Estimation of the additional costs of chemotherapy for patients with advanced non-small cell lung cancer

BACKGROUND: A large multicentre randomised trial, the Big Lung Trial, which in part compared supportive care with or without cisplatin-based chemotherapy in patients with advanced non-small cell lung cancer, provided an opportunity to evaluate the impact on the UK National Health Service of the costs incurred with the use of chemotherapy. METHODS: This costing study was based on the retrospective collection of resource use data from hospital records. Case notes from 194 patients (98 chemotherapy + supportive care (C), 96 supportive care alone (NoC)) were inspected in eight centres recruiting the largest numbers of patients into the Big Lung Trial. Quantities were multiplied by fixed unit costs to calculate a total cost for each patient. The main outcome measure was the total cost incurred by the use of secondary care resources (including investigations, chemotherapy, radiotherapy, surgical procedures, inpatient days, outpatient attendances, and hospice inpatient care) in the two groups. RESULTS: Patients randomised to receive cisplatin-based chemotherapy had an average of 3.4 more inpatient bed days than the mean of 11.9 days for patients randomised to supportive care alone, and more outpatient attendances. NoC patients were more likely to have received palliative radiotherapy. The mean total cost for C patients was 5355 sterling pound compared with 3595 sterling pound for the NoC group, difference 760 sterling pound (95% CI 781 sterling pound to 2742 sterling pound ). When split, the cost in the C group associated with the administration of chemotherapy was 1233 sterling pound and non-chemotherapy costs were 4122 sterling pound . CONCLUSION: The additional cost of chemotherapy was not offset by a reduction in subsequent costs (as the non-chemotherapy costs were similar), so the survival benefit of about 10 weeks observed in the C group was achieved with the cost of chemotherapy administration.     

Effects of hypertonic saline,alternate day and daily rhDNase on healthcare use,costs and outcomes in children with cystic fibrosis

BACKGROUND: Daily recombinant human deoxyribonuclease (rhDNase) is an established but expensive treatment in cystic fibrosis (CF). An alternative lower cost therapy is hypertonic saline (HS), which has been shown to improve lung function in short term studies. This study compares the costs and consequences of daily rhDNase with alternate day rhDNase and HS in children with CF. METHODS: In an open, randomised, crossover trial, 48 children with CF were allocated consecutively to 12 weeks of once daily 2.5 mg rhDNase, alternate day 2.5 mg rhDNase, and twice daily 5 ml 7% HS. Outcomes assessed included forced expiratory volume in 1 second (FEV(1)) and quality of life. All healthcare resource use was prospectively recorded for each patient. Unit costs were collected and combined with resource use data to give the total health service costs per patient for each treatment strategy. RESULTS: Daily rhDNase resulted in a significantly greater increase in mean FEV(1) than HS (8%, 95% CI 2 to 14) but there was no significant difference in FEV(1) between daily and alternate day rhDNase (2%, 95% CI -4 to 9). Over a 12 week period the mean incremental costs of daily rhDNase compared with HS was pound 1409 (95% CI pound 440 to pound 2318), and the incremental cost of using daily rather than alternate day rhDNase was pound 513 (95% CI - pound 546 to pound 1510). CONCLUSIONS: Daily rhDNase is more effective than 5 ml 7% HS twice daily delivered by jet nebuliser, but significantly increases healthcare costs. Administering rhDNase on an alternate day rather than a daily basis is as effective, with a potential for cost savings.     

Randomised controlled trial of the effectiveness of a respiratory health worker in reducing impairment, disability, and handicap due to chronic airflow limitation.

A randomised controlled trial was undertaken to determine whether a respiratory health worker was effective in reducing the respiratory impairment, disability, and handicap experienced by patients with chronic airflow limitation attending a respiratory outpatient department. The 152 adults (aged 30-75 years) who participated had a prebronchodilator forced expiratory volume in one second (FEV1) below 60% predicted and no other disease. They were randomised to receive the care of a respiratory health worker or the normal services provided by the outpatient department. The respiratory health worker provided health education and symptom and treatment monitoring in liaison with primary care services. After one year there was little difference between the two groups in spirometric values (FEV1 and forced vital capacity before and after salbutamol 200 micrograms), disability (six minute walking distance and paced step test), and handicap (sickness impact profile, hospital anxiety and depression scale). Patients not looked after by the respiratory health worker were more likely to die (relative risk 2.9 (95% confidence limits 0.8, 10.2); when age and FEV1 were controlled for this risk increased to 5.5 (95% confidence limits 1.2, 24.5). Patients looked after by the respiratory health worker attended their general practitioner more frequently and were prescribed a greater range of drugs. This is the third study to have found limited measurable benefit in terms of morbidity from the intervention of a respiratory health worker. This may be due to the ability of such workers to keep frail patients alive.     

Outpatient management of childhood asthma by paediatrician or asthma nurse: randomised controlled study with one year follow up

BACKGROUND: Until now, care provided by asthma nurses has been additional to care provided by paediatricians. A study was undertaken to compare nurse led outpatient management of childhood asthma with follow up by a paediatrician. METHODS: Seventy four children referred because of insufficient control of persistent asthma were randomly allocated to 1 year follow up by a paediatrician or asthma nurse. The main outcome measure was the percentage of symptom-free days. Additional outcome measures were airway hyperresponsiveness, lung function, daily dose of inhaled corticosteroids (ICS), number of exacerbations, number of additional visits to the general practitioner, absence from school, functional health status, and disease specific quality of life. RESULTS: There were no significant differences at the end of the 1 year study period between the two treatment groups in percentage of symptom-free days (mean difference 2.5%; 95% CI -8.8 to 13.8), airway hyperresponsiveness (log10 PD20 0.06; -0.19 to 0.32), functional health status (10.1; -0.3 to 19.8), disease specific quality of life of patients (0.08; -0.9 to 0.7), and disease specific quality of life of caregivers (0.09; -0.2 to 0.3), nor in any other outcome parameters. Most outcome parameters improved considerably over the 1 year study period. These improvements were achieved although the daily dose of ICS was reduced by a mean of 26% compared with the dose received by children at referral. All parents were satisfied with the asthma care received. CONCLUSIONS: After initial assessment in a multidisciplinary clinic, childhood asthma can be successfully managed by an asthma nurse in close cooperation with a paediatrician. During close follow up by paediatrician or asthma nurse, asthma control improved despite a reduction in ICS dose.     

MASTERPLAN: study of the role of nurse practitioners in a multifactorial intervention to reduce cardiovascular risk in chronic kidney disease patients

Moderate to severe chronic kidney disease (CKD) is associated with increased cardiovascular risk. Usually nephrologists are primarily responsible for the care of CKD patients. However, in many cases treatment goals, as formulated in guidelines, are not met. The addition of a nurse practitioner might improve the quality of care. The Multifactorial Approach and Superior Treatment Efficacy in Renal Patients with the Aid of Nurse Practitioners (MASTERPLAN) study is a randomized controlled multicenter trial, aimed at investigating whether a multifactorial approach in patients with moderate to severe CKD (stage 3 and 4) to achieving treatment goals using both a polydrug strategy and lifestyle treatment either with or without the addition of a nurse practitioner will reduce cardiovascular risk and slow the decline of kidney function. Patients (n=793) have been randomized to nurse care or physician care. In the nurse-care arm of the study, nurse practitioners use flowcharts to address risk factors requiring drug and/or lifestyle modification. They have been trained to coach patients by motivational interviewing with the aim of improving patient self-management. At baseline, both treatment groups show equal distributions with regard to key variables in the study. Moreover, in only 1 patient were all risk factors within the limits as defined in various guidelines, which underscores the relevance of our initiative.     

The role of the nurse specialist in the care of patients with diabetic foot ulcers

Successful management of patients with diabetic foot ulcers requires a multidisciplinary approach in which team members use their unique skills to achieve wound healing and prevent wound recurrence. This article describes the role of the nurse specialist and defines the roles of the baccalaureate-prepared wound care nurse specialist and the master's-prepared wound care nurse specialist. A case presentation highlights the role of the nurse practitioner in the outpatient wound clinic setting.     

Creation of a treatment protocol for nurse‐led management of anal fissure

Objective To create a protocol for colorectal nurse‐led management of patients with idiopathic anal fissure. Patients and methods The outcome of 135 patients with anal fissure presenting over a 3‐year period to one (half time equivalent) Colorectal Surgeon in a District General Hospital, in whom initial management was centred on the use of 0.2% glyceryl trinitrate (GTN) was audited. Patients unavailable for complete follow‐up, those with fissures of a specific aetiology and those in whom GTN was contra‐indicated were excluded. 44% of patients were initially seen by a suitably trained and supported Nurse Practitioner (NP). Results Succes rates for fissure healing with 0.2% GTN were similar to those reported in other studies. There were no differences in outcome between those patients managed by the NP and those managed by the Consultant/Specialist Registrar. As a result of the audit, a treatment protocol for use by Nurse Practitioners (as well as surgical staff), a patient information leaflet, and policy documents relating to NP management of anal fissures have been developed. Conclusion It has been possible to construct a treatment protocol allowing rational management of patients with anal fissure by suitably trained and supported nurse specialists within their own clinic. This may be adapted to encompass future treatment developments.     

Nurse or surgeon follow‐up after rectal cancer: a randomized trial

Aim Follow‐up programmes consume a large amount of resources with less time for the surgeon to take on new patients. The aim of this randomized study was to compare patient satisfaction, resource utilization and medical safety in patients curatively operated for rectal cancer who were followed up by either a surgeon or a nurse. Method The nurse was trained by the colorectal surgeon before the start of the study. Curatively operated patients were asked to give their consent to participate. Randomization was performed by the stoma therapist. After each consultation, the patient completed a questionnaire. Results A total of 110 patients (58 men) age 68 (range 41–87) years were included between 2002 and 2005. Only three patients refused participation. Patient satisfaction was high according to the Visual Analogue Scale (VAS): 9.4 for the surgeon and 9.5 for the nurse (NS). Consultation time was longer for the nurse: 24 vs 15 min (P = 0.001), with more blood samples being taken (29%vs 7%, P = 0.002). Radiological investigations exceeding the routine were made in 11%vs 4% (NS) cases. Surgical assistance was needed in 13 of 182 consultations with the nurse [mean 6 (1–15) min, total 75 min]. Distant metastases were detected in seven patients in the surgeon group and eight in the nurse group (P = 0.953). Total costs of follow‐up did not differ. Conclusion Patient satisfaction was equally high for the specialist nurse as for the colorectal surgeon. On only a few occasions was surgical assistance necessary and total costs for the follow‐up showed no difference. Medical safety appeared uncompromised. Nurse‐led follow‐up is encouraged.     

Clinical and economic choices in the treatment of respiratory infections in cystic fibrosis: Comparing hospital and home care

BACKGROUND: A cost-effectiveness evaluation comparing home-based and hospital-based treatment with intravenous antibiotics for respiratory exacerbations in adults with cystic fibrosis (CF) has not been previously undertaken. METHODS: The study was conducted in a UK adult CF centre from a health service perspective. Clinical outcome and resource use data were obtained from a retrospective one-year study and combined with unit cost data in an incremental economic analysis. The primary outcome measure was percentage change in FEV(1); "effectiveness" was defined as maintenance of baseline average FEV(1) over the one-year study period. RESULTS: 116 patients received 454 courses of intravenous antibiotics. At the end of 1 year, there had been a mean percentage decline in FEV(1) compared with baseline average for home-treated patients but an improvement for hospital-treated patients (Tukey's HSD mean difference 10.1%, 95% CI 2.9 to 17.2, p = 0.003). Treatment was deemed "effective" in more hospital (58.8%) than home (42.6%) patients. The cost of hospital treatment was higher than home treatment (mean difference 9,005 pounds, 95% CI 3,507 to 14,700, p<0.001). The mean ICER was 46,098 pounds (2.5th and 97.5th percentiles -374,044 and 362,472). CONCLUSIONS: Hospital treatment was more effective but more expensive than home treatment. Potential methods to improve outcome at home should be considered but these may have resource implications.     

Outcome analysis and patient satisfaction following octant transrectal ultrasound-guided prostate biopsy: a prospective study comparing consultant urologist, specialist registrar and nurse practitioner in urology

PURPOSE: To determine whether transrectal ultrasound-guided biopsy of the prostate is equally reliable and acceptable if performed by urology nurse practitioner or urologist. SCOPE: Octant biopsies were taken by each operator (consultant urologist n=2, urology specialist registrar n=1 and urology nurse practitioner n=2) from 50 consecutive unselected patients and demographics and cancer detection rate were compared between the groups. A postal survey was performed following nurse practitioner biopsy to assess patient satisfaction and acceptance of nurse practitioner biopsy. CONCLUSION: Transrectal ultrasound-biopsy of prostate whether performed by nurse practitioner or urologist is equally reliable if adequate training is provided. Patients are happy to undergo prostate biopsy and receive information about the diagnosis from an appropriately trained prostate cancer nurse specialist.     

Acute care nurse practitioners in transplantation: adding value to your program

Nurse practitioners are nurses who are prepared at the graduate level. They exercise autonomy in clinical decision making, perform physical examinations and obtain health histories, diagnose and treat a variety of illnesses, provide education and counseling to patients, perform procedures, and ultimately provide cost-effective care. The role of the nurse practitioner evolved in the 1960s, when nurse practitioners filled a void in response to the nationwide shortage of physicians. Today, nurse practitioners specialize both by degree and by certification examination. There are several types of nurse practitioners, including acute care, adult, family practice, and pediatric. The incorporation of acute care nurse practitioners (ACNPs) in transplant programs is an emerging field and varies across the country from center to center. The goals of this article are to (1) identify implications for ACNPs in transplant, (2) discuss the value of using ACNPs in practice, and (3) explore billing and regulatory aspects of ACNPs in transplant programs.     

Domiciliary non-invasive ventilation for recurrent acidotic exacerbations of COPD: an economic analysis

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) pose a significant burden to healthcare providers with frequent exacerbations necessitating hospital admission. Randomised controlled data exist supporting the use of acute non-invasive ventilation (NIV) in patients with exacerbations of COPD with mild to moderate acidosis. The use of NIV is also described in chronic stable COPD, with evidence suggesting a reduction in hospital admissions and general practitioner care. We present economic data on the impact of domiciliary NIV on the need for admission to hospital and its attendant costs. METHODS: A cost and consequences analysis of domiciliary NIV based on a before and after case note audit was performed in patients with recurrent acidotic exacerbations of COPD who tolerated and responded well to NIV. The primary outcome measure was the total cost incurred per patient per year from the perspective of the acute hospital. Effectiveness outcomes were total days in hospital and in intensive care. RESULTS: Thirteen patients were identified. Provision of a home NIV service resulted in a mean (95% CI) saving of pound sterling 8254 (pound sterling 4013 to pound sterling 12,495) (Euro 11,720; Euro 5698 to Euro 17,743) per patient per year. Total days in hospital fell from a mean (SD) of 78 (51) to 25 (25) (p=0.004), number of admissions from 5 (3) to 2 (2) (p=0.007), and ICU days fell from a total of 25 to 4 (p=0.24). Outpatient visits fell from a mean of 5 (3) to 4 (2) (p=0.14). CONCLUSIONS: This study suggests that domiciliary NIV for a highly selected group of COPD patients with recurrent admissions requiring NIV is effective at reducing admissions and minimises costs from the perspective of the acute hospital. Such evidence is important in obtaining financial support for providing such a service.     

Rationale and design of the MASTERPLAN study: Multifactorial approach and superior treatment efficacy in renal patients with the aid of nurse practitioners

BACKGROUND: Chronic kidney disease (CKD) is an established risk factor for cardiovascular disease (CVD). In addition, patients with renal disease are exposed to a myriad of risk factors that increase their risk even further. The treatment of risk factors in these patients is paramount to reducing cardiovascular risk and for attenuating renal failure progression. It is well known that lifestyle interventions are difficult, and that medical treatment targets are seldom met. A multifactorial approach with the aid of nurse practitioners has shown to be beneficial for achieving treatment goals and reducing events in patients with diabetes mellitus and with heart failure. We propose that this will also hold for the CKD population. TRIAL DESIGN: A multicenter randomized clinical trial will be performed to study whether intensive medical care delivered by a nurse practitioner and a nephrologist will reduce cardiovascular risk compared to care provided by the nephrologist alone. The acronym MASTERPLAN describes the study: Multifactorial approach and superior treatment efficacy in renal patients with the aid of nurse practitioners. Eight hundred patients will be randomized to physician care or nurse practitioner support. For all patients the same set of guidelines and treatment goals will apply. Both groups will receive treatment according to current guidelines and have access to specific cardioprotective medication. Nurse practitioners will intensify therapy by promoting lifestyle intervention, and meticulous implementation of relevant guidelines. Patients will be followed-up for 5 yrs after baseline. Primary endpoints are all-cause mortality, cardiovascular morbidity and cardiovascular mortality.     

Primary total hip replacement follow-up study

We carried out a postal survey of randomly selected orthopaedic surgeons in the North East of England, enquiring about outpatient follow-up patterns after primary total hip replacement. The aim was to compare and contrast the number and timing of appointments as well as assess the involvement of orthopaedic nurse practitioners (ONP). The number of visits in the first post-operative year varied between two and five. The average duration before the first, second and third follow-up was 5 weeks, 4 months and 13 months respectively. Ninety-three percent of the consultants follow their patients indefinitely. For the patients who are followed for life, 71% are seen in the ONP clinic and 29% in the consultant clinic. Fifty percent of the consultants sub-specialising in lower limb arthroplasty follow their patients up to 1 year, after which the care is taken over by an orthopaedic nurse practitioner, compared to 70% of the general orthopaedic consultants. With increasing number of total hip replacement operations being performed, guidelines and consistency would be desirable in order to make the follow-up of patients efficient in terms of the time and cost.     

Carotid endarterectomy then and now: outcome and cost-effectiveness of modern practice

BACKGROUND: During the past decade, our practice of performing carotid endarterectomy (CEA) has changed dramatically, most notably by an abrupt shift from routine to selective preoperative angiography, reliance on defined care plans with full-time nurse practitioner oversight, and increasing reliance on eversion endarterectomy and cervical block anesthesia. This study was designed to determine whether these shifts in policy have been associated with lower costs without sacrificing clinical outcome. METHODS: All patients undergoing CEA from July 1993 to December 2000 were identified, and inpatient and outpatient charts were reviewed. Cost data were obtained from the central hospital accounting system and converted to 2001 dollars. Thirty-day outcomes and costs were quantified each year and compared between each of 2 temporally well-defined groups: those undergoing "routine" versus "selective" angiography and those cared for before and after defined patient care protocols were instituted. RESULTS: A total of 1168 CEAs were analyzed. Thirty-day combined stroke and death rate was 3.1%, and no trends or significant differences over time were seen. From 1993 to 2000 the cost of CEA fell from $9302 to $6216 (P<.0002), and length of stay was reduced 1 full day (P=.005). Institution of "selective" angiography was associated with an immediate cost savings of approximately $2000 per case (P<.0001), and nurse practitioner oversight along with institution of defined clinical protocols with a $530 (P<.05) decline in nonoperating room-related costs. CONCLUSIONS: Changes in policy from routine to selective angiography, reliance on defined postoperative care pathways, eversion endarterectomy, and cervical block anesthesia have been associated with significant cost savings, with no compromise in clinical outcome at our institution.     

Plasma volume changes associated with two hydroxyethyl starch colloids following acute hypovolaemia in volunteers

This randomised double blind prospective study compared the effective intravascular volume expansion and maintenance, with two types of starches following induced haemorrhagic hypovolaemia. Twenty healthy male volunteers aged between 18 and 65 year were bled 10% of their total blood volume in fully monitored conditions and under the supervision of a trained specialist doctor and research nurse. The lost blood volume was replaced using one of the starch solutions. Effective intravascular volume expansion was monitored hourly using the (51)Cr radio-labelled red blood cell dilution technique, we compared the effects of two hydroxyethyl starch colloid preparations, one a high molecular weight and the other a low molecular weight preparation, on the plasma volume changes over time. The large molecular weight starch (Hextend) provided a less well-sustained volume expansion effect than the smaller one (Voluven)     

Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme

BACKGROUND: Pulmonary rehabilitation programmes improve the health of patients disabled by lung disease but their cost effectiveness is unproved. We undertook a cost/utility analysis in conjunction with a randomised controlled clinical trial of pulmonary rehabilitation versus standard care. METHODS: Two hundred patients, mainly with chronic obstructive pulmonary disease, were randomly assigned to either an 18 visit, 6 week rehabilitation programme or standard medical management. The difference between the mean cost of 12 months of care for patients in the rehabilitation and control groups (incremental cost) and the difference between the two groups in quality adjusted life years (QALYs) gained (incremental utility) were determined. The ratio between incremental cost and utility (incremental cost/utility ratio) was calculated. RESULTS: Each rehabilitation programme for up to 20 patients cost pound 12,120. The mean incremental cost of adding rehabilitation to standard care was pound -152 (95% CI -881 to 577) per patient, p=NS. The incremental utility of adding rehabilitation was 0.030 (95% CI 0.002 to 0.058) QALYs per patient, p=0.03. The point estimate of the incremental cost/utility ratio was therefore negative. The bootstrapping technique was used to model the distribution of cost/utility estimates possible from the data. A high likelihood of generating QALYs at negative or relatively low cost was indicated. The probability of the cost per QALY generated being below pound 0 was 0.64. CONCLUSIONS: This outpatient pulmonary rehabilitation programme produces cost per QALY ratios within bounds considered to be cost effective and is likely to result in financial benefits to the health service.     

Impact of a nurse practitioner-assisted preoperative assessment program on quality

BACKGROUND: The anesthesia manpower shortage in the last few years in the US has limited many hospital pediatric surgical services. We sought to meet an increasing surgical caseload, while providing safe, timely and patient-centered care by instituting a nurse practitioner-assisted preoperative evaluation (NPAPE) program. The strategic goal of this program was to shift anesthesiologists from the preanesthesia clinic to the operating room (OR), while maintaining the quality of preoperative care. Our study sought to evaluate the quality of the NPAPE program. METHODS: One thousand five hundred and nine children aged 1 month-18 years, 463 parents, 25 anesthesiologists and 20 preoperative clinic nurses were studied. Indicators of quality were incidence of respiratory complications (apnea/hypopnea, laryngospasm, bronchospasm, and supplemental oxygen use in postanesthesia care unit), patient preoperative preparation time and parent and staff (anesthesiologists and preoperative clinic nurse) satisfaction. These indicators were recorded for 1 week every 3 months for 1 year. The first week (baseline) was an anesthesiologist-only preoperative assessment (three anesthesiologists performing approximately 120 evaluations per day). The subsequent four data collection weeks at 3, 6, 9, and 12 months were nurse practitioner (NP)-aided preoperative assessments (one anesthesiologist with six NPs performing approximately 120 evaluations per day). RESULTS: The incidence of respiratory complications, patient preoperative preparation time, and levels of parental satisfaction did not differ significantly between anesthesiologist-only and NP-aided assessments. However, anesthesiologist and preoperative clinic nurse satisfaction increased significantly postimplementation of the program. CONCLUSIONS: Our study revealed that within a year of its implementation, the NPAPE program maintained patient safety, timeliness, and a high level of parent satisfaction as well as increased staff satisfaction, while shifting two anesthesiologists to the OR. A NP-assisted preoperative evaluation program can offer operational advantages without compromising care.     

Territorial emergency: physician or nurse?

This study was conceived to assess a pattern of Italian prehospital critical care team, especially referring to the advanced life support (ALS) rescue team. Function and management of ALS rescue team and its relationship with other members of the emergency medical system (intra hospital physician, basic life support team, general practitioner) are analysed; stress is laidon the knowledge, the background and the complexity of the emergency procedures. The benefit of 2 major prehospital options of the ALS team, composed by 1 physician and 1 nurse staffing or by 2 trained nurse staffing, is discussed; the importance of educational programs for ambulance teams, a comparison of cost-effectiveness and the number of emergency teams availability is underlined. The authors, finally emphasize the advantages of a territorial coverage with an integrated system of ambulances staffed with specially trained rescuers or technicians, ambulances with rescuers and nurses, and ALS teams staffed with emergency physician and 1 nurse (integrated or not with ambulances with 2 trained nurses), being perfectly capable to face up any background in pre-hospital emergency medicine setting.