,获得医生结直肠癌治疗质量的综合得分。结果 不同医生对评价指标的使用率之间存在较大的差异,术前检查生化指标、肾功能、胸部X线使用率的变异范围为3.9%~97.8%,病理报告中记录检出淋巴结数和阳性淋巴结数使用率的变异范围为95.9%~100.0%;根据潜变量模型计算的综合质量得分,医生的综合质量得分最高为xita[12]=0.405 7,即该医生的治疗质量最好;其次为xita[1]=0.3875;最低为xita[3]=-0.596 7。结论 整合多维评价指标获得综合质量得分,可以多角度全面地对医生治疗质量进行综合评价;计算单指标使用率,可以在综合评价的基础上得到医生对各评价指标的使用情况。     

Palliative care, care for life: a study of the specificity of residential palliative care

In this study, the authors describe the concept of palliative care as applied in a palliative care unit. They conducted in-depth interviews with 8 patients, 9 relatives, and 24 caregivers from two residential palliative care units. Observation of the care and of team meetings and analysis of patient records provided additional data. Palliative care involves a specific concept of care, the central focus of which is life. This is realized by two strategies. The first is to create space to live by diverting attention from the sick body, moving the illness into the background. The second is to fill the space as meaningfully as possible, so that patients can enjoy life even in the face of death. The quality of the caregiving process in palliative care is determined by a range of conditions and processes that reflect its complexity.     

A five-year prospective study of quality of life after colorectal cancer

Purpose

Long-term (??5?years) quality of life after colorectal cancer is not well described. The present study assessed quality of life (QOL) and psychological distress in colorectal cancer survivors more than 5?years to describe changes over time and antecedents of long-term outcomes.

Method

A prospective survey of a population-based sample of 763 colorectal cancer patients assessed socio-demographic variables, health behaviors, optimism, threat appraisal, and perceived social support at 5?months post-diagnosis as predictors of QOL and psychological distress 5?years post-diagnosis.

Results

QOL improved over time (P?P?>?0.07 for each measure). Risk factors for poorer QOL and/or greater psychological distress included: later stage disease, having a permanent stoma, rectal cancer, fatigue, smoking, being single, low social support, low optimism, and a more negative cancer threat appraisal. Being women, having a pet, having a private health insurance, and receiving both surgery and adjuvant treatment were protective.

Conclusion

Consistent with response shift theory, the antecedents of QOL after colorectal cancer are multifactorial and include predisposing socio-demographic, medical, and psychological variables. Psychosocial interventions that target both social support and threat appraisal may be effective for this patient group. Additional stepped-up support may be needed for people from a poorer social environment who have multiple risk factors for poorer adjustment. Health system effects require further investigation.     

Palliative care in cancer: elements for debating the guidelines

The aim of this study was to present elements for debating guidelines on palliative care programs for cancer. A literature survey searched various databases (MEDLINE, LILACS, and Cochrane Library), homepages of palliative care organizations, publications by renowned authors in this area, reference textbooks on the subject, relevant articles cited by these books, and the thesis/dissertation database of CAPES (the Brazilian Coordinating Body for Training University Level Personnel). The data were grouped into four thematic categories: symptomatic palliation, organization of services, psychosocial characteristics, and spiritual characteristics. The article then proceeds to discuss cancer as a public health problem and its impact on individuals, the concept of palliative care and its context in health care, program models and their guidelines, death and dying, and care and caregivers. The study concludes by discussing the challenges for the Brazilian National Health System in structuring end-of-life programs as a consequence of the population's aging and increasing cancer incidence.     

Down's syndrome: cost, quality and value of life

Routine prenatal screening is based on the assumption that it is reasonable for prospective parents to choose to prevent a life with Down's syndrome. This paper questions whether Down's syndrome necessarily involves the costs, limitations and suffering which are assumed in the prenatal literature, and examines the lack of evidence about the value and quality of life with Down's syndrome. Tensions between the aims of prenatal screening policies to support women's personal choices, prevent distress, and reduce the suffering and costs of disability, versus the inadvertent effects of screening which can undermine these aims, are considered. Strengths and weaknesses in medically and socially based models of research about disability, and their validity and reliability are reviewed. From exploratory qualitative research with 40 adults who have congenital conditions which are tested for prenatally, interviews with five adults with Down's syndrome are reported. Interviewees discuss their relationships, education and employment, leisure interests, hopes, aspects of themselves and of society they would like to change, and their views on prenatal screening. They show how some people with Down's syndrome live creative, rewarding and fairly independent lives, and are not inevitably non-contributing dependents. Like the other 35 interviewees, they illustrate the importance of social supports, and their problems with excluding attitudes and barriers. Much more social research with people who have congenital conditions is required, if prenatal screening policies and counselling are to be evidence based.     

Malnutrition was associated with poor quality of life in colorectal cancer: a retrospective analysis

BACKGROUND AND OBJECTIVE: Malnutrition is a significant cause of morbidity and mortality in advanced colorectal cancer, and little is known about its relationship with quality of life (QoL). We investigated the relationship between nutritional status and QoL in colorectal cancer. METHODS: We examined a case series of 58 stage III-IV colorectal cancer patients treated at Cancer Treatment Centers of America. Nutritional status was evaluated using laboratory measures of serum albumin, prealbumin, and transferrin, subjective global assessment (SGA) and bioelectrical impedance analysis. QoL was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30). RESULTS: The prevalence of malnutrition, as determined by SGA, was 41% (24 of 58). Well-nourished patients had statistically significantly better QoL scores on the global, physical, and role functions compared to malnourished patients. Interestingly, the median role function score in well-nourished patients was 41.6 points higher than the corresponding score in malnourished patients, indicating a "much better" functioning from a patient's perspective. Similarly, QoL scores on multiple symptom scales were statistically significantly better among well-nourished patients. CONCLUSION: This study suggests that malnutrition is associated with poor QoL, as measured by the QLQ-C30 in colorectal cancer.     

Palliative care: a perspective of comprehensive care for the cancer patient

The purpose of this article is to ponder on the relevance of palliative care in assisting ill patients with neoplasias in their dwellings, since palliative care aims at giving patients and their families the best attainable quality of life. Despite the great emphasis placed upon this type of care being aimed at terminal patients, many of its principles are also applicable to initial stages of the disease, used in combination with the therapeutic measures required by the specific pathologic process. Thus, throughout this article, I outline some aspects concerning ethics, philosophy, and assistance which have guided this therapeutic modality from its start until today.     

Health care cost containment in the Federal Republic of Germany

Since 1977, cost containment has been an integral part of health policy in the Federal Republic of Germany. The common goal of the cost-containment acts was to bring the growth of health care expenditures in line with growth of wages and salaries of sickness fund members. The Health Care Reform Act of 1989 is the most recent manifestation of this policy. The main features of the numerous cost-containment acts are described in this article, and the effects of cost containment on supply and demand are analyzed.     

Costs and quality of life of multiple sclerosis in Germany

This cost-of-illness analysis based on information from 2973 patients with multiple sclerosis (MS) in Germany is part of a Europe-wide study on the costs of MS. The objective was to analyze the costs and quality of life (QOL) related to the level of disease severity. Patients from six centres (office- and hospital-based physicians) and patients enrolled in a database were asked to participate in the survey; 38% answered a mail questionnaire. In addition to details on the disease (type of disease, relapses, level of functional disability), the questionnaire asked for information on all resource consumption, medical, non-medical, work absence, informal care, as well as QOL (measured as utility). The mean age of the cohort was 45 years, and 18% of patients were 65 years of age or older. Forty-seven percent of patients had mild disease (Expanded Disability Status Scale [EDSS] score 0–3), 36% had moderate disease (EDSS score 4–6.5) and 12% had severe disease (EDSS score ≥7). The mean EDSS score in the sample was 3.8 (median 4.0), with a mean utility of 0.62. Costs and utility are highly correlated with disease severity. Workforce participation decreases from 73% in very early disease to less than 10% in the very late stages, leading to a tenfold rise in productivity losses in the late stages of disease. Hospitalisation and ambulatory visits rise by a factor of 5–6 between early and late disease; investments and services increase from basically no cost to € 2700; and informal care increases by a factor of 27 for patients with an EDSS score of 7 and by a factor of 50 for patients at the very severe end of the EDSS scale (8–9). Hence, total mean costs per patient are determined essentially by the distribution of the severity levels in the sample, increasing from approximately € 18 500 at an EDSS score of 0–1 to € 70 500 at an EDSS score of 8–9. The same is true for utility, which decreases from 0.86 to 0.10 as the disease becomes severe. However, the utility loss compared to the general population is high at all levels of the disease, leading to an estimated loss of 0.2 quality-adjusted life-years per patient. Relapses are associated with a cost of approximately € 3 000 and a utility loss of 0.1 during the quarter in which they occur. Compared with a similar study performed in 1999, resource consumption, with the exception of drugs, is somewhat lower. This is most likely due to a difference in the severity distribution of the two samples and to changes in health-care consumption overall in the country, such as the introduction of diagnosis-related groups (DRGs, Fallpauschalen).