Lay carers' satisfaction with community palliative care: results of a postal survey. South Tyneside MAAG Palliative Care Study Group

This paper reports the substantive findings of a study that examined the feasibility of using postal questionnaires to assess the satisfaction of lay caregivers with the care received in the community by those dying of cancer. The focus of the analysis was the quality of information provided by health professionals, health services used in the final year of the dying person's life and the lay carer's views about the quality of these services. The study was a retrospective survey of lay carers identified from death certificates over a 9-month period. Of the 355 people contacted, 156 completed the questionnaires, a 44% response rate. The results of the survey indicate that information provision was deemed unsatisfactory by a large proportion of respondents, and that dissatisfaction with care received from hospital, the district nursing service and the general practitioner was common. Levels of satisfaction with care were clearly related to a range of service factors. Our survey also highlighted clear differences in the perceived quality of specialist and generic services for those dying of cancer. A comparison of the findings from this postal study with those reported in earlier retrospective interview surveys of lay carers suggests that the use of the postal questionnaire is a valid and cost-effective approach for assessing quality of care. The data provide baseline information against which improvements in the quality of care can be measured.     

Appropriate disclosure of a diagnosis of dementia: identifying the key behaviours of 'best practice'

Background

It has been argued that quality improvements that result from user charges reduce their negative impact on utilization especially of the poor. In Uganda, because there was no concrete evidence for improvements in quality of care following the introduction of user charges, the government abolished user fees in all public health units on 1^st March 2001. This gave us the opportunity to prospectively study how different aspects of quality of care change, as a country changes its health financing options from user charges to free services, in a developing country setting. The outcome of the study may then provide insights into policy actions to maintain quality of care following removal of user fees.

Methods

A population cohort and representative health facilities were studied longitudinally over 3 years after the abolition of user fees. Quantitative and qualitative methods were used to obtain data. Parameters evaluated in relation to quality of care included availability of drugs and supplies and; health worker variables.

Results

Different quality variables assessed showed that interventions that were put in place were able to maintain, or improve the technical quality of services. There were significant increases in utilization of services, average drug quantities and stock out days improved, and communities reported health workers to be hardworking, good and dedicated to their work to mention but a few. Communities were more appreciative of the services, though expectations were lower. However, health workers felt they were not adequately motivated given the increased workload.

Conclusion

The levels of technical quality of care attained in a system with user fees can be maintained, or even improved without the fees through adoption of basic, sustainable system modifications that are within the reach of developing countries. However, a trade-off between residual perceptions of reduced service quality, and the welfare gains from removal of user fees should guide such a policy change.     

Lifestyle interventions to prevent osteoporotic fractures: a systematic review

The purpose of this study was to evaluate the clinical effectiveness of lifestyle interventions for preventing osteoporotic fractures in people at high risk. Data sources were electronic bibliographic databases, reference lists of systematic reviews, meta-analyses and included trials, registers of trials and conference databases. There was no language restriction. Study selection comprised randomized controlled trials (RCTs), with appropriate comparator groups and at least 8 weeks of follow-up, reporting a fracture endpoint. Two reviewers independently abstracted data on the population, interventions evaluated, trial quality and outcomes of interest: fractures at any site, spinal, hip and wrist fractures. Six RCTs, enrolling over 1,656 participants, met the inclusion criteria. Overall, trials were of uncertain quality. We categorized trials by type of intervention: exercise ( n =3), multifactorial interventions (environmental modifications, exercise programs and review of medical conditions, medication and aids) ( n =2) and exposure to sunlight ( n =1), and used random effects meta-analyses to combine data within these categories. Exercise was associated with a non-significantly lower risk of spinal fractures (RR=0.52, 95% CI=0.17 to 1.60). Multifactorial interventions were associated with a lower risk of hip fracture, which was of borderline statistical significance (RR=0.37, 95% CI=0.13 to 1.03). Exposure to sunlight was associated with a non-significantly lower risk of hip fracture (RR=0.17, 95% CI=0.02 to 1.35). While withdrawals from treatment were poorly reported, there was no indication of adverse effects of treatment. Multifactorial interventions may reduce the risk of hip fractures when delivered by residential care staff and health visitors. More RCTs of higher quality, recording fractures at all sites susceptible to osteoporotic fractures, are necessary to evaluate exercise interventions, exposure to sunlight and the place of lifestyle alongside pharmacological interventions.     

Novel self-assembling PEG-p-(CL-co-TMC) polymeric micelles as safe and effective delivery system for Paclitaxel

Paclitaxel (PTX) is an effective anti-cancer drug currently used to treat a wide variety of cancers. Unfortunately, nonaqueous vehicle containing Cremophor^® EL is associated with serious clinical side effects. This work aimed to evaluate the ability of polymeric micelles to (i) solubilize PTX without Cremophor^® EL and to be used as a (ii) safe and (iii) effective delivery system for PTX. Hence, we developed novel self-assembling poly(ethyleneglycol)₇₅₀-block-poly(ε-caprolactone-co-trimethylenecarbonate) (PEG-p-(CL-co-TMC)) polymeric micelles which form micelles spontaneously in aqueous solution. The solubility of PTX increased up to three orders of magnitude. The PTX-loaded micelles showed a slow release of PTX with no burst effect. The HeLa cells viability assessed by the MTT test was lower for PTX-loaded micelles than for Taxol^® (IC₅₀ 10.6 vs. 17.6 μg/ml). When solubilized in micelles, PTX induced apoptosis comparable with Taxol^®. The maximum tolerated doses (MTD) of PTX-loaded micelles and Taxol^® in mice were 80 mg/kg and 13.5 mg/kg, respectively, after intraperitoneal administration; and 45 mg/kg and 13.5 mg/kg, respectively, after intravenous administration. Similar anti-tumor efficacy of PTX-loaded micelles and Taxol^® was observed at the dose of 13.5 mg/kg on TLT-tumor-bearing mice, while the body weight loss was only observed in Taxol^® group. However, as higher dose was tolerated (80 mg/kg – IP), a higher growth delay was induced with PTX-loaded micelles. These results demonstrated that PTX-loaded self-assembling micelles present a similar anti-tumor efficacy as Taxol^®, but significantly reduced the toxicity allowing the increase in the dose for better therapeutic response.