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• W2004398955 abstract "Background & Aims: Patients with chronic intestinal dysmotility (CID) have a lifelong disease, and no curative treatment is available. Interventions are needed to improve the care and support of the patients. The aim of this study was to measure health-care consumption in adult patients with CID before and after the introduction of a specialized day-care unit. Methods: Retrospective analysis was made of medical and nursing records from 3 different health-care delivery systems: period I, traditional care (1987–1996); period II, outpatient clinic (1997–1999); and period III, specialized day-care unit (2000–2002). There were 54 patients (44 women) with a median age of 47 years (range, 22–80 years). Results: The need for admissions to hospital care decreased from 80% to 35% of the patients after the introduction of the specialized day-care unit (P < .002). Also, the mean number of days in hospital care per patient and year was reduced from 39.4 to 3.3 days. The number of outpatient visits remained unaltered. The average cost per patient-year decreased from $32,698 during traditional health-care services to $9,681 after introducing the specialized day-care unit (P < .002). Irrespective of the form of care delivery, the majority of patients (67%–77%) needed daily treatment with analgesics, and 81%–84% needed nutritional support on a regular basis. Conclusions: Individually tailored care at a specialized day-care unit leads to substantially decreased needs for hospital stays and lower costs in patients with CID. Background & Aims: Patients with chronic intestinal dysmotility (CID) have a lifelong disease, and no curative treatment is available. Interventions are needed to improve the care and support of the patients. The aim of this study was to measure health-care consumption in adult patients with CID before and after the introduction of a specialized day-care unit. Methods: Retrospective analysis was made of medical and nursing records from 3 different health-care delivery systems: period I, traditional care (1987–1996); period II, outpatient clinic (1997–1999); and period III, specialized day-care unit (2000–2002). There were 54 patients (44 women) with a median age of 47 years (range, 22–80 years). Results: The need for admissions to hospital care decreased from 80% to 35% of the patients after the introduction of the specialized day-care unit (P < .002). Also, the mean number of days in hospital care per patient and year was reduced from 39.4 to 3.3 days. The number of outpatient visits remained unaltered. The average cost per patient-year decreased from $32,698 during traditional health-care services to $9,681 after introducing the specialized day-care unit (P < .002). Irrespective of the form of care delivery, the majority of patients (67%–77%) needed daily treatment with analgesics, and 81%–84% needed nutritional support on a regular basis. Conclusions: Individually tailored care at a specialized day-care unit leads to substantially decreased needs for hospital stays and lower costs in patients with CID. See Swidsinki A et al on page 568 for the companion article in the August 2008 issue of Gastroenterology. See Swidsinki A et al on page 568 for the companion article in the August 2008 issue of Gastroenterology. The term chronic intestinal dysmotility (CID) encompasses at least 2 rare types of gastrointestinal motor disorders, chronic intestinal pseudo-obstruction (CIP) and enteric dysmotility (ED).1Rosa-e-Silva L. Gerson L. Davila M. et al.Clinical, radiologic, and manometric characteristics of chronic intestinal dysmotility: the Stanford experience.Clin Gastroenterol Hepatol. 2006; 4: 866-873Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar CIP is the most severe form of intestinal dysmotility and represents the end-stage of diseases leading to failed peristalsis. In adults, CIP is characterized by recurrent, often severe symptoms with abdominal pain, vomiting, and diarrhea or constipation, ranging from a few episodes of subocclusion per year to continuously symptomatic disease.2Colemont L.J. Camilleri M. Chronic intestinal pseudo-obstruction: diagnosis and treatment.Mayo Clin Proc. 1989; 64: 60-70Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 3Faulk D.L. Anuras S. Christensen J. Chronic intestinal pseudoobstruction.Gastroenterology. 1978; 74: 922-931PubMed Scopus (162) Google Scholar The diagnosis of CIP rests on identification of clinical and radiologic signs mimicking bowel obstruction and the exclusion of a mechanical cause for observed signs.4Christensen J. Dent J. Malagelada J.R. et al.Pseudo-obstruction.Gastroenterol Intl. 1990; 3: 107-119Google Scholar, 5Mann S.D. Debinski H.S. Kamm M.A. Clinical characteristics of chronic idiopathic intestinal pseudo-obstruction in adults.Gut. 1997; 41: 675-681Crossref PubMed Scopus (175) Google Scholar, 6Stanghellini V. Cogliandro R.F. De Giorgio R. et al.Natural history of chronic idiopathic intestinal pseudo-obstruction in adults: a single center study.Clin Gastroenterol Hepatol. 2005; 3: 449-458Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar The diagnosis is supported by the presence of abnormal small bowel motility patterns.6Stanghellini V. Cogliandro R.F. De Giorgio R. et al.Natural history of chronic idiopathic intestinal pseudo-obstruction in adults: a single center study.Clin Gastroenterol Hepatol. 2005; 3: 449-458Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar, 7Stanghellini V. Camilleri M. Malagelada J.R. Chronic idiopathic intestinal pseudo-obstruction: clinical and intestinal manometric findings.Gut. 1987; 28: 5-12Crossref PubMed Scopus (285) Google Scholar, 8Richards W. Parish K. Williams Jr, L.F. The usefulness of small-bowel manometry in the diagnosis of gastrointestinal motility disorders.Am Surg. 1990; 56: 238-244PubMed Google Scholar However, not all patients with severe bowel symptoms and abnormal small bowel motor activity also have signs of pseudo-obstruction. Patients with abnormal motor activity but no subocclusive events were recently defined as ED.9Wingate D. Hongo M. Kellow J. et al.Disorders of gastrointestinal motility: towards a new classification.J Gastroenterol Hepatol. 2002; 17: S1-S14Crossref PubMed Scopus (115) Google Scholar It is unclear whether CIP and ED represent different stages of dysmotility, or whether they indeed are separate groups. In this report we used CID to denote both CIP and ED, because the 2 conditions are similar with regard to clinical presentation and management. The development of a specialized day-care unit for patients with CID was prompted by severe difficulties in the hospital care of patients with CID. Many of the patients referred to our unit had a history of recurrent, long-lasting hospital stays with severe and intractable symptoms and nutritional problems. The main aim was to measure health-care consumption in adult patients with CID before and after the introduction of a specialized day-care unit. From January 1, 1987 to December 31, 1998 a total of 72 patients were diagnosed with CID at the Centre for Gastroenterology at Karolinska University Hospital, Huddinge. Eighteen patients were followed up at other hospitals in Sweden. The remaining 54 patients lived in the Stockholm region and visited the center for regular follow-ups, thus constituting our study material. Medical and nursing records of the patients were reviewed from the day when each patient's individual diagnosis was made until December 31, 2002. Data regarding the number of days in hospital were confirmed for each patient via a central electronic hospital system, which also logged all outpatient visits. The review of all the documents in the patients' records concentrated on the clinical features of the disease, length of hospital stays, survival, pain treatment, and nutritional support. Demographic and social data were also collected from the records. Between 1987 and 1996, the patients visited different outpatient clinics at the hospital and met different specialists including surgeons, anesthesiologists, internists, gastroenterologists, and endocrinologists on their visits. The visits normally lasted for 20 minutes. Whenever a patient's condition deteriorated, eg, more severe abdominal pain or nutritional problems, the patient had to seek help in the emergency room. When admitted, patients were put in different wards in the hospital. The first changes in health-care delivery to our patients were made in 1997. It was decided that patients should be seen at a single outpatient clinic specializing in motility disorders and be offered consultation with a restricted number of physicians and nurses with a special interest in this group of patients. Team consultations could also include anesthesiologists, dietitians, psychologists, and medical social workers. The visits to the physicians were extended to 40 minutes each, and the same nurse kept in contact with patients by telephone between visits. A specialized day-care unit for adult patients with severe motility disorders was established 3 years later in January 2000. The specialized day-care unit had 2 beds, a nurse's office, and a consulting room. The patients met a specialized, multi-professional team of motility experts and nurses, together with a dietitian and a psychologist. Along with anesthesiologists and nurses specializing in pain treatment, the team developed an individual treatment and care program for each patient. Treatment plans and care goals were set in collaboration with patients and families and documented in the medical and nursing records. The nurses saw the patients for follow-up of therapeutic measures and monitoring of nutritional status. They also gave advice and support to patients and their families about managing self-care. Costs for in-hospital care, outpatient visits, and the specialized day-care unit were received from the Finance Department at Karolinska University Hospital. Only costs accrued after patients had been diagnosed with CID were included for analysis. Costs for in-hospital care were based on the average daily cost per bed in the relevant department, which included staff salaries and training, pharmacy services, radiologic and other laboratory services, and overhead costs. Costs for outpatient visits were determined from the hospital's charging system for outpatient services. Costs for care at the specialized day-care unit included all costs for establishing and maintaining that unit (staff salaries and training, pharmacy services, radiologic and other laboratory services, and overhead costs), irrespective of whether it was used by patients. Costs for homecare were determined from the number of days in homecare and the charges for this incurred by Stockholm County Council and the cost for home parenteral nutrition. To compare costs between time periods, costs were calculated in US dollars at 2002 prices. We compared the 3 time periods with regard to different parameters reflecting health care consumption. Because period I was longer in duration than periods II and III and because patients were at risk at different times during the different time periods, we weighted costs and other health care consumption measures for each individual by the time in years at risk during each period. Health-care consumption measures were thereby expressed as costs per patient-year. The majority of patients (n = 33) were studied during all 3 periods, whereas some only attended during 1 or 2 of the periods. Differences between related groups concerning binary variables were tested by McNemar test. Continuous data were compared by using Wilcoxon signed rank test, and we used Friedman test for comparisons between all 3 periods. Statistical significance was accepted if P < .05. The study was approved by the Ethical Committee of Karolinska University Hospital, Huddinge, Stockholm. All patients received verbal and written information about the study and consented to having their medical and nursing records reviewed. Table 1 shows the sociodemographic data of the 54 patients at the time of data compilation. The majority of the patients were women (81%). More than half of the patients were married or cohabiting. Forty-seven patients were of working age, but only 6 were able to work full-time.Table 1Sociodemographic Data From 54 Patients With CIDCID (n = 54)Gender Female44 (81%) Male10 (19%)Age, y47 (22–80)Marital status Married or cohabiting33 (61%) Single, living alone21 (39%)EducationaData available for 40 of the patients. Compulsory schoolbCompulsory school is 9 years long for Swedish children aged 7–16.11 (28%) Upper-secondary school15 (37%) University12 (30%) Other2 (5%)Occupation Working full-time6 (11%) Working part-time with no sickness benefit3 (5%) Sickness benefits part-time7 (13%) Sickness benefits full-time31 (57%) Retired7 (13%)NOTE. Data are given as numbers and (percentages), with the exception of age, which is given as a median and (range).a Data available for 40 of the patients.b Compulsory school is 9 years long for Swedish children aged 7–16. Open table in a new tab NOTE. Data are given as numbers and (percentages), with the exception of age, which is given as a median and (range). The patients had often had symptoms for many years before being diagnosed with CID (Table 2). Almost all of the patients had abdominal pain (93%), and a majority of patients also had abdominal distention, nausea, and vomiting.Table 2Clinical Features of 54 Patients With CIDCID patients (n = 54)Symptom duration before diagnosis5.6 (1–66) yAbdominal pain50 (93%)Distention42 (78%)Nausea32 (59%)Vomiting27 (50%)Constipation22 (41%)Diarrhea19 (35%)Urinary symptoms8 (15%)NOTE. Data are given as numbers and (percentages) of patients, with the exception of symptom duration, which is given as median and (range). Open table in a new tab NOTE. Data are given as numbers and (percentages) of patients, with the exception of symptom duration, which is given as median and (range). Patients entered and attended the 3 organizational forms of health-care delivery on the basis of the time at which they were diagnosed. During period I, traditional health-care services (1987–1996), 43 patients were diagnosed with CID and attended at least 1 form of health-care delivery. Six patients died during this period. In contrast, during period II, the outpatient clinic (1997–1999), 11 new patients were diagnosed, and 5 patients died. In period III, the specialized day-care unit (2000–2002), 43 patients were admitted and attended. Three patients died before the end of period III. Thirty-three patients attended all 3 organizational forms of health-care delivery. As care organization changed, the proportion of patients admitted for in-hospital care decreased from 80% during period I to 62% during period II and 35% during period III. The difference between period I and period II was not significant (P = .628), but after the introduction of the specialized day-care unit, the proportion of patients needing in-hospital care decreased significantly (P = .015 for period II vs III and P = .022 for period I vs III). The reasons for admission to hospital were abdominal pain in 71%, line sepsis complicating parenteral nutrition in 15%, and other causes such as nutritional needs or other symptoms in 14% of admissions. The number of days in hospital per patient-year decreased when the organization changed from traditional health-care services to the specialized day-care unit (Table 3). The decrease from period I to period II did not reach statistical significance (P = .09), but the decrease from period II to period III (P = .005) and that from period I to period III (P = .003) were highly significant.Table 3Number of Days in Hospital Care for Patients With CID During Different Health-Care Delivery SystemsNo. of days in hospital care per patient-year and periodPeriod I (n = 43)Period II (n = 48)Period III (n = 43)Mean39.721.43.3Median15.61.80Range0–2040–3440–30NOTE. Data are given per patient-year and period times as mean, median, and range. Open table in a new tab NOTE. Data are given per patient-year and period times as mean, median, and range. The number of outpatient visits to doctors, the emergency room, and the specialized day-care unit were monitored. During period I, patients made on average 15.9 visits per patient-year (median, 11.7; range, 1.1–97.1). During period II, the mean number of visits per patient-year was 12.6 (median, 8.5; range, 0.3–50.0), and during period III, patients made 11.1 visits per patient-year (median, 7.6; range, 0.3–49.7). There were no significant differences in the number of outpatient visits during the 3 organizational care forms. Table 4 shows the costs of care during the 3 health-care delivery systems. Hospital care constituted the major cost during period I. During period III, the whole cost of the specialized day-care unit was added, but during period III, in-hospital care costs were further reduced. The addition of the specialized day-care unit was cost-effective in the sense that the average cost per patient-year during period III was 25% of the same cost during period I (P < .002) and 44% of the cost during period II (P < .005).Table 4Care Costs for Patients With CID During 3 Different Health-Care Delivery SystemsPeriod I (n = 43)Period II (n = 48)Period III (n = 43)Total cost per patient-year Mean32,69818,7819,681 Median15,2754,7924,998 Range1,191–152,420221–268,6413,640–51,254Cost for in-hospital care per patient-year Mean29,58716,3002,935 Median11,6161,7390 Range0–152,2780–270,5200–23,355Cost for home care and TPN per patient-year Mean4001431,507 Median000 Range0–17,1890–2,5840–37,249Cost for outpatient visits per patient-year Mean2,7112,3381,687 Median1,4811,602947 Range103–21,2470–12,065aOne patient who died during period II spent the whole time in hospital care.44.2–6,795Cost for specialized day-care unit per patient-year Mean3,552bCosts for care at the specialized day-care unit included all costs for that unit (total $439,372), irrespective of whether it was used by patients.NOTE. Data are given as cost per patient-year and period times as mean, median, and range. Costs are given in US dollars ($1 = 9.70 Swedish kronor) at 2002 prices.a One patient who died during period II spent the whole time in hospital care.b Costs for care at the specialized day-care unit included all costs for that unit (total $439,372), irrespective of whether it was used by patients. Open table in a new tab NOTE. Data are given as cost per patient-year and period times as mean, median, and range. Costs are given in US dollars ($1 = 9.70 Swedish kronor) at 2002 prices. There were 33 patients available for assessment for all 3 periods. The mean cost per patient-year in that group decreased from $19,385 in period I to $12,433 in period II and $10,488 in period III. The latter figure included a fixed cost for the day-care unit of $3,552. The change in cost was significant at P < .05 (Friedman test). Six patients died during period I; 4 patients committed suicide; 1 patient died of septicemia; and 1 patient died of cancer of the pancreas. Another 5 patients died during period II: 1 of liver cirrhosis caused by alcohol abuse, 1 of septic complications 3 months after small bowel transplantation, 1 of lung cancer, 1 of endocarditis, and 1 of cardiac arrhythmia. Three patients died during period III; 1 patient committed suicide, 1 died of breast cancer, and 1 died of heart failure. The analgesics used were classified into strong opiates (morphine, ketobemidone, pethidine, oxycodone, methadone, hydromorphone, phentanyl, buprenorfin), weak opiates (codeine, dextropropoxifen), and nonopiate analgesics (eg, gabapentin, octreotide, spasmolytics). Irrespective of the form of care delivery system, 67%–77% of the patients needed daily treatment with analgesics, whereas 10%–16% of the patients could do without any analgesics (Table 5).Table 5Use of Analgesics Among Patients With CID When Attending Traditional Health-Care Services (Period I), Outpatient Clinic (Period II), and Specialized Day-Care Unit (Period III)Period I (n = 43)Period II (n = 48)Period III (n = 43)Strong opiates201413Weak opiates796Nonopiate analgesics5914No analgesics111610 Open table in a new tab The majority of patients (81%–84%) needed nutritional support on a regular basis, irrespective of the form of care delivery. In the different health-care delivery systems 17%–26% of the patients needed total or partial parenteral nutrition. Most patients could be helped by dietetic supplements (Figure 1). The main purpose of this study was to examine health-care consumption in patients with CID before and after changing health-care delivery forms. The results of our study showed that patients with CID require extensive medical and nursing care. This has also been demonstrated in previous studies.5Mann S.D. Debinski H.S. Kamm M.A. Clinical characteristics of chronic idiopathic intestinal pseudo-obstruction in adults.Gut. 1997; 41: 675-681Crossref PubMed Scopus (175) Google Scholar, 6Stanghellini V. Cogliandro R.F. De Giorgio R. et al.Natural history of chronic idiopathic intestinal pseudo-obstruction in adults: a single center study.Clin Gastroenterol Hepatol. 2005; 3: 449-458Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar, 10Schuffler M.D. Rohrmann C.A. Chaffee R.G. et al.Chronic intestinal pseudo-obstruction: a report of 27 cases and review of the literature.Medicine (Baltimore). 1981; 60: 173-196PubMed Google Scholar Our results confirmed that patients with CID have a serious condition, for which long-term support is necessary. The most striking result of the implementation of the specialized day-care unit was that the need of hospital care could be reduced to less than 10% of the preimplementation need. The cost of hospital care was also the main determinant of total cost, which was reduced to 30% of its preimplementation level. The majority of patients could be managed at the specialized day-care unit with continuity of nursing and doctoral staff. This might have given the patients a better feeling of security than when they were confronted with different doctors and nurses. Similar results were demonstrated by Nightingale et al11Nightingale A.J. Middleton W. Middleton S.J. et al.Evaluation of the effectiveness of a specialist nurse in the management of inflammatory bowel disease (IBD).Eur J Gastroenterol Hepatol. 2000; 12: 967-973Crossref PubMed Scopus (79) Google Scholar for patients with IBD. Both the number of days in hospital and the number of hospital stays decreased when a nurse specialized in IBD care became involved in the care of the patients. For chronically ill patients, it is widely acknowledged that consistent attention by the same care professionals is important for improving well-being and satisfaction with health care11Nightingale A.J. Middleton W. Middleton S.J. et al.Evaluation of the effectiveness of a specialist nurse in the management of inflammatory bowel disease (IBD).Eur J Gastroenterol Hepatol. 2000; 12: 967-973Crossref PubMed Scopus (79) Google Scholar, 12Scolapio J.S. Ukleja A. Bouras E.P. et al.Nutritional management of chronic intestinal pseudo-obstruction.J Clin Gastroenterol. 1999; 28: 306-312Crossref PubMed Scopus (30) Google Scholar The need for individual tailoring of care for patients with CIP has been outlined by Silk13Silk D.B. Chronic idiopathic intestinal pseudo-obstruction: the need for a multidisciplinary approach to management.Proc Nutr Soc. 2004; 63: 473-480Crossref PubMed Scopus (19) Google Scholar as an important means for improving care. A study of individually tailored care in patients with IBD demonstrated that patients were much more satisfied with the information they received. Opportunities to identify and pinpoint each patient's care needs were increased by continuity in treatment and access to an IBD nurse.11Nightingale A.J. Middleton W. Middleton S.J. et al.Evaluation of the effectiveness of a specialist nurse in the management of inflammatory bowel disease (IBD).Eur J Gastroenterol Hepatol. 2000; 12: 967-973Crossref PubMed Scopus (79) Google Scholar The need for analgesics did not alter with the changes in the care organization, but there was a trend toward fewer patients requiring strong opiates while receiving more individually tailored care (29% and 30% of patients during care periods II and III, respectively, in contrast to 47% during care period I). The use of opiates in CID carries a substantial risk of deterioration in bowel function, which in turn can lead to increased severity of disease and the need for more opiates to control symptoms. At the same time, abdominal pain is often severe in patients with CID. It is therefore important to offer these patients controlled opiate maintenance treatment when the pain has a debilitating impact on the patient's existence. Although opiate dependence might be a risk, this is reduced if the patient's pain relief is continually monitored by the same multidisciplinary team, which consistently follows up the treatment.14Maier C. Schaub C. Willweber-Strumpf A. et al.Langfristige Effekte von Opioiden bei Patienten mit chronischen nicht-tumorbedingten Schmerzen: Ergebnisse einer Nachuntersuchung 5 Jähre nach Ersteinstellung.Schmerz. 2005; 19: 410-417Crossref PubMed Scopus (27) Google Scholar Trials have been conducted with both antiepileptic and antidepressant medication but without any great success.15Di Lorenzo C. Pseudo-obstruction: current approaches.Gastroenterology. 1999; 116: 980-987Abstract Full Text Full Text PDF PubMed Google Scholar Our clinical experience and results from previous studies5Mann S.D. Debinski H.S. Kamm M.A. Clinical characteristics of chronic idiopathic intestinal pseudo-obstruction in adults.Gut. 1997; 41: 675-681Crossref PubMed Scopus (175) Google Scholar, 6Stanghellini V. Cogliandro R.F. De Giorgio R. et al.Natural history of chronic idiopathic intestinal pseudo-obstruction in adults: a single center study.Clin Gastroenterol Hepatol. 2005; 3: 449-458Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar demonstrated how complicated it is to achieve effective pain relief for this group of patients. More than 80% of the patients in our follow-up needed some form of nutritional support, and this remained unaltered with the changes in the care organization. Previous studies reported that more than half of all patients with CIP require nutritional support.5Mann S.D. Debinski H.S. Kamm M.A. Clinical characteristics of chronic idiopathic intestinal pseudo-obstruction in adults.Gut. 1997; 41: 675-681Crossref PubMed Scopus (175) Google Scholar, 6Stanghellini V. Cogliandro R.F. De Giorgio R. et al.Natural history of chronic idiopathic intestinal pseudo-obstruction in adults: a single center study.Clin Gastroenterol Hepatol. 2005; 3: 449-458Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar, 10Schuffler M.D. Rohrmann C.A. Chaffee R.G. et al.Chronic intestinal pseudo-obstruction: a report of 27 cases and review of the literature.Medicine (Baltimore). 1981; 60: 173-196PubMed Google Scholar Patients with CID have a pronounced risk of malnutrition.5Mann S.D. Debinski H.S. Kamm M.A. Clinical characteristics of chronic idiopathic intestinal pseudo-obstruction in adults.Gut. 1997; 41: 675-681Crossref PubMed Scopus (175) Google Scholar, 6Stanghellini V. Cogliandro R.F. De Giorgio R. et al.Natural history of chronic idiopathic intestinal pseudo-obstruction in adults: a single center study.Clin Gastroenterol Hepatol. 2005; 3: 449-458Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar, 10Schuffler M.D. Rohrmann C.A. Chaffee R.G. et al.Chronic intestinal pseudo-obstruction: a report of 27 cases and review of the literature.Medicine (Baltimore). 1981; 60: 173-196PubMed Google Scholar The general dietary advice is to take frequent, small, possibly liquid meals that are low in fat and fiber.10Schuffler M.D. Rohrmann C.A. Chaffee R.G. et al.Chronic intestinal pseudo-obstruction: a report of 27 cases and review of the literature.Medicine (Baltimore). 1981; 60: 173-196PubMed Google Scholar, 12Scolapio J.S. Ukleja A. Bouras E.P. et al.Nutritional management of chronic intestinal pseudo-obstruction.J Clin Gastroenterol. 1999; 28: 306-312Crossref PubMed Scopus (30) Google Scholar, 16Smith D.S. Williams C.S. Ferris C.D. Diagnosis and treatment of chronic gastroparesis and chronic intestinal pseudo-obstruction.Gastroenterol Clin North Am. 2003; 32: 619-658Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 17Panganamamula K.V. Parkman H.P. Chronic intestinal pseudo-obstruction.Curr Treat Options Gastroenterol. 2005; 8: 3-11Crossref PubMed Scopus (44) Google Scholar, 18Sutton D.H. Harrell S.P. Wo J.M. Diagnosis and management of adult patients with chronic intestinal pseudoobstruction.Nutr Clin Pract. 2006; 21: 16-22Crossref PubMed Scopus (27) Google Scholar One of the reasons why a patient with CID might stop eating is that food intake often makes symptoms worse. Mann et al5Mann S.D. Debinski H.S. Kamm M.A. Clinical characteristics of chronic idiopathic intestinal pseudo-obstruction in adults.Gut. 1997; 41: 675-681Crossref PubMed Scopus (175) Google Scholar have identified that the major goals for the management of patients with CID are to make the diagnosis as early as possible, to control abdominal pain, and to maintain sufficient nutrition. Regardless of future study approaches, data on the patients' own perceptions of health-related life quality would be valuable as an outcome variable for this patient group to identify specific needs and facilitate the coordination of their care. In conclusion, the results from our study showed that interventions involving individually tailored care by multidisciplinary staff can be implemented and lead to a significant reduction of costs and need for hospitalization. We think that changes in the care organization as described in this study can best be achieved if there is continuity among health professionals, cooperation in multidisciplinary teams, and a pronounced interest in caring for this group of patients. Data for this follow-up were collected from patient records. It is well-known that this method has weaknesses such as incomplete or missing notes.19Nordström G. Gardulf A. Nursing documentation in patient records.Scand J Caring Sci. 1996; 10: 27-33Crossref PubMed Scopus (33) Google Scholar However, since 1999, the medical and nursing records used in this follow-up have been documented electronically, which has improved legibility and content. Moreover, all doctors, nurses, and dietitians wrote their notes in the same record for each patient. Data could also be verified by other independent computer systems in the hospital. Despite the weaknesses that might be inherent to retrospective data collection, we believe that for these 54 patients, we have an accurate portrayal of their care requirements and treatments over time in relation to changes in the form of care. During the study period there was a general trend in Sweden toward shorter hospital stays for almost all patient groups. A similar trend could be seen for patients with other gastrointestinal diseases. For example, the average length of hospital stays for patients with IBD in our hospital was 10.1 days in 1998 and 5.2 days in 2002. However, for patients with IBD, a specialized day-care unit had started already in 1998. We found a decrease both in the number of hospital admissions and in the length of admissions. We also found a decrease in the proportion of patients that needed hospitalization. It is therefore unlikely that a general trend toward shorter hospital stays would explain the observed decrease of the need for hospital care. Costs per patient could not be calculated in retrospect. This is a limitation that follows from the Swedish health care system at the time of our study. We calculated the average cost per day in hospital for the relevant department. This cost estimate included all major costs, and we think the average cost is valid for the group of patients with severe motility disorders. The estimate was 10%–20% higher than cost estimates from the appropriate diagnosis-related groups. The latter system, with relative weights for different diagnostic groups, was used for determining the monetary compensation to the hospital from Stockholm County Council during the last 3 years of the study period. A possible weakness in our cost calculation for outpatient visits is that we were unable to include drug expenditure. We found only small differences in the use of analgesics between the different time periods, and in our experience, there was no significant alteration in prescription policies for other drugs during the study. For this reason, we do not think omitting drug expenditure will influence the conclusions from our study. We included the total cost for the specialized day-care unit and divided this by the total number of patient-years during period III. This is probably an overestimate of the true cost, because a number of new patients also used the day-care unit. Because the unit was created specifically to help the patients who were available at that time, we think it is reasonable to attribute the total cost to those patients." @default.
• W2004398955 created "2016-06-24" @default.
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• W2004398955 date "2008-08-01" @default.
• W2004398955 modified "2023-10-02" @default.
• W2004398955 title "Health Care Use in Patients With Chronic Intestinal Dysmotility Before and After Introducing a Specialized Day-Care Unit" @default.
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