Patient Duration Research Articles

Cost analysis of palliative care for terminally ill cancer patients in the UK after switching from weak to strong opioids. Palliative Care Advisory Committee.

We constructed a UK-based decision model of palliative care for terminally ill cancer patients who were switched from a weak to a strong opioid so that the expected direct healthcare costs in the UK could be estimated from the time a patient commenced a strong opioid until death. Decision analysis techniques were used to estimate the expected total direct healthcare cost per patient, stratified according to the first choice of strong opioid. The model was based on prescription data on 1975 terminally ill cancer patients who were on the Intercontinental Medical Statistics database, Mediplus (IMS Ltd, Middlesex, England). Resource-use data were obtained from published literature, a Delphi Panel and an advisory panel with expertise in palliative care. The expected cost of managing terminally ill cancer patients after they switched from a weak to a strong opioid ranged from 2391 pounds sterling (Pounds) to 3701 Pounds at 1995/1996 prices, depending primarily on the patient's duration of survival. Sensitivity analyses showed that the cost could be as low as 1500 Pounds or as high as 6000 Pounds, depending on resource use (at 1995/1996 prices). The key cost drivers were: hospice care, hospitalisation, general practitioner (GP) consultations and specialist nurse visits. In contrast, neither the choice of opioid nor managing constipation impacted substantially on the expected cost. Approximately two-thirds of the expected total cost was incurred by the UK National Health Service (NHS), with the remainder incurred by voluntary and charitable sectors. Hospice care and hospitalisation collectively accounted for between 50 and 80% of the expected costs. Management of patients in the community by the primary healthcare team accounted for between 10 and 40% of the costs. The acquisition cost of opioids accounted for between 2 and 8% of the expected cost and discounting the cost of these drugs sold to hospitals did not impact substantially on the total expected costs. The use of other resources such as antiemetics, NSAIDS, antidepressants and gastrointestinal drugs accounted for up to 3% of the expected cost. The expected cost of palliative care in the UK healthcare setting ranged from approximately 2500 Pounds to 4000 Pounds (1500 Pounds to 6000 Pounds in the sensitivity analysis) depending on the length of survival after patients switch from weak to strong opioids. Since opioids account for only 2 to 8% of expected costs, factors other than economic issues, such as tolerability profile, patient preference and convenience of use, should form the basis of clinical decision-making between opioids with similar analgesic efficacy.

Which informal carers are most satisfied with services for dying cancer patients?

This paper examines the relationship between the satisfaction of informal carers with the care delivered to dying people in the last year of life and patient and carer characteristics. A secondary analysis was conducted on a subsample from the Regional Study of Care for the Dying (RSCD) in which bereaved relatives or friends of a random sample of deaths in 1990 in 20 health districts across England were interviewed some 10 months after the death. There were 1,858 informal carers who were close relatives or friends/neighbours of people who died from cancer in this analysis. Results show that highly satisfied carers were those who perceived caring as rewarding (OR=2.31, 95% Cl: 1.04–5.11), those who reported having had no unmet needs while caring for the deceased at home (OR=2.50, 95% Cl: 1.87–3.34), and those who rated their post-bereavement health as excellent (0R=2.61, 95% Cl: 1.70–3.90). Reporting for the deceased who were owner-occupiers was also associated with a high odds ratio for satisfaction (0R=2.52, 95% Cl: 1.37–4.61). Factors such as the patient's duration of functional limitation, the duration of confusion and psychological symptoms, and the carer's strength of religious faith were also found to predict satisfaction but to a lesser extent. Health planners and managers should be aware that informal carers' overall satisfaction with health and social services is predicted by carer and patient attributes.

Predicting the Duration of Mechanical Ventilation: The Importance of Disease and Patient Characteristics

To analyze the determinants of an individual patient's duration of mechanical ventilation and assess interhospital variations for average durations of ventilation. Prospective, multicenter, inception, cohort study. Forty-two ICUs at 40 US hospitals. A total of 5,915 patients undergoing mechanical ventilation on ICU day 1 selected from the acute physiology and chronic health evaluation (APACHE) III database of 17,440 admissions. None. Utilizing APACHE III data collected on the 5,915 patients, multivariate regression analysis was performed on selected patients and disease characteristics to determine which variables were significantly associated with the duration of mechanical ventilation. An equation predicting duration of ventilation was then developed using the significant predictor variables and its accuracy was evaluated. Variables significantly associated with duration of ventilation included primary reason for ICU admission, day 1 acute physiology score (APS) of APACHE III, age, prior patient location and hospital length of stay, activity limits due to respiratory disease, serum albumin, respiratory rate, and PaO2/FIo2 measurements. Using an equation derived from these variables, predicted durations of ventilation were then calculated and compared with actual observed durations for each of the 42 ICUs. Average duration of ventilation for the 42 ICUs ranged from 2.6 to 7.9 days, but 60% of this variation was accounted for by differences in patient characteristics. For patients admitted to the ICU and ventilated on day 1, total duration of ventilation is primarily determined by admitting diagnosis and degree of physiologic derangement as measured by APS. An equation developed using multivariate regression techniques can accurately predict average duration of ventilation for groups of ICU patients, and we believe this equation will be useful for comparing ventilator practices between ICUs, controlling for patient differences in clinical trials of new therapies or weaning techniques, and as a quality improvement mechanism.