Wednesday, February 25, 2009

Pall-Pourri: quality, stroke prognosis, rational prescribing

JAMA continues its Perspectives on Care at the Close of Life series with one on referring patients to high quality palliative care at the end of life. It focuses on the referral process, clinician interaction with palliative consultants, and discusses recent efforts to better define and measure quality of care delivered by palliative care and hospice programs. Like all the PCCL articles it is a relatively chatty discussion and literature review: what I appreciated about this one is that it is a realistic and understandable discussion about the similarities & differences between hospital-based palliative care and hospice programs and would make a useful & safe reference/teaching/marketing tool for those with colleagues who, umm..., still don't seem to get the differences ('we can't get palliative care involved - she still wants treatment').

Minor point/unveiling of my ignorance: the table mentions that mean length of stay in hospice in the US is 2 months with median of 21 days. I had it stuck in my head that the mean was in the 2-3 week range. There is no citation for that figure - please leave a comment if you know where the latest figures are.

Stroke has a paper which gives some general prognostic data on intracerebral hemorrhage. The data come from a prospectively gathered, regional (Italy) stroke registry, and involves following 588 patients with ICH (mean age 74 years). Gross mortality was 35% at 7 days, 50% at 30 days, and 59% at 1 year. This paper offers confirmatory evidence that posterior fossa hemorrhages portend a significantly worse prognosis (hazard ratio for death at 30 days was 1.7; gross rate of mortality was not given). I had not seen hard numbers like this before, and the authors caution that these mortality rates are higher than what has been previously reported, perhaps due to the older age of this cohort.

Clinical Therapeutics and Pharmacology has a paper discussing rational prescribing for patients with limited life-expectancy (free full-text available). It's a mostly theoretical discussion, arguing for a consistent approach which balances benefits, risks, goals, life-expectancy, and time to expected benefits. A good introduction to the topic - teaching file sort of stuff. The image is available is an actually readable size in the original paper.

(From Dr. Lyle Fettig's delicious link-pile.)

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