Use of resources and costs of palliative care with parenteral fluids and analgesics in the home setting for patients with end-stage cancer

Background: In 1992 a home care technology project was started in which infusion therapy in the home setting was made available for patients with end-stage cancer. Beside aspects of feasibility and quality of life the resource utilization and costs of this transition was studied.Patients and methods: We conducted a cost evaluation study, to determine the actual cost of managing patients with end- stage cancer who require parenteral administration of fluid or analgesics in the home setting. A total of 128 patients were prospectively followed, with a detailed analysis of some aspects in a sample of 24 patients.Results: The cost for each patient was found to be between $250.00 and $300.00 per day, half of which are for hospital charges, even with this active home care technology program. One-third of the costs can be attributed to primary health care activities, in particular those of the district nurses. A hypothetical control group (n = 25) was constructed based on current practice and chart review. Patients in this group would have cost around $750.00 per day. With a median treatment period of 16 days this means a saving of $8000.00 per patient.Conclusion: Our data suggest that significant savings can be obtained by implementing programs transferring palliative care technology to the home setting.     

Mitoxantrone, methotrexate, and 5-fluorouracil (MMF) in hormone-refractory advanced breast cancer

Thirty-nine patients with metastatic breast cancer who had not received prior chemotherapy for metastatic disease were treated in a phase II trial with a combination of mitoxantrone (10 mg/m2), methotrexate (40 mg/m2) and 5-fluorouracil (600 mg/m2) i.v. every 3 weeks (MMF). Thirty-three patients could be evaluated with regard to response and toxicity. Objective response was observed in 33% (3/33 complete responses, 8/33 partial responses). Dominant sites of disease were bone (16 patients), liver (7 patients), skin/lymph node (7 patients), lung (1 patient) and breast (2 patients). Responses occurred in bone (4/16), liver (3/7) and skin/lymph node (4/7). Moderate to severe alopecia (grade 3-4 WHO criteria) occurred in 3/33 (10%) patients; moderate to severe nausea and vomiting in 2/33 (6%) patients. Haematological toxicity consisted of predominantly leukopenia. Leukopenia grade 3-4 (nadir below 2000 x 10(9)/litre) occurred in 22/33 (67%) patients; thrombocytopenia grade 3-4 (nadir below 50,000 X 10(9)/litre) occurred in 3 patients (9%). The MMF regimen appears to be effective. The non-haematological toxicity compares favourably with that of the more commonly used chemotherapy regimens, but the anti-tumour activity may be less.     

The effect of six-monthly visits to the dentist on dental treatment needs

An analysis of dental data from a sample of individuals in possession of a certificate of dental fitness matched by age and sex with individuals, most of whom had not attended a dentist for some two-five years, revealed that the regular attender had fewer carious and more filled teeth and less gingival disease. There was no evidence that insisting on a six-monthly inspection had lowered the need for restorative treatment but it did reduce the need for teeth to be extracted.     

A survey of edentulous individuals in a district in Amsterdam, the Netherlands

A survey of a representative adult population of a district in Amsterdam (the Jordaan) revealed an overall edentulousness rate of 23%. Proportionally more females than males wore complete dentures, and the lower socioeconomic group was proportionally better represented in edentate group than were the middle and the higher classes. No significant differences were found in comparisons of the edentulousness rate in the Study group and other investigations in Holland and England and Wales. It is suggested that there might be a relationship between the rate of edentulousness and changes in the amount of freely disposable income.     

Assessment of the quality of life of patients with advanced and end-stage cancer or serious infections with a symptom-based or an impact-based instrument

In 1992 a project was started in which home care technology was made available to patients with cancer or serious infections. Primary care providers were trained and supported to administer parenteral drugs and fluids in the home setting. Between 1992 and 1995 we applied the Rotterdam Symptom Checklist (RSCL) and the Sickness Impact Profile (SIP) as questionnaires for quality of life (QoL) assessment in a group of 112 hospitalized patients who were prepared to receive further treatment at home. Scores on the RSCL revealed a high level of symptomatology in both the physical and the psychological dimension. Factor analysis showed a five-factor rather than a two-factor structure. The SIP showed considerable restrictions in daily living, particularly in the physical dimension. Whereas the RSCL and the SIP correlated well in the psychological and physical dimensions in advanced cancer patients, this correlation disappeared in the group of end-stage cancer patients. The data indicate that the health-related QoL of end-stage cancer patients cannot be reliably be assessed with a symptom-based instrument alone; it needs to be supplemented by other instruments, such as the SIP.     

Using patient-reported symptoms of dyspnea for screening reduced respiratory function in patients with motor neuron diseases

Journal of Neurology - Poor monitoring of respiratory function may lead to late initiation of non-invasive ventilation (NIV) in patients with motor neuron diseases (MND). Monitoring could be...     

Examiner variability in the assessment of dental restorations

A series of examiner variability studies were carried out in the assessment of restorations in adults made by extended duty ancillaries (E.D.A.s). While there were some differences between the two supervising team dentists these were smaller than those found when dentists who did not work in the project were examined. The use of indirect evaluation by examining bitewing radiographs for the presence of overhangs was no improvement over the clinical examination in terms of examiner agreement, and moreover only identified half of the restorations scheduled for replacement clinically. Using the results of these experiments, it is suggested that quality control should take into account examiner variability and consequently a 3-4% sample would be sufficient to maintain standards.