[Application of guidelines for the treatment of headache and cancer pain by private practitioners]

[General practitioners' guideline for palliative care. A survey of guideline acceptance in quality circles of primary medical care]

PURPOSE

The implementation of the general practitioners' (GPs) guideline for palliative care released in 2007 with consent of the developing group was accompanied by an anonymous and voluntary survey designed to assess acceptance and feasibility of the recommendations. 60 quality circles of the GP-based care program in Hesse which are run by the PMV research group were used for guideline implementation.

MATERIAL AND METHODS

The quality of the palliative care quality circle meeting itself was checked with a standardized questionnaire (feedback, n = 473 of 515 participating GPs). After several weeks, the follow-up questioning on acceptance of the corresponding guideline was performed (n = 391 of 440 attendees) using twelve items to evaluate the guideline recommendations. The closed questions were appraised employing a Likert scale and the open questions after classifying the free text in categories.

RESULTS

96% of the respondents considered palliative medicine to be important in daily routine. The majority agreed with form and content of this CME meeting (feedback, response rate 91%). The complexity, handling, and practical relevance of the guideline were evaluated positively (response rate 88%). 82% of GPs reported that they would recommend the guideline to colleagues. Specific, practical guideline recommendations on (non)pharmacological strategies in treating dyspnea, on reducing xerostomia and on comedication in the case of opioid treatment were confirmed by 80-94% of the participants, and 75-92% rated these recommendations as practical.

CONCLUSION

The relevance of palliative care in daily routine was shown by the responses evaluating the quality circle session. The grade of acceptance of the guideline is comparable to the other GPs' guidelines with focus on pharmacotherapy. 10-13% of the respondents were not able to judge the relevance nor the practicability of selected recommendations. Future implementation should therefore consider attitude and experience with palliative care. To date, the questionnaires have not been designed to evaluate individual adherence to palliative care guideline.

[Problems and deficits in the transition from inpatient and outpatient care of cancer patients. A qualitative analysis]

INTRODUCTION

Problems and deficits in the transition between hospital-based and outpatient care of cancer patients were evaluated. The project was initiated by the Public Health Department of the City of Aachen and was carried out with cooperation from all hospitals in the urban areas.

METHOD

From September 2002 to April 2003 a total of 145 cancer patients fulfilling the inclusion criteria from 4 regional hospitals were documented at 4 time points within a period of 6-8 weeks by questionnaires, telephone and personal interviews. Aspects of interest were disease type, symptom burden, well-being, the homecare situation and medical aids required.

RESULTS

Patients and their relatives reported on inadequate pain management, insufficient preparation of transition, problems in information flow, organisational problems, lack of attention and humaneness, deficiency of care, delay of diagnosis, inadequate access to services, insufficient prescription of drugs and adjuvants, financial problems and quarrels with the health insurance company on payment of aid devices. Coping strategies were mostly non-functional and not problem-orientated.

DISCUSSION

Special attention should be paid to psychosocial and interpersonal needs of patients. Volunteers may have an important role in the care of patients and relatives. The introduction of case managers might lead to an advancement of care. Sensitisation of physicians, nurses and other caregivers for deficits in transition of patients is needed and should be covered in palliative care education and training.

[Problems and deficits in the transition from inpatient to outpatient care of cancer patients]

INTRODUCTION

Initiated by the Public Health Department of the City of Aachen problems and deficits in the transition from hospital-based to outpatient care of cancer patients were evaluated.

METHOD

From September 2002 to April 2003 the data of 145 cancer patients who met the inclusion criteria and had been treated in four regional hospitals were collected by questionnaire, phone and personal interview at four different points in time within a period of six to eight weeks and documented. Aspects of interest included: type of disease, symptom burden, well-being, home care situation and medical aids required.

RESULTS

Problems and deficits in the transition from hospital-based to outpatient care of cancer patients were only infrequently encountered. Specific structural deficits or general problems were not identified. The majority of patients felt comfortable with their medical transition process. For a special subgroup of patients who died during the trial period worse outcomes were documented than for the whole sample.

DISCUSSION

Worse outcomes of the dying patients indicate disease progression with reduced quality of life, higher symptom burden and less satisfaction. The complex study method and the resulting selection bias may have contributed to underestimating transition problems. A more simple method could reduce the burden for the patients and the amount of missing data and thus allow for a deeper insight into the patients' needs.

Quality of analgesic treatment in patients with advanced prostate cancer: do we do a better job now? The Swiss Group for Clinical Cancer Research (SAKK) experience

GOALS OF WORK

The aim of this study was to evaluate pain intensity and the application of the WHO guidelines for cancer pain treatment in patients with prostate cancer treated at Swiss cancer centers.

MATERIALS AND METHODS

We analyzed a series of five multicenter phase II clinical trials which examined the palliative effect of different chemotherapies in patients with advanced hormone-refractory prostate carcinoma. Of 170 patients, 1,018 visits were evaluable for our purpose, including ratings of pain intensity by patients and prescribed analgesics.

MAIN RESULTS

No or mild pain was indicated by patients in 36 to 55% of the visits, more than mild pain in 30 to 46%. In 21% of the visits, the WHO pain treatment criteria (treatment according to one of the three steps; oral, rectal or transdermal application of the main dose; administration on a regular schedule) were fulfilled, and the Cleeland index was positive according to all recommendations. In 6% of the visits, neither the WHO criteria were fulfilled nor was the Cleeland index positive. This indicates insufficient pain treatment not following the WHO guidelines and that the prescribed analgesics were not sufficiently potent for the rated pain intensity.

CONCLUSIONS

In this selective Swiss sample, the standard of analgesic treatment is high. However, there is still scope for improvement. This cannot solely be solved by improving the knowledge of the physicians. Programs to change the patients' attitude towards cancer pain, training to improve the physicians' communication skills, and institutional changes may be promising strategies.

Einsatz der WHO-Leitlinien für die Tumorschmerztherapie vor Zuweisung in eine Schmerzklinik

In 1986 the World Health Organization (WHO) released guidelines for cancer pain relief. Since then, several controlled studies on effectiveness and practicability of these guidelines have been published. Various authors described inadequate use of these guidelines. We analysed, whether the pain medication of 160 cancer patients referred to the anesthesiological pain clinic at the university hospital of Vienna corresponded to the WHO guidelines or not. Adequacy of pain treatment was assessed using the pain management index (PMI). Multiple criteria were chosen to assess the conformity of the treatment with the guidelines. Furthermore we studied the effect of a strict use of the WHO guidelines in these patients. The average pain intensity of the referred patients was 75 mm (VAS). Negative PMI scores, indicating inadequate pain therapy, were found in 39 % of cases. A violation of the rules was found in 38% of the therapy schedules. Pain medication was then modified by switching to fixed time intervals, escalation of the steps of the WHO ladder, increasing the dosage or treating neuropathic pain with adjuvant drugs. Two weeks later the average pain score of the patients was reduced to 27 mm (VAS). At that time 72% of the patients quoted an adequate reduction of pain. Inadequate knowledge or disregard of the WHO guidelines for cancer pain relief are common and result in unnecessary and prolonged suffering in these patients.

A population-based evaluation of an intervention to improve advanced stage cancer pain management

The purpose of this study was to evaluate the effect of a community-oriented intervention in one part of the Free Town of Bremen, northern Germany (population 541,000) on the prescription prevalence of World Health Organization (WHO) class III opioids for cancer patients in their final year of life. A community-oriented, multimodal intervention included information, teaching, and training modules tailored to physicians, pharmacists, nursing staff, and patients and their relatives, and the public. Prescription prevalences were calculated for the intervention region (Bremen-Nord) and a control region (Bremen-Mitte) before and after the intervention. Specifically, a population-based, controlled, quantitative assessment of opioid prescriptions for patients with cancer during their final year of life was undertaken for two time periods, prior to 1992-1993 and after 1995-1996, respectively. Prescription ascertainment was based on duplicates kept in the pharmacies. Patients comprised two anonymized complete 4-month samples who died in 1993 and 1996, respectively, with cancer as the primary or a contributory cause of death on their death certificates. A total of 1282 prescriptions were abstracted from duplicates in 109 of 119 pharmacies in Bremen-Mitte and all 31 pharmacies in Bremen-Nord (overall pharmacy participation proportion 93%) and individually matched to 856 patients with cancer in their final year of life. In 1993, 16.3% of all terminal cancer patients in Bremen-Mitte and 19.1% in Bremen-Nord had received at least one prescription for a WHO class III opioid. Corresponding numbers after the intervention were 20% and 21%, respectively. The total amount of class III opioids, however, increased 20% in Bremen-Mitte and 210% in Bremen-Nord after the intervention. In 1996, the spectrum of prescribed opioids had changed markedly toward the WHO recommendations. The proportion of prescribing physicians remained constant. These data suggest that a community-oriented intervention in one part of Bremen had a limited impact on cancer pain therapy on the population level. A measurable change of prescription practice seemed to be restricted to the minority of physicians, who had prior experience with prescribing WHO class III opioids.