J M Culebras — Page 4 | PubMed Health

PubMedDate not supplied

[The value of life. Development of an assessment system for therapeutic strategies].

The wide therapeutic supply which a present is available for diverse disorders, together with a excess of indiscriminate scientific information, occasionally complicates the possibility of acquiring a wide experience in the treatment of certain patients (limited experience). To acquire genuinely useful experience, it is necessary to accumulate simiular experiences from our environment, with it being necessary to precisely define, in an objective manner, concepts which until now are difficult to quantify (risk of mortality or morbidity, survival, quality of life, etc.). The definition of these parameters, shall favor the creation of homogenous groups (isoseverity indices), which is the first step in the evaluation of more complex conceps, such as; quality of life, increase of life expectancy, quality adjusted life years (QALY's), and beneficial application, all of which validated in diverse hospital media. Based on the previous, we would obtain other calculated parameters; the benefit (of the patient), the use (of the procedure), and the efficacy (of the physician or the unit). Once these parameters have been standarized, it shall be possible to compare them with the results published in other media, considered to be standards, with the aim of establishing the corresponding self-evaluation. The evaluation of the cost of each process, is a compulsory procedure, to produce, if possible, based on the previous results, a better distribution of the means without a decrease in the quality of assistance. With the aim of evaluating the results in an objective and quantifiable manner, we have worked these last years on developing assessment applied to the evaluation of predictive and isoseverity indices, such as the cost/benefit evaluation in critical, geriatric, and oncological patients, and in those with artificial nutrition in the home. The fruit of this labor has come together in the production of a computerized information system (SAETA), which builds de previously validated modules into is structure, thus permiting the storage and subsequent multifactoral analysis of the results.

Decision Theory↗

PubMedDate not supplied

[Carbohydrates--no glucose--in parenteral nutrition. A fading concept?].

An update is made on the binominal use/benefit of non-glucose carbohydrates (polyalcohols or polyols) in parenteral nutrition. The most recently published results, despite the controversy from different areas, have motivated the updating of the criteria metabolic aspects, indications and contraindications of the different carbohydrates alternatives of glucose (xylitol, sorbitol, glycerol, fructose), in the parenteral nutrition of patients with different degrees of aggression and situations of glucose intolerance or insulin resistance. It is known that, due to causes which are not entirely understood, non-glucose carbohydrates have not yet been considered as effective energy sources alternative to glucose in clinical situations described as unfavorable for their use. However, we may consider that in view of our own experience and that of previous publications, these carbohydrates have not only not decreased their use expectancy but, on the contrary, have increased as their advantages were clinically confirmed, without the appearance of major complications in this therapeutic modality. For this reason we consider that the understanding of the characteristics and the different metabolic aspects (pharmacological dose) of the polyols must make us review their clinical use, both alone as in different combinations.

Fructose↗

PubMedDate not supplied

[Evaluation of the quality of life in artificial nutrition].

If we define quality of life as being the social, physiological, mental intellectual, and general well being of people, we realize that there is no known health care system that is able to guarantee that well being in all its possible aspects. When we as clinicians assess the positive effects of a treatment applied to a patient, we are not only assessing the offered quality of life, but also the quantity of life, so what we are really assessing is the usefulness. We could say, therefore, that while the quality of life is subjective, not exact, and cannot be quantified, the usefulness on the other hand, can and should be measured and quantified, even though, as this is a subjective assessment, it is somewhat difficult to quantify. The object of our publication is to find an appropriate method for assessing this parameter in the area that concerns us: artificial nutrition. Artificial nutrition is indicated when the patient cannot does not want to, or does not know how to eat in the natural manner. Therefore, in principle it could seem inhuman and even unethical to deny a vital support measure that is practically without any risks in a patient who cannot feed him-or herself. However, in a situation of limited resources, if the treatment were inappropriate we should consider that possibility. Under these circumstances we could consider that even a concept as essential as nutrition (in this case artificial) would lose its inalienable character. In order to assess usefulness, one must include parameters that can be quantified in percentages and whose results can be set out in units of time (years, months, or days). We use the concept of the individual usefulness, whose unit of time is the QALY (Quality Adjusted Life Years). In 1996 we made a personal modification of Rosser's Index, which was specific for evaluating the quality of life obtained by means of artificial nutrition. This consisted of substituting the assessment parameters of intensity of pain, by other that are specific in function of the limitation of the ingestion capacity presented by the patient who was subjected to AN. The third factor that corresponds to the concept of usefulness would be the index of beneficial applicability percentage of patients who benefit from the support. The combination of these three factors, applicability, life expectancy, and quality of life, would yield the usefulness of the procedure. In order to assess usefulness in all its aspects, one must also define intention, as this can be applied with three goals: essential or curative, complementary or adjuvant, and maintenance or merely palliative. We can say that the economical limitations and the cost of the therapeutic resources leads to rationing by the administration. In the face of this action, we would recommend a rational and reasonable restriction of the available resources, which lead to the so-called rationalization, a term that is more correct ethically and esthetically, than rationing. As a final conclusion we could state that ethics and economics help us to use the resources appropriately, without any contradictions, as the economy attempts to give the society the greatest possible degree of well being based on the available resources, and that is an ethical objective, The quantification of the benefits obtained by applying a treatment using measureable units, involves socio-economic concepts such as usefulness, cost/benefit, quality of life, etc. should not elicit rejection as though we were dealing with a merchandising of our ethical values. We clinicians are capable of assessing this together, both with regard to the obtained costs and benefits, and with regard to the final results, both intra- and extra-hospital, and using the appropriate tools, we can reach conclusions that can guide us objectively in making decisions, with the aim of optimizing our therapeutic actions.

Costs and Cost Analysis↗