Home treatment of patients with cystic fibrosis using the 'Intermate': the first year's experience

Economic burden of ambulatory and home-based care for adults with cystic fibrosis

OBJECTIVE

The purpose of this study was to measure costs associated with care for adults with cystic fibrosis, from a societal perspective.

METHODS

Over a 4-week period, 110 participants completed the Ambulatory and Home Care Record, a self-administered data collection instrument that measures costs to the health system, costs to employers, care recipients' direct out-of-pocket expenditures, and time costs borne by care recipients and their family caregivers. Health system costs were based on the costs incurred through expenditures on physicians, hospital clinics, pharmaceuticals, and home care agencies. Out-of-pocket costs were obtained using self-reports by care recipients, and time losses were valued using the human capital approach.

RESULTS

The annual mean societal costs of ambulatory care for cystic fibrosis was $Can29 885 per care recipient (year 2002 value). Time losses incurred by care recipients and their family caregivers accounted for the majority (72%) of these costs, and system costs accounted for the second highest percentage of costs (21%). Although almost all participants (109) recorded out-of-pocket expenditures, these costs accounted for only a small proportion (3%) of total costs.

CONCLUSION

Measuring societal costs is necessary for practitioners, managers, and policy decision-makers, to ensure that care recipients and their families receive the necessary resources to provide care.

Socio-economic burden of rare diseases: A systematic review of cost of illness evidence

Cost-of-illness studies, the systematic quantification of the economic burden of diseases on the individual and on society, help illustrate direct budgetary consequences of diseases in the health system and indirect costs associated with patient or carer productivity losses. In the context of the BURQOL-RD project ("Social Economic Burden and Health-Related Quality of Life in patients with Rare Diseases in Europe") we studied the evidence on direct and indirect costs for 10 rare diseases (Cystic Fibrosis [CF], Duchenne Muscular Dystrophy [DMD], Fragile X Syndrome [FXS], Haemophilia, Juvenile Idiopathic Arthritis [JIA], Mucopolysaccharidosis [MPS], Scleroderma [SCL], Prader-Willi Syndrome [PWS], Histiocytosis [HIS] and Epidermolysis Bullosa [EB]). A systematic literature review of cost of illness studies was conducted using a keyword strategy in combination with the names of the 10 selected rare diseases. Available disease prevalence in Europe was found to range between 1 and 2 per 100,000 population (PWS, a sub-type of Histiocytosis, and EB) up to 42 per 100,000 population (Scleroderma). Overall, cost evidence on rare diseases appears to be very scarce (a total of 77 studies were identified across all diseases), with CF (n=29) and Haemophilia (n=22) being relatively well studied, compared to the other conditions, where very limited cost of illness information was available. In terms of data availability, total lifetime cost figures were found only across four diseases, and total annual costs (including indirect costs) across five diseases. Overall, data availability was found to correlate with the existence of a pharmaceutical treatment and indirect costs tended to account for a significant proportion of total costs. Although methodological variations prevent any detailed comparison between conditions and based on the evidence available, most of the rare diseases examined are associated with significant economic burden, both direct and indirect.

A prospective cohort study of the use of domiciliary intravenous antibiotics in bronchiectasis

BACKGROUND

We introduced domiciliary intravenous (IV) antibiotic therapy in patients with bronchiectasis to promote patient-centred domiciliary treatment instead of hospital inpatient treatment.

AIM

To assess the efficacy and safety of domiciliary IV antibiotic therapy in patients with non-cystic fibrosis bronchiectasis.

METHODS

In this prospective study conducted over 5 years, we assessed patients' eligibility for receiving domiciliary treatment. All patients received 14 days of IV antibiotic therapy and were monitored at baseline/day 7/day 14. We assessed the treatment outcome, morbidity, mortality and 30-day readmission rates.

RESULTS

A total of 116 patients received 196 courses of IV antibiotics. Eighty courses were delivered as inpatient treatment, 32 as early supported discharge (ESD) and 84 as domiciliary therapy. There was significant clinical and quality of life improvement in all groups, with resolution of infection in 76% in the inpatient group, 80% in the ESD group and 80% in the domiciliary group. Morbidity was recorded in 13.8% in the inpatient group, 9.4% in the ESD group and 14.2% in the domiciliary IV group. No mortality was recorded in either group. Thirty-day readmission rates were 13.8% in the inpatient group, 12.5% in the ESD group and 14.2% in the domiciliary group. Total bed days saved was 1443.

CONCLUSION

Domiciliary IV antibiotic therapy in bronchiectasis is clinically effective and was safe in our cohort of patients.

Location and duration of treatment of cystic fibrosis respiratory exacerbations do not affect outcomes

RATIONALE

Individuals with cystic fibrosis (CF) are subject to recurrent respiratory infections (exacerbations) that often require intravenous antibiotic treatment and may result in permanent loss of lung function. The optimal means of delivering therapy remains unclear.

OBJECTIVES

To determine whether duration or venue of intravenous antibiotic administration affect lung function.

METHODS

Data were retrospectively collected on 1,535 subjects recruited by the US CF Twin and Sibling Study from US CF care centers between 2000 and 2007.

MEASUREMENTS AND MAIN RESULTS

Long-term decline in FEV₁ after exacerbation was observed regardless of whether antibiotics were administered in the hospital (mean, -3.3 percentage points [95% confidence interval, -3.9 to -2.6]; n = 602 courses of therapy) or at home (mean, -3.5 percentage points [95% confidence interval, -4.5 to -2.5]; n = 232 courses of therapy); this decline was not different by venue using t tests (P = 0.69) or regression (P = 0.91). No difference in intervals between courses of antibiotics was observed between hospital (median, 119 d [interquartile range, 166]; n = 602) and home (median, 98 d [interquartile range, 155]; n = 232) (P = 0.29). Patients with greater drops in FEV₁ with exacerbations had worse long-term decline even if lung function initially recovered with treatment (P < 0.001). Examination of FEV₁ measures obtained during treatment for exacerbations indicated that improvement in FEV₁ plateaus after 7-10 days of therapy.

CONCLUSIONS

Intravenous antibiotic therapy for CF respiratory exacerbations administered in the hospital and in the home was found to be equivalent in terms of long-term FEV₁ change and interval between courses of antibiotics. Optimal duration of therapy (7-10 d) may be shorter than current practice. Large prospective studies are needed to answer these essential questions for CF respiratory management.

Valuing care recipient and family caregiver time: a comparison of methods

OBJECTIVES

The purpose of this study is to compare the approaches used for valuing family caregiver and care recipient time devoted to providing and receiving care.

METHODS

Valuation approaches were operationalized within a cohort of cystic fibrosis care recipients (n = 110). Base-case analyses, grounded in human capital theory, applied earnings estimates to caregiving time to impute the market value of time lost from labor. Unpaid labor and leisure time was valued with a replacement cost (homemaker's wage rate). Total time costs were computed and sensitivity analyses were conducted to describe the effects of alternative valuation methods on total costs.

RESULTS

The mean time cost per care recipient-caregiver dyad over 28 days was $2,026CAD. The majority (76 percent) of time costs were due to losses from unpaid labor and leisure time. Varying the valuation of paid labor time did not result in significantly different total time costs (p = .0877). However, varying the method of valuing unpaid labor and leisure time did significantly affect total costs (p < .0001).

CONCLUSIONS

Care recipients and caregivers primarily lost time from unpaid labor and leisure in the treatment of cystic fibrosis. Moreover, when the above losses were aggregated, the method of valuation greatly influenced overall results. The findings clearly indicate that omitting caregiver and unpaid labor and leisure costs may result in an inaccurate assessment of ambulatory and home-based healthcare programs.

[Efficiency of the home intravenous antibiotics treatment in cystic fibrosis]

BACKGROUND AND OBJECTIVE

The objective of our study was to determine the costs saving with the implementing of a home intravenous antibiotic treatment (HIVAT) program for patients with cystic fibrosis and to compare it with the conventional system (inpatient).

PATIENTS AND METHOD

Consecutive patients in an adults cystic fibrosis unit were selected who received some days of HIVAT, between January 2002 and December 2004. For the analysis of costs saving of the HIVAT, we used the difference between the total costs of the avoided stay days and the costs generated by the domiciliary therapy (drugs, expendable equipment) and by the ambulatory medicine unit in case the patients were not hospitalized. All patients received a therapy with an intravenous antibiotic for a minimum of 14 days. All these data were provided by the accounting service of the hospital with the aid management Clinical Financier Program (GECLIF).

RESULTS

22 patients with cystic fibrosis needed 85 intravenous antibiotics treatments during the 3 years of the study, of which: 43 cycles were completely domiciliary, 14 inpatient and 28 were combined (hospital and home). The 71 cycles of HIVAT originated 909 days at home, with an average (standard deviation) of 12.80 (4.18) days and 43 treatments in ambulatory medicine unit. The home antibiotic treatments that originated greater cost (3,964.34 Euro) was meropenem (1 g/6 h) i.v. with linezolid (600 mg/12 h) via oral combination during 14 days, and in second place the association of ceftazidime, tobramycine and linezolid, whose cost in cycle of 14 days was of 2464.84 Euro. The average saving cost in the 3 years of study was of 2,647.29 Euro by each cycle of HIVAT and global 197,689.78 Euro.

CONCLUSIONS

HIVAT obtained important sanitary costs saving and this was greater every year, not due to the increase of days at home, but due to the rising cost per day of hospital stays every new year.

Comparison of hospital and home intravenous antibiotic therapy in adults with cystic fibrosis

AIM AND OBJECTIVE

This study aimed to compare home and hospital treatment for clinical outcome and quality of life in adult cystic fibrosis patients receiving i.v. antibiotics for acute respiratory exacerbations.

BACKGROUND

Cystic fibrosis patients require intravenous (i.v.) antibiotic therapy to treat acute respiratory exacerbations. Traditionally, patients would be admitted to hospital to complete a 14-day course of i.v. antibiotics. The option of home i.v. antibiotic therapy for acute respiratory exacerbations has become an expectation of cystic fibrosis patients.

DESIGN AND METHOD

Comparison of hospital and home i.v. antibiotic therapy in adults with cystic fibrosis for clinical outcomes and quality of life was studied using a quasi-experimental design. A pre- and post-test was used to measure clinical outcomes of forced expiratory volume in one second (FEV(1)), forced vital capacity (FVC), oxygen saturations (SaO(2)), body mass index (BMI) and quality of life using the Cystic Fibrosis Quality of Life (CFQoL) questionnaire.

RESULTS

Thirty adult cystic fibrosis patients (15 hospital and 15 home) were recruited to the study once they had chosen where they undertook their treatment. When the groups were compared for clinical outcomes, the hospital group showed greater improvement in FVC. There were no differences in quality of life when the hospital and home groups were compared, although changes achieved with treatment showed differences. In the home group, there were improvements in all nine quality of life domains, with statistically significant improvement in five domains, whereas in the hospital group there were improvements in eight out of nine quality of life domains, with only two showing statistically significant improvement.

RELEVANCE TO CLINICAL PRACTICE

Lung function improved more in the hospital group, suggesting that acute respiratory exacerbations were not as effectively treated at home, although there appeared to be greater quality of life when undertaking home treatment. The CFQoL questionnaire was able to detect transient changes in health status during the course of i.v. antibiotics.

CONCLUSION

If the patient's right to choose where they receive treatment is to be supported, taking into account quality of life further research is required to determine the reasons for home care being less clinically effective in treating acute respiratory exacerbations in cystic fibrosis patients.

Comparing costs of home- versus hospital-based treatment of infections in adults in a specialist cystic fibrosis center

Objectives: This study aimed to produce valid patient-based UK National Health Service (NHS) costs for adults with cystic fibrosis to identify differences between hospital- and home-based treatments for infections.

Methods: A costing study was carried out in adults with cystic fibrosis (CF) in the United Kingdom, who required intravenous antibiotic treatments for respiratory infections, administered either at home or in the hospital. The perspective was that of the NHS hospital trust. Data were collected retrospectively for each patient for 1 year using clinical records. Data were collected for 116 adults with CF between 2000 and 2001, when 42,382 treatment days (454 courses) of intravenous antibiotics were administered; 213 courses with intention-to-treat at home and 241 courses with intention-to-treat in the hospital. The mean length of a course was 15.3 days.

Results: Patients who had >60 percent of courses at home over 1 year had a mean cost of £13,528, compared with £22,609 for patients who had >60 percent of courses in the hospital, and a mean cost of £19,927 for patients who had an equal mix of home and hospital care (p = .0001).

Conclusions: The key cost-generating events in CF respiratory infections are hospital admissions. Future studies assessing costs should concentrate on factors affecting admissions, length of stay, staff input, and alternative methods of home-care provision, rather than marginal effects, such as using different antibiotics.

[Evaluation of a home hospitalization program in patients with exacerbations of chronic obstructive pulmonary disease]

OBJECTIVE

We carried out a randomized controlled trial to evaluate the efficacy of a home hospitalization (HH) program for patients hospitalized for exacerbation of chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

Patients who were clinically stable and had stable arterial blood gases were randomized to the conventional hospitalization group or the HH group.

RESULTS

Of the 88 patients evaluated, 40 (20 in each group) were enrolled. No differences were observed in baseline characteristics, in clinical recovery, or arterial blood gases between the 2 groups at discharge. At 1-month follow up there were no differences in mortality or in the number of readmissions. The mean length of hospitalization in patients with HH was 9.2 days (4 days in hospital and 5 days at home), compared to 12.2 days in patients with conventional hospitalization.

CONCLUSIONS

Our results show that a hospital-supervised HH program including the participation of pneumologists and nursing staff allows for the recovery of patients hospitalized for exacerbation of COPD who have stable symptoms and arterial blood gases with no increase in the rate of readmission, relapse, or therapeutic failure.

[Home intravenous antibiotic treatments in cystic fibrosis units of Madrid]

BACKGROUND AND OBJECTIVE

A descriptive study of the home intravenous antibiotic treatment (HIVAT) course in cystic fibrosis (CF) units of Madrid in an 18 month period. Different patient features were recorded, antibiotherapy, intravenous access, complications and their resolutions. We accessed the improvement of the pulmonary function, forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) at the end of the treatment.

PATIENTS AND METHOD

For an 18 months period (January 2002-June 2003) the patients with CF who received HIVAT and fulfilled the previously fixed criteria were included. The next clinic variables were collected: age, sex, bacterial colonization of respiratory tree, pancreatic function and pulmonary function in steady phase, before and after HIAT.

RESULTS

56 patients, 31 male and 25 female, were given 90 courses of HIAT (34 patients received only one course). Mean age was 20.06 (8.07) years. 57.1% of the patients were colonized by Pseudomonas aeruginosa. The most frequently used antibiotics were ceftazidime and tobramycin. Courses of treatment lasted a mean of 4.08 (5.09) days inpatient and 11.89 (4.96) at home. In 87.7% of the course were used the intravenous cannulae, Port-a-cath in 6.7% and Venocath in 7.8%. The intravenous access was replaced, in the 64.4% of the cases, by the nurse of the CF Unit, in the 21.4% in the emergency room of the nearest hospital and in 11.9% in primary care center. Three occasions skin reactions were reported. The parameters of pulmonary function improved significatively after HIVAT.

CONCLUSIONS

The HIVAT is a therapeutic option that, following predetermined inclusion criteria, has a low complication rate and improves pulmonary function.

Cystic fibrosis: cost of illness and considerations for the economic evaluation of potential therapies

Cystic fibrosis (CF) is the most common life-shortening inherited disease of the Caucasian race, with a prevalence of around 1 in 2500 live births. Advances in the treatment and management of respiratory and pancreatic disorders have dramatically increased the life expectancy of patients with CF. This article presents an overview of cost-of-illness studies of CF, identifies deficits in the available health economic analyses of CF and discusses which specific factors are essential for the economic evaluation of potential therapies, based on a critical review of the health economic literature on two main therapeutic strategies. Cost-of-illness studies of CF have predominantly been restricted to direct costs. According to the literature, direct costs amount to between 6200- 16300 US dollars (1996 values) per patient per year. As most studies likely underestimated the actual costs (e.g. by disregarding provision of certain healthcare services), real healthcare costs tend to be at the upper end of the cost range. Healthcare costs depend on the patient's age (for adults, costs are approximately twice as high as for children), the grade of severity (the cost relationship of severe to mild CF is between 4.5 and 7.1) and other factors. Lifetime direct costs of CF are estimated at 200 000-300000 US dollars (at 1996 values and a discount rate of 5%). Home intravenous (IV) antibacterial therapy and recombinant human DNase (rhDNase; dornase alfa) treatment are the two main therapeutic strategies most often evaluated in health economic studies of CF. While home IV antibacterial therapy (compared with inpatient IV antibacterial therapy) is assumed to be cost saving, rhDNase treatment is a very cost-intensive therapy intended to efficiently achieve health improvements. Health economic analyses of future CF therapeutic technologies should present explicit data regarding healthcare services provision, resource consumption and unit costs. Indirect costs and patient costs should be considered more often than they have to date, particularly when they are significantly influenced by novel CF technologies. The perspective of health economic studies should be stated explicitly and always include the societal perspective. More economic studies should be based on a controlled, and preferably randomised, design. The observation period must be long enough to identify long-term effects of interventions. A greater number of effectiveness studies should be performed to determine costs and outcomes of therapies applied under everyday life conditions for patients with CF. Finally, international comparison studies should identify the influence of different healthcare systems on the costs and outcomes of interventions.

Parents and partners: lay carers' perceptions of their role in the treatment and care of adults with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is the most common autosomal recessive genetic disease in Caucasian people, traditionally conceptualized as a condition whereby sufferers died in childhood. However, the current median survival age of 30 and a predicted median survival age of 40 for those born with the disease over the last decade ensure that families members will assist hospital staff with treatment and care well into most patients' adulthood.

AIMS

This study explores the perceptions and experiences of lay care-giving amongst parents and partners of adults with CF who were being treated at a specialist CF centre in England.

METHODS

Thirty-one relatives of adults with CF were interviewed in their own homes using an interview topic guide. All interviews were audiotape recorded and transcribed verbatim. Analysis of data was assisted by ATLAS-ti, a software package for qualitative research.

FINDINGS

Two main themes surrounding lay carers' role in treatment and care were identified. Firstly, the notion of lay carers giving 'expert' care, both in hospital and at home was recognized. Parents' expertise was greater than that of partners until the patient required intensive hospital interventions, when partner expertise increased. Secondly, the degree of lay carers' felt inclusion in the hospital consultation appeared to depend on the nature of their relationship with the patient and the patients' health state.

CONCLUSION

Lay carers are routinely performing tasks for adults with CF that were once the remit of trained nurses. Families need higher levels of nursing and social support when certain treatments are used at home. Attention needs to be directed to how lay carers of adult patients can be included in hospital consultations.

Pharmaceutical intervention in the care of cystic fibrosis patients

In a prospective, randomised, cross-over study including cystic fibrosis patients with indications for HIVAT (home intravenous antibiotic treatment) the prospect of pharmaceutical intervention was investigated. A comparison between the use of disposable infusion devices with antibiotics from the pharmacy and when the patients prepared the drugs themselves was performed. During a first treatment course the patients received either infusion devices during 5 days or reconstituted the drugs themselves during 5 days, or vice versa. During a second treatment course the order was the reversed. Eight patients were included, out of which six completed the original design as a cross-over study, yielding a total of 550 doses of antibiotics. The patients preferred infusion devices from the pharmacy prepared according to GMP (Good Manufacturing Practice) as opposed to reconstituting the antibiotics themselves. Points of view presented included no anxiety over the correct dosage of drugs and less disruption of family and social life. In a practical sense, portable devices are more expensive than the preparation of the drugs by the patients themselves. However, when comparing with in-hospital treatment the direct costs for a hospital stay exceed that of the devices. Another part of the study evaluated the quality of life using a modified form of SEIQoL-DW (Schedule for the Evaluation of Individual Quality of Life - Direct Weighting). Twenty patients took part in the study and the overall quality of life scores increased significantly when patients received infusion devices compared to reconstituting the drugs themselves.

Trends in community care and patient participation: implications for the roles of informal carers and community nurses in the United Kingdom

This paper argues that the interfaces between formal and informal care-giving are changing as a result of two current trends; the increased scope of home-based nursing care and the emphasis on participation both within nursing and in the wider health and social care arenas. These various changes are explored in relation to the provision of intensive and complex nursing care in the home. It will be argued that the changing interfaces between formal and informal care have important implications for the respective roles of nurses and informal carers which hitherto have been relatively overlooked. These implications urgently need addressing in research, policy and public debate if professional nurses are to provide appropriate help and support to informal carers.

Community-based care in cystic fibrosis: role of the cystic fibrosis nurse specialist and implications for patients and families

Improved survival for cystic fibrosis has rapidly increased over the past four decades, with patients now living well into adult life. With changes in the structure of the National Health Service and the formation of provider units and general practitioner (GP) fund-holding practices, it is important to strengthen links between the hospital and community teams to ensure that the CF patient receives adequate care. Increasingly, treatment is being carried out at home, and this emphasis on home-based therapy demands that parents/carers and patients must acquire the skills and knowledge of complex therapies in order to optimize health. It is the role of the CF nurse specialist (NS) to educate those who will deliver the care, co-ordinate the provision of services at home, liaise with the CF team and community health-care professionals and to support the patient and their carers.