The association between palliative care team consultation and hospital costs for patients with advanced cancer: An observational study in 12 Dutch hospitals.

BACKGROUND: Early palliative care team consultation has been shown to reduce costs of hospital care. The objective of this study was to investigate the association between palliative care team (PCT) consultation and the content and costs of hospital care in patients with advanced cancer. MATERIAL AND METHODS: A prospective, observational study was conducted in 12 Dutch hospitals. Patients with advanced cancer and an estimated life expectancy of less than 1 year were included. We compared hospital care during 3 months of follow-up for patients with and without PCT involvement. Propensity score matching was used to estimate the effect of PCTs on costs of hospital care. Additionally, gamma regression models were estimated to assess predictors of hospital costs. RESULTS: We included 535 patients of whom 126 received PCT consultation. Patients with PCT had a worse life expectancy (life expectancy <3 months: 62% vs. 31%, p < .01) and performance status (p < .01, e.g., WHO status higher than 2:54% vs. 28%) and more often had no more options for anti-tumour therapy (57% vs. 30%, p < .01). Hospital length of stay, use of most diagnostic procedures, medication and other therapeutic interventions were similar. The total mean hospital costs were €8,393 for patients with and €8,631 for patients without PCT consultation. Analyses using propensity scores to control for observed confounding showed no significant difference in hospital costs. CONCLUSIONS: PCT consultation for patients with cancer in Dutch hospitals often occurs late in the patients' disease trajectories, which might explain why we found no effect of PCT consultation on costs of hospital care. Earlier consultation could be beneficial to patients and reduce costs of care.

Clinical tests for the evaluation of postural instability in patients with parkinson's disease.

OBJECTIVE: To determine which test for postural instability in Parkinson's disease (PD) is reliable, valid, and easy to perform in a clinical setting. DESIGN: Cross-sectional reliability and validity study. SETTING: Academic center for movement disorders. PARTICIPANTS: Forty-two patients with PD and 15 controls. Based on the results of a structured interview, the patients were divided in PD-unstable (n=22) and PD-stable (n=20) groups. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Several variants of the retropulsion test with differences in execution and scoring. Responses were scored on 5 different rating scales (ratings of Nutt, Bloem, Pastor; the Unified Parkinson's Disease Rating Scale [UPDRS]; the Short Parkinson Evaluation Scale). These tests were compared with steady-stance positions. RESULTS: The interrater reliability was high for most ratings, with weighted kappa ranging from.63 for the UPDRS to.98 for both the Pastor rating and steady-stance positions. Most ratings distinguished between the groups. However, the Nutt rating had the highest overall predictive accuracy, with a sensitivity of.63 and a specificity of.88. CONCLUSIONS: The most valid test for postural stability in PD was an unexpected shoulder pull, executed once, with taking more than 2 steps backward considered abnormal. This retropulsion test is easy to use in a clinical setting.

DDT and DDE exposure in mothers and time to pregnancy in daughters.

Reproductive-tract anomalies after administration of the potent oestrogen, diethylstilboestrol, in pregnant women raised concerns about the reproductive effects of exposure to weakly oestrogenic environmental contaminants such as bis[4-chlorophenyl]-1,1,1-trichloroethane (p,p'-DDT) or its metabolites, such as bis[4-chlorophenyl]-1,1-dichloroethene (p,p'-DDE). We measured p,p'-DDT and p,p'-DDE in preserved maternal serum samples drawn 1-3 days after delivery between 1960 and 1963. We recorded time to pregnancy in 289 eldest daughters 28-31 years later. Daughters' probability of pregnancy fell by 32% per 10 microg/L p,p'-DDT in maternal serum (95% CI 11-48). By contrast, the probability of pregnancy increased 16% per 10 microg/L p,p'-DDE (6-27). The decreased fecundability associated with prenatal p,p'-DDT remains unexplained. We speculate that the antiandrogenic activity of p,p'-DDE may mitigate harmful androgen effects on the ovary during gestation or early life.