Related Articles

Background

Physical exercise has been identified as a potential intervention to improve quality of life in women with breast cancer. We sought to summarize the available evidence concerning the effects of exercise on breast cancer patients and survivors.

Methods

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsychINFO, CancerLit, PEDro and SportDiscus as well as conference proceedings, clinical practice guidelines and other unpublished literature resources. We included only randomized controlled trials that examined exercise interventions for breast cancer patients or survivors with quality of life, cardiorespiratory fitness or physical functioning as primary outcomes. We also extracted data on symptoms of fatigue, body composition and adverse effects.

Results

Of 136 studies identified, 14 met all the inclusion criteria. Despite significant heterogeneity and relatively small samples, the point estimates in terms of the benefits of exercise for all outcomes were positive even when statistical significance was not achieved. Exercise led to statistically significant improvements in quality of life as assessed by the Functional Assessment of Cancer Therapy–General (weighted mean difference [WMD] 4.58, 95% confidence interval [CI] 0.35 to 8.80) and Functional Assessment of Cancer Therapy–Breast (WMD 6.62, 95% CI 1.21 to 12.03). Exercise also led to significant improvements in physical functioning and peak oxygen consumption and in reducing symptoms of fatigue.

Interpretation

Exercise is an effective intervention to improve quality of life, cardiorespiratory fitness, physical functioning and fatigue in breast cancer patients and survivors. Larger trials that have a greater focus on study quality and adverse effects and that examine the long-term benefits of exercise are needed for this patient group.

Background

Aged patients with coronary heart disease (CHD) have a high prevalence of co-morbidity associated with poor quality of life, high health care costs, and increased risk for adverse outcomes. These patients are often lacking an optimal home care which may result in subsequent readmissions. However, a specific case management programme for elderly patients with myocardial infarction (MI) is not yet available. The objective of this trial is to examine the effectiveness of a nurse-based case management in patients aged 65 years and older discharged after treatment of an acute MI in hospital. The programme is expected to influence patient readmission, mortality and quality of life, and thus to reduce health care costs compared with usual care. In this paper the study protocol is described.

Methods/design

The KORINNA (Koronarinfarkt Nachbehandlung im Alter) study is designed as a single-center randomized two-armed parallel group trial. KORINNA is conducted in the framework of KORA (Cooperative Health Research in the Region of Augsburg). Patients assigned to the intervention group receive a nurse-based follow-up for one year including home visits and telephone calls. Key elements of the intervention are to detect problems or risks, to give advice regarding a broad range of aspects of disease management and to refer to the general practitioner, if necessary. The control group receives usual care. Twelve months after the index hospitalization all patients are re-assessed. The study has started in September 2008. According to sample size estimation a total number of 338 patients will be recruited. The primary endpoint of the study is time to first readmission to hospital or out of hospital death. Secondary endpoints are functional status, participation, quality of life, compliance, and cost-effectiveness of the intervention. For the economic evaluation cost data is retrospectively assessed by the patients. The incremental cost-effectiveness ratio (ICER) will be calculated.

Discussion

The KORINNA study will contribute to the evidence regarding the effectiveness of case management programmes in aged people with MI. The results can be an important basis for clinicians, administrators and health policy makers to decide on the provision of high-quality care to older patients with CHD.

Trial registration

ISRCTN02893746

Objective: to assess the effect of home versus day rehabilitation on patient outcomes.

Design: randomised controlled trial.

Setting: post-hospital rehabilitation.

Participants: two hundred and twenty-nine hospitalised patients referred for ambulatory rehabilitation.

Interventions: hospital-based day rehabilitation programme versus home-based rehabilitation programme.

Main Outcome Measures: at 3 months, information was collected on hospital readmission, transfer to residential care, functional level, quality of life, carer stress and carer quality of life. At 6 months, place of residence, hospital re-admissions and mortality status were collected.

Results: there were significant improvements in the functional outcomes from baseline to 3 months for all participants. At discharge, carers of patients in day hospital reported higher Caregiver Strain Index (CSI) scores in comparison to home rehabilitation carers (4.95 versus 3.56, P = 0.047). Patients in day hospital had double the risk of readmission compared to those in home rehabilitation (RR = 2.1; 95% CI 1.2–3.9). This effect persisted at 6 months.

Conclusions: day hospital patients are more likely to be readmitted to hospital possibly due to increased access to admitting medical staff. This small trial favours the home as a better site for post-hospital rehabilitation.

It has been reported that many women referred to outpatient colposcopy clinics fail to attend for their appointments. The aim of this paper is to search the literature to assess the extent of default from colposcopy and to identify interventions, suitable for implementation within primary care, to reduce the proportion of women defaulting. Searches were performed on MEDLINE, PsychLIT, Bids and Cancerlit from 1986 to September 1997 using the terms colposcopy or cervical/Pap smear in association with default, non-attendance, adherence, patient compliance, treatment refusal, patient dropouts, attendance, barriers or intervention. The inclusion criteria for primary papers were that they contained data that enables the calculation of default rates for colposcopy or the results of interventions aimed at improving the default rates. Thirteen publications describing default rates and four describing interventions were included as primary papers. Combining the data from these studies suggests default rates of 3%, 11%, and 12% for assessment/treatment visits, first review, and second review respectively. The intervention studies suggested a need to tailor the intervention to the population and the type of information to suit the individual. Varying definitions make comparison of default rates difficult, and the use of a crude non-attendance rate may result in an overestimate of default rates. The vast majority of women invited to colposcopy eventually attend. It is questionable if there is a need for interventions to increase compliance. Where necessary, greater cooperation across the primary/secondary care interface and use of the extended primary care team may be a more cost-effective means of increasing compliance.

Objective To investigate if published studies tend to report favourable cost effectiveness ratios (below $20 000, $50 000, and $100 000 per quality adjusted life year (QALY) gained) and evaluate study characteristics associated with this phenomenon.

Design Systematic review.

Studies reviewed 494 English language studies measuring health effects in QALYs published up to December 2001 identified using Medline, HealthSTAR, CancerLit, Current Content, and EconLit databases.

Main outcome measures Incremental cost effectiveness ratios measured in dollars set to the year of publication.

Results Approximately half the reported incremental cost effectiveness ratios (712 of 1433) were below $20 000/QALY. Studies funded by industry were more likely to report cost effectiveness ratios below $20 000/QALY (adjusted odds ratio 2.1, 95% confidence interval 1.3 to 3.3), $50 000/QALY (3.2, 1.8 to 5.7), and $100 000/QALY (3.3, 1.6 to 6.8). Studies of higher methodological quality (adjusted odds ratio 0.58, 0.37 to 0.91) and those conducted in Europe (0.59, 0.33 to 1.1) and the United States (0.44, 0.26 to 0.76) rather than elsewhere were less likely to report ratios below $20 000/QALY.

Conclusion Most published analyses report favourable incremental cost effectiveness ratios. Studies funded by industry were more likely to report ratios below the three thresholds. Studies of higher methodological quality and those conducted in Europe and the US rather than elsewhere were less likely to report ratios below $20 000/QALY.

Low back pain (LBP) can restrict function with all the personal, interpersonal, and social consequences, such as a loss of independence and the inability to fulfil diverse roles in social life. Therefore, the prevention of the consequences of LBP would reduce costs, individual burdens and social burdens. Being able to fulfil the requirements of daily living is a cornerstone of quality of life. Early identification of patients who are likely to develop chronic pain with persistent restricted function is important, as effective prevention needs informed allocation of health care and social work. The aim of this study was to report and discuss the predictive value of instruments used to identify patients at risk of chronic LBP. Medline, Embase, CINAHL, Central, PEDro, Psyndex, PsychInfo/PsycLit, and Sociofile were systematically searched up to July 2004. Reference lists of systematic reviews on risk factors, and reference lists of the studies included were also searched. The selected studies evaluated predictive values of tools or predictive models applied 2–12 weeks after an initial medical consultation for a first or a new episode of non-specific LBP with restriction in function. Instruments had to predict function-related outcomes. Because of the heterogeneity of the instruments used we did not pool the data. Sixteen publications on function-related outcomes were included. The predictive instruments in these studies showed only moderate ability to predict or explain function-related outcome (maximal 51% of the variability). There was great variability in the predictors included and not all known risk factors were included in the models. The reviewed tools showed a limited ability to predict function-related outcome in patients with risk of chronic low back pain. Future instruments should be based on models with a comprehensive set of known risk factors. These models should be constructed and validated by international, coordinated research teams.

Objectives

To determine the effectiveness of early assisted discharge for chronic obstructive pulmonary disease (COPD) exacerbations, with home care provided by generic community nurses, compared with usual hospital care.

Design

Prospective, randomised controlled and multicentre trial with 3-month follow-up.

Setting

Five hospitals and three home care organisations in the Netherlands.

Participants

Patients admitted to the hospital with an exacerbation of COPD. Patients with no or limited improvement of respiratory symptoms and patients with severe unstable comorbidities, social problems or those unable to visit the toilet independently were excluded.

Intervention

Early discharge from hospital after 3 days inpatient treatment. Home visits by generic community nurses. Primary outcome measure was change in health status measured by the Clinical COPD Questionnaire (CCQ). Treatment failures, readmissions, mortality and change in generic health-related quality of life (HRQL) were secondary outcome measures.

Results

139 patients were randomised. No difference between groups was found in change in CCQ score at day 7 (difference in mean change 0.29 (95% CI −0.03 to 0.61)) or at 3 months (difference in mean change 0.04 (95% CI –0.40 to 0.49)). No difference was found in secondary outcomes. At day 7 there was a significant difference in change in generic HRQL, favouring usual hospital care.

Conclusions

While patients’ disease-specific health status after 7-day treatment tended to be somewhat better in the usual hospital care group, the difference was small and not clinically relevant or statistically significant. After 3 months, the difference had disappeared. A significant difference in generic HRQL at the end of the treatment had disappeared after 3 months and there was no difference in treatment failures, readmissions or mortality. Early assisted discharge with community nursing is feasible and an alternative to usual hospital care for selected patients with an acute COPD exacerbation.

Trial registration: NetherlandsTrialRegister NTR 1129.

Objective:

To familiarize athletic trainers with methodologic issues regarding the development and implementation of neuropsychological tests used in programs for monitoring sport-related cerebral concussion.

Data Sources:

Knowledge base and MEDLINE and PsychLit searches from 1980–2000 using the terms sports, athletes, concussion, and brain.

Data Synthesis:

Neuropsychological testing is a proven method for evaluating symptoms of concussion that results from a variety of different causes. These tests have been shown to be effective in evaluating symptoms of subtle cognitive dysfunction in a number of patient groups. Applying these tests in an athletic population has required some procedural modifications, including the use of brief test batteries, collection of preseason baseline data, and evaluation of subtle postconcussive changes in test scores over time. New methods are now being used for improved evaluation of the reliability and validity of neuropsychological tests in athletes. Proper scientific analysis of the psychometric properties of neuropsychological tests and the ultimate value of their use in the sport setting will require years of detailed study on large numbers of athletes with and without symptoms of concussion.

Conclusions/Recommendations:

Athletic trainers and related personnel need to be aware of the training and methodologic issues associated with neuropsychological testing. Knowledge of the scientific properties of these tests, their advantages, and current limitations will ultimately enhance the athletic trainer's ability to use information from neuropsychological testing in an effective manner.

Objectives To determine whether advice and training on working techniques and lifting equipment prevent back pain in jobs that involve heavy lifting.

Data sources Medline, Embase, CENTRAL, Cochrane Back Group’s specialised register, CINAHL, Nioshtic, CISdoc, Science Citation Index, and PsychLIT were searched up to September-November 2005.

Review methods The primary search focused on randomised controlled trials and the secondary search on cohort studies with a concurrent control group. Interventions aimed to modify techniques for lifting and handling heavy objects or patients and including measurements for back pain, consequent disability, or sick leave as the main outcome were considered for the review. Two authors independently assessed eligibility of the studies and methodological quality of those included. For data synthesis, we summarised the results of studies comparing similar interventions. We used odds ratios and effect sizes to combine the results in a meta-analysis. Finally, we compared the conclusions of the primary and secondary analyses.

Results Six randomised trials and five cohort studies met the inclusion criteria. Two randomised trials and all cohort studies were labelled as high quality. Eight studies looked at lifting and moving patients, and three studies were conducted among baggage handlers or postal workers. Those in control groups received no intervention or minimal training, physical exercise, or use of back belts. None of the comparisons in randomised trials (17 720 participants) yielded significant differences. In the secondary analysis, none of the cohort studies (772 participants) had significant results, which supports the results of the randomised trials.

Conclusions There is no evidence to support use of advice or training in working techniques with or without lifting equipment for preventing back pain or consequent disability. The findings challenge current widespread practice of advising workers on correct lifting technique.

Background:

Urgent, unplanned hospital readmissions are increasingly being used to gauge the quality of care. We reviewed urgent readmissions to determine which were potentially avoidable and compared rates of all-cause and avoidable readmissions.

Methods:

In a multicentre, prospective cohort study, we reviewed all urgent readmissions that occurred within six months among patients discharged to the community from 11 teaching and community hospitals between October 2002 and July 2006. Summaries of the readmissions were reviewed by at least four practising physicians using standardized methods to judge whether the readmission was an adverse event (poor clinical outcome due to medical care) and whether the adverse event could have been avoided. We used a latent class model to determine whether the probability that each readmission was truly avoidable exceeded 50%.

Results:

Of the 4812 patients included in the study, 649 (13.5%, 95% confidence interval [CI] 12.5%–14.5%) had an urgent readmission within six months after discharge. We considered 104 of them (16.0% of those readmitted, 95% CI 13.3%–19.1%; 2.2% of those discharged, 95% CI 1.8%–2.6%) to have had a potentially avoidable readmission. The proportion of patients who had an urgent readmission varied significantly by hospital (range 7.5%–22.5%; χ2 = 92.9, p < 0.001); the proportion of readmissions deemed avoidable did not show significant variation by hospital (range 1.2%–3.7%; χ2 = 12.5, p < 0.25). We found no association between the proportion of patients who had an urgent readmission and the proportion of patients who had an avoidable readmission (Pearson correlation 0.294; p = 0.38). In addition, we found no association between hospital rankings by proportion of patients readmitted and rankings by proportion of patients with an avoidable readmission (Spearman correlation coefficient 0.28, p = 0.41).

Interpretation:

Urgent readmissions deemed potentially avoidable were relatively uncommon, comprising less than 20% of all urgent readmissions following hospital discharge. Hospital-specific proportions of patients who were readmitted were not related to proportions with a potentially avoidable readmission.

Context

A history of depression may increase risk for developing Alzheimer disease (AD) later in life. Clarifying this relation might improve understanding of risk factors for and disease mechanisms in AD.

Objective

To systematically review and complete a meta-analysis on the relation of depression and AD.

Data Sources

We conducted electronic bibliographic searches of MEDLINE, PsychLit, EMBASE, and BIOSIS using search terms sensitive to studies of etiology combined with searches on terms related to depression and AD and reviewed reference lists of articles.

Study Selection

Studies with data contrasting depressed vs nondepressed patients who did and did not later develop AD were included. Studies that related continuous measures of depression and cognitive status were excluded.

Data Extraction

Numerical data were independently extracted by 3 reviewers. They also rated studies on a scale that assessed quality indicators for observational studies. Data on the interval between observation of depression and the diagnosis of AD were collected when available.

Data Synthesis

Meta-analytic evaluation with random-effects models resulted in pooled odds ratios of 2.03 (95% confidence interval, 1.73–2.38) for case-control and of 1.90 (95% confidence interval, 1.55–2.33) for cohort studies. Findings of increased risk were robust to sensitivity analyses. Interval between diagnoses of depression and AD was positively related to increased risk of developing AD, suggesting that rather than a prodrome, depression may be a risk factor for AD.

Conclusions

A history of depression may confer an increased risk for later developing AD. This relation may reflect an independent risk factor for the disease.

Background

Care pathways have become a popular tool to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. We performed a disease specific systematic review to determine how care pathways in the hospital treatment of heart failure affect in-hospital mortality, length of in-hospital stay, readmission rate and hospitalisation cost when compared with standard care.

Methods

Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched from 1985 to 2010. Each study was assessed independently by two reviewers. Methodological quality of the included studies was assed using the Jadad methodological approach for randomised controlled trials, controlled clinical trials and the New Castle Ottawa Scale for case–control studies, cohort studies and time interrupted series.

Results

Seven studies met the study inclusion criteria and were included in the systematic review with a total sample of 3,690 patients. The combined overall results showed that care pathways have a significant positive effect on mortality and readmission rate. A shorter length of hospital stay was also observed compared with the standard care group. No significant difference was found in the hospitalisation costs. More positive results were observed in controlled trials compared to randomized controlled trials.

Conclusion

By combining all possible results, it can be concluded that care pathways for treatment of heart failure decrease mortality rates and length of hospital stay, but no statistically significant difference was observed in the readmission rates and hospitalisation costs. However, one should be cautious with overall conclusions: what works for one organization may not work for another because of the subtle differences in processes and bottlenecks.

Objective To evaluate the use of healthcare resources during the last six months of life among patients of US hospitals with strong reputations for high quality care in managing chronic illness.

Design Retrospective cohort study based on claims data from the US Medicare programme.

Participants Cohorts receiving most of their hospital care from 77 hospitals that appeared on the 2001 US News and World Report “best hospitals” list for heart and pulmonary disease, cancer, and geriatric services.

Main outcome measures Use of healthcare resources in the last six months of life: number of days spent in hospital and in intensive care units; number of physician visits; percentage of patients seeing 10 or more physicians; percentage enrolled in hospice. Terminal care: percentage of deaths occurring in hospital; percentage of deaths occurring in association with a stay in an intensive care unit.

Results Extensive variation in each measure existed among the 77 hospital cohorts. Days in hospital per decedent ranged from 9.4 to 27.1 (interquartile range 11.6-16.1); days in intensive care units ranged from 1.6 to 9.5 (2.6-4.5); number of physician visits ranged from 17.6 to 76.2 (25.5-39.5); percentage of patients seeing 10 or more physicians ranged from 16.9% to 58.5% (29.4-43.4%); and hospice enrolment ranged from 10.8% to 43.8% (22.0-32.0%). The percentage of deaths occurring in hospital ranged from 15.9% to 55.6% (35.4-43.1%), and the percentage of deaths associated with a stay in intensive care ranged from 8.4% to 36.8% (20.2-27.1%).

Conclusion Striking variation exists in the utilisation of end of life care among US medical centres with strong national reputations for clinical care.

Introduction

This report describes the case mix, outcome and activity (duration of intensive care unit [ICU] and hospital stay, inter-hospital transfer, and readmissions to the ICU) for admissions to ICUs for acute severe asthma, and investigates the effect of case mix factors on outcome.

Methods

We conducted a secondary analysis of data from a high-quality clinical database (the Intensive Care National Audit and Research Centre [ICNARC] Case Mix Programme Database) of 129,647 admissions to 128 adult, general critical care units across England, Wales and Northern Ireland over the period 1995–2001.

Results

Asthma accounted for 2152 (1.7%) admissions, and in 57% mechanical ventilation was employed during the first 24 hours in the ICU. A total of 147 (7.1%) patients died in intensive care and 199 (9.8%) died before discharge from hospital. The mean age was 43.6 years, and the ratio of women to men was 2:1. Median length of stay was 1.5 days in the ICU and 8 days in hospital. Older age, female sex, having received cardiopulmonary resuscitation (CPR) within 24 hours before admission, having suffered a neurological insult during the first 24 hours in the ICU, higher heart rate, and hypercapnia were associated with greater risk for in-hospital death after adjusting for Acute Physiology and Chronic Health Evaluation II score. CPR before admission, neurological insult, hypoxaemia and hypercapnia were associated with receipt of mechanical ventilation after adjusting for Acute Physiology and Chronic Health Evaluation II score.

Conclusion

ICU admission for asthma is relatively uncommon but remains associated with appreciable in-hospital mortality. The greatest determinant of poor hospital survival in asthma patients was receipt of CPR within 24 hours before admission to ICU. Clinical management of these patients should be directed at preventing cardiac arrest before admission.

Background: While several studies have analysed sex and socioeconomic differences in cancer incidence and mortality, sex differences in oncological health care have been seldom considered.

Objective: To investigate sex based inequalities in hospital readmission among patients diagnosed with colorectal cancer.

Design: Prospective cohort study.

Setting: Hospital Universitary in L'Hospitalet (Barcelona, Spain).

Participants: Four hundred and three patients diagnosed with colorectal between January 1996 and December 1998 were actively followed up until 2002.

Main outcome measurements and methods: Hospital readmission times related to colorectal cancer after surgical procedure. Cox proportional model with random effect (frailty) was used to estimate hazard rate ratios and 95% confidence intervals of readmission time for covariates analysed.

Results: Crude hazard rate ratio of hospital readmission in men was 1.61 (95% CI 1.21 to 2.15). When other significant determinants of readmission were controlled for (including Dukes's stage, mortality, and Charlson's index) a significant risk of readmission was still present for men (hazard rate ratio: 1.52, 95% CI 1.17 to 1.96).

Conclusions: In the case of colorectal cancer, women are less likely than men to be readmitted to the hospital, even after controlling for tumour characteristics, mortality, and comorbidity. New studies should investigate the role of other non-clinical variable such as differences in help seeking behaviours or structural or personal sex bias in the attention given to patients.

Objectives To evaluate the evidence for strategies to prevent falls or fractures in residents in care homes and hospital inpatients and to investigate the effect of dementia and cognitive impairment.

Design Systematic review and meta-analyses of studies grouped by intervention and setting (hospital or care home). Meta-regression to investigate the effects of dementia and of study quality and design.

Data sources Medline, CINAHL, Embase, PsychInfo, Cochrane Database, Clinical Trials Register, and hand searching of references from reviews and guidelines to January 2005.

Results 1207 references were identified, including 115 systematic reviews, expert reviews, or guidelines. Of the 92 full papers inspected, 43 were included. Meta-analysis for multifaceted interventions in hospital (13 studies) showed a rate ratio of 0.82 (95% confidence interval 0.68 to 0.997) for falls but no significant effect on the number of fallers or fractures. For hip protectors in care homes (11 studies) the rate ratio for hip fractures was 0.67 (0.46 to 0.98), but there was no significant effect on falls and not enough studies on fallers. For all other interventions (multifaceted interventions in care homes; removal of physical restraints in either setting; fall alarm devices in either setting; exercise in care homes; calcium/vitamin D in care homes; changes in the physical environment in either setting; medication review in hospital) meta-analysis was either unsuitable because of insufficient studies or showed no significant effect on falls, fallers, or fractures, despite strongly positive results in some individual studies. Meta-regression showed no significant association between effect size and prevalence of dementia or cognitive impairment.

Conclusion There is some evidence that multifaceted interventions in hospital reduce the number of falls and that use of hip protectors in care homes prevents hip fractures. There is insufficient evidence, however, for the effectiveness of other single interventions in hospitals or care homes or multifaceted interventions in care homes.

Objectives

Many hospital admissions are due to inappropriate medical treatment, and discharge of fragile elderly patients involves a high risk of readmission. The present study aimed to assess whether a follow-up programme undertaken by GPs and district nurses could improve the quality of the medical treatment and reduce the risk of readmission of elderly newly discharged patients.

Design and setting

The patients were randomized to either an intervention group receiving a structured home visit by the GP and the district nurse one week after discharge followed by two contacts after three and eight weeks, or to a control group receiving the usual care.

Patients

A total of 331 patients aged 78+ years discharged from Glostrup Hospital, Denmark, were included.

Main outcome measures

Readmission rate within 26 weeks after discharge among all randomized patients. Control of medication, evaluated 12 weeks after discharge on 293 (89%) of the patients by an interview at home and by a questionnaire to the GP.

Results

Control-group patients were more likely to be readmitted than intervention-group patients (52% v 40%; p = 0.03). In the intervention group, the proportions of patients who used prescribed medication of which the GP was unaware (48% vs. 34%; p = 0.02) and who did not take the medication prescribed by the GP (39% vs. 28%; p = 0.05) were smaller than in the control group.

Conclusion

The intervention shows a possible framework securing the follow-up on elderly patients after discharge by reducing the readmission risk and improving medication control.

Objective: To determine the effect of a shared care programme on the attitudes of newly referred cancer patients towards the healthcare system and their health related quality of life and performance status, and to assess patients' reports on contacts with their general practitioner (GP).

Setting: Department of Oncology at Aarhus University Hospital and general practices.

Design: Randomised controlled trial in which patients completed questionnaires at three time points. The shared care programme included transfer of knowledge from the oncologist to the GP, improved communication between the parties, and active patient involvement.

Participants: 248 consecutive cancer patients recently referred to the department.

Main outcome measures: Patients' attitudes towards the healthcare services, their health related quality of life, performance status, and reports on contacts with their GPs.

Results: The shared care programme had a positive effect on patient evaluation of cooperation between the primary and secondary healthcare sectors. The effect was particularly significant in men and in younger patients (18–49 years) who felt they received more care from the GP and were left less in limbo. Young patients in the intervention group rated the GP's knowledge of disease and treatment significantly higher than young patients in the control group. The number of contacts with the GP was significantly higher in the intervention group. The EORTC quality of life questionnaire and performance status showed no significant differences between the two groups.

Conclusions: An intersectoral shared care programme in which GPs and patients are actively involved has a positive influence on patients' attitudes towards the healthcare system. Young patients and men particularly benefit from the programme.

Background

The management of patients with surgically incurable bowel cancer at presentation is controversial. The aims of treatment are to optimise quality of life and prolong survival. It has been believed that the most effective palliation is achieved by resection of the primary cancer in order to pre-empt future complications. This study reviews and compares the outcomes of patients with incurable bowel cancer managed by resection and non-resection strategies over a 7-year period in a single District General Hospital.

Patients and methods

All patients with surgically incurable bowel cancer at presentation were identified from the prospectively collected local ACPGBI database. Survival, using Kaplan-Meier method and log-rank test, was compared between patients managed by resection of the primary, non-resectional intervention (surgery, stent & oncological treatments) and those managed with supportive care only. The primary endpoint of the study was survival on an intention to treat basis, compared using Kaplan-Meier and log-rank tests.

Results

Of 646 consecutive newly diagnosed bowel cancer patients over a 7 year period 154 cases (24%) were deemed surgically incurable at presentation. Of these surgical resection was carried out in 45 patients (29%), non-resectional intervention was followed in 52 patients (34%) and supportive treatment alone in 57 patients (37%). Median survival of each group was as follows: resected patients 11 months (I.Q range 3–18 months), non-resectional intervention 7 months (I.Q range 2–15 months) and supportive care alone 2 months (I.Q range 1–8 months). Only one patient (2%) managed by non-resectional intervention required later surgery to treat primary tumour related complications. Survival was not significantly different between resection and non-resection treatments. The overall operative mortality for the resection group was 16% (7/45 cases), with an elective mortality of 14% (4/28 cases) and emergency mortality 18% (3/17 cases).

Conclusion

In an unselected bowel cancer population surgical resection of the primary tumour in patients presenting with incurable disease does not improve survival and is associated with a high risk of post-operative mortality.

Objective

To determine the effectiveness of planned short hospital stays versus standard care for people with serious mental illness.

Design

Systematic review of all randomised controlled trials comparing planned short hospital stay versus long hospital stay or standard care for people with serious mental illness.

Subjects

Four trials enrolled 628 patients.

Main outcomes measures

Relapse; readmission; death (suicides and all causes); violent incidents (self, others, property); lost to follow up; premature discharge; delayed discharge; mental state (not improved); social functioning; patient satisfaction, quality of life, self esteem, and psychological wellbeing; family burden; imprisonment; employment status; independent living; total cost of care; and average length of hospital stay.

Results

Patients allocated to planned short hospital stays had no more readmissions (in four trials, odds ratio 0.93, 95% confidence interval 0.66 to 1.29 with no heterogeneity between trials), no more losses to follow up (in three trials of 404 patients, 1.09, 0.62 to 1.91 with no heterogeneity between trials), and more successful discharges on time (in three trials of 404 patients, 0.47, 0.27 to 0.85) than patients allocated long hospital stays or standard care. Some evidence showed that patients allocated planned short hospital stay were no more likely to leave hospital prematurely and had a greater chance of being employed than those allocated long hospital stay or standard care. Data on mental, social, and family outcomes could not be summated, and there were few or no data on patient satisfaction, deaths, violence, criminal behaviour, and costs.

Conclusion

The effectiveness of care in mental hospitals is important to patients, carers, and policy makers. Despite inadequacies in the data, this review suggests that planned short hospital stays do not encourage a “revolving door” pattern of care for people with serious mental illness and may be more effective than standard care. Further pragmatic trials are needed on the most effective organisation and delivery of care in mental hospitals.

Key messagesThe effectiveness of care in mental hospitals is important to patients, carers, and policymakers irrespective of the quality and quantity of community care and the provision of newer psychotic drugsInpatient costs use around 80% of mental health resources, yet a longstanding record of poor or inadequate evidence on the organisation and delivery of hospital care was highlightedDespite this, planned short hospital stays seem to be as successful, or more so, than standard care: patients experienced no more readmissions and no more losses to follow up and were more likely to be discharged on time than those receiving standard careFurther pragmatic trials are needed that focus on the most effective organisation and delivery of care in mental hospitals

OBJECTIVE: To determine whether financial incentives increase patients' compliance with healthcare treatments. DATA SOURCES: Systematic literature review of computer databases--Medline, Embase, PsychLit, EconLit, and the Cochrane Database of Clinical Trials. In addition, the reference list of each retrieved article was reviewed and relevant citations retrieved. STUDY SELECTION: Only randomised trials with quantitative data concerning the effect, of financial incentives (cash, vouchers, lottery tickets, or gifts) on compliance with medication, medical advice, or medical appointments were included in the review. Eleven papers were identified as meeting the selection criteria. DATA EXTRACTION: Data on study populations, interventions, and outcomes were extracted and analysed using odds ratios and the number of patients needed to be treated to improve compliance by one patient. RESULTS: 10 of the 11 studies showed improvements in patient compliance with the use of financial incentives. CONCLUSIONS: Financial incentives can improve patient compliance.

Objective To determine whether, from a health provider and patient perspective, surgical stabilisation of the spine is cost effective when compared with an intensive programme of rehabilitation in patients with chronic low back pain.

Design Economic evaluation alongside a pragmatic randomised controlled trial.

Setting Secondary care.

Participants 349 patients randomised to surgery (n = 176) or to an intensive rehabilitation programme (n = 173) from 15 centres across the United Kingdom between June 1996 and February 2002.

Main outcome measures Costs related to back pain and incurred by the NHS and patients up to 24 months after randomisation. Return to paid employment and total hours worked. Patient utility as estimated by using the EuroQol EQ-5D questionnaire at several time points and used to calculate quality adjusted life years (QALYs). Cost effectiveness was expressed as an incremental cost per QALY.

Results At two years, 38 patients randomised to rehabilitation had received rehabilitation and surgery whereas just seven surgery patients had received both treatments. The mean total cost per patient was estimated to be £7830 (SD £5202) in the surgery group and £4526 (SD £4155) in the intensive rehabilitation arm, a significant difference of £3304 (95% confidence interval £2317 to £4291). Mean QALYs over the trial period were 1.004 (SD 0.405) in the surgery group and 0.936 (SD 0.431) in the intensive rehabilitation group, giving a non-significant difference of 0.068 (–0.020 to 0.156). The incremental cost effectiveness ratio was estimated to be £48 588 per QALY gained (–£279 883 to £372 406).

Conclusion Two year follow-up data show that surgical stabilisation of the spine may not be a cost effective use of scarce healthcare resources. However, sensitivity analyses show that this could change—for example, if the proportion of rehabilitation patients requiring subsequent surgery continues to increase.

Objective To evaluate the impact and cost effectiveness of a programme to transform adult critical care throughout England initiated in late 2000.

Design Evaluation of trends in inputs, processes, and outcomes during 1998-2000 compared with last quarter of 2000-6.

Setting 96 critical care units in England.

Participants 349 817 admissions to critical care units.

Interventions Adoption of key elements of modernisation and increases in capacity. Units were categorised according to when they adopted key elements of modernisation and increases in capacity.

Main outcome measures Trends in inputs (beds, costs), processes (transfers between units, discharge practices, length of stay, readmissions), and outcomes (unit and hospital mortality), with adjustment for case mix. Differences in annual costs and quality adjusted life years (QALYs) adjusted for case mix were used to calculate net monetary benefits (valuing a QALY gain at £20 000 ($33 170, €22 100)). The incremental net monetary benefits were reported as the difference in net monetary benefits after versus before 2000.

Results In the six years after 2000, the risk of unit mortality adjusted for case mix fell by 11.3% and hospital mortality by 13.4% compared with the steady state in the three preceding years. This was accompanied by substantial reductions both in transfers between units and in unplanned night discharges. The mean annual net monetary benefit increased significantly after 2000 (from £402 ($667, €445) to £1096 ($1810, €1210)), indicating that the changes were relatively cost effective. The relative contribution of the different initiatives to these improvements is unclear.

Conclusion Substantial improvements in NHS critical care have occurred in England since 2000. While it is unclear which factors were responsible, collectively the interventions represented a highly cost effective use of NHS resources.

Background

The assessment of needs for cancer care is a critical step in providing high quality care and achieving cancer patients' and families' satisfaction. Instruments can be used to assess needs and guide cancer care planning. This study discusses the importance of the needs assessment, relationships between needs, satisfaction and quality of life; and reviews the assessment instruments of needs experienced by cancer patients and their families.

Methods

A systematic search was conducted in MEDLINE and CANCERLIT data bases. Instruments were evaluated based on their conceptual and measurement models as well as their demonstrated reliability and validity. The authors also sought information pertaining to instruments' burden of administration and responsiveness. Measures compromised by a lack of published psychometric description were not included.

Results

This search identified 17 patient needs assessment instruments and seven family needs assessment instruments. The development and psychometric proprieties of most of these instruments were well documented. However, data on their responsiveness and burden of administration were scarce.

Conclusions

Each selected instrument meets some but not all of our criteria for validity, reliability, responsiveness and burden. It is questionable whether any instrument can be developed meeting all the requirements. However, there is still a need to continue researching and developing needs assessment instruments leading to effective intervention and improving quality of cancer care.

Background

Readmissions are costly and have implications for quality of care. Studies have been reported to support effects of transitional care programs in reducing hospital readmissions and enhancing clinical outcomes. However, there is a paucity of studies executing full economic evaluation to assess the cost-effectiveness of these transitional care programs. This study is therefore launched to fill this knowledge gap.

Methods

Cost-effectiveness analysis was conducted alongside a randomized controlled trial that examined the effects of a Health-Social Transitional Care Management Program (HSTCMP) for medical patients discharged from an acute regional hospital in Hong Kong. The cost and health outcomes were compared between the patients receiving the HSTCMP and usual care. The total costs comprised the pre-program, program, and healthcare utilization costs. Quality of life was measured with SF-36 and transformed to utility values between 0 and 1.

Results

The readmission rates within 28 (control 10.2%, study 4.0%) and 84 days (control 19.4%, study 8.1%) were significantly higher in the control group. Utility values showed no difference between the control and study groups at baseline (p = 0.308). Utility values for the study group were significantly higher than in the control group at 28 (p < 0.001) and 84 days (p = 0.002). The study group also had a significantly higher QALYs gain (p < 0.001) over time at 28 and 84 days when compared with the control group. The intervention had an 89% chance of being cost-effective at the threshold of £20000/QALY.

Conclusions

Previous studies on transitional care focused mainly on clinical outcomes and not too many included cost as an outcome measure. Studies examining the cost-effectiveness of the post-discharge support services are scanty. This study is the first to examine the cost-effectiveness of a transitional care program that used nurse-led services participated by volunteers. Results have shown that a health-social partnership transitional care program is cost-effective in reducing healthcare costs and attaining QALY gains. Economic evaluation helps to inform funders and guide decisions for the effective use of competing healthcare resources.