Palliative Care Costs in Different Ambulatory-Based Settings: A Systematic Review.

BACKGROUND: Cost-of-illness studies in palliative care are of growing interest in health economics. There is no standard methodology to capture direct and non-direct healthcare and non-healthcare expenses incurred by health services, patients and their caregivers in the course of the ambulatory palliative care process. OBJECTIVE: We aimed to describe the type of healthcare and non-healthcare expenses incurred by patients with cancer and non-cancer patients and their caregivers for palliative care in ambulatory-based settings and the methodology used to capture the data. METHODS: We conducted a systematic review of studies on the costs of ambulatory-based palliative care in patients with cancer (breast, lung, colorectal) and non-cancer conditions (chronic heart failure, chronic obstructive pulmonary disease, dementia) found in six bibliographic databases (PubMed, EMBASE [via Ovid], Cochrane Database of Systematic Reviews, EconLit, the National Institute for Health Research Health Technology Assessment Database and the National Health Service Economic Evaluation Database at the University of York, and Google Scholar). The studies were published between January 2000 and December 2022. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology for study selection and assessed study quality using the Quality of Health Economic Studies instrument. The study was registered in PROSPERO (CRD42021250086). RESULTS: Of 1434 identified references, 43 articles met the inclusion criteria. The primary data source was databases. More than half of the articles presented data from public healthcare systems (65.12%) were retrospective (60.47%), and entailed a bottom-up costing analysis (93.2%) made from a healthcare system perspective (53.49%). The sociodemographic characteristics of patients and families/caregivers were similar across the studies. Cost outcomes reports were heterogeneous; almost all of the studies collected data on direct healthcare costs (97.67%). The main driver of costs was inpatient care (55.81%), which increased during the end-of-life period. Nine studies (20.97%) recorded costs due to productivity losses for caregivers and three recorded such costs for patients. Caregiving costs were explored through an opportunity cost analysis in all cases, based on interviews conducted with and questionnaires administered to patients and caregivers, mainly via telephone calls (23.23%). CONCLUSIONS: This systematic review reveals that studies on the costs of ambulatory-based palliative care are increasing. These studies are mostly conducted from a healthcare system perspective, which leaves out costs related to patients'/caregivers' economic burden. There is a need for prospective studies to assess this financial burden and evaluate, with strong evidence, the interventions and actions designed to improve the quality of life of palliative care patients. Future studies should propose cost calculation approaches using a societal perspective to better estimate the economic burden imposed on patients in ambulatory-based palliative care.

Manejo perioperatorio del paciente con síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) / Perioperative management of patients with obstructive sleep apnea-hypopnea syndrome (OSAHS)

Resumen Los pacientes con diagnóstico de síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) pueden ser llevados de forma segura a cualquier procedimiento quirúrgico, incluso de manera ambulatoria si tienen control adecuado de sus otras comorbilidades. El tratamiento con presión positiva continúa en vía aérea (CPAP) en pacientes con diagnóstico confirmado disminuye el riesgo de presentar complicaciones cardiovasculares a largo plazo. La sedación debe ser hecha por un anestesiólogo, quien, además, debe vigilar al paciente y disponer del equipo adecuado para atender complicaciones respiratorias emergentes. Se sugiere que, en estos pacientes, los procedimientos sean hechos en el ámbito hospitalario, donde se tenga disponibilidad en la unidad de cuidados post-anestésicos y personal para monitoreo por al menos una hora tras finalizar el procedimiento. El tratamiento con CPAP debe continuar según sea ordenado por el médico tratante. Es importante que desde la valoración preanestésica se identifique a los pacientes con riesgo de SAHOS para lograr trazar un plan anestésico que disminuya las complicaciones a nivel respiratorio y del manejo de la vía área.

Abstract Patients diagnosed with obstructive sleep apnea-hypopnea syndrome (OSAHS) can safely undergo a surgical procedure, even on an outpatient basis, if other comorbidities are adequately controlled. Continuous positive airway pressure (CPAP) treatment in patients with a confirmed diagnosis decreases the risk of long-term cardiovascular complications. Sedation should be done by an anesthesiologist, who must also monitor the patient and have the appropriate equipment to deal with emerging respiratory complications. Procedures undergone by these patients should be performed in a hospital setting, in which a post-anesthetic care unit and staff are available for follow-up, at least for an hour after the procedure ends. CPAP treatment should be continued as ordered by the treating physician. Identifying patients with OSAHS risk during the preanesthetic evaluation is important to propose an anesthetic plan that reduces respiratory complications and improves airway management.

Factores asociados con anestesia regional fallida de plexo braquial para cirugía de extremidad superior / Factors associated with failed brachial plexus regional anesthesia for upper limb surgery

Introduction: Brachial plexus block as an anesthetic technique for upper limb surgery has some advantages over general anesthesia. The technique is widely used in our practice, with high effectiveness and adequate safety profile. However, the relationship between block failure and failure-determining factors has not been measured. Objectives: To identify and quantify brachial plexus block failure-associated factors for upper limb surgery as an initial observation aimed at developing prevention-oriented risk profiles and strategies. Materials and methods: An analytical observational study was conducted by collecting data from electronic medical records of upper limb surgery using brachial plexus block from the San Ignacio University Hospital between 2011 and 2012. Block failures were identified using standardized clinical criteria, measuring potentially associated factors. Dichotomous comparisons were made and uni-and multivariate logistic regression analysis was performed to identify potential statistically significant variables, based on failed cases and successful controls. Results: None of the proposed factors was independently associated with failure of brachial plexus block. A qualitative description of failed cases presented confounding factors associated with local practices and the failure characteristics did not show a clinically plausible trend. Conclusions: There were no factors determined by patient, anesthetic procedure, surgical procedure and operator that could be independently associated with brachial plexus block failure. The suggestion is to fine-tune the definition of failures, not just in the research environment, but in the current clinical practice; to improve the anesthesia records to rise the numbers and the quality of data bases for a quantitative determination of the risk of peripheral regional anesthesia failure and design prevention strategies focused on risk groups.

Introducción: El bloqueo de plexo braquial como técnica anestésica para cirugía de extremidad superior presenta ventajas sobre la anestesia general. Es ampliamente usada en nuestro medio con alta efectividad y adecuado perfil de seguridad. Sin embargo, no existe la cuantificación de las asociaciones entre fallo del bloqueo y factores determinantes del fallo. Objetivos: Identificar y cuantificar los factores asociados al fallo del bloqueo de plexo braquial como observación inicial para crear perfiles de riesgo y estrategias para prevenirlo. Materiales y métodos: Se realizó un estudio observacional analítico, recolectando los datos de historias clínicas de bloqueos de plexo braquial para cirugía de miembro superior del Hospital Universitario San Ignacio de los años 2011-2012, identificando los bloqueos fallidos con criterios clínicos estandarizados, midiendo los factores potencialmente asociados a estos. Partiendo del grupo de fallos (casos) y grupo exitoso (controles) se establecieron comparaciones dicotómicas y análisis de regresión logística con análisis uni- y multivariado para identificar variables con significancia estadística. Resultados: Ninguno de los factores propuestos se asoció de forma independiente al fallo de bloqueo de plexo braquial. La descripción cualitativa de los casos fallidos presenta factores de confusión asociados a prácticas clínicas locales y ninguna tendencia clínicamente plausible en la característica de los fallos. Conclusiones: Ningún factor determinado por el paciente, procedimiento anestésico, procedimiento quirúrgico, operador se asocia de forma independiente a fallo del bloqueo de plexo braquial. Se propone afinar la definición de fallo, no solo en el contexto investigativo, si no en la práctica clínica actual, mejorar los sistemas de registro en anestesia para ampliar en número y calidad las bases de datos que permitan aproximarse cuantitativamente al riesgo de fallo de anestesia regional periférica y plantear estrategias de prevención enfocadas en grupos de riesgo.

¿Dosis bajas de bupivacaina subaracnoidea reducen la incidencia de hipotensión durante la cesárea? / Low dose of bupivacaina subaracnoidea reduce the incident of low blood pressure during the cesarean section?

El bloqueo subaracnoideo es una modalidad de anestesia usada con frecuencia para la realización de cesáreas. Entre los medicamentos utilizados para tal bloqueo, los anestésicos locales (específicamente la bupivacaína) y los opioides solos o combinados son los más frecuentes, con efectividad y seguridad probadas. Se propone cada vez con más frecuencia que las dosis de anestésicos locales sean menores, con el objeto de disminuir la incidencia de hipotensión materna uno de los efectos secundarios más frecuentes y menos deseados con esta técnica. Se tomaron 109 pacientes obstétricas sin patologías concomitantes, programadas para cesárea en la Clínica San Pedro Claver y se aleatorizaron para recibir 12.5 mg ó 7.5 mg de bupivacaína pesada, en todos los casos con 15 mg de fentanil intratecal, hipotetizando que dosis menores disminuirían la incidencia de hipotensión sin afectar la calidad de la anestesia colocada. Se encontró que la incidencia de hipotensión fue 68.6 por ciento en el grupo de 7.5 mg y de 72.4 por ciento en el grupo de 12.5 mg con un RR de 0.94 (IC95 por ciento 0.74 y 1.21). No se pudo demostrar diferencia entre el uso de una u otra dosis de medicamento en relación con la calidad de la anestesia y la aparición de efectos adversos. Se concluye que el uso de cualquiera de las dos dosis es efectivo y seguro en pacientes obstétricas...