The relationship between general practitioners, hospital consultants and community nurses when caring for people in the last year of their lives.

The general practitioners, hospital consultants and community nurses who had cared for a random sample of people who died were asked about their relationships with the other professional groups and for their views and experiences of specialist domiciliary terminal care services. Many of the general practitioners and the nurses were critical of hospital communication over discharge. The most frequent criticism made by community nurses of general practitioners was that they did not ask for nursing help early enough for people who were dying. This may be because many general practitioners regarded the community nursing services as overstretched. General practitioners were rather less enthusiastic than the other two professional groups about specialist medical or nursing domiciliary terminal care services. They were, however, more convinced of the helpfulness of these services if they had some experience of them.     

Expenditures on health care in the last year of life.

18-26% of public expenditure on health care is devoted to care of patients in their last year of life. 60% of this expenditure is on patients in somatic nursing homes. The figures do not tell directly whether too much or too little money in Norwegian health care is spent on people in the end stage of life. In order to answer this question, one must look at the quality of terminal care and assess the share of patients having a reasonable benefit of the care they receive.     

The role of the cranial CT scan in municipal hospitals.

House officer predictions of lesions and CT scan diagnosis were compared for accuracy in a municipal and community hospital setting. The input of the CT scan into initial patient care was also evaluated. In the municipal hospital, house officers made fewer most-correct diagnoses, and the CT scan more often established the correct diagnosis (P less than .03) and altered therapy (P less than .02). Results suggest that municipal hospital patients could benefit from accessible CT scanners.     

Medicare beneficiaries' costs of care in the last year of life.

This paper profiles Medicare beneficiaries' costs for care in the last year of life. About one-quarter of Medicare outlays are for the last year of life, unchanged from twenty years ago. Costs reflect care for multiple severe illnesses typically present near death. Thirty-eight percent of beneficiaries have some nursing home stay in the year of their death; hospice is now used by half of Medicare cancer decedents and 19 percent of Medicare decedents overall. African Americans have much higher end-of-life costs than others have, an unexpected finding in light of their generally lower health care spending.     

500,000 lives saved each year. ORT 10 years after

Oral rehydration therapy (ORT) was hailed 10 years ago as potentially the most significant medical advance of the century. ORT is a simple and inexpensive means of treating diarrheal dehydration, which killed approximately 5 million children each year in the late 1970s. Today 25% of the world's children have access to ORT, and it is estimated that every year it saves 500,000 lives. Where ORT is not widely available, diarrheal dehydration remains the leading killer of children. It is still responsible for 25% of the 250,000 worldwide child deaths each week. Because there have been problems with acceptance of the ORT formula of salt, sugar, and water, researchers have been experimenting with cereal-based oral rehydration formulas that are much like traditional home remedies for diarrhea. In addition to relieving dehydration, these cereal-based formulas lessen severity and duration of diarrheal illness. Critics, however, claim that they fail to provide a child with sufficient calories, and call for a combination of ORT with early feeding--4-8 hours after completion of rehydration. Even with growing evidence of the benefits of early feeding, the practice of withholding food from children with diarrhea persists in the developing world and in the U.S. Problems in developing countries are greater, but each year 14 of every 1,000 American infants are hospitalized because of acute diarrhea. The major hurdle that ORT faces in the U.S. is that it is a simple form of therapy attempting to displace a higher technology. As long the U.S. health care system serves as a model for developing countries, distrust of ORT by American doctors will hamper efforts to spread ORT in the developing world.     

Governing people's lives. Strategies for improving the health of the nations in England, Denmark, Norway and Sweden.

Public health strategies reflect governments' wish to make people's lives longer and healthier. This can either be achieved by influencing the frames of people's lives and activities or the way they behave, i.e. to try to 'conduct their conduct'. In this paper the motivations for and methods of four national public health strategies are analysed. They are the English, the Norwegian, the Danish and the Swedish. Four questions are addressed: i) how is the governing activities aimed at improving the health of the population justified; ii) which issues are defined as problems; iii) which causes of the problems are identified; and iv) which governing techniques are suggested to solve the problems. The English and Danish programmes focus on mortality while the others give high priority to non-lethal diseases and conditions. The Danish programme mainly aims at making people conduct themselves in a more healthy way, i.e. change their behaviour, often guided by health professionals. The Norwegian paper has empowerment as its central strategy. The strategy is based on the assumption that if people get more power over their own lives they will become more healthy and behave in a more healthy way. The Swedish emphasis is on changing people's living conditions and much less is said about the role of the individual. The English programme launches a national contract where individuals and authorities should work both to change people's behaviour and their living conditions. All strategies deal with the increasing social inequality in health, the English and Swedish strategies more than the others. There does not seem to be a specific Nordic model in this field of welfare state politics.     

The quality of the last year of life of older persons

Researchers have begun devising measures of the quality of the entire last year of life of older community residents. Investigators in Philadelphia surveyed 150 living elderly on features of their quality of life, and matched the responses with 200 retrospective estimates obtained from relatives of decedents who had resided in the community much of the year. Most indicators showed declines for the decreased over their final year when compared with persons still alive; 82 percent of the decedents, however, experienced a majority of "positive-quality" months in their last year. Debates on the costs and ethical aspects of treatment and care need to take account of "positive" and "negative" aspects of quality of life reflecting individuals' multifaceted existence.     

Risk indicators for hospitalization during the last year of life.

OBJECTIVE. High levels of hospital expenditures for older people during their last year of life are widely documented. However, evidence of the association between prospectively measured indicators and subsequent hospitalization is sparse. This article investigates the pattern of hospitalization for a sample of Medicare enrollees during their last year of life. DATA SOURCES. Data from the Longitudinal Study of Aging, a national study of persons age 70 and older, are used. Only data on decedents are used. STUDY DESIGN. We determine individual characteristics (including functional status, evidence of disease, living arrangement, and prior hospitalization) shortly before the last year of life. A distinction is made between terminal and nonterminal admissions. National estimates and regression analyses using survey weights are conducted. PRINCIPAL FINDINGS. The likelihood of any use is high regardless of age, functional status, or the presence of major diseases. Although only a few indicators are associated with having a terminal stay, a number of indicators are associated with nonterminal use. Nonterminal stays and total nights hospitalized are positively associated with prior evidence of disease, prior hospitalization, and age, although the probability of nonterminal use decreases with age for persons over 82 years old. The relationship between use and functional status depends on whether persons lived alone, were institutionalized, or had private health insurance. CONCLUSIONS. This study demonstrates that while it is difficult to predict who will be admitted to the hospital at the time of death, a number of characteristics existing before the last year of life are associated with nonterminal hospitalization and total nights hospitalized during the last year of life.     

The 100,000 lives campaign: crystallizing standards of care for hospitals

The 100,000 Lives Campaign has the attention of U.S. hospitals, professional groups, and the media. Its aim has been endorsed, and its planks are being implemented, by more than 2,300 diverse hospitals in every state. We posit that the six planks of the campaign have become national standards of care and propose four theories of liability for hospitals that ignore the campaign or fail to implement its planks. As a result of the campaign, hospitals and their boards now face a legal incentive to reduce needless deaths through six specific interventions.     

The role of hospital infection control in the quality system of hospitals.

Like other highly specialized fields, quality systems have their own vocabulary which we must be familiar with; it has been internationally standardized. This standard should be adhered to in order to avoid unnecessary ambiguities and confusion, and to facilitate exchange of information between disciplines. We, in the infection control field, are quality pioneers in hospitals. We have, within our discipline, created quality systems and practised quality surveillance for decades. This must be recognized. Medical quality audits intended for comparisons between hospitals, services and wards require measurable quality criteria and comparable measures for the presence of all relevant patient-related risk factors. To specify quality within our field we need much more detailed information on the effect and cost of infection control practices, as well as the costs of the infections we intend to control. To progress one step further, patients or their representatives, politicians, need to express what monetary value should be put on health, namely freedom from infection and its consequences.     

The role of hospitals in primary health care: the managerial implications.

This paper is the result of a discussion group developed by IHF for the purpose of preparing material for submission to WHO. The paper extrapolates and expands on the proceedings of the discussion group. The author argues that the ideals of community care will remain simply theoretical unless senior management and the corresponding resources are allocated to it.