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AIM: To describe the cost of palliative day care (PDC), assessing the value of all resources whether paid for or not. To examine different patterns of resource use resulting from attending PDC. METHODS: Five PDC centres in southern England provided detailed cost and resource use data, both paid and unpaid for. The PDC group were consecutive new referrals to a PDC centre who were well enough to be interviewed. The comparison group were recruited from home care teams. Data were collected at baseline, six to eight weeks and 12-15 weeks, on health and social care utilization in the month prior to interview. Data were divided into cohorts based on time from first interview to death and analysed separately. MAIN OUTCOMES: Annual cost of running a day care centre, and cost per patient per day. Use of all health and social care resources over time, stratified by time from death. Comparison of health and social care by stage of illness, and by PDC attendance. RESULTS: PDC cost around pound 54 per person per day in 1999, rising to pound 75 including unpaid resources. 145 patients had data on health and social care use. The patterns of care showed that, overall, patients accessed few services other than PDC. Comparison group patients did not access similar services elsewhere. PDC might substitute home nursing and GP care for patients who attend PDC at least three months before death but this data is not conclusive. Inpatient care was negligible for both groups. CONCLUSIONS: A full economic evaluation could not be undertaken without robust evidence of the effectiveness of PDC. PDC centres made use of resources that were not paid for and shared resources with inpatient units, reducing costs. Service use was different for patients who attended compared with patients who did not. Similar services were not accessed elsewhere in the community; PDC does not appear to replicate other services for this group of patients. [ABSTRACT FROM AUTHOR]

Summarizes findings of studies which assess the cost-effectiveness of palliative care teams. Strengths and weaknesses of the teams; Evolution of economic evaluation in defining and measuring the costs and benefits of palliative care; Quality of the studies.

Examines the effectiveness of palliative care teams in Great Britain, using `grey literature' as sources. Assessment of the suitability of grey literature; Types of grey literature used.

Evaluates the effectiveness of palliative day care offered in specialist palliative care centers in England's North and South Thames region. Types of patients receiving day care; Comparison between the centers; Patients' level of awareness about day care hospice.

To evaluate the effectiveness of palliative day care in improving pain, symptom control, and quality of life (QOL), 120 consecutive new referrals to five specialist palliative day care centers were recruited into a prospective comparative study. Fifty-three comparison patients were identified as those patients receiving usual palliative care services (home care, inpatient care), but did not attend day care. Patients were assessed at 3 interviews (baseline, 6-8 weeks, and 12-15 weeks) using measures of health-related quality of life: McGill Quality of Life Questionnaire (MQOL) and Palliative Care Outcome Scale (POS). There were two main analyses: 1) patient demographic data were analyzed using chi-square (chi(2)), and 2) QOL data were compared, based on distribution of scores, using the Mann-Whitney test (MQOL and POS), and Wilcoxon Signed Rank for within group differences (POS data only); P < 0.05 was taken as significant. The patients were representative of those attending palliative day care in the UK. At baseline, the day care group were (non-significantly) worse than the comparison group in the MQOL support domain (P = 0.065). The comparison group had marginally more severe pain at baseline (P = 0.053) and more severe symptoms at second assessment (P = 0.025). Both patient groups maintained overall health-related quality of life during the three months of the study. Palliative day care was not found to improve overall health-related quality of life. The limitations of the QOL measures in identifying the effects (patient outcomes) of palliative day care and the differences between the two patient groups (age, employment, unequal sample sizes) were limitations of the study and indicate the need for further research in this area. [ABSTRACT FROM AUTHOR]

Palliative care provision varies widely, and the effectiveness of palliative and hospice care teams (PCHCT) is unproven. To determine the effect of PCHCT, 10 electronic databases (to 2000), 4 relevant journals, associated reference lists, and the grey literature were searched. All PCHCT evaluations were included. Anecdotal and case reports were excluded. Forty-four studies evaluated PCHCT provision. Teams were home care (22), hospital-based (9), combined home/hospital care (4), inpatient units (3), and integrated teams (6). Studies were mostly Grade II or III quality. Funnel plots indicated slight publication bias. Meta-regression (26 studies) found slight positive effect, of approximately 0.1, of PCHCTs on patient outcomes, independent of team make-up, patient diagnosis, country, or study design. Meta-analysis (19 studies) demonstrated small benefit on patients' pain (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.23-0.64), other symptoms (OR: 0.51, CI: 0.30-0.88), and a non-significant trend towards benefits for satisfaction, and therapeutic interventions. Data regarding home deaths were equivocal. Meta-synthesis (all studies) found wide variations in the type of service delivered by each team; there was no discernible difference in outcomes between city, urban, and rural areas. Evidence of benefit was strongest for home care. Only one study provided full economic cost-benefit evaluation. This is the first study to quantitatively demonstrate benefit from PCHCTs. Such comparisons were limited by the quality of the research. [ABSTRACT FROM AUTHOR]

Palliative day care (PDC) provides individualized care to meet patients' needs and preferences and has posed problems for economic evaluation. Current methods are limited in their ability to capture relevant outcomes. The choice experiment elicits preferences for multiple aspects of care rather than a single outcome. A choice experiment was undertaken at four centers in England. A random effects probit model was used. Interaction terms relating to patient and service characteristics were explored. Seventy-nine patients participated. All characteristics of PDC except bathing and hairdressing were significant (P < 0.001). Access to specialist therapies was three times as important as medical support and twice as important as staying all day. Interaction terms were not significant, except for age and preference for specialist therapies, although the sample may not have been adequate to detect differences. Choice experiments provided useful insights by quantifying preferences for services, providing an alternative to cost-effectiveness analysis.

The goals of the work described in this paper were to describe palliative day care from the patient's perspective. Five palliative day care centres in the UK are described. The study subjects were new referrals to the five palliative day care centres, which provided facilities for medical and nursing assessment and also for social and therapeutic activities. This reflects the range of palliative day care services provided in the London region. Three interviews were carried out with each patient over a 3-month period. The descriptive data were examined for content, and the themes were analysed for the frequency of responses within and between interviews. The responses were also examined within three different models of day care (defined by the services). In all, 120 day care patients were recruited from the five centres. Patients attending for day care were mainly white, over 65 years old, retired, and with a cancer diagnosis. These were a representative sample of day care patients in the London region. Patients attended day care to 'meet people' and 'get them out of home' and found the environment 'nice and friendly'. The relationships with the staff and volunteers were also important, and they enjoyed the various activities. At each interview the most important theme identified was 'meeting people'. For this to be supported it would mean encouraging the activities within day care that provide patients with an environment in which they can meet people. This will mean different things to different people, as highlighted in the different philosophies obtained at individual centres.

This review aimed to identify and appraise all systematic reviews of palliative care services, to examine their findings in relation to methods used, and to explore whether further methods such as meta-analysis and meta-regression may be worthwhile. Ten databases were searched and augmented by hand searching specific journals, contacting authors, and examining the reference lists of all papers retrieved. Five systematic reviews met the inclusion criteria, and the update electronic search identified a further systematic review which found similar studies. A total of 39 studies were identified by the five systematic reviews. Of the 39 studies, 15 were RCTS, and 12 of those were North American. In comparison, the majority of U.K. studies were retrospective. Each review concluded similarly that there was a lack of good quality evidence on which to base conclusions. The more recent reviews were more rigorous, but none used a quantitative analysis. Despite the difficulties in combining heterogeneous interventions and outcomes in meta-analysis or meta-regression, such techniques may be valuable. More high quality evidence is needed to compare the relative merits of the differences in models of palliative care services, so that countries can learn from other appropriate systems of care at end of life.

A systematic review into palliative care team effectiveness was undertaken which has, inherent in its methodology, grey literature searching. Over 100 letters were written to a systematically chosen range of service providers, commissioners, and experts in combination with requests for information in six UK national cancer/palliative care organization newsletters. In addition, the System for Information on Grey Literature (SIGLE ) database was searched. As a result, 25 document hard copies were received. The documents were, in all but one case (this one study was also highlighted by the SIGLE search), not relevant as they were predominated by annual reports, service descriptions, and needs assessments. In terms of obtaining unpublished studies for possible inclusion in the review, this comprehensive search was unsuccessful and, therefore, it would appear that grey literature searching is not a useful tool in palliative care systematic reviews.

Objective: To assess the cost effectiveness of adding universal hepatitis B vaccination in infancy or pre-adolescence to a policy of selective vaccination of at risk groups., Design: Costs of a selective policy and additional costs of universal vaccination policies were estimated from costs of vaccine delivery and published data on target populations. Additional years of life gained were calculated for each policy by applying life tables to estimates of mortality attributable to hepatitis B., Setting: England and Wales., Results: Compared with no vaccination, vaccination in infancy was the most cost effective followed by vaccination in preadolescence. Selective vaccination was the least effective (cost per year of life gained 2568 pounds, 2824 pounds, and 8564 pounds respectively). Adding vaccination in infancy or at pre-adolescence to a selective policy cost 1537 pounds or 1658 pounds per year of life gained. Discounting years gained in the future at 6% per annum, however, made pre-adolescent vaccination more cost effective than infant or selective vaccination (51,817 pounds, 94,821 pounds, and 124,779 pounds per discounted year of life gained). Adding pre-adolescent vaccination to a selective policy cost 32,125 pounds per discounted year of life gained and infant vaccination, 77,085 pounds., Conclusions: Universal vaccination against hepatitis B was more cost effective than selective vaccination in a low prevalence country. Discounting future health gain, however, made universal infant vaccination lest cost effective than universal pre-adolescent vaccination. If future health gained is as important as present gain the addition of universal vaccination to a selective policy is equivalent to the cost per quality adjusted year of life from renal transplantation or breast cancer screening.