Evaluation of an interdisciplinary training program in palliative care: addressing the needs of rural and northern communities.

Our study was a pilot test of an interdisciplinary training program in palliative care to improve the quality of care to terminally ill cancer and AIDS patients in rural and northern communities in Manitoba. The program involved two weeks of intense palliative care training for nurses, social workers, physicians, and volunteers. Four teams were trained during a six-month period. A repeated measures design was used to assess the effectiveness of the program. Results indicated that health professionals' knowledge about care of the dying, care of individuals with HIV/AIDS, and attitudes toward care of the dying improved upon completion of the training program and remained improved three months following the program. Improvements in use of medications, increased attention to family care, increased discussion of DNR orders, and increased consultation related to symptom management were evident following the training program. The parallel training program for volunteers was also judged to be effective.

"We don't do that in palliative care".

Five situations have been presented to consider whether there are interventions which are "not done in palliative care". No attempt was made to cover all possible circumstances. The only limits which emerged are (a) an absolute limitation on criminal action and (b) a relative limitation on non-beneficial treatment. Determination of what is non-beneficial is subject to various considerations: firstly, not recommending non-beneficial interventions; secondly, giving special allowance for experimental interventions in properly conducted trials; and, thirdly, accepting the patient's right to gamble on a trial of therapy.

Policy, resources and practice: a palliative care ward.

The Palliative Care Program undertook a commitment to assure direct admission of patients, terminally ill at home, to inpatient beds. This was accomplished by a priority policy which distinguished Home Care patients from those to be transferred. A simulation enabled us to define a rule for the control of transfers. It also made it possible to anticipate the impact of an increase in demand which might exceed the capacity of the ward and to estimate the size of ward expansion which might be necessary. In fact, the program adjusted to increased demand by modifying both practice and policy, always guided by the boundaries originally identified by the computer simulation. The calculated limits have corresponded remarkably to both the physical resources and to the staff's capacity for work.

Is it normal for terminally ill patients to desire death?

Among 44 terminally ill patients, the majority (N = 34) had never wished death to come early. Of the remainder, three were or had been suicidal and seven more had desired early death. All 10 patients who had desired death were found to be suffering from clinical depressive illness. The methodologic difficulties encountered by the authors were the lack of a brief, efficient interview schedule suitable for debilitated patients and criteria for depressive disorder that do not depend on suicidal thoughts or on symptoms that can also be caused by physical disease.

Acute myocardial infarction: survey of urban and rural hospital mortality.

Mortality rates for acute myocardial infarction (AMI) in the province of Manitoba were studied by a retrospective, randomized survey of urban and rural hospital records. Urban hospitals had formal coronary care unit (CCU). Selected rural hospitals lacked CCUs but usually possessed portable monitoring and defibrillation equipment. Twenty-seven percent of 852 cases in the study population died. The mortality rate for unequivocal AMI was 14% to 15% to both urban and rural hospitals. Patients with possible AMI had high mortality rates in both facilities (41% to 45%). Subgroup analysis of the definite AMI population failed to reveal statistically significant differences in urban vs rural mortality, although a consistent trend toward superior performance in urban centers was found. The magnitude of the potential of a rural hospital intervention program to reduce the AMI mortality nevertheless appeared to be small.

Assessing the impact of tonsillectomies.

This paper explores outcomes associated with the tonsillectomy operation using multiple control groups and a large claims-based data bank from the Canadian province of Manitoba. Given the difficulty of conducting large-scale clinical trials of common surgical procedures, the use of multiple methods for evaluating such interventions is both advocated and implemented in this study. When the data are restricted to respiratory diagnoses, the findings suggest that, on the average, tonsil surgery saves between one half and one and a half episodes of illness per patient over the two years after surgery. Such savings are much more pronounced among individuals having several tonsillitis episodes in the preoperative year. However, when all medical claims are considered, the estimated savings from the tonsillectomy operation are somewhat reduced. Individual variation in predisposition to "see the doctor" appears to account for such results; visits about conditions other than respiratory take up much of the "savings" produced by tonsil surgery. The findings are discussed in terms of the costs and benefits of the tonsillectomy operation, and future research needs are outlined.

Elective surgical rates--do high rates mean lower standards? Tonsillectomy and adenoidectomy in Manitoba.

We used claims data from the Canadian province of Manitoba to test alternative explanations for regional differences in tonsillectomy and adenoidectomy rates. Respiratory morbidity, standards of selection for operation, and surgical resources were compared with elective surgical rates across geographic areas. Statistically significant correlations were not found. Individual practice patterns were then examined. In some regions, a few physicians accounted for the great majority of tonsil/adenoid operations. In other regions, the work was much more widely distributed. Despite great variation among individual physicians in the frequency of performing tonsil/adenoid operations and the standards of selection for operation, use of these procedures and standards applied were only weakly related to such variables as physician age, place of training and specialty.

A new audit prodecure applied to an old question: Is the frequency of T&A justified?

A unique medical audit procedure has been employed to combine the scope of population data with the detail of case histories. All tonsillectomy and adenoidectomy (T&As) in Manitoba for one year were studied. A group of individuals treated for respiratory illness but not having T&As were also identified. Individual histories were reconstructed from medical insurance claims. These cases were reviewed to test conformity between practice and authoritative standards for surgical intervention. The quality of the data on which this procedure depends withstood a battery of challenges. The analysis indicates that most cases selected for surgery lack evidence of meeting authoritative standards. However, a sizeable group of individuals not selcted for surgery perhaps should have been, if the same standards are applied. Also, those physicians performing the most operations had the highest criteria for patient selection.