Comparison of Home and Hospital Care of Advanced Cancer Patients

Evidence on the economic value of end-of-life and palliative care interventions: a narrative review of reviews

BACKGROUND

As the demand for palliative care increases, more information is needed on how efficient different types of palliative care models are for providing care to dying patients and their caregivers. Evidence on the economic value of treatments and interventions is key to informing resource allocation and ultimately improving the quality and efficiency of healthcare delivery. We assessed the available evidence on the economic value of palliative and end-of-life care interventions across various settings.

METHODS

Reviews published between 2000 and 2019 were included. We included reviews that focused on cost-effectiveness, intervention costs and/or healthcare resource use. Two reviewers extracted data independently and in duplicate from the included studies. Data on the key characteristics of the studies were extracted, including the aim of the study, design, population, type of intervention and comparator, (cost-) effectiveness resource use, main findings and conclusions.

RESULTS

A total of 43 reviews were included in the analysis. Overall, most evidence on cost-effectiveness relates to home-based interventions and suggests that they offer substantial savings to the health system, including a decrease in total healthcare costs, resource use and improvement in patient and caregivers' outcomes. The evidence of interventions delivered across other settings was generally inconsistent.

CONCLUSIONS

Some palliative care models may contribute to dual improvement in quality of care via lower rates of aggressive medicalization in the last phase of life accompanied by a reduction in costs. Hospital-based palliative care interventions may improve patient outcomes, healthcare utilization and costs. There is a need for greater consistency in reporting outcome measures, the informal costs of caring, and costs associated with hospice.

An Evaluation of Systematic Reviews of Palliative Care Services

This review aimed to identify and appraise all systematic reviews of palliative care services, to examine their findings in relation to methods used, and to explore whether further methods such as meta-analysis and meta-regression may be worthwhile. Ten databases were searched and augmented by hand searching specific journals, contacting authors, and examining the reference lists of all papers retrieved. Five systematic reviews met the inclusion criteria, and the update electronic search identified a further systematic review which found similar studies. A total of 39 studies were identified by the five systematic reviews. Of the 39 studies, 15 were RCTS, and 12 of those were North American. In comparison, the majority of U.K. studies were retrospective. Each review concluded similarly that there was a lack of good quality evidence on which to base conclusions. The more recent reviews were more rigorous, but none used a quantitative analysis. Despite the difficulties in combining heterogeneous interventions and outcomes in meta-analysis or meta-regression, such techniques may be valuable. More high quality evidence is needed to compare the relative merits of the differences in models of palliative care services, so that countries can learn from other appropriate systems of care at end of life.

Description of a Home Care Service for Cancer Patients through Quantitative Indexes of Evaluation

Home care (HC) was created and developed in Romagna, as in other parts of Italy, thanks to the endeavor of a private Institution, the « Istituto Oncologico Romagnolo ». The care Is gratis to advanced cancer patients and is based on the palliative philosophy of treatment of the symptoms and the person within the framework of continuity of care permitted by the oncologic approach. To evaluate the intensiveness of the operation in terms of medical and nursing care by means of quantitative indexes, we examined several variables which emerged from a retrospective analysis of our case study. The average duration of care of the 484 patients in the program as of 31 December 1990 was 84.1 days. Four hundred and twenty-three patients of the 484 (87.1 % of the total) have died and 61 were still in the HC program at the time of this analysis. The 61 living patients were thus excluded from the descriptive analysis to give greater homogeneity to the study group. The average duration of care for the 423 decreased patients was 68.1 days. Out of a total of 28,759 days of HC for the entire group, the patients actually spent 23,534 days (81.8 %) at home. The average duration of hospitalization was 13.5 days, and in 33.2% of the cases it was motivated by psychologic and family causes. The place of death was the home in 44.3 % of the cases. A medical or nursing visit was made at the home every 1.4 days, and the average number of visits per patient was 39.0. Although none of the indexes alone can give overall indications of the intensiveness of a HC service, they may constitute a working proposal for the definition of the most objective criteria possible for the quantitative evaluation of such experiences.

Age-related Differences in Patients Admitted to a Palliative Home Care Service

Aims

The aim of the study was to investigate possible differences in access to the service, symptomatology and therapy in relation to age among terminal cancer patients admitted to a home care program. We examined prospectively all 116 terminal cancer patients enrolled in a home care program in 1998, comparing those up to 70 years of age (48 patients) with those above 70 (68 patients). We also compared the age-related characteristics of this population with those of all 348 patients enrolled in the program in 1989-1991. There were no significant differences between the two age groups of the 1998 population in terms of symptoms, tumor site or medication, although NSAID use tended to be greater in older patients, and opioid and anti-emetic use greater in younger patients. Patients up to 70 years of age had significantly shorter survival from admission to home care than those over 70, and a greater proportion had metastases. There were no such significant age-related differences as regards survival and the presence of metastases in patients enrolled 10 years before. In conclusion, among terminally ill cancer patients referred to a palliative home care service in Milan, mostly treated at the National Cancer Institute, the 10-year admission trend showed that palliative care is made available increasingly later, particularly to those up to 70 years of age, in contrast to current recommendations.

Integration between Oncology and Palliative Care: A Plan for the Next Decade?

With the groundbreaking work of three Milan professors—Bonadonna, Veronesi, and Ventafridda—in the 1980s as the starting point, this article aims to shed light on the potential benefits of a closer and more formal integration between oncology and palliative care. More specifically, we address why integration is needed, how to do it, and the potential benefits to the patients, families, and society. The costs for cancer care are increasing rapidly. Especially during the last year of life, some treatments are futile and expensive without proven benefit for patients in terms of prolonged survival with adequate quality of life (QoL). The latest WHO definition of palliative care supports an upstream introduction of palliative care. More recent studies indicate that such an early integration has the potential to improve the patients’ QoL and reduce their symptom burden. Successful integration presupposes formal structures and explicit obligations on how and when to integrate. The Norwegian model for palliative care is presented. It covers the range of oncologic and palliative services from community health care via the local hospital to the tertiary hospital and rests on standardized care pathway as the key instrument to promote integration. Our present state of knowledge indicates that integration does not shorten life; perhaps even the opposite. Futile oncological treatment can be reduced and the QoL of patients and carers improved. We need more evidence on the potential effect upon costs, but present data indicate that integration does not increase them.

Determination of morphine, codeine, and paclitaxel in human serum and plasma by micellar electrokinetic chromatography

A micellar electrokinetic chromatography method is proposed for the determination of morphine, codeine, and paclitaxel at clinical relevant levels in human serum and plasma, which are employed in the treatment of patients with cancer. Optimal conditions for the separation were investigated. A background electrolyte solutions consisting of 20 mM borate buffer adjusted to pH 8.5, sodium dodecyl sulphate 60 mM and 15% methanol, hydrodynamic injection, and 25 kV as separation voltage were used. Detection wavelength was 212 nm for morphine and codeine and 200 nm for paclitaxel. Aspects such as stability of the solutions, linearity, accuracy, precision, and robust and ruggedness were examined in order to validate the proposed method. Detection limits obtained for all the studied compounds ranged between 26 and 52 ng/mL. Before micellar electrokinetic chromatography determination, the samples were purified and enriched by means of an extraction-preconcentration step with a preconditioned C(18) cartridge. This method was applied to the analysis of serum and plasma samples from different cancer patients undergoing treatment with paclitaxel or/and codeine.

[Well-being of patients receiving specialized palliative care at home or in hospital]

BACKGROUND

A major goal of palliative care is sustaining quality of life (QoL) for patients suffering from severe symptoms, which is determined by physical and psychological consequences of an illness as well as other factors, such as the meaning of life and family support. Patients have reported high levels of QoL despite worsening symptoms. The self-estimated QoL of patients receiving outpatient and inpatient palliative care was analyzed using retrospective data from the German Hospice and Palliative Care Evaluation (HOPE).

MATERIALS AND METHODS

A descriptive analysis of questionnaires given to 2,030 patients (1,616 inpatients, 414 outpatients) and their professional care takers was carried out assessing symptoms, well-being and care-related information.

RESULTS

At the beginning of treatment inpatients had a higher symptom burden than outpatients. Reduced pain, tiredness and weakness and improved well-being allowed inpatients to be discharged. Outpatients suffering from severe dyspnea, constipation and anxiety were more likely to be admitted to hospital. Well-being was associated with symptom burden, weakness and tiredness in both self-evaluation and care-taker assessment particularly for outpatients.

CONCLUSIONS

While tiredness and weakness influenced QoL especially for outpatients, patient-specific factors may surpass them in patient perception. To improve the QoL of palliative care patients, individual factors must be assessed in addition to symptom control.

The National Tumor Association Foundation (ANT): A 30 year old model of home palliative care

BACKGROUND

Models of palliative care delivery develop within a social, cultural, and political context. This paper describes the 30-year history of the National Tumor Association (ANT), a palliative care organization founded in the Italian province of Bologna, focusing on this model of home care for palliative cancer patients and on its evaluation.

METHODS

Data were collected from the 1986-2008 ANT archives and documents from the Emilia-Romagna Region Health Department, Italy. Outcomes of interest were changed in: number of patients served, performance status at admission (Karnofsky Performance Status score [KPS]), length of participation in the program (days of care provided), place of death (home vs. hospital/hospice), and satisfaction with care. Statistical methods included linear and quadratic regressions. A linear and a quadratic regressions were generated; the independent variable was the year, while the dependent one was the number of patients from 1986 to 2008. Two linear regressions were generated for patients died at home and in the hospital, respectively. For each regression, the R square, the unstandardized and standardized coefficients and related P-values were estimated.

RESULTS

The number of patients served by ANT has increased continuously from 131 (1986) to a cumulative total of 69,336 patients (2008), at a steady rate of approximately 121 additional patients per year and with no significant gender difference. The annual number of home visits increased from 6,357 (1985) to 904,782 (2008). More ANT patients died at home than in hospice or hospital; this proportion increased from 60% (1987) to 80% (2007). The rate of growth in the number of patients dying in hospital/hospice was approximately 40 patients/year (p < 0.01), vs. approximately 177 patients/year for patients who died at home. The percentage of patients with KPS < 40 at admission decreased from 70% (2003) to 30% (2008); the percentage of patients with KPS > 40 increased. Mean days of care for patients with KPS > 40 exceeded mean days for patients with KPS < 40 (p < 0.001). Patients and caregivers reported high satisfaction with care in each year of assessment; in 2008, among 187 interviewed caregivers, 95% judged the quality of doctors' assistance, and 91% judged the quality of nurses' assistance, to be "optimal."

CONCLUSIONS

The ANT home care model of palliative care delivery has been well-received, with progressively growing numbers of patients served. It has resulted in a greater proportion of home deaths and in patients' accessing palliative care at an earlier point in the disease trajectory. Changes in ANT chronicle palliative care trends in general.

Quality of life as a predictor of cancer survival among Chinese liver and lung cancer patients

The utility of quality of life (QoL) scores in predicting cancer survival remains inconclusive because of methodological and/or statistical heterogeneity. We examined whether QoL scores predicted survival among Chinese liver (n=176) and lung cancer (n=358) patients. Cox proportional hazards models examined if QoL and psychosocial variables predicted survival after fully adjusting for sociodemographic and clinical factors. The results showed that global QoL scores did not predict survival in either patient group. Less advanced cancer stage (HR=2.574, p<0.05) was associated with longer survival in liver cancer. Longer survival in lung cancer was predicted by younger age (HR=1.016, p<0.05), less advanced cancer stage (HR=1.978, p<0.001), having had treatment before baseline (HR=0.671, p<0.05), better physical well-being (HR=0.941, p<0.001) and better appetite (HR=0.888, p<0.001). Global QoL (FACT-G(Ch)) scores do not predict survival in Chinese liver and lung cancer patients. QoL physical well-being subscale predicted lung cancer survival.

Quality of life of cancer patients receiving inpatient and home-based palliative care

AIMS

This paper reports a comparative study of the symptom experience, physical and psychological health, perceived control of the effects of cancer and quality of life of terminally ill cancer patients receiving inpatient and home-based palliative care, and the factors that predict quality of life.

BACKGROUND

Quality of life is a major goal in the care of patients with terminal cancer. In addition to symptom management, psychological care and provision of support, being cared for at home is considered an important determinant of patient well-being. A more comprehensive understanding of the impact of cancer on patients and their families will inform the delivery of palliative care services.

METHODS

Fifty-eight patients with terminal cancer (32 inpatients, 26 home-based) were recruited from major palliative care centres in Australia in 1999. A structured questionnaire designed to obtain sociodemographic information, medical details and standard measures of symptoms, physical and psychological health, personal control and quality of life was administered by personal interview.

RESULTS

The two groups were similar on most demographic measures, although more home-care patients were married, of Australian descent and had private health insurance cover. The most prevalent symptoms reported were weakness, fatigue, sleeping during the day and pain. Patients receiving home-based services had statistically significantly less symptom severity and distress, lower depression scores, and better physical health and quality of life than those receiving inpatient care. Home-care patients also reported statistically significantly more control over the effects of their illness, medical care and treatment received, and the course of the disease. Multiple regression analyses showed that better global physical health, greater control over the effects of cancer and lower depression scores were statistically significant predictors of higher quality of life.

CONCLUSIONS

The main issues arising from the findings for nurses are the early detection and management of both physical and psychological symptoms, particularly fatigue, pain, anxiety and depression, and the need to use strategies that will empower patients to have a greater sense of control over their illness and treatment. Research is needed to identify other factors that may impact on quality of life, and to establish the extent to which inpatient and home-based care meets the needs of both the patient with terminal cancer and their family.

Utilization and costs of the introduction of system-wide palliative care in Alberta, 1993-2000

BACKGROUND

De-institutionalization of health care services provided to terminally ill cancer patients is a cost-effective strategy that underpins health care reforms in Canada. The objective of this study therefore is to evaluate the economic implications associated with Canadian innovations in the delivery of palliative care services.

METHODS

We identified 16,282 adults who died of cancer between 1993 and 2000 in two Canadian cities with newly introduced palliative care programs. Linkage of administrative databases was used to measure healthcare resource utilization. We sought to describe the utilization of palliative care services and its consequences for overall health care system costs.

RESULTS

Use of palliative services increased from 45 to 81% of cancer patients during the study period. Identifiable public health care services cost dollars 28093Cdn/patient (19033US dollars, 11,508GBł, 17,778 euro) for terminally ill cancer patients in their last year of life. Acute care accounted for two-thirds (67%) of these costs; physician (10%), residential hospice care (8%), nursing homes (6%), home care (6%) and prescription medications (3%) comprise the remainder. Increased costs associated with the introduction of palliative care programs were offset by cost savings realized when terminally ill cancer patients spent less time in hospital. Palliative home care and residential hospice care accounted for the bulk of this substitution effect. Cost neutrality was observed from the public perspective.

DISCUSSION

These results demonstrate that the introduction of comprehensive and community-based palliative care services resulted in increased palliative care service delivery and cost neutrality, primarily achieved through a decreased use of acute care beds.

Zoledronic acid significantly improves pain scores and quality of life in breast cancer patients with bone metastases: a randomised, crossover study of community vs hospital bisphosphonate administration

Patients with bone metastases from breast cancer often experience substantial skeletal complications – including debilitating bone pain – which negatively affect quality of life. Zoledronic acid (4 mg) has been demonstrated to reduce significantly the risk of skeletal complications in these patients and is administered via a short, 15-min infusion every 3 weeks, allowing the possibility for home administration. This study compared the efficacy and safety of zoledronic acid administered in the community setting vs the hospital setting in breast cancer patients with ⩾1 bone metastasis receiving hormonal therapy. After a lead-in phase of three infusions of 4 mg zoledronic acid in the hospital setting, 101 patients were randomized to receive three open-label infusions in the community or hospital setting, followed by three infusions in the opposite venue (a total of nine infusions). The Brief Pain Inventory (BPI) and the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire 30 (EORTC QLQ-C30) were used to assess potential benefits of zoledronic acid therapy. At study end, analysis of the BPI showed significant reductions in worst pain (P=0.008) and average pain in the last 7 days (P=0.039), and interference with general activity (P=0.012). In each case, there were significantly greater improvements in pain scores after treatment in the community setting compared with the hospital crossover setting for worst pain (P=0.021), average pain (P=0.003), and interference with general activity (P=0.001). Overall global health status showed a significant median improvement of 8.3% (P=0.013) at study end. Physical, emotional, and social functioning also showed significant overall improvement (P=0.013, 0.005, and 0.043, respectively). Furthermore, physical, role, and social functioning showed significantly greater improvements after treatment in the community setting compared with the hospital crossover setting (P=0.018, 0.001, and 0.026, respectively). There was no difference between hospital and community administration in renal or other toxicity, with zoledronic acid being well tolerated in both treatment settings. These data confirm the safety and quality-of-life benefits of zoledronic acid in breast cancer patients with bone metastases, particularly when administered in the community setting.

Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers?

Palliative care provision varies widely, and the effectiveness of palliative and hospice care teams (PCHCT) is unproven. To determine the effect of PCHCT, 10 electronic databases (to 2000), 4 relevant journals, associated reference lists, and the grey literature were searched. All PCHCT evaluations were included. Anecdotal and case reports were excluded. Forty-four studies evaluated PCHCT provision. Teams were home care (22), hospital-based (9), combined home/hospital care (4), inpatient units (3), and integrated teams (6). Studies were mostly Grade II or III quality. Funnel plots indicated slight publication bias. Meta-regression (26 studies) found slight positive effect, of approximately 0.1, of PCHCTs on patient outcomes, independent of team make-up, patient diagnosis, country, or study design. Meta-analysis (19 studies) demonstrated small benefit on patients' pain (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.23-0.64), other symptoms (OR: 0.51, CI: 0.30-0.88), and a non-significant trend towards benefits for satisfaction, and therapeutic interventions. Data regarding home deaths were equivocal. Meta-synthesis (all studies) found wide variations in the type of service delivered by each team; there was no discernible difference in outcomes between city, urban, and rural areas. Evidence of benefit was strongest for home care. Only one study provided full economic cost-benefit evaluation. This is the first study to quantitatively demonstrate benefit from PCHCTs. Such comparisons were limited by the quality of the research.

Reduced utilisation of specialist care among elderly cancer patients: a randomised study of a primary healthcare intervention

The aim of this study was to evaluate the effect of an individual support (IS) intervention including intensified primary healthcare on the utilisation of specialist care among cancer patients, and to investigate if such an effect was modified by the patient's age (less than 70 years or 70 years and more). Newly diagnosed cancer patients (n=416) were randomised between the intervention and a control condition, and data were collected on the utilisation of specialist care within 3 months from inclusion. Intensified primary healthcare comprised extended information from the specialist clinics, and education and supervision in cancer care for general practitioners (GPs) and home-care nurses. The support given also included interventions designed to diminish problems of weight loss and psychological distress. The intervention reduced the number of admissions (NoA) and the days of hospitalisation (DoH) after adjustment for weight loss and psychological distress, but only for older patients. Older patients randomised to the intervention (n=82) experienced 393 fewer DoH than the older control patients (n=79). In addition, the proportion of older patients in the IS group who utilised acute specialist care was smaller compared with older control patients group. The conclusion is that older cancer patients' utilisation of specialist care may be reduced by intensified primary healthcare services.

Home palliative care as a cost-saving alternative: evidence from Catalonia

The aim of this study was to provide a comparative assessment of the health care resources consumed during the final month of life of patients undergoing palliative treatment and who died from cancer in the town of Mataró, Spain, in 1998, with respect to whether they benefited from home care teams or not. Relevant differences in the use of health care resources were found between the groups. Patients in the standard care group presented more hospital care admissions and longer length of stay, higher use of emergency and outpatient visits, and greater use of palliative care units within nursing homes than patients in the home care group. The monetary quantification of the use of the above-mentioned resources showed a 71% increase in the cost per patient in the standard care when compared to home care. According to the results of this study, home care teams for terminal cancer patients allow for savings to the health care system. A series of policy making and health services research implications are discussed.

Cultural issues and ethical dilemmas in palliative and end-of-life care in Spain

BACKGROUND

The concept of palliative care differs according to cultures and traditions. In Spain, palliative care programs have expanded in recent years. The European Commission Research Project in Palliative Care Ethics has sponsored ongoing research to analyze and clarify the conceptual differences in providing palliative care to patients in European countries with diverse cultures and backgrounds.

METHODS

The authors present key ethical issues in clinical practice in palliative and end-of-life care in Spain and how these issues are influenced by Spanish culture. They discuss typical characteristics of the Spanish conceptual approach to palliative care, which might be relevant in an even larger Latin palliative care context.

RESULTS

The cultural tradition in Spain influences attitudes toward euthanasia, sedation, the definition of terminality, care in the last 48 hours of life, diagnosis disclosure, and information. The overall care of terminally ill patients with an Hispanic background includes not only the treatment of disease, but also the recognition and respect of their traditions and culture.

CONCLUSIONS

The Spanish palliative care movement has shifted its focus from starting new programs to consolidating and expanding the training of the professionals already working in the existing programs. Although there is a general consensus that a new philosophy of care is needed, the interpretation and application of this general philosophy are different in diverse sociocultural contexts.

A randomized controlled trial of a hospital at home service for the terminally ill

This study evaluated the impact of a Cambridge hospital at home service (CHAH) on patients' quality of care, likelihood of remaining at home in their final 2 weeks of life and general practitioner (GP) visits. The design was a randomized controlled trial, comparing CHAH with standard care. The patient's district nurse, GP and informal carer were surveyed within 6 weeks of patient's death, and 225 district nurses, 194 GPs and 144 informal carers of 229 patients responded. There was no clear evidence that CHAH increased likelihood of remaining at home during the final 2 weeks of life. However, the service was associated with fewer GP out of hours visits. All respondent groups rated CHAH favourably compared to standard care but emphasized different aspects. District nurses rated CHAH as better than standard care in terms of adequacy of night care and support for the carer, GPs in terms of anxiety and depression, and informal carers in terms of control of pain and nausea. Thus whilst CHAH was not found to increase the likelihood of remaining at home, at appeared to be associated with better quality home care.

Palliative care: an international view

This review article addresses first the different palliative care models currently in use. Studies addressing the effectiveness of the models used are briefly summarized. Special attention is further given to models developed and tested in palliative care in children. Finally, the problems and pitfalls encountered in evaluating palliative care services are highlighted and recommendations are made where further research is still warranted.

Intensified primary cancer care: a randomized study of home care nurse contacts

Newly diagnosed cancer patients (n=527) were randomised to intensified primary care or a control group. Intensified primary care comprised routines to improve general practitioners' and home care nurses' possibilities to support and monitor patients, i.e. increased information from specialist care, education and supervision in cancer care. The aims of this paper are to evaluate the effects of intensified primary care on cancer patients' home care nurse contacts, and to study if patients' use of home care services 6 months after diagnosis can be predicted. The intervention resulted in a marked increase of follow-up contacts. About 90% of intensified primary care patients reported such contacts, compared to 26% of control patients. The results indicate that standard care does not routinely include follow-up contacts, not even for the oldest (80+ years) or those with advanced disease. Only 27% and 36% of these groups of control patients reported follow-ups. Logistic regression analysis identified intensified primary care as the strongest predictor for reporting a continuing contact 6 months after diagnosis. Intensified primary care patients were 14 times more likely than controls to report a such contact. The strongest predictor of a continuing contact in the intensified primary care group was high age. Patients with advanced disease were more likely than patients with non-advanced disease to report a continuing contact, and living in a rural district was positively associated with reporting a contact. A majority of the patients (70%) assessed the time for the first contact as the 'right time' and estimated that the nurse gave expected support to a very large or large extent (67%). The results suggest that routines like those implemented through intensified primary care may be an effective strategy to increase the accessibility and continuity of care, especially for elderly people and for patients with a need for long-term contacts.

The impact of different models of specialist palliative care on patients' quality of life: a systematic literature review

This study set out to systematically review the research evidence about the impact of alternative models of specialist palliative care on the quality of life of patients. Eighty-six relevant papers were identified and reviewed, including 22 descriptive and 27 comparative studies. We found few comparative trials of reasonable quality. There was some evidence that in-patient palliative care provided better pain control than home care of conventional hospital care, but this research was dated and open to criticism. Research on palliative home care teams and co-ordinating nurses has demonstrated limited impact on quality of life over conventional care for patients dying at home. These negative findings may be due to the limitations of the assessment tools used. There is a need for larger studies to provide clear evidence as to whether specialist palliative care services provide improvements in patients' quality of life. This review does not exclude the possibility that models of care might be justifiable on other grounds such as patient preference or cost-effectiveness.

Do specialist palliative care teams improve outcomes for cancer patients? A systematic literature review

The objective of the study was to determine whether teams providing specialist palliative care improve the health outcomes of patients with advanced cancer and their families or carers when compared to conventional services. The study involved a systematic literature review of published research. The source of the data included studies identified from a systematic search of computerized databases (Medline, psychINFO, CINAHL and BIDS to the end of 1996), hand-searching specialist palliative care journals, and studying bibliographies and reference lists. The inclusion criteria for articles were that the study considered the use of specialist palliative care teams caring for patients with advanced cancer. Articles were assessed and data extracted and synthesized, with studies graded according to design. A variety of outcomes were considered by the authors. These addressed aspects of symptom control, patient and family or carer satisfaction, health care utilization and cost, place of death, psychosocial indices and quality of life. Overall, 18 relevant studies were identified, including five randomized controlled trials. Improved outcomes were seen in the amount of time spent at home by patients, satisfaction by both patients and their carers, symptom control, a reduction in the number of inpatient hospital days, a reduction in overall cost, and the patients' likelihood of dying where they wished to for those receiving specialist care from a multiprofessional palliative care team. It was concluded that all evaluations were of services considered to be leading the field, or were pioneering training and treatments. However, when compared to conventional care, there is evidence that specialist teams in palliative care improve satisfaction and identify and deal with more patient and family needs. Moreover, multiprofessional approaches to palliative care reduce the overall cost of care by reducing the amount of time patients spend in acute hospital settings.

Care process and satisfaction analysis of a transmural home care program

This study investigated both professional caregiver workload as well as the patients' and caregivers' satisfaction with a transmural home care program. Seventy-nine patients were included in the intervention program. The specialist nurse coordinator, general practitioner, community nurse providing 'intensive' community care, community nurses providing 'standard' community care, and the home helper spent in total an average of 7.5, 4.4, 55.6, 55.0, and 112.3 h, respectively, on each patient during the care process (mean survival of the 79 patients was 101.2 days). The 24 h telephone service and transmural home team were contacted in total 100 and 8 times, respectively. Patient and caregiver satisfaction with the care provided scored (very) high. Considering this acceptable workload and given that the program did not interfere with existing standard health care structures, it can be concluded that such care may easily be introduced by other hospitals and related primary care teams.

An estimate of the annual direct cost of treating cutaneous melanoma

BACKGROUND

Although the survival benefits of early stage melanoma have been clearly documented, the potential economic impact of early versus late stage disease has not been assessed.

OBJECTIVE

Our purpose was to estimate the annual direct cost of diagnosing and treating melanoma, based on the number of projected cases of melanoma entering each stage in 1997.

METHODS

A model was constructed with assumptions derived from the literature and clinical experience at the Massachusetts General Hospital Melanoma Center and the Boston University Medical Center. Cost estimates were based on 1997 Boston area Medicare reimbursements.

RESULTS

The annual direct cost of treating newly diagnosed melanoma in 1997 was estimated to be $563 million. Stage I and II disease each comprised about 5% of the total cost; stage III and stage IV disease consumed 34% and 55% of the total cost, respectively. About 90% of the total annual direct cost of treating melanoma in 1997 was attributable to less than 20% of patients (those patients with advanced disease, that is, stage III and stage IV).

CONCLUSION

In addition to the potential survival advantages, aggressive primary prevention through sun protection and intensive screening to enhance earlier detection should reduce the economic burden of melanoma care.

The experience of cancer

The illness career of the person with cancer has been characterized as a 'living-dying' experience in which, faced with the intolerable incompatibility of life and death, the individual and his or her family attempt to maintain control and 'normalize' everyday activity. Unfortunately, in their everyday struggles, families in North America appear to face social isolation from existing community services and networks that might assist them. Perhaps because the illness is so heavily medicalized and stigmatized, most persons with cancer and their families do not participate in them. A minority benefit from self-help organizations such as Cancer Society groups and survivor coalitions. The palliative care and hospice/home care movements provide an alternative to dying in the acute-care hospital, again, for a minority. Half of those with cancer survive more than 5 years; for these persons, the ordeal has just begun. Survivors must cope with physical disabilities due to surgery and the side effects of other treatments, the psychological traumas of fear of recurrence and social stigma, and the disappointment of a considerably reduced range of future possibilities for career and development. The fact that their relationships with others are negatively affected is well documented, particularly with intimate relationships. In a sense, a person never really 'gets over' cancer: it is a sword of Damocles that continues to hang over the individual and his or her family for the rest of the person's life.(ABSTRACT TRUNCATED AT 250 WORDS)

Questioning diagnosis disclosure in terminal cancer patients: a prospective study evaluating patients' responses

This study attempted to assess the degree of knowledge of the diagnosis, and the attitude towards that information, in a group of terminally ill cancer patients. We also tried to determine the influence of the knowledge of the diagnosis on other patient psychosocial needs. We assessed 97 patients (64 in an oncology service, 33 in a palliative care unit) by means of a semistructured personal interview, and a psychosocial needs questionnaire. Data collected showed that 68% of patients had not been informed of their diagnosis; 60% of this group had a high degree of suspicion of their diagnosis, but 42% of noninformed patients did not want to receive more information. Information on diagnosis appears to be beneficial in establishing satisfactory relationships and communication between patients and relatives and staff. We have tried to answer the most relevant issues related to diagnosis disclosure in our clinical setting, questioning the feasibility of truth telling within our cultural boundaries.

Palliative home care and place of death among cancer patients: a population-based study

This population-based study of all cancer deaths (n = 12,343) occurring in Genoa, Italy, from 1986 to 1990 investigated the relation between place of death and age, sex, marital status, education, cancer site and provision of palliative home care (PHC). The proportion of home deaths significantly increased from 27.9% (1986) to 33.0% (1990) and was twice as frequent among PHC users (60.8%) than among nonusers (29.3%). The number of patients dying of cancer who received PHC increased from 41 in 1986 (1.6% of cancer deaths) to 191 in 1990 (8.0% of cancer deaths). PHC users, when compared to nonusers were younger, more frequently married, had a higher level of education and were more frequently affected by cancers of the lung, breast or prostate. Multivariate analysis shows that the probability of home death increased with increasing age and education level and was higher in females and in married patients. The provision of PHC was the strongest predictor of home death (OR = 4.00; 95% CI = 3.33-4.81), while the temporal trend almost disappeared. These results suggest that most of the increase in home deaths from 1986 to 1990 is attributable to the PHC and that expansion of the PHC services may enable about 60% of cancer patients to die at home. These results appear to be desirable from the individual patient's viewpoint and in a public health perspective.

The organization of hospital-based home care for terminally ill cancer patients: the Motala model

In 1977, the first palliative home care programme in Sweden, the Motala hospital-based home care, was established to provide a high level of medical care on a 24-hour basis, as an alternative and a replacement to hospital care. The current study summarizes the care and organizational needs of 179 consecutive terminally ill cancer patients treated during a 10-year period. Of the patients, 70% came from acute clinics. The median time of care was 36 days. The need for help with activities of daily living was a significant predictor of the length of survival, with the greatest difference between four or less compared to five or six items (p = 0.0006). Analgesics were needed by 96% of the patients, and 78% were provided with various facilities such as hospital beds. The input of family members as primary caregivers was essential for successful care, as were security factors such as easy availability of a nurse or doctor, at any time day or night, and an immediate, guaranteed hospital bed, if needed. As many as 89% of the patients who wished to live at home until death actually did so. We conclude that hospital-based home care according to the Motala model can replace hospital care for selected patients, but only if both the patient and the family approve.