Rationing critical care beds

Limited availability of healthcare resource in the face of excess demand leads inevitably to rationing. A systematic review of rationing of critical care beds tells us that more people die who might have lived.

A widespread literature search looked at adult patients who were seriously ill and considered for admission to an intensive care unit, These could be retrospective or prospective cohort study, rationing based on reduced bed availability or triaging of patients referred for admission. Outcomes included severity of illness, length of stay, and mortality.

Ten studies were available. There were considerable differences in the studies, though most reported patient outcomes and nine had follow-up rates above 90%.

The most useful information came from the triaging studies, four of which reported mortality rates for 1,220 patients admitted and 558 not admitted to an intensive care bed. In each of these four studies mortality was higher in patients refused admission to an intensive care bed. These studies were performed in Israel (2), Hong Kong, UK and USA.

Overall mortality was 29% in those admitted to ICU, compared with 50% in those refused an intensive care bed. For every five patients refused an intensive care bed, one more died than would have been the case if they had been admitted to intensive care.

This is the headline result from some quite complex data, though any other results would probably not carry much weight because they mostly come from single studies. But this finding remains an important reminder for those responsible for provision of healthcare and use of resources. Rationing comes with a price, for intensive care beds, of more deaths in those refused admission. This is clearly a topic that demands more research, especially because saving money might mean spending it elsewhere in the system.

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NICE guidance for lung cancer

Guidelines for achieving earlier diagnosis, greater use of evidence based treatments, and better coordination of care for patients with lung cancer have been published for England and Wales. The recommendations, from the National Institute for Clinical Excellence (NICE), are aimed at improving the poor survival rates from lung cancer.

The guidelines recommend urgent referral for chest x-ray examination for anyone with haemoptysis or unexplained or persistent symptoms that might indicate lung cancer, including cough, chest pain, dyspnoea, or weight loss. Patients whose chest x-ray examination or computed tomogram suggests lung cancer should be referred urgently to a chest physician working as a member of a lung cancer multi-disciplinary team.

Every cancer network must have rapid access to positron emission tomography (FDG-PET) to improve staging of lung cancer, say the guidelines. They also recommend that all cancer units should have one or more trained lung cancer nurse specialists to see patients before and after diagnosis to provide continuing support and to facilitate communication between all professionals involved in an individual patient's care.

Currently just 5.5% of people diagnosed with lung cancer in England and 6% of those in Wales live for more than five years. This is about 5% lower than the European average and 7-10% lower than the rate for the United States.

The guidance is based on a review of evidence by NICE and the National Collaborating Centre for Acute Care, a group set up by NICE to include representatives from the medical royal colleges, professional bodies, and patient organisations. For the first time, NICE worked in collaboration with the Scottish Intercollegiate Guidelines Network (SIGN).

The guidelines recommend greater use of modern, evidence based treatments. Patients with stages I or II non-small cell lung cancer that is medically inoperable should be treated using continuous hyperfractionated accelerated radiotherapy (CHART)—an intensive form of radiotherapy given three times a day over a relatively short period of just over two weeks—rather than standard radiotherapy.

The guidelines also recommend offering chemotherapy to patients with stages III and IV non-small cell lung cancer who are generally well—to improve survival, disease control, and quality of life.

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Irritable bowel syndrome

Irritable bowel syndrome consists of abdominal pain and intermittent diarrhoea, constipation, or bloating. Possible contributing factors include stress or anxiety, visceral hypersensitivity, altered bowel motility, neurotransmitter imbalances, and inflammation. No single mechanism explains all cases, and no specific dietary causes are known. Symptoms usually begin before the age of 50, and up to 20% of the population may be affected.

Manning criteria for diagnosing irritable bowel syndrome state that  irritable bowel syndrome exists if 3 or  more are present:

· Abdominal pain

· Relief of pain on defecation

· Increased stool frequency with pain

· Looser stools with pain

· Mucus in stools

· Feeling of incomplete evacuation

However one needs to evaluate further if the patient is aged > 50 or has weight loss, blood in stools, anaemia or fever.

The criteria with the presence of three of the six criteria is 66% to 90% sensitive and 61% to 93% specific for a diagnosis if none of the factors requiring further evaluation are present.

One needs to perform abdominal and rectal examinations. A full blood count will rule out anaemia. Further testing at this point  is probably unnecessary for patients aged under 50 who meet the Manning criteria.

Evidence supports increased dietary fibre for constipation, drugs for specific symptoms, and multicomponent behaviour therapy, including education, coping strategies, relaxation, and cognitive behaviour therapy. Comorbid psychiatric illness should be treated.

Treatment for specific predominant symptoms may include: bulking agents (wheat bran, psyllium) for constipation, loperamide for diarrhoea (initially 2 mg four times daily as needed), and tricyclic antidepressants for pain (starting with scheduled amitriptyline 25 mg at bedtime). It may be important to explore life stresses that trigger symptoms, and consider relaxation or cognitive therapy.

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