Organisation des soins palliatifs en Belgique - KCE

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146 Palliative Care KCE reports 115 curative status. However, their exclusion may have led to an under-estimation of costs. With respect to haematological cancers, patients suffering from Hodgkin’s or non- Hodgkin’s lymphoma were included. However, patients suffering from leukaemia were excluded because leukaemia is considered to be an acute disease that is unlikely to result in an admission to a palliative care unit. Patients from different wards were pooled for the purpose of the cost analysis. Patients who had a hospital stay exceeding six days were enrolled. Nursing home residents who died between 1st July 2007 and 31st December 2007 were included. The starting date of 1st July 2007 was intentionally chosen because invoicing procedures became legally more transparent from that date onwards. Patients who moved to another nursing home or were admitted to the nursing home during the 30 days preceding death were excluded. Home care patients deceased between 1st July 2008 and 1st November 2008 were enrolled. Since the type of pathology influences costs, the study included patients who suffer a chronic disease. This means that acute illness, sudden death and death following therapeutic complications were excluded. Information about the diagnosis of patients was requested to ensure that patients in the three settings (i.e. hospitals, nursing homes and home care) are comparable. A physician (Prof. Menten) and a nurse (Betty Kutten) assessed the real care provided to terminal patients during the last 30 days of their life with a view to determining whether the patient received palliative care or classical care. This assessment was carried out in collaboration with the treating physician and/or nurse. An exclusion criterion was incomplete medical/nursing records. The following decision algorithm was used by the two researchers to label the terminal patients as “palliative” or “classical care” patients in hospitals and in nursing homes. First there in all hospitals and nursing homes a meeting between the researchers and the chief nurse and/or the treating physician(s) or the palliative nurse clarified the institutional attitudes concerning the transition from cure to care. The following points were discussed e.g., availability of written palliative guidelines, use of ‘do not reanimate codes’, practice of advanced care planning in palliative care, management of terminal patients In hospitals, all patient files from the geriatric, cardiology and oncology wards who died between 1st January 2007 and 30th June 2007, were analysed one by one by the two researchers to look for the decision making process in the last 30 days of life. In nursing homes, all files of the patients who died between 1 st July and 31st December 2007 were included. Medical and nursing notes were analysed. Based on these notes the patients were classified in two groups i.e. “classical care” and palliative patients. Then the researchers analysed the administration of drugs, of artificial food and fluid, the diagnostic and therapeutic interventions, the transfers to others wards… to check if the patients effectively received what was planned. If a “classical care” patient received finally just pain and symptom control, he was included in the palliative group although the caregivers did not state they intended to treat the patient as a palliative patient. On the opposite, some patient called “palliative patients” got intensive diagnostic or therapeutic interventions, sometimes started by the physician in charge, sometimes on request of the family: in this case, the patient originally called “palliative patient” was included in the “classical care” group based on what was done really instead of what was intended to do. 11.2.2.2 Selection of settings The study purported to compare costs between palliative care and classical care in three different settings, i.e. hospitals, nursing homes and at home. Therefore, costs were calculated for: • Hospital patients with palliative care; • Hospital patients with classical care; • Hospital patients in palliative care units;
KCE Reports 115 Palliative Care 147 • Nursing home patients with palliative care; • Nursing home patients with classical care; • Home care patients receiving advice from a mobile palliative support team (only patients with palliative care). Home care patients without a mobile palliative support team (i.e. patients with classical care) were excluded due to the small number of such patients in our data collection during this short inclusion period. However, such patients are included in the analysis of health expenditure on palliative home care (cf. infra). 11.2.2.3 Selection of institutions The goal was to include a representative sample of institutions within the settings of hospitals, nursing homes and home care. Choice of hospitals The study included a university hospital, a public hospital and a catholic hospital; one of each type in Dutch-speaking Belgium and one of each type in French-speaking Belgium. Specific hospitals were selected for pragmatic reasons i.e. the Catholic university hospital of Leuven and the public university hospital of Sart Tilman in Liège. Moreover, many hospitals are part of merged institutions with a mixed public-private character: the researchers’ choice was restricted to the few public and catholic hospitals that have a unique character. Finally, it should be noted that “CHR du Val de Sambre” does not have any palliative care unit. Choice of nursing homes The study included public and Catholic (Caritas) nursing homes in Dutch-speaking and French-speaking Belgium. Nursing homes satisfying these criteria were selected for pragmatic reasons. Originally, a distinction was planned between small nursing homes (< 60 beds) and large nursing homes (> 200 beds). Contacts with nursing homes revealed that few (large) institutions that satisfied these criteria were willing to participate in the study. Moreover, small nursing homes had a limited number of eligible patients as such institutions have few deaths over the course of a year. Therefore, the limits were changed to less than 110 beds for small nursing homes and more than 150 beds for large nursing homes. However, the experts consulted in September 2008 argued that the size of the institution was not a relevant factor influencing costs. They also felt that the difference between 110 and 150 beds was too small to allow for a meaningful comparison. Therefore, it was decided that size of institutions had no longer to be taken into account when including institutions in the sample. Choice of home care Networks providing mobile palliative support teams in palliative home care were selected for pragmatic reasons. To this effect, the Delta network (Chênée, Liège) in French-speaking Belgium and the “Palliatief Netwerk Arrondissement Leuven” (PANAL) in Dutch-speaking Belgium were included in the study. Both networks were responsible for a city (Leuven and Liège) and a large rural area so that patients from cities and rural areas could be included. For this reason networks in Brussels and Antwerp were not considered. 11.2.2.4 Sample size To the best of the authors’ knowledge, this is the first study of the costs of palliative care in Belgian hospitals, nursing homes and home care. In the absence of data on the prevalence of terminal patients and on the variance of costs at the time of the study, it was not possible to use statistical formulae to calculate sample sizes or to explore specific hypotheses using statistical tests.
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108. Le Tiotropium dans le traiteme
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