Use of resources and costs of palliative care with parenteral fluids and analgesics in the home setting for patients with end-stage cancer.
BACKGROUND: In 1992 a home care technology project was started in which infusion therapy in the home setting was made available for patients with end-stage cancer. Beside aspects of feasibility and quality of life the resource utilization and costs of this transition was studied. PATIENTS AND METHODS: We conducted a cost evaluation study, to determine the actual cost of managing patients with endstage cancer who require parenteral administration of fluid or analgesics in the home setting. A total of 128 patients were prospectively followed, with a detailed analysis of some aspects in a sample of 24 patients. RESULTS: The cost for each patient was found to be between $250.00 and $300.00 per day, half of which are for hospital charges, even with this active home care technology program. One-third of the costs can be attributed to primary health care activities, in particular those of the district nurses. A hypothetical control group (n = 25) was constructed based on current practice and chart review. Patients in this group would have cost around $750.00 per day. With a median treatment period of 16 days this means a saving of $8000.00 per patient. CONCLUSION: Our data suggest that significant savings can be obtained by implementing programs transferring palliative care technology to the home setting. (+info)
An operational evaluation of the Community Oral Rehydration Units in Peru.
Since 1984, in Latin America donor agencies and national governments have extensively supported the implementation of the Community Oral Rehydration Units (CORUs) in an attempt to increase the access to oral rehydration therapy and improve the case management of diarrhoea at the community level. This study surveyed 40 CORUs in two regions of Peru to assess their operation, the number of patients with diarrhoea attended, and the knowledge of volunteers in charge. The results show that CORUs were mainly implemented close to existing health centres; the median of case load was 2.0 patients in the preceding month; and the volunteers' knowledge of case management was principally deficient in the diagnosis of hydration status, dietary management and in preventive measures. This lack of knowledge was replicated by professionals at the supervising health centres. Despite the fact that CORUs have been functioning for around four years, they exhibit numerous deficiencies which prevent them from fulfilling their objectives. A global review of the whole CORU strategy is called for. (+info)
Falling diarrhoea mortality in Northeastern Brazil: did ORT play a role?
The impact of oral rehydration therapy (ORT) on the recent decline in diarrhoea mortality in the northeast of Brazil was studied. Proportionate infant mortality fell from 32% in 1980 to 17% in 1989 and infant deaths attributed to diarrhoea dropped from 41% to 25%, resulting in an overall reduction of 57%. Similar decreases were observed for children aged 1-4 years. Diarrhoea admissions also fell from 57% of infant hospitalizations in 1980 to 30% in 1990. None of the other major causes of death or admissions showed such decline. ORT was introduced in the early 1980s, being used in 35% of all episodes in 1991 and in 62% of those regarded as severe by the mother. Other changes included a worsening of socioeconomic conditions and increases in water supply, vaccine coverage, breastfeeding duration and nutritional status. A simulation model estimated that changes in factors other than ORT would lead to a 21% reduction in infant diarrhoea mortality, or about one-third of the actual decline. Finally, an ecological analysis showed that ORT use rates were inversely correlated to infant diarrhoea mortality (r=-0.61; p=0.04). Despite the shortcomings of the available data, these findings suggest an important impact of ORT on diarrhoea mortality. (+info)
The impact of face-to-face educational outreach on diarrhoea treatment in pharmacies.
Private pharmacies are an important source of health care in developing countries. A number of studies have documented deficiencies in treatment, but little has been done to improve practices. We conducted two controlled trials to determine the efficacy of face-to-face educational outreach in improving communication and product sales for cases of diarrhoea in children in 194 private pharmacies in two developing countries. A training guide was developed to enable a national diarrhoea control programme to identify problems and their causes in pharmacies, using quantitative and qualitative research methods. The guide also facilitates the design, implementation, and evaluation of an educational intervention, which includes brief one-on-one meetings between diarrhoea programme educators and pharmacists/owners, followed by one small group training session with all counter attendants working in the pharmacies. We evaluated the short-term impact of this intervention using a before-and-after comparison group design in Kenya, and a randomized controlled design in Indonesia, with the pharmacy as unit of analysis in both countries (n = 107 pharmacies in Kenya; n = 87 in Indonesia). Using trained surrogate patients posing as mothers of a child under five with diarrhoea, we measured sales of oral rehydration salts (ORS); sales of antidiarrhoeal agents; and history-taking and advice to continue fluids and food. We also measured knowledge about dehydration and drugs to treat diarrhoea among Kenyan pharmacy employees after training. Major discrepancies were found at baseline between reported and observed behaviour. For example, 66% of pharmacy attendants in Kenya, and 53% in Indonesia, reported selling ORS for the previous case of child diarrhoea, but in only 33% and 5% of surrogate patient visits was ORS actually sold for such cases. After training, there was a significant increase in knowledge about diarrhoea and its treatment among counter attendants in Kenya, where these changes were measured. Sales of ORS in intervention pharmacies increased by an average of 30% in Kenya (almost a two-fold increase) and 21% in Indonesia compared to controls (p < 0.05); antidiarrhoeal sales declined by an average of 15% in Kenya and 20% in Indonesia compared to controls (p < 0.05). There was a trend toward increased communication in both countries, and in Kenya we observed significant increases in discussion of dehydration during pharmacy visits (p < 0.05). We conclude that face-to-face training of pharmacy attendants which targets deficits in knowledge and specific problem behaviours can result in significant short-term improvements in product sales and communication with customers. The positive effects and cost-effectiveness of such programmes need to be tested over a longer period for other health problems and in other countries. (+info)
The status of ORT (oral rehydration therapy) in Bangladesh: how widely is it used?
During 1980-1990 BRAC, a Bangladeshi non-governmental organization, taught over 12 million mothers how to prepare oral rehydration therapy (ORT) at home with lobon (common salt) and gur (unrefined brown sugar). This was followed by a strong promotion and distribution of prepackaged ORS by various agencies including the government. In 1993 we assessed knowledge of ORT preparation, its local availability and its use for the management of diarrhoea. Over 9000 households in 90 villages were revisited; 306 government outreach health workers, 296 drug sellers, and 237 village doctors were interviewed; 152 government facilities and 495 pharmacies/shops were visited. ORT prepared by mothers in a sub-sample of the households was analyzed for chloride content and interviewers collected information on use of ORT for diarrhoeal episodes occurring in the preceding two weeks. The data quality was assessed through a resurvey of sample respondents within two weeks of the first interview. Over 70% of the mothers could prepare a chemically 'safe and effective' ORS. A significant proportion of these mothers were very young at the time of the mass campaigns using house to house teaching, implying an intergenerational transfer of the knowledge on ORT. ORT was found to be used in 60% of all diarrhoeal episodes, but the rate varied with the type of diarrhoea, being highest for daeria (severe watery diarrhoea) and lowest for amasha (dysentery). Drug sellers and village doctors now recommend ORT much more frequently than before. Members of the medical profession (qualified and unqualified) still lag behind in prescribing the use of ORT. The availability of pre-packaged ORS in rural pharmacies has improved enormously. There is convincing evidence that the widescale promotion in the past of ORS for dehydration in diarrhoea has led to this marked improvement today. Nevertheless the use of rice-based ORS, culturally appropriate messages and the promotion of ORS with food offer opportunities to further improve the utilization of ORT. (+info)
A reassessment of the cost-effectiveness of water and sanitation interventions in programmes for controlling childhood diarrhoea.
Cost-effectiveness analysis indicates that some water supply and sanitation (WSS) interventions are highly cost-effective for the control of diarrhoea among under-5-year-olds, on a par with oral rehydration therapy. These are relatively inexpensive "software-related" interventions such as hygiene education, social marketing of good hygiene practices, regulation of drinking-water, and monitoring of water quality. Such interventions are needed to ensure that the potentially positive health impacts of WSS infrastructure are fully realized in practice. The perception that WSS programmes are not a cost-effective use of health sector resources has arisen from three factors: an assumption that all WSS interventions involve construction of physical infrastructure, a misperception of the health sector's role in WSS programmes, and a misunderstanding of the scope of cost-effectiveness analysis. WSS infrastructure ("hardware") is generally built and operated by public works agencies and financed by construction grants, operational subsidies, user fees and property taxes. Health sector agencies should provide "software" such as project design, hygiene education, and water quality regulation. Cost-effectiveness analysis should measure the incremental health impacts attributable to health sector investments, using the actual call on health sector resources as the measure of cost. The cost-effectiveness of a set of hardware and software combinations is estimated, using US$ per case averted, US$ per death averted, and US$ per disability-adjusted life year (DALY) saved. (+info)
Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery.
OBJECTIVES: To determine whether preoperative optimisation of oxygen delivery improves outcome after major elective surgery, and to determine whether the inotropes, adrenaline and dopexamine, used to enhance oxygen delivery influence outcome. DESIGN: Randomised controlled trial with double blinding between inotrope groups. SETTING: York District Hospital, England. SUBJECTS: 138 patients undergoing major elective surgery who were at risk of developing postoperative complications either because of the surgery or the presence of coexistent medical conditions. INTERVENTIONS: Patients were randomised into three groups. Two groups received invasive haemodynamic monitoring, fluid, and either adrenaline or dopexamine to increase oxygen delivery. Inotropic support was continued during surgery and for at least 12 hours afterwards. The third group (control) received routine perioperative care. MAIN OUTCOME MEASURES: Hospital mortality and morbidity. RESULTS: Overall, 3/92 (3%) preoptimised patients died compared with 8/46 controls (17%) (P=0.007). There were no differences in mortality between the treatment groups, but 14/46 (30%) patients in the dopexamine group developed complications compared with 24/46 (52%) patients in the adrenaline group (difference 22%, 95% confidence interval 2% to 41%) and 28 patients (61%) in the control group (31%, 11% to 50%). The use of dopexamine was associated with a decreased length of stay in hospital. CONCLUSION: Routine preoperative optimisation of patients undergoing major elective surgery would be a significant and cost effective improvement in perioperative care. (+info)
Intraosseous lines in preterm and full term neonates.
AIM: To evaluate the use of intraosseous lines for rapid vascular access in primary resuscitation of preterm and full term neonates. METHODS: Thirty intraosseous lines were placed in 27 newborns, in whom conventional venous access had failed. RESULTS: All the neonates survived the resuscitation procedure, with no long term side effects. CONCLUSION: Intraosseous infusion is quick, safe, and effective in compromised neonates. (+info)