The Use of Healthcare Services by Prostate Cancer Patients in the Last 12 Months of Life: How Do We Improve the Quality of Care During This Period?

INTRODUCTION: Current research on prostate cancer is heavily focused on early detection and new treatments. There is a lack of research on the overall morbidity prostate cancer survivors face and the amount of healthcare treatment they receive toward the end of their lives. Identifying these care needs will allow appropriate healthcare modeling, resource allocation and service re-design to ensure higher quality care toward the end of life. The aim of this study is to quantify and analyze the use of healthcare services by patients dying with but not necessarily of prostate cancer. METHODS: All patients who died with a diagnosis of prostate cancer during a 2-year period at a single hospital were included. Data on outpatient attendances, elective and emergency admissions and palliative care involvement in the 12 months prior to death were collected. RESULTS: A total of 77 patients were included and of these, 60 (78.0%) had 545 scheduled appointments with 473 (86.8%) attendances. More non-attendances occurred in the last 6 months of life; 56 vs 16, p < 0.001. Nurse led clinics doubled in the last 6 months of life, 117 vs 66. There were 173 admissions from 63 (81.8%) patients resulting in 1816 days inpatient stay. This averaged to 2.7 admissions per patient for 10.5 days per episode. 32 (41.6%) patients were seen by palliative care resulting in 192 visits in total. 78 (40.6%) were inpatient and 114 (59.4%) were community reviews. CONCLUSIONS: In the last year of life, prostate cancer patients use a considerable amount of healthcare resources. Understanding this clinical and economical burden is important for healthcare remodeling to provide better quality care that is cost effective.

Management of the distal ureter during nephroureterectomy for upper urinary tract transitional cell carcinoma: a review.

INTRODUCTION: The standard treatment for upper urinary tract transitional cell carcinoma (UUT-TCC) is open radical nephroureterectomy with excision of a bladder cuff. We assess the successful endoscopic completion and oncological efficacy of the various minimally invasive transurethral techniques devised for the management of the intramural ureter during nephroureterectomy. MATERIALS AND METHODS: A comprehensive review of the English literature until February 2009 using the PubMed database returned 42 relevant papers. Five methods of endoscopic management of the distal ureter were identified and compared to the open technique. RESULTS: There are no randomised studies. Successful completion of the endoscopic procedure was less (91%) for the ureteric stripping technique than for the other endoscopic modalities (99.8-100%). Recurrences were highest for laparoscopic extravesical ureteric stapling in conjunction with cystoscopic detachment of the ureter, although the numbers analysed were small. For the other endoscopic modalities, bladder recurrence, positive margins and retroperitoneal recurrence (20-37, 0-4 and 1-3%, respectively) in case series were similar compared with the open method (36, 5 and 3%, respectively). CONCLUSIONS: Current non-randomised evidence is open to selection bias and is insufficient to support or refute endoscopic management of the distal ureter as an alternative to open bladder cuff excision. We highlight the reported inefficiency of the ureteric stripping technique.