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PubMed2006

Patients and carer experiences of care provision after a diagnosis of lung cancer in Scotland.

INTRODUCTION: This qualitative study was set out to explore experiences of care provision of 60 patients diagnosed with lung cancer and a carer of their choice MATERIALS AND METHODS: Participants were invited to take part in three in-depth interviews over a 6-month period. After considerable sample attrition due to worsening disease or death over the study period, 23 complete patient data sets were available for analysis. Fifteen complete carer data sets were analysed. RESULTS: Four key domains of need were identified: (1) the pathway to confirmation of diagnosis, (2) communication of diagnosis, treatment options and prognosis, (3) provision of co-ordinated, family-oriented care and (4) support away from acute services. Discernable shifts in patients' needs were apparent over time within and across the four domains, illustrating a complex relationship between the categories of need experienced by patients and carers. DISCUSSION: Around the time of diagnosis, the priorities of patients and carers centred around their needs for information about the process of treatment and the options open to them. As time went on, they appeared to experience feelings of greater isolation and physical dependency and were particularly aware of deficiencies in the coordination of supportive care. Many patients appeared to rely on the relationship they had developed with their hospital consultant and, therefore, found it difficult to make the transition into palliative care or at least a more primary-care-led service once treatment was over. CONCLUSION: Data from the study point to the importance of heightening general practitioner awareness of potential signs and symptoms of lung cancer. Findings indicate the need to evaluate the benefits to patients and carers of rapid access to diagnostic tests and results and support the establishment of effective and streamlined supportive care pathways for patients with lung cancer.

Adult↗
PubMed2005

Patient-physician communication in oncology: past, present, and future.

PURPOSE OF REVIEW: Contemporary oncology practice acknowledges the importance of partnering with the patient and family in dealing with the illness. Patients also value their physicians as important sources of support when they provide information about the illness, encouragement, and hope, discuss treatment options, and address their concerns. For this reason outcomes associated with the quality of the physician-patient relationship have received increasing recognition. This review highlights relevant studies bearing on important outcomes of communication with the cancer patient and discusses the implication for training oncologists of the future. RECENT FINDINGS: Evidence is mounting that effective and empathic communication with the cancer patient and family can influence desirable outcomes in cancer care, which affect patient quality of life, satisfaction with care, and medical outcomes. Evidence also exists that communication and interpersonal skills can be taught and learned. Oncology training programs traditionally do not offer experience in this aspect of care although communication skills have now been defined as a core competency for oncology trainees. Finding motivated faculty to teach and providing time and structure in the curriculum are also major obstacles to be overcome. SUMMARY: Communication skills are the cornerstone of comprehensive cancer care. Learning this aspect of patient care can expand the supportive role of the oncologist especially at crucial times for the patient and family such as diagnosis, disease recurrence, and transition to palliative care.

Communication↗
PubMed2003

Health, life expectancy, and health care spending among the elderly.

BACKGROUND: Life expectancy among the elderly has been improving for many decades, and there is evidence that health among the elderly is also improving. We estimated the relation of health status at 70 years of age to life expectancy and to cumulative health care expenditures from the age of 70 until death. METHODS: Using the 1992-1998 Medicare Current Beneficiary Survey, we classified persons' health according to functional status and whether or not they were institutionalized and according to self-reported health. We used multistate life-table methods and microsimulation to estimate life expectancy for persons in various states of health. We linked annual health care expenditures with transitions between health states. RESULTS: Elderly persons in better health had a longer life expectancy than those in poorer health but had similar cumulative health care expenditures until death. A person with no functional limitation at 70 years of age had a life expectancy of 14.3 years and expected cumulative health care expenditures of about 136,000 dollars (in 1998 dollars); a person with a limitation in at least one activity of daily living had a life expectancy of 11.6 years and expected cumulative expenditures of about 145,000 dollars. Expenditures varied little according to self-reported health at the age of 70. Persons who were institutionalized at the age of 70 had cumulative expenditures that were much higher than those for persons who were not institutionalized. CONCLUSIONS: The expected cumulative health expenditures for healthier elderly persons, despite their greater longevity, were similar to those for less healthy persons. Health-promotion efforts aimed at persons under 65 years of age may improve the health and longevity of the elderly without increasing health expenditures.

Activities of Daily Living↗
PubMed1996

Ambulatory infusional cancer chemotherapy: nursing role in patient management. The Cancer Center of Boston.

The role of nursing in infusional cancer chemotherapy (ICC) may vary depending on the practice setting. Nurses in free-standing centers and office practices perform many duties that nurses in other facilities may not, because of the lack of many of the supports that benefit hospitals with their multidepartmental and hierarchical structures. Nurses function collaboratively with physicians in the planning and the implementation of patient treatment. Patient-related nursing responsibilities include patient/family education, drug preparation and administration, patient assessment for treatment toxicity, recognition and management of complications related to the catheter or infusion device, and telephone triage. Other duties more removed from patient care might include inventory management, research data collection and management, quality assurance and improvement, compliance with regulatory issues, and a myriad of other responsibilities. The transition of patient care to the outpatient setting has broadened the scope of nursing to include nonpatient care responsibilities due to financial constraints brought about by health care reform, changes in reimbursement patterns, and overhead required to maintain and deliver quality patient care. As a result of nursing responsibilities, it becomes paramount that the aforementioned constructs for program support are in place and that all nurses are consistently trained and have a template to follow for patient treatment and management. Nursing ability to perform patient-related tasks should be proven by formal written and practical competencies repeated annually and as procedural changes are implemented. The paragraphs to follow suggest nursing management of patients receiving ICC using a model developed at The Cancer Center of Boston (TCC).

Ambulatory Care↗
PubMedDate not supplied

Home care of the high-risk newborn.

When a newborn at high risk because of prematurity is discharged from the hospital, the family involved faces a time of crisis. Because parents experience increased stress during the transition to home care, both the parents and their infant are vulnerable to the effects of the added stress on the family's health and well-being. Community nursing intervention is a necessary component of care for the family of a high-risk newborn. Nursing strategies that address specific counseling and teaching needs of the family of a high-risk newborn are presented.

Counseling↗
PubMed2007

The importance of transitions between dialysis and transplantation in the care of end-stage renal disease patients.

Analyses describing outcomes of kidney transplantation usually exclude the survival of wait-listed patients and dialysis patients with failed kidney transplants, and thus reflect only a portion of the typical transplant process. We determined death rates during the continuum of wait-listing, transplantation, and after allograft failure among adult end-stage renal disease patients in the United States between 1995 and 2003. Before transplantation, death rates increased with longer waiting times. Death rates were lowest during the period of allograft function and highest after allograft failure. Patients were at particularly high risk during periods of transition between dialysis and transplantation (death rates during the peri-transplant period and during the re-initiation of dialysis after transplant failure were 8.2/100 patient-years (95% confidence interval (CI) 7.7, 8.8) and 17.9/100 patient-years (95% CI 15.7, 20.3), respectively compared to 6.4/100 patient-years (95% CI 6.25, 6.51) during the period of wait-listing. Diabetic patients and older patients were at increased risk at all time points. The most common known cause of death in all age subgroups was cardiovascular disease. The proportion of death owing to sepsis was greatest after allograft failure (16.8% of all deaths were due to sepsis compared to 14.0% during wait-listing, and 12.7% during the period of allograft function). Consideration of the entire transplant experience as a whole should help to focus patient care on periods of particularly high risk, and emphasizes opportunities to improve outcomes by strategies aimed at preventing death owing to cardiovascular and infectious causes.

Adolescent↗
PubMed2005

A case study on easing an institutional bottleneck in aged care.

This is a case study about a cross-sector Interim Health Care Strategy (IHCS) developed by a Victorian metropolitan health service in partnership with a private residential facility and a community agency to provide a range of transitional or interim care initiatives for public hospital patients awaiting permanent residential care after completing acute or subacute treatment, Australia. The aims were to improve access to emergency and acute inpatient services, while meeting the needs of residential care clients in the metropolitan suburbs. The components included care within a residential care facility, community-based interim care and a subsequent Extended Rehabilitation Program. This IHCS has shown how a cross-sector initiative can improve care and outcomes of patients awaiting residential care placement. The case study shows how a multifaceted strategy that built upon existing relationships with strong planning, organisational commitment and a facilitating structure was successful in improving care integration.

Aged↗
PubMed1999

Academic medical centers: a prescription for success in an era of managed care and capitation.

Academic medical centers (AMCs) have traditionally symbolized technological advancements and specialization in patient care. AMCs are defined as institutions that include at a minimum a hospital and associated clinics and a medical education role. Today, these institutions face a transition to managed care and radical changes in the financing of health care. These issues are not unique to the private sector health care industry. Military AMCs also must respond to many of the same changes. Their survival may rest on the ability to recognize that they can no longer ignore trends favoring lower costs, less specialization, and more primary care. This paper describes actions being taken at AMCs throughout the country to pursue innovative ways of providing accessible, high-quality, and affordable health care while maintaining quality training programs. Besides examining changes currently taking place within the academic medical industry, recommendations are offered for new initiatives.

Academic Medical Centers↗
PubMed1996

Hospice and palliative care: program needs and academic issues.

With the renaissance of interest in how best to care for patients with terminal illness comes the need to recognize palliative care and hospice programs as the completion of comprehensive cancer care, not as its antithesis. In practical terms, admission to a hospice program is appropriate when efforts to control the biologic disease have ceased to be helpful and the primary medical focus is on symptom control and quality of life. In this article, the authors explore the goals of palliative care, review the transition to a hospice program, and assess the Medicare Hospice Benefit. Furthermore, they reflect on the importance of and barriers to the appropriate adoption of palliative care programs as well as palliative care education in oncology.

Comprehensive Health Care↗
PubMedDate not supplied

Foster youth transitions to adulthood: a longitudinal view of youth leaving care.

The well-being of youths who age out of the out-of-home care system in the U.S. has long been of great interest to child welfare practitioners and policymakers. In spite of this interest, however, very little is known about how these youths fare when they must make the transition to independence. The Foster Youth Transitions to Adulthood Study is tracking the experiences of 141 young adults who left care in Wisconsin in 1995 and 1996. This article describes these youths and their experiences in the first 12 to 18 months after leaving care. The findings suggest that the transition to independence is a difficult time for youth leaving the out-of-home care system.

Activities of Daily Living↗
PubMed2003

Transitioning the patient with Turner's syndrome from pediatric to adult care.

The level of medical and neuropsychological complexity throughout the life span of a patient with Turner's syndrome (TS) provides the rationale for a more structured transition from pediatric to adult health care. During late adolescence, the focus of care shifts from maximizing final adult height to completing feminization with estrogen therapy, detecting early antecedents of associated adult conditions, implementing needed therapeutic lifestyle changes, and assessing psychobehavioral risk. An increased prevalence of the dysmetabolic syndrome and osteoporosis is observed in TS. The prevention of obesity and assurance of adequate calcium intake and weight-bearing activities combined with early detection and treatment of specific abnormalities can ameliorate these associated adult morbidities. During the final phase of transition, the pediatric endocrinologist should engage the patient with TS in developing a comprehensive adult care roadmap or 'transition passport', which serves as a powerful educational tool. The aim of refining the transition process is to improve adult outcomes and quality of life for patients with TS.

Adolescent↗
PubMed1994

Health seeking behaviour and self-treatment for common childhood symptoms in rural Guatemala.

This study was conducted in the Guatemalan highland department of Sacatepequez, in a sample of 146 rural women insured by the Social Security system. It examined their health care behaviour when their children presented common childhood symptoms such as diarrhoea, fever, cough and worms. The mothers generally sought help and treatment advice from an older woman in the family, and did so more often for diarrhoea (82%) and fever (64%) than for cough (43%) or worms (28%). Obtaining advice in a pharmacy or from a drug seller ranked second (range: 8%-38%, depending on the symptom), before the procurement of professional help at a medical service (range: 8%-23%). Traditional healers were hardly consulted (range: 0%-3%). In the case of self-treatment the women predominantly relied on Western drugs: around 80% in diarrhoea and fever, and above 50% in cough. Herbs and traditional external remedies were little used, except in cough (27% herbs) and worms (58% external remedies). None of the mothers reported ORS as home treatment for diarrhoea. Problems of geographical or financial accessibility could not explain the low utilisation of the Western health care system. The acceptability of public services, however, was poor. Largely because the Social Security clinic did not prescribe the "potent" modern drugs mothers preferred for the treatment of childhood symptoms--at least, not for uncomplicated illness episodes. Women hence turned to the--partially informal--private sector, which unabashedly responds to their demands. Clear away the discrepancy between the "rational" needs perceived by the official health sector and the demands of the population is one of the bigger challenges to health care planning in transitional communities such as the one studied.

Adult↗
PubMed1991

Palliative care. The nurse's role in helping families through the transition of "fading away".

Oncology nurses are finding themselves increasingly involved in providing palliative care. A foundational tenet of palliative care is that the entire family, not just the patient, is the unit of care. Although nursing literature on care of the family is growing, nursing approaches tend to be described in general terms. A recent study of families caring for a member with advanced cancer generated a theoretic scheme which indicated that the families' experience could be conceptualized as a transition: the transition of fading away. This theoretic scheme served as the foundation for identifying nursing approaches which could be helpful to families engaged in the transition. This paper expands on the nursing approaches so that nurses may be better prepared to help families through the transition of fading away.

Adaptation, Psychological↗
PubMed2004

[Multidimensional impacts of transitional mid-life healthcare].

Mid-life transition is a passage from young adulthood to old age, which can be expressed from transition concept--five attributes and four types of transitions. Mid-life changes that occur over several years, usually between the ages of 40 and 60. Common "disconnectedness" issues during this period such as menopause will occur during mid-life. Individuals become increasingly aware of the special nature of physiological and psychological changes that take place, and express a complex combination of feelings and response patterns in light of these changes. Middle-aged adults often face multidimensional issues related to developmental transition, changes in family structure related to organization transitions, life events related to situational transitions, and perimenopausal changes related to health transitions. Nurses who provide care to middle-aged clients need to consider transitional issues from a multidimensional and holistic perspective.

Adult↗
PubMed2002

Family perspectives on the quality of pediatric palliative care.

BACKGROUND: As a prelude to establishing a Pediatric Palliative Care Program, we solicited information from families about their experiences and their suggestions for improving the quality of end-of-life care. Participants were English- and Spanish-speaking family members of deceased pediatric patients who received care at Lucile Salter Packard Children's Hospital, Stanford University Medical Center, Palo Alto, Calif. METHODS: Sixty-eight family members of 44 deceased children were interviewed regarding treatment, transition to palliative care, and bereavement follow-up. Four clinical social workers and one clinical psychologist reviewed the participants' responses and identified frequently occurring themes. RESULTS: Several areas of unsatisfactory interactions with staff were identified: confusing, inadequate, or uncaring communications regarding treatment or prognosis; preventable oversights in procedures or policies; failure to include or meet the needs of siblings and Spanish-speaking family members; and inconsistent bereavement follow-up. A discrepancy emerged between the high degree of pain described by the families and parents' perceptions that pain had been managed well. Community hospice programs are frequently poorly prepared to serve pediatric patients. CONCLUSIONS: There is a need to improve pediatric palliative care. Recurring themes in the family interviews suggest useful issues to consider in the development of a palliative care program.

Adolescent↗
PubMed1996

Lower utilization of dermatologists in managed care: despite growth in managed care, visits to dermatologists did not decrease: an analysis of National Ambulatory Medical Care Survey data, 1990-1992.

Growth of managed care and the decline of direct access are two of the major issues confronting dermatology. Previous study has demonstrated that patients in managed care are less likely than patients with indemnity insurance to see a dermatologist for skin problems, and it was predicted that this would result in a slowing in the demand for dermatologist services. To examine whether the changing health-care environment has resulted in fewer visits to dermatologists, we used National Ambulatory Medical Care Survey data from the years 1990-1992 to examine utilization of dermatologist services over a period in which managed care grew by 32%. Patients with HMO/prepaid insurance were less likely to have their skin care provided by dermatologists than patients with commercial insurance (Blue Cross/Blue Shield and other commercial carriers) or Medicare. A reduction in the number of visits to dermatologists was observed among patients with HMO/prepaid insurance despite the growth in HMO/prepaid insurance as a form of payment; when all payors were considered, however, the number of visits to dermatologists increased from the 1989 level, reaching a plateau in 1992. The number of visits for skin disease to all physicians increased from 56.5 million to 63.5 million, whereas the proportion of this care delivered by dermatologists decreased from 39.6% to 37.9%. The overall increase in visits for skin conditions tempered the reduction in demand for dermatology services expected with the growing transition to managed care.

Dermatology↗
PubMed2004

Implementation of the diagnosis procedure combination in specific-function hospitals.

A Nobel medical payment system, the Diagnosis Procedure Combination (DPC), was implemented in Nippon Medical School Hospital and 81 other specific-function hospitals in 2003. This payment system depends on the length of hospital stay and diagnosis and medical procedures, and differs from the existing payment system, which depends on a piece rate. The daily payment differs for among almost 2,500 groups of DPC defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10), and procedures, such as operations (K and J codes of the existing payment system). One of the most important outcomes may be a decrease in lengths of hospital stay, because the range of mean lengths of stay in specific-function hospitals has been officially stated to be 14 to 30 days, and the difference between the longest and shortest mean is almost double. The new medical payment system should stimulate competition among hospitals. In order to decrease the length of stay, we developed clinical pathways for patients undergoing surgery, such as laparoscopic cholecystectomy, gastrectomy, and inguinal hernia operations, as well as clinical protocols for the surgical procedures, such as percutaneous transhepatic cholangiodrainage (PTCD) and percutaneous endoscopic gastrostomy (PEG). Health care is undergoing a challenging transition, and we must improve patient care and clinical practice.

Critical Pathways↗