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ObjectivesThe Marie Curie Cancer Care Delivering Choice Programme (DCP) aims to help palliative patients be cared for in their place of choice. In this study, new palliative care services delivered in two counties in England included end-of-life care coordination centres, an out-of-hours telephone line and discharge in-reach nurses. The study aimed to investigate the impact of DCP on place of death and hospital usage (emergency department (ED) and admissions).MethodsRetrospective cohort of all eligible palliative patients who died over a 6-month period in two counties (n=3594). Participants were those who died of conditions considered to be eligible for end-of-life care, as defined by the Public Health England National End of Life Care Intelligence Network. The sample included people who did and did not access DCP services. DCP service, hospital admission and ED use data, demographic and death data were collected on all eligible participants. Data were analysed using descriptive statistics and logistic regression.ResultsAfter adjusting for potential confounders, those using Delivering Choice were at least 30% less likely to die in hospital or have an emergency hospital admission or ED visit in the last 30 or 7 days of life than those who did not.ConclusionsRecipients of DCP services were less likely to die in or use hospital services. Those considering new ways of providing end-of-life care could explore the possibility of adopting similar services and evaluating the outcomes from patient, carer and system perspectives.

The objectives of this study are to ascertain how many patients who died in a district general hospital in England might have been able to be cared for at home, to obtain the cost of each inpatient stay, to make an estimate of the maximum resource implications of care packages for these patients, and to calculate the savings in hospital admissions that could be used for the development of community services. These objectives are dependant on full implementation of the End of Life Strategy. A descriptive study of all inpatient deaths in one year in a district general hospital in the south west of England was conducted. Data collection - case notes of all patients who died at the hospital from the beginning of June 2006 to end of May 2007. A total of 599 case notes of 627 patients who died in the study period were reviewed. A total of 331 patients (56%) were not assessed as being in the last year of life. Of the remaining 44%, 152 (26%) were clearly in the last year of life and 110 (18%) had significant co-morbidities and could probably have been recognised as being in the last year of life. A total of 399 (67%) of patients were appropriately admitted to hospital for their final illness, 194 (33%) could have been looked after at home. At least 119 (20%) clearly and 75 (13%) probably could have stayed at home. The mean cost of admission was 3173 pound per patient. A total of 77 (13%) of patients were admitted from nursing homes and 53 (69%) of these could have stayed in the nursing home to die. A total of 44% of all patients who died within the district general hospital had chronic life threatening illnesses. A maximum of one third of all hospital deaths could have been looked after at home if excellent end of life services were in place. When commissioning end of life care services, it is possible to calculate how many extra patients may need community care packages and the cost that could be redistributed from hospital to community for these services.

Practice population, geographic and hospital supply factors are consistently associated with asthma and COPD admissions. Higher smoking rates among such patients in a practice are associated with higher admission rates. There is little evidence from this study that other modifiable general practice factors are important in influencing admission rates.

In this paper, we consider periodic solutions of discontinuous non-smooth maps. We show how the fixed points of a general piecewise linear map with a discontinuity (‘a map with a gap’) behave under parameter variation. We show in detail all the possible behaviours of period 1 and period 2 solutions. For positive gaps, we find that period 2 solutions can exist independently of period 1 solutions. Conversely, for negative gaps, period 1 and period 2 solutions can coexist. Higher periodic orbits can also exist and be stable and we give several examples of how these solutions behave under parameter variation. Finally, we compare our results with those of Jain & Banerjee (Jain & Banerjee 2003 Int. J. Bifurcat. Chaos 13 , 3341–3351) and Banerjee et al . (Banerjee et al . 2004 IEEE Trans. Circ. Syst. II 51 , 649–654) and explain their numerical simulations.