1
|
Brenne AT, Løhre ET, Knudsen AK, Lund JÅ, Thronæs M, Driller B, Brunelli C, Kaasa S. Standardizing Integrated Oncology and Palliative Care Across Service Levels: Challenges in Demonstrating Effects in a Prospective Controlled Intervention Trial. Oncol Ther 2024:10.1007/s40487-024-00278-3. [PMID: 38744750 DOI: 10.1007/s40487-024-00278-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Patients with cancer often want to spend their final days at home. In Norway, most patients with cancer die in institutions. We hypothesized that full integration of oncology and palliative care services would result in more time spent at home during end-of-life. METHODS A prospective non-randomized intervention trial was conducted in two rural regions of Mid-Norway. The hospitals' oncology and palliative care outpatient clinics and surrounding communities participated. An intervention including information, education, and a standardized care pathway was developed and implemented. Adult non-curative patients with cancer were eligible. Proportion of last 90 days of life spent at home was the primary outcome. RESULTS We included 129 patients in the intervention group (I) and 76 patients in the comparison group (C), of whom 82% of patients in I and 78% of patients in C died during follow-up. The mean proportion of last 90 days of life spent at home was 0.62 in I and 0.72 in C (p = 0.044), with 23% and 36% (p = 0.073), respectively, dying at home. A higher proportion died at home in both groups compared to pre-study level (12%). During the observation period the comparison region developed and implemented an alternative intervention to the study intervention, with the former more focused on end-of-life care. CONCLUSION A higher proportion of patients with cancer died at home in both groups compared to pre-study level. Patients with cancer in I did not spend more time at home during end-of-life compared to those in C. The study intervention focused on the whole disease trajectory, while the alternative intervention was more directed towards end-of-life care. "Simpler" and more focused interventions on end-of-life care may be relevant for future studies on integration of palliative care into oncology. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02170168.
Collapse
Affiliation(s)
- Anne-Tove Brenne
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Erik Torbjørn Løhre
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Kari Knudsen
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- European Palliative Care Research Centre (PRC), Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jo-Åsmund Lund
- Department of Oncology, Møre Og Romsdal Hospital Trust, Ålesund, Norway
- Department of Health Sciences in Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway
| | - Morten Thronæs
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Bardo Driller
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Oncology, Møre Og Romsdal Hospital Trust, Ålesund, Norway
- Department for Research and Innovation, Møre Og Romsdal Hospital Trust, Ålesund, Norway
| | - Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Instituto Nazionale dei Tumori, Milan, Italy
| | - Stein Kaasa
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- European Palliative Care Research Centre (PRC), Oslo University Hospital and University of Oslo, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
2
|
Iqbal J, Moineddin R, Fowler RA, Krzyzanowska MK, Booth CM, Downar J, Lau J, Le LW, Rodin G, Seow H, Tanuseputro P, Earle CC, Quinn KL, Hannon B, Zimmermann C. Socioeconomic Status, Palliative Care, and Death at Home Among Patients With Cancer Before and During COVID-19. JAMA Netw Open 2024; 7:e240503. [PMID: 38411960 PMCID: PMC10900963 DOI: 10.1001/jamanetworkopen.2024.0503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
Importance The COVID-19 pandemic had a profound impact on the delivery of cancer care, but less is known about its association with place of death and delivery of specialized palliative care (SPC) and potential disparities in these outcomes. Objective To evaluate the association of the COVID-19 pandemic with death at home and SPC delivery at the end of life and to examine whether disparities in socioeconomic status exist for these outcomes. Design, Setting, and Participants In this cohort study, an interrupted time series analysis was conducted using Ontario Cancer Registry data comprising adult patients aged 18 years or older who died with cancer between the pre-COVID-19 (March 16, 2015, to March 15, 2020) and COVID-19 (March 16, 2020, to March 15, 2021) periods. The data analysis was performed between March and November 2023. Exposure COVID-19-related hospital restrictions starting March 16, 2020. Main Outcomes and Measures Outcomes were death at home and SPC delivery at the end of life (last 30 days before death). Socioeconomic status was measured using Ontario Marginalization Index area-based material deprivation quintiles, with quintile 1 (Q1) indicating the least deprivation; Q3, intermediate deprivation; and Q5, the most deprivation. Segmented linear regression was used to estimate monthly trends in outcomes before, at the start of, and in the first year of the COVID-19 pandemic. Results Of 173 915 patients in the study cohort (mean [SD] age, 72.1 [12.5] years; males, 54.1% [95% CI, 53.8%-54.3%]), 83.7% (95% CI, 83.6%-83.9%) died in the pre-COVID-19 period and 16.3% (95% CI, 16.1%-16.4%) died in the COVID-19 period, 54.5% (95% CI, 54.2%-54.7%) died at home during the entire study period, and 57.8% (95% CI, 57.5%-58.0%) received SPC at the end of life. In March 2020, home deaths increased by 8.3% (95% CI, 7.4%-9.1%); however, this increase was less marked in Q5 (6.1%; 95% CI, 4.4%-7.8%) than in Q1 (11.4%; 95% CI, 9.6%-13.2%) and Q3 (10.0%; 95% CI, 9.0%-11.1%). There was a simultaneous decrease of 5.3% (95% CI, -6.3% to -4.4%) in the rate of SPC at the end of life, with no significant difference among quintiles. Patients who received SPC at the end of life (vs no SPC) were more likely to die at home before and during the pandemic. However, there was a larger immediate increase in home deaths among those who received no SPC at the end of life vs those who received SPC (Q1, 17.5% [95% CI, 15.2%-19.8%] vs 7.6% [95% CI, 5.4%-9.7%]; Q3, 12.7% [95% CI, 10.8%-14.5%] vs 9.0% [95% CI, 7.2%-10.7%]). For Q5, the increase in home deaths was significant only for patients who did not receive SPC (13.9% [95% CI, 11.9%-15.8%] vs 1.2% [95% CI, -1.0% to 3.5%]). Conclusions and Relevance These findings suggest that the COVID-19 pandemic was associated with amplified socioeconomic disparities in death at home and SPC delivery at the end of life. Future research should focus on the mechanisms of these disparities and on developing interventions to ensure equitable and consistent SPC access.
Collapse
Affiliation(s)
- Javaid Iqbal
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Monika K Krzyzanowska
- Department of Medicine, University of Toronto, Ontario, Canada
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - James Downar
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyere Research Institute, Bruyere Continuing Care, Ottawa, Ontario, Canada
| | - Jenny Lau
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lisa W Le
- Department of Biostatistics, University Health Network, Toronto, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Peter Tanuseputro
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Craig C Earle
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Kieran L Quinn
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Ontario, Canada
| |
Collapse
|
3
|
Gill SUA, Hollegaard S, Schønnemann KR. Implementation of early palliative care in an oncologic outpatient clinic - an observational study of the first year. Acta Oncol 2023; 62:522-527. [PMID: 37190969 DOI: 10.1080/0284186x.2023.2212410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 05/05/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND As earlier studies found that early onset specialized palliative care (ESPC) results in better quality of life (QoL), less hospitalization and chemotherapy toward end-of life, we implemented ESPC in our oncology outpatient clinic. The aim of this study was to describe reasons for referral, interventions performed and the satisfaction among the oncologic staff. MATERIAL AND METHODS The outpatient ESPC clinic was established in the department of oncology. Prespecified selected data was obtained from the patients records. All patients were asked to fill in a questionnaire concerning their symptoms and QOL. A survey among the oncologic personnel concerning their perception of the clinic was conducted. All data were consecutively collected in a share point database. RESULTS We included 134 patients. The primary referral symptoms were pain (69%) or psychological/existential challenges (23%). 55% of patients filled in an EORTC questionnaire and rated a median (QoL) of 3.4. Interventions initiated were on based on the following symptoms: pain (70%), constipation (53%), nausea (15%), dyspnea (10%) and depression (7%). Median waiting time was 13 days. Of the 134 patients referred to the ESPC clinic 101 was admitted. Symptoms and problems were resolved in the ESPC clinic for 81 of the 101 admitted patients (80%), i.e., after one consultation for 25 patients and after a follow up course in the clinic for 56 patients. A survey among the staff at the Department of Oncology demonstrated a high degree of satisfaction with the ESPC clinic. CONCLUSIONS We report experiences from implementation of ESPC in our outpatient oncologic clinic, where 81 (80%) of the admitted patients could be finished after one or a few follow up contacts, as their symptoms had been resolved. There was a high degree of satisfaction with the clinic among the oncologic staff.
Collapse
Affiliation(s)
- Sabine Ute Alice Gill
- Palliative Care Unit, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Stine Hollegaard
- Palliative Care Unit, Department of Oncology, Odense University Hospital, Odense, Denmark
| | | |
Collapse
|
4
|
Wang X, Turner EL, Li F. Improving sandwich variance estimation for marginal Cox analysis of cluster randomized trials. Biom J 2023; 65:e2200113. [PMID: 36567265 PMCID: PMC10482495 DOI: 10.1002/bimj.202200113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/31/2022] [Accepted: 10/29/2022] [Indexed: 12/27/2022]
Abstract
Cluster randomized trials (CRTs) frequently recruit a small number of clusters, therefore necessitating the application of small-sample corrections for valid inference. A recent systematic review indicated that CRTs reporting right-censored, time-to-event outcomes are not uncommon and that the marginal Cox proportional hazards model is one of the common approaches used for primary analysis. While small-sample corrections have been studied under marginal models with continuous, binary, and count outcomes, no prior research has been devoted to the development and evaluation of bias-corrected sandwich variance estimators when clustered time-to-event outcomes are analyzed by the marginal Cox model. To improve current practice, we propose nine bias-corrected sandwich variance estimators for the analysis of CRTs using the marginal Cox model and report on a simulation study to evaluate their small-sample properties. Our results indicate that the optimal choice of bias-corrected sandwich variance estimator for CRTs with survival outcomes can depend on the variability of cluster sizes and can also slightly differ whether it is evaluated according to relative bias or type I error rate. Finally, we illustrate the new variance estimators in a real-world CRT where the conclusion about intervention effectiveness differs depending on the use of small-sample bias corrections. The proposed sandwich variance estimators are implemented in an R package CoxBcv.
Collapse
Affiliation(s)
- Xueqi Wang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
| | - Elizabeth L. Turner
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
| | - Fan Li
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, 06511, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, 06511, USA
| |
Collapse
|
5
|
Performance of methods for analyzing continuous data from stratified cluster randomized trials – A simulation study. Contemp Clin Trials Commun 2023. [DOI: 10.1016/j.conctc.2023.101115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
|
6
|
Flierman I, Gieteling E, Van Rijn M, Van Grootven B, van Doorne I, Jamaludin FS, Willems DL, Muller M, Buurman BM. Effectiveness of transmural team-based palliative care in prevention of hospitalizations in patients at the end of life: A systematic review and meta-analysis. Palliat Med 2023; 37:75-87. [PMID: 36541477 DOI: 10.1177/02692163221135616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Team-based palliative care interventions have shown positive results for patients at the end of life in both hospital and community settings. However, evidence on the effectiveness of transmural, that is, spanning hospital and home, team-based palliative care collaborations is limited. AIM To systematically review whether transmural team-based palliative care interventions can prevent hospital admissions and increase death at home. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE (Ovid), Embase (Ovid), CINAHL (Ebsco), PsychINFO (Ovid), and Cochrane Library (Wiley) were systematically searched until January 2021. Studies incorporating teams in which hospital and community professionals co-managed patients, hospital-based teams with community follow-up, and case-management interventions led by palliative care teams were included. Data was extracted by two researchers independently. RESULTS About 19 studies were included involving 6614 patients, of whom 2202 received an intervention. The overall pooled odds ratio of at least one hospital (re)admissions was 0.46 (95% confidence interval (CI) 0.34-0.68) in favor of the intervention group. The highest reduction in admission was in the hospital-based teams with community follow-up: OR 0.21 (95% CI 0.07-0.66). The pooled effect on home deaths was 2.19 (95% CI 1.26-3.79), favoring the intervention, with also the highest in the hospital-based teams: OR 4.77 (95% CI 1.23-18.47). However, studies had high heterogeneity regarding intervention, study population, and follow-up time. CONCLUSION Transmural team-based palliative care interventions, especially hospital-based teams that follow-up patients at home, show an overall effect on lowering hospital admissions and increasing the number of patients dying at home. However, broad clinical and statistical heterogeneity of included studies results in uncertainty about the effect size.
Collapse
Affiliation(s)
- Isabelle Flierman
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam UMC Location AMC, University of Amsterdam, Department of General Practice, Section of Medical Ethics, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands
| | - Elske Gieteling
- Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands.,Amsterdam UMC Location VUmc, Department of Medicine for Older People, Amsterdam, The Netherlands.,Amstelland Hospital, Department of Internal Medicine, Amstelveen, The Netherlands
| | - Marjon Van Rijn
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands.,Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Science, Amsterdam, The Netherlands
| | - Bastiaan Van Grootven
- Research Foundation Flanders - FWO, Brussels, Belgium + KU Leuven, Department of Public Health and Primary Care, Leuven, Belgium
| | - Iris van Doorne
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands
| | - Faridi S Jamaludin
- Amsterdam UMC, University of Amsterdam, Research Support, Medical Library AMC, Meibergdreef 9, Amsterdam, The Netherlands
| | - Dick L Willems
- Amsterdam UMC Location AMC, University of Amsterdam, Department of General Practice, Section of Medical Ethics, Amsterdam, The Netherlands
| | - Majon Muller
- Amsterdam UMC Location VUmc, Department of Medicine for Older People, Amsterdam, The Netherlands
| | - Bianca M Buurman
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands.,Amsterdam UMC Location VUmc, Department of Medicine for Older People, Amsterdam, The Netherlands
| |
Collapse
|
7
|
Wang CL, Lin CY, Yang SF. Hospice Care Improves Patients' Self-Decision Making and Reduces Aggressiveness of End-of-Life Care for Advanced Cancer Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15593. [PMID: 36497668 PMCID: PMC9735887 DOI: 10.3390/ijerph192315593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 06/17/2023]
Abstract
The aim of the current study is to evaluate the different degrees of hospice care in improving patients' autonomy in decision-making and reducing aggressiveness of cancer care in terminal-stage cancer patients, especially in reducing polypharmacy and excessive life-sustaining treatments. This was a retrospective cross-sectional study conducted in a single medical center in Taiwan. Patients with advanced cancer who died in 2010-2019 were included and classified into three subgroups: hospice ward admission, hospice shared care, and no hospice care involvement. In total, 8719 patients were enrolled, and 2097 (24.05%) admitted to hospice ward; 2107 (24.17%) received hospice shared care, and 4515 (51.78%) had no hospice care. Those admitted to hospice ward had significantly higher rates of having completed do-not-resuscitate order (100%, p < 0.001) and signed the do-not-resuscitate order by themselves (48.83%, p < 0.001), and they had lower aggressiveness of cancer care (2.2, p < 0.001) within the 28 days before death. Hospice ward admission, hospice shared care, and age > 79 years were negatively associated with aggressiveness of cancer care. In conclusion, our study showed that patients with end-of-life hospice care related to higher patient autonomy in decision-making and less excessively aggressive cancer care; the influence of care was more overt in patients approaching death. Further clinical efforts should be made to clarify the patient and the families' satisfaction and perceptions of quality after hospice care involvement.
Collapse
Affiliation(s)
- Chun-Li Wang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Chia-Yen Lin
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| |
Collapse
|
8
|
Fhoula B, Hadid M, Elomri A, Kerbache L, Hamad A, Al Thani MHJ, Al-Zoubi RM, Al-Ansari A, Aboumarzouk OM, El Omri A. Home Cancer Care Research: A Bibliometric and Visualization Analysis (1990-2021). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13116. [PMID: 36293702 PMCID: PMC9603182 DOI: 10.3390/ijerph192013116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/05/2022] [Accepted: 10/09/2022] [Indexed: 06/16/2023]
Abstract
Home cancer care research (HCCR) has accelerated, as considerable attention has been placed on reducing cancer-related health costs and enhancing cancer patients' quality of life. Understanding the current status of HCCR can help guide future research and support informed decision-making about new home cancer care (HCC) programs. However, most current studies mainly detail the research status of certain components, while failing to explore the knowledge domain of this research field as a whole, thereby limiting the overall understanding of home cancer care. We carried out bibliometric and visualization analyses of Scopus-indexed papers related to home cancer care published between 1990-2021, and used VOSviewer scientometric software to investigate the status and provide a structural overview of the knowledge domain of HCCR (social, intellectual, and conceptual structures). Our findings demonstrate that over the last three decades, the research on home cancer care has been increasing, with a constantly expanding stream of new papers built on a solid knowledge base and applied to a wide range of research themes.
Collapse
Affiliation(s)
- Boutheina Fhoula
- Division of Engineering Management and Decision Sciences, College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Majed Hadid
- Division of Engineering Management and Decision Sciences, College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Adel Elomri
- Division of Engineering Management and Decision Sciences, College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Laoucine Kerbache
- Division of Engineering Management and Decision Sciences, College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Anas Hamad
- Pharmacy Department, National Center for Cancer Care & Research, Hamad Medical Corporation, Doha 3050, Qatar
| | | | - Raed M. Al-Zoubi
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- Department of Biomedical Sciences, College of Health Sciences, QU-Health, Qatar University, Doha 2713, Qatar
- Department of Chemistry, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan
| | - Abdulla Al-Ansari
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Omar M. Aboumarzouk
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- College of Medicine, QU-Health, Qatar University, Doha 2713, Qatar
- School of Medicine, Dentistry and Nursing, The University of Glasgow, Glasgow G12 8QQ, UK
| | - Abdelfatteh El Omri
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| |
Collapse
|
9
|
Bjørnelv G, Hagen TP, Forma L, Aas E. Care pathways at end-of-life for cancer decedents: registry based analyses of the living situation, healthcare utilization and costs for all cancer decedents in Norway in 2009-2013 during their last 6 months of life. BMC Health Serv Res 2022; 22:1221. [PMID: 36183057 PMCID: PMC9526273 DOI: 10.1186/s12913-022-08526-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/29/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Research on end-of-life care is often fragmented, focusing on one level of healthcare or on a particular patient subgroup. Our aim was to describe the complete care pathways of all cancer decedents in Norway during the last six months of life. METHODS We used six national registries linked at patient level and including all cancer decedents in Norway between 2009-2013 to describe patient use of secondary, primary-, and home- and community-based care. We described patient's car pathway, including patients living situation, healthcare utilization, and costs. We then estimated how cancer type, individual and sociodemographic characteristics, and access to informal care influenced the care pathways. Regression models were used depending on the outcome, i.e., negative binomial (for healthcare utilization) and generalized linear models (for healthcare costs). RESULTS In total, 52,926 patients were included who died of lung (16%), colorectal (12%), prostate (9%), breast (6%), cervical (1%) or other (56%) cancers. On average, patients spent 123 days at home, 24 days in hospital, 16 days in short-term care and 24 days in long-term care during their last 6 months of life. Healthcare utilization increased towards end-of-life. Total costs were high (on average, NOK 379,801). 60% of the total costs were in the secondary care setting, 3% in the primary care setting, and 37% in the home- and community-based care setting. Age (total cost-range NOK 361,363-418,618) and marital status (total cost-range NOK354,100-411,047) were stronger determining factors of care pathway than cancer type (total cost-range NOK341,318- 392,655). When patients died of cancer types requiring higher amounts of secondary care (e.g., cervical cancer), there was a corresponding lower utilization of primary, and home- and community-based care, and vice versa. CONCLUSION Cancer patient's care pathways at end-of-life are more strongly associated with age and access to informal care than underlying type of cancer. More care in one care setting (e.g., the secondary care) is associated with less care in other settings (primary- and home- and community based care setting) as demonstrated by the substitution between the different levels of care in this study. Care at end-of-life should therefore not be evaluated in one healthcare level alone since this might bias results and lead to suboptimal priorities.
Collapse
Affiliation(s)
- Gudrun Bjørnelv
- grid.5510.10000 0004 1936 8921Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway ,grid.5947.f0000 0001 1516 2393Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Terje P. Hagen
- grid.5510.10000 0004 1936 8921Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Leena Forma
- grid.502801.e0000 0001 2314 6254Faculty of Social Sciences, Tampere University, Tampere, Finland ,grid.436211.30000 0004 0400 1203Laurea University of Applied Sciences, Vantaa, Finland
| | - Eline Aas
- grid.5510.10000 0004 1936 8921Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway ,Division for Health Services, Institute of Public Health, Oslo, Norway
| |
Collapse
|
10
|
García-Sanjuán S, Fernández-Alcántara M, Clement-Carbonell V, Campos-Calderón CP, Orts-Beneito N, Cabañero-Martínez MJ. Levels and Determinants of Place-Of-Death Congruence in Palliative Patients: A Systematic Review. Front Psychol 2022; 12:807869. [PMID: 35095694 PMCID: PMC8792401 DOI: 10.3389/fpsyg.2021.807869] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Congruence, understood as the agreement between the patient's preferred place of death and their actual place of death, is emerging as one of the main variables indicating the quality of end-of-life care. The aim of this research was to conduct a systematic literature review on levels and determinants of congruence in palliative patients over the period 2010-2021. Method: A systematic review of the literature in the databases of PubMed, Scopus, Web of Science, PsycINFO, CINAHL, Cuiden, the Cochrane Library, CSIC Indexes, and IBECS. Information was extracted on research characteristics, congruence, and associated factors. Results: A total of 30 studies were identified, mainly of retrospective observational design. The congruence values varied substantially between the various studies, ranging from 21 to 100%. The main predictors of congruence include illness-related factors (functional status, treatments and diagnosis), individual factors (age, gender, marital status, and end of life preferences), and environmental factors (place of residence, availability of health, and palliative care services). Conclusion: This review, in comparison with previous studies, shows that treatment-related factors such as physical pain control, marital status, having a non-working relative, age, discussing preferred place of death with a healthcare professional, and caregiver's preference have been associated with higher levels of congruence. Depending on the study, other factors have been associated with either higher or lower congruence, such as the patient's diagnosis, gender, or place of residence. This information is useful for designing interventions aimed towards greater congruence at the end of life.
Collapse
Affiliation(s)
- Sofía García-Sanjuán
- Department of Nursing, Alicante Institute for Health and Biomedical Research (ISABIAL), University of Alicante, Alicante, Spain
| | | | | | | | - Núria Orts-Beneito
- Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - María José Cabañero-Martínez
- Department of Nursing, Alicante Institute for Health and Biomedical Research (ISABIAL), University of Alicante, Alicante, Spain
| |
Collapse
|
11
|
Care at Doorsteps for Persons with Severe Mental Illnesses as a Part of District Mental Health Program (DMHP): A Qualitative Needs Assessment and Psychosocial Framework. Community Ment Health J 2022; 58:145-153. [PMID: 33723734 DOI: 10.1007/s10597-021-00803-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 02/13/2021] [Indexed: 10/21/2022]
Abstract
Care at Doorstep (CAD) is a home care service that includes medical and social care by skilled professionals. The purpose of this paper is to explore the need for CAD among users of the district mental health programme (DMHP) in Ramanagaram, Karnataka, India who have severe mental illness. The design of this study was descriptive where a qualitative inductive methodology was adopted. Data was collected from interviews of 20 caregivers and 7 mental health service providers linked to the DMHP. Socio demographic information was collected from participants and a semi-structured interview guides were used to explore needs and challenges in delivering care at home by the professionals. The themes that emerged from the manually transcribed and coded data were categorized as needs and challenges and used for developing a CAD model.
Collapse
|
12
|
Implementing a Standardized Care Pathway Integrating Oncology, Palliative Care and Community Care in a Rural Region of Mid-Norway. Oncol Ther 2021; 9:671-693. [PMID: 34731447 PMCID: PMC8593089 DOI: 10.1007/s40487-021-00176-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/19/2021] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION To improve quality across levels of care, we developed a standardized care pathway (SCP) integrating palliative and oncology services for hospitalized and home-dwelling palliative cancer patients in a rural region. METHODS A multifaceted implementation strategy was directed towards a combination of target groups. The implementation was conducted on a system level, and implementation-related activities were registered prospectively. Adult patients with advanced cancer treated with non-curative intent were included and interviewed. Healthcare leaders (HCLs) and healthcare professionals (HCPs) involved in the development of the SCP or exposed to the implementation strategy were interviewed. In addition, HCLs and HCPs exposed to the implementation strategy answered standardized questionnaires. Hospital admissions were registered prospectively. RESULTS To assess the use of the SCP, 129 cancer patients were included. Fifteen patients were interviewed about their experiences with the patient-held record (PHR). Sixty interviews were performed among 1320 HCPs exposed to the implementation strategy. Two hundred and eighty-seven HCPs reported on their training in and use of the SCP. Despite organizational cultural differences, developing an SCP integrating palliative and oncology services across levels of care was feasible. Both HCLs and HCPs reported improved quality of care in the wake of the implementation process. Two and a half years after the implementation was launched, 28% of the HCPs used the SCP and 41% had received training in its use. Patients reported limited use and benefit of the PHR. CONCLUSION An SCP may be a usable tool for integrating palliative and oncology services across care levels in a rural region. An extensive implementation process resulted in improvements of process outcomes, yet still limited use of the SCP in clinical practice. HCLs and HCPs reported improved quality of cancer care following the implementation process. Future research should address mandatory elements for usefulness and successful implementation of SCPs for palliative cancer patients.
Collapse
|
13
|
Rubagumya F, Mitera G, Ka S, Manirakiza A, Decuir P, Msadabwe SC, Adani Ifè S, Nwachukwu E, Ohene Oti N, Borges H, Mutebi M, Abuidris D, Vanderpuye V, Booth CM, Hammad N. Choosing Wisely Africa: Ten Low-Value or Harmful Practices That Should Be Avoided in Cancer Care. JCO Glob Oncol 2021; 6:1192-1199. [PMID: 32735489 PMCID: PMC7392774 DOI: 10.1200/go.20.00255] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Choosing Wisely Africa (CWA) builds on Choosing Wisely (CW) in the United States, Canada, and India and aims to identify low-value, unnecessary, or harmful cancer practices that are frequently used on the African continent. The aim of this work was to use physicians and patient advocates to identify a short list of low-value practices that are frequently used in African low- and middle-income countries. METHODS The CWA Task Force was convened by the African Organization for Research and Training in Cancer and included representatives from surgical, medical, and radiation oncology, the private and public sectors, and patient advocacy groups. Consensus was built through a modified Delphi process, shortening a long list of practices to a short list, and then to a final list. A voting threshold of ≥ 60% was used to include an individual practice on the short list. A consensus was reached after a series of teleconferences and voting processes. RESULTS Of the 10 practices on the final list, one is a new suggestion and 9 are revisions or adaptations of practices from previous CW campaign lists. One item relates to palliative care, 8 concern treatment, and one relates to surveillance. CONCLUSION The CWA initiative has identified 10 low-value, common interventions in Africa’s cancer practice. The success of this campaign will be measured by how the recommendations are implemented across sub-Saharan Africa and whether this improves the delivery of high-quality cancer care.
Collapse
Affiliation(s)
- Fidel Rubagumya
- Rwanda Military Hospital, Kigali, Rwanda.,University of Global Health Equity, Burera, Rwanda
| | | | - Sidy Ka
- Joliot Curie Cancer Institute, Dakar, Senegal
| | | | | | | | | | | | | | | | | | - Dafalla Abuidris
- National Cancer Institute, University of Geriza, Wad Madani, Sudan
| | | | - Christopher M Booth
- Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
| | - Nazik Hammad
- Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
14
|
Ullgren H, Fransson P, Olofsson A, Segersvärd R, Sharp L. Health care utilization at end of life among patients with lung or pancreatic cancer. Comparison between two Swedish cohorts. PLoS One 2021; 16:e0254673. [PMID: 34270589 PMCID: PMC8284833 DOI: 10.1371/journal.pone.0254673] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/30/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives The purpose was to analyze trends in intensity of care at End-of-life (EOL), in two cohorts of patients with lung or pancreatic cancer. Setting We used population-based registry data on health care utilization to describe proportions and intensity of care at EOL comparing the two cohorts (deceased in the years of 2010 and 2017 respectively) in the region of Stockholm, Sweden. Primary and secondary outcomes Main outcomes were intensity of care during the last 30 days of life; systemic anticancer treatment (SACT), emergency department (ED) visits, length of stay (LOS) > 14 days, intensive care (ICU), death at acute care hospital and lack of referral to specialized palliative care (SPC) at home. The secondary outcomes were outpatient visits, place of death and hospitalizations, as well as radiotherapy and major surgery. A multivariable logistic regression analysis was used for associations. A moderation variable was added to assess for the effect of SPC at home between the cohorts. Results Intensity of care at EOL increased over time between the cohorts, especially use of SACT, increased with 10%, p<0.001, (n = 102/754 = 14% to n = 236/972 = 24%), ED visits with 7%, p<0.001, (n = 25/754 = 3% to n = 100/972 = 10%) and ICU care, 2%, p = 0.04, (n = 12/754 = 2% to n = 38/972 = 4%). High intensity of care at EOL were more likely among patients with lung cancer. The difference in use of SACT between the years, was moderated by SPC, with an increase of SACT, unstandardized coefficient β; 0.87, SE = 0.27, p = 0.001, as well as the difference between the years in death at acute care hospitals, that decreased (β = 0.69, SE = 0.26, p = 0.007). Conclusion These findings underscore an increase of several aspects regarding intensity of care at EOL, and a need for further exploration of the optimal organization of EOL care. Our results indicate fragmentation of care and a need to better organize and coordinate care for vulnerable patients.
Collapse
Affiliation(s)
- Helena Ullgren
- Department of Nursing, Umeå University, Umeå, Sweden
- Regional Cancer Center, Stockholm, Gotland, Sweden
- Theme cancer, Karolinska University Hospital, Stockholm, Sweden
- * E-mail:
| | - Per Fransson
- Department of Nursing, Umeå University, Umeå, Sweden
| | | | - Ralf Segersvärd
- Regional Cancer Center, Stockholm, Gotland, Sweden
- Department of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Lena Sharp
- Regional Cancer Center, Stockholm, Gotland, Sweden
- Department of Innovative Care, LIME, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
15
|
Smith GM, Calton BA, Rabow MW, Marks AK, Bischoff KE, Pantilat SZ, O'Riordan DL. Comparing the Palliative Care Needs of Patients Seen by Specialty Palliative Care Teams at Home Versus in Clinic. J Pain Symptom Manage 2021; 62:28-38. [PMID: 33246071 DOI: 10.1016/j.jpainsymman.2020.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/06/2020] [Accepted: 11/17/2020] [Indexed: 12/25/2022]
Abstract
CONTEXT Understanding the unique needs of patients seen in clinic versus at home can help palliative care (PC) teams choose how to maximize available resources. OBJECTIVES To compare the characteristics and PC needs of patients seen by PC teams in clinic versus at home. METHODS We analyzed data from the Palliative Care Quality Network between August 2016 and September 2019 and compared demographics, diagnosis, reason for referral, PC needs, functional status, self-reported symptoms, and patient-reported quality of life. RESULTS Compared to patients receiving PC in clinic, patients receiving PC at home were more likely to be of age 80 years or older (odds ratio [OR] 7.5, 95% CI 5.0, 10.9, P < 0.0001), have lower functional status (mean Palliative Performance Scale score 53% vs. 68%, P < 0.0001), and were less likely to screen positive for needing pain management (OR 0.31, 95% CI 0.22, 0.42, P < 0.0001) or other symptom management (OR 0.61, 95% CI 0.41, 0.90, P = 0.01). Patients receiving care at home were more likely to be referred for care planning (goals of care discussions or advance care planning) (OR 11.5, 95% CI 8.3, 16.0 P < 0.0001) and patient/family support (OR 5.9, 95% CI 4.2, 8.3, P < 0.0001). CONCLUSION Patients seen by PC teams at home had worse function and were more likely to be referred for care planning, while patients seen in clinic had more PC needs related to pain and symptom management. Despite these differences, both populations have significant PC needs that support routine assessment and require appropriately staffed interdisciplinary teams to address these needs.
Collapse
Affiliation(s)
- Grant M Smith
- Stanford Section of Palliative Medicine, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California, USA.
| | - Brook A Calton
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Michael W Rabow
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Angela K Marks
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Kara E Bischoff
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - David L O'Riordan
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
16
|
Fahy BN. Current Guidelines for Integration of Palliative Care in Oncology. Surg Oncol Clin N Am 2021; 30:431-447. [PMID: 34053660 DOI: 10.1016/j.soc.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Multiple cancer societies and professional medical organizations recommend integration of palliative care into routine oncology care. A growing body of literature supports the benefits of palliative care in patients with cancer. Palliative care improves pain and other symptoms, enhances quality of life, and reduces depression. The best method and timing for integration of palliative care is unclear. Multiple barriers exist that prevent optimal palliative care integration; these barriers will require additional education and research to overcome.
Collapse
Affiliation(s)
- Bridget N Fahy
- Department of Surgery, Division of Surgical Oncology, University of New Mexico, 1 University of New Mexico, MSC 07-4025, Albuquerque, NM 87131, USA; Division of Palliative Medicine, University of New Mexico, Albuquerque, NM, USA.
| |
Collapse
|
17
|
Chiang JK, Kao YH. Quality of end-of-life care of home-based care with or without palliative services for patients with advanced illnesses. Medicine (Baltimore) 2021; 100:e25841. [PMID: 33950997 PMCID: PMC8104190 DOI: 10.1097/md.0000000000025841] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/19/2021] [Indexed: 01/04/2023] Open
Abstract
Palliative care has improved quality of end-of-life (EOL) care for patients with cancer, and these benefits may be extended to patients with other serious illnesses. EOL care quality for patients with home-based care is a critical problem for health care providers. We compare EOL quality care between patients with advanced illnesses receiving home-based care with and without palliative services.The medical records of deceased patients who received home-based care at a community teaching hospital in south Taiwan from January to December 2019 were collected retrospectively. We analyzed EOL care quality indicators during the last month of life.A total of 164 patients were included for analysis. Fifty-two (31.7%) received palliative services (HP group), and 112 (68.3%) did not receive palliative services (non-HP group). Regarding the quality indicators of EOL care, we discovered that a lower percentage of the HP group died in a hospital than did that of the non-HP group (34.6% vs 62.5%, P = .001) through univariate analysis. We found that the HP group had lower scores on the aggressiveness of EOL care than did the non-HP group (0.5 ± 0.9 vs 1.0 ± 1.0, P<.001). Furthermore, palliative services were a significant and negative factor of dying in a hospital after adjustment (OR = 0.13, 95%CI = 0.05-0.36, P < .001).For patients with advanced illnesses receiving home-based care, palliative services are associated with lower scores on the aggressiveness of EOL care and a reduced probability of dying in a hospital.
Collapse
Affiliation(s)
- Jui-Kun Chiang
- Department of Family Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Chiayi
| | - Yee-Hsin Kao
- Department of Family Medicine, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
| |
Collapse
|
18
|
Hjermstad MJ, Hamfjord J, Aass N, Dajani O, Lundeby T, Wester T, Kaasa S. Using Process Indicators to Monitor Documentation of Patient-Centred Variables in an Integrated Oncology and Palliative Care Pathway-Results from a Cluster Randomized Trial. Cancers (Basel) 2021; 13:2194. [PMID: 34063594 PMCID: PMC8124531 DOI: 10.3390/cancers13092194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Despite robust evidence from randomized controlled trials (RCTs) demonstrating clinical and patient-reported benefits of integrated oncology and palliative care, the tumour-centred focus is predominant. This single-centre process evaluation monitors documentation of required patient-centred variables during an RCT. METHODS Performance status, patient self-reported symptoms, weight and summaries to general practitioners were assessed from June 2017 to July 2020 in three consultation types: first oncological after study inclusion and palliative and oncological consultations during chemotherapy. Descriptive statistics were used to monitor if the pre-defined program fulfilment of ≥85% documentation was reached. RESULTS 435 consultations were monitored in 76 patients; 60.5% males, 86.8% with GI cancers; 76 (17.5%) were from the first oncological consultations, 87 (20.0%) and 272 (62.5%) from palliative or subsequent oncological consultations. Program fulfilment differed across consultation types with 94.8% in the palliative consultations (83.3-100%), relative to 65.8% (62.5-75.0%) and 69.2% (57.0-84.3%) for first and subsequent oncological consultations over time, respectively. Use of self-reported symptoms was consistently lower in the oncological consultations. CONCLUSIONS The documentation level of required core variables was not satisfactory, notwithstanding their high clinical relevance and continuous reminders during study. Pre-trial optimization strategies are paramount to promote integration and reduce professional and personal barriers towards a more patient-centred focus.
Collapse
Affiliation(s)
- Marianne Jensen Hjermstad
- Department of Oncology, Oslo University Hospital, 4950 Oslo, Norway; (J.H.); (N.A.); (O.D.); (T.L.); (T.W.); (S.K.)
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, 4956 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
| | - Julian Hamfjord
- Department of Oncology, Oslo University Hospital, 4950 Oslo, Norway; (J.H.); (N.A.); (O.D.); (T.L.); (T.W.); (S.K.)
- Faculty of Medicine, University of Oslo, 0372 Oslo, Norway
| | - Nina Aass
- Department of Oncology, Oslo University Hospital, 4950 Oslo, Norway; (J.H.); (N.A.); (O.D.); (T.L.); (T.W.); (S.K.)
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, 4956 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
- Faculty of Medicine, University of Oslo, 0372 Oslo, Norway
| | - Olav Dajani
- Department of Oncology, Oslo University Hospital, 4950 Oslo, Norway; (J.H.); (N.A.); (O.D.); (T.L.); (T.W.); (S.K.)
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, 4956 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
| | - Tonje Lundeby
- Department of Oncology, Oslo University Hospital, 4950 Oslo, Norway; (J.H.); (N.A.); (O.D.); (T.L.); (T.W.); (S.K.)
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, 4956 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
| | - Torunn Wester
- Department of Oncology, Oslo University Hospital, 4950 Oslo, Norway; (J.H.); (N.A.); (O.D.); (T.L.); (T.W.); (S.K.)
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, 4956 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
| | - Stein Kaasa
- Department of Oncology, Oslo University Hospital, 4950 Oslo, Norway; (J.H.); (N.A.); (O.D.); (T.L.); (T.W.); (S.K.)
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, 4956 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
- Faculty of Medicine, University of Oslo, 0372 Oslo, Norway
| |
Collapse
|
19
|
Flöther L, Pötzsch B, Jung M, Jung R, Bucher M, Glowka A, Medenwald D. Treatment effects of palliative care consultation and patient contentment: A monocentric observational study. Medicine (Baltimore) 2021; 100:e24320. [PMID: 33761631 PMCID: PMC9282054 DOI: 10.1097/md.0000000000024320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 12/03/2020] [Accepted: 12/22/2020] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT Palliative care is a central component of the therapy in terminally ill patients. During treatment in non-palliative departments this can be realized by consultation.To analyze the change in symptom burden during palliative care consultation.In this observational study, we enrolled all cancer cases (n = 163) receiving inpatient treatment for 2015 to 2018 at our institution. We used the MDASI-questionnaire (0 = 'not present' and 10 = "as bad as you can imagine") and the FAMCARE-6 (1 = very satisfied, 5 = very dissatisfied) to analyze the treatment effect and patient satisfaction, respectively.We examined the association of symptom burden and patient satisfaction using Spearman-correlation. Comparing mean values, we applied the Wilcoxon-test and one-way ANOVA.An improvement in MDASI-core-items after treatment completion was significant (P < .05) in 14/18 symptoms. The change in perception of pain showed the strongest improvement (median: 5 to 3). Initially the MDASI-items "activity" (median = 8) and emotional distress (median = 5 and 6) were viewed as especially incriminating. There was no evidence for a correlation between patients' age, the type of diagnosis and time since diagnosis.The analysis of FAMCARE-6 patient contentment was lower or equal to two in all of the six items. There was a weak negative association between the change in symptom burden of psycho-emotional items "distress/feeling upset" (P = .006, rSp = -0,226), "sadness" and patient satisfaction in FAMCARE-6.A considerable improvement of the extensive symptom burden particularly of pain relief was achieved by integrating palliative consultation in clinical practice.
Collapse
Affiliation(s)
- Lilit Flöther
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - Barabara Pötzsch
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - Maria Jung
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - Robert Jung
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - Michael Bucher
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - André Glowka
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
- Institut für Medizinische Epidemiologie, Biometrie und Informatik Universitätsmedizin Halle (Saale), Germany
| | - Daniel Medenwald
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik und Poliklinik für Strahlentherapie
| |
Collapse
|
20
|
Abstract
BACKGROUND The policy several countries is to provide people with a terminal illness the choice of dying at home; this is supported by surveys that indicate that the general public and people with a terminal illness would prefer to receive end-of-life care at home. This is the fifth update of the original review. OBJECTIVES To determine if providing home-based end-of-life care reduces the likelihood of dying in hospital and what effect this has on patients' symptoms, quality of life, health service costs and caregivers compared with inpatient hospital or hospice care. SEARCH METHODS We searched CENTRAL, Ovid MEDLINE(R), Embase, CINAHL, and clinical trials registries to 18 March 2020. We checked the reference lists of systematic reviews. For included studies, we checked the reference lists and performed a forward search using ISI Web of Science. We handsearched palliative care journals indexed by ISI Web of Science for online first references. SELECTION CRITERIA Randomised controlled trials evaluating the effectiveness of home-based end-of-life care with inpatient hospital or hospice care for people aged 18 years and older. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. When appropriate, we combined published data for dichotomous outcomes using a fixed-effect Mantel-Haenszel meta-analysis to calculate risk ratios (RR) with 95% confidence intervals (CI). When combining outcome data was not possible, we reported the results from individual studies. MAIN RESULTS We included four randomised trials and found no new studies from the search in March 2020. Home-based end-of-life care increased the likelihood of dying at home compared with usual care (RR 1.31, 95% CI 1.12 to 1.52; 2 trials, 539 participants; I2 = 25%; high-certainty evidence). Admission to hospital varied among the trials (range of RR 0.62, 95% CI 0.48 to 0.79, to RR 2.61, 95% CI 1.50 to 4.55). The effect on patient outcomes and control of symptoms was uncertain. Home-based end-of-life care may slightly improve patient satisfaction at one-month follow-up, with little or no difference at six-month follow-up (2 trials; low-certainty evidence). The effect on caregivers (2 trials; very low-certainty evidence), staff (1 trial; very low-certainty evidence) and health service costs was uncertain (2 trials, very low-certainty evidence). AUTHORS' CONCLUSIONS The evidence included in this review supports the use of home-based end-of-life care programmes for increasing the number of people who will die at home. Research that assesses the impact of home-based end-of-life care on caregivers and admissions to hospital would be a useful addition to the evidence base, and might inform the delivery of these services.
Collapse
Affiliation(s)
- Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
| | - Bee Wee
- Nuffield Department of Medicine and Sir Michael Sobell House, Churchill Hospital, Oxford, UK
| |
Collapse
|
21
|
Gamblin V, Prod'homme C, Lecoeuvre A, Bimbai AM, Luu J, Hazard PA, Da Silva A, Villet S, Le Deley MC, Penel N. Home hospitalization for palliative cancer care: factors associated with unplanned hospital admissions and death in hospital. BMC Palliat Care 2021; 20:24. [PMID: 33499835 PMCID: PMC7839201 DOI: 10.1186/s12904-021-00720-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 01/18/2021] [Indexed: 11/10/2022] Open
Abstract
Background Home hospitalization at the end of life can sometimes be perturbed by unplanned hospital admissions (UHAs, defined as any admission that is not part of a preplanned care procedure), which increase the likelihood of death in hospital. The objectives were to describe the occurrence and causes of UHAs in cancer patients receiving end-of-life care at home, and to identify factors associated with UHAs and death in hospital. Methods A retrospective, single-center study (performed at a regional cancer center in the city of Lille, northern France) of advanced cancer patients discharged to home hospitalization between January 2014 and December 2017. We estimated the incidence of UHA over time using Kaplan-Meier method and Kalbfleish and Prentice method. We investigated factors associated with the risk UHA in cause-specific Cox models. We evaluated factors associated with death in hospital in logistic regressions. Results One hundred and forty-two patients were included in the study. Eighty-two patients (57.7 %) experienced one or more UHAs, a high proportion of which occurred within 1 month after discharge to home. Most UHAs were related to physical symptoms and were initiated by the patient’s family physician. A post-discharge palliative care consultation was associated with a significantly lower incidence of UHAs. Sixty-five patients (47.8 % of the deaths) died in hospital. In a multivariate analysis, living alone and the presence of one or more children at home were associated with death in hospital. Conclusions More than 40 % of cancer patients receiving end of life home hospitalization were not readmitted to hospital, reflecting the effectiveness of this type of palliative care setting. However, over half of the UHAs were due to an acute intercurrent event. Our results suggest that more efforts should be focused on anticipating these events at home – primarily via better upstream coordination between hospital physicians and family physicians.
Collapse
Affiliation(s)
- Vincent Gamblin
- Palliative Care Unit, Oscar Lambret Center, 3 rue Frédéric Combemale, 59300, Lille, France.
| | - Chloé Prod'homme
- Palliative Care Unit, Lille University Hospital and Medical School, 59000, Lille, France.,ETHICS (Experiment, Transhumanism, Human Interactions, Care and Society) - EA7446, Lille Catholic University, 59800, Lille, France
| | - Adrien Lecoeuvre
- Direction of Research and Innovation, Oscar Lambret Center, 3 rue Frédéric Combemale, 59020, Lille, France
| | - André -Michel Bimbai
- Direction of Research and Innovation, Oscar Lambret Center, 3 rue Frédéric Combemale, 59020, Lille, France
| | - Joël Luu
- Direction of Research and Innovation, Oscar Lambret Center, 3 rue Frédéric Combemale, 59020, Lille, France
| | | | - Arlette Da Silva
- Palliative Care Unit, Oscar Lambret Center, 3 rue Frédéric Combemale, 59300, Lille, France
| | - Stéphanie Villet
- Palliative Care Unit, Oscar Lambret Center, 3 rue Frédéric Combemale, 59300, Lille, France
| | - Marie-Cécile Le Deley
- Direction of Research and Innovation, Oscar Lambret Center, 3 rue Frédéric Combemale, 59020, Lille, France.,Paris-Saclay University, Paris-Sud University, UVSQ, CESP, INSERM, Gif-sur-Yvette, France
| | - Nicolas Penel
- Direction of Research and Innovation, Oscar Lambret Center, 3 rue Frédéric Combemale, 59020, Lille, France.,Lille University Hospital and Medical School, 59045, Lille, France
| |
Collapse
|
22
|
Jennings N, Chambaere K, Chamely S, Macpherson CC, Deliens L, Cohen J. Palliative and End-of-Life Care in a Small Caribbean Country: A Mortality Follow-back Study of Home Deaths. J Pain Symptom Manage 2020; 60:1170-1180. [PMID: 32650139 DOI: 10.1016/j.jpainsymman.2020.06.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 11/28/2022]
Abstract
CONTEXT Empirical information on circumstances of dying from advanced illness in developing countries remains sparse. Evidence indicates that out-of-hospital end-of-life care can have significant benefits such as increased satisfaction for the patient and caregivers and cost-effective for a health-care system. Services that are aimed to deliver care at private homes may be a good model for low- and middle-income countries or other low-resourced settings. OBJECTIVES To examine specialized, generalist, and informal palliative care provision and to describe the end-of-life care goals and treatments received. METHOD A mortality follow-back study with data obtained from general practitioners certifying a random sample of death certificates of adult decedents who died between March and August 2018. The questionnaire inquired about the characteristics of care and treatment preceding death. RESULTS Three hundred nine questionnaires were mailed, and the response rate was 31% (N = 96), of which 76% were nonsudden deaths. Of these cases, 27.4% received no palliative care, 39.7% received it from a general practitioner, and 6.8% from a specialized palliative care service. Comfort maximization (60.3%) was the main goal of care in the last week of life, and analgesics (53.4%) were the predominant treatment for achieving this goal. In addition, 60.3% received informal palliative care from a family member. CONCLUSION The largest part of end-of-life care at home in Trinidad and Tobago is provided by family members, whereas professional caregivers feature less prominently. To ensure quality in end-of-life care, better access to analgesics is needed, and adequate support and education for family members as well as general practitioners are highly recommended.
Collapse
Affiliation(s)
- Nicholas Jennings
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; St. George's University, Bioethics Department, St. George's Grenada.
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Stacey Chamely
- Independent researcher, San Fernando, Trinidad and Tobago
| | - Cheryl C Macpherson
- Bioethics Division, St. George's University School of Medicine and Windward Islands Research and Education Foundation, St. George's, Grenada
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium; Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| |
Collapse
|
23
|
Isenberg SR, Kavalieratos D, Chow R, Le L, Wegier P, Zimmermann C. Quality versus risk of bias assessment of palliative care trials: comparison of two tools. BMJ Support Palliat Care 2020:bmjspcare-2020-002539. [PMID: 33208350 DOI: 10.1136/bmjspcare-2020-002539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/16/2020] [Accepted: 08/24/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Randomised controlled trials (RCTs) of palliative care interventions are challenging to conduct and evaluate. Tools used to judge the quality of RCTs do not account for the complexities of conducting research in seriously ill populations and may artificially downgrade confidence in palliative care research. OBJECTIVE To compare assessments from the Palliative Care Trial Assessment Tool (PCTAT) and Cochrane Risk of Bias (RoB) tool. DESIGN Reviewers assessed 43 RCTs using PCTAT and RoB. We compared assessments of each trial, assessed overall agreement (weighted kappa (Kw)) and examined (dis)agreement for comparable items. We assessed quality of life at 1-3 months among trials grouped according to RoB or PCTAT score (using meta-analysis) and whether RoB or quality improved over time (Cochran-Armitage trend test). RESULTS Of 43 trials, those rated low RoB had a mean PCTAT score of 73 (SD 10); those rated high RoB had a mean PCTAT score of 56 (SD 14). Overall Kw was 0.33 (95% CI 0.19 to 0.42). Total agreement between comparable items was observed for 56% of trials (24/43) and total disagreement for 21% (8/43). The standardised mean difference in quality of life was statistically significant among RCTs with low RoB and high PCTAT, but not for those with medium/low PCTAT or high/unclear RoB. Quality of reporting improved over time, whereas RoB did not. CONCLUSION Although there was fair agreement between tools, areas of disagreement/non-comparability suggest the tools capture different aspects of bias/quality. A specific tool to evaluate quality of palliative care trials may be warranted.
Collapse
Affiliation(s)
- Sarina R Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dio Kavalieratos
- Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Ronald Chow
- Division of Palliative Care and Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Lisa Le
- Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Pete Wegier
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Humber River Hospital, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Division of Palliative Care and Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
- Division of Medical Oncology and Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
24
|
Borhan S, Papaioannou A, Ma J, Adachi J, Thabane L. Analysis and reporting of stratified cluster randomized trials-a systematic survey. Trials 2020; 21:930. [PMID: 33203468 PMCID: PMC7672868 DOI: 10.1186/s13063-020-04850-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 10/29/2020] [Indexed: 12/04/2022] Open
Abstract
Background In order to correctly assess the effect of intervention from stratified cluster randomized trials (CRTs), it is necessary to adjust for both clustering and stratification, as failure to do so leads to misleading conclusions about the intervention effect. We have conducted a systematic survey to examine the current practices about analysis and reporting of stratified CRTs. Method We used the search terms to identify the stratified CRTs from MEDLINE since the inception to July 2019. In phase 1, we screened the title and abstract for English-only studies and selected, including the main results paper of the identified protocols, for the next phase. In phase 2, we screened the full text and selected studies for data abstraction. The data abstraction form was piloted and developed using the REDCap. We abstracted data on multiple design and methodological aspects of the study including whether the primary method adjusted for both clustering and stratification, reporting of sample size, randomization, and results. Results We screened 2686 studies in the phase 1 and selected 286 studies for phase 2—among them 185 studies were selected for data abstraction. Most of the selected studies were two-arm 140/185 (76%) and parallel-group 165/185 (89%) trials. Among these 185 studies, 27 (15%) of them did not provide any sample size or power calculation, while 105 (57%) studies did not mention any method used for randomization within each stratum. Further, 43 (23%) and 150 (81%) of 185 studies did not provide the definition of all the strata, while more than 60% of the studies did not include all the stratification variable(s) in the flow chart or baseline characteristics table. More than half 114/185 (62%) of the studies did not adjust the primary method for both clustering and stratification. Conclusion Stratification helps to achieve the balance among intervention groups. However, to correctly assess the intervention effect from stratified CRTs, it is important to adjust the primary analysis for both stratification and clustering. There are significant deficiencies in the reporting of methodological aspects of stratified CRTs, which require substantial improvements in several areas including definition of strata, inclusion of stratification variable(s) in the flow chart or baseline characteristics table, and reporting the stratum-specific number of clusters and individuals in the intervention groups. Supplementary information Supplementary information accompanies this paper at 10.1186/s13063-020-04850-w.
Collapse
Affiliation(s)
- Sayem Borhan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Biostatistics Unit, Research Institute of St Joseph's Healthcare, Hamilton, ON, Canada.,GERAS Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Alexandra Papaioannou
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,GERAS Centre, Hamilton Health Sciences, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Jonathan Adachi
- GERAS Centre, Hamilton Health Sciences, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada. .,Biostatistics Unit, Research Institute of St Joseph's Healthcare, Hamilton, ON, Canada. .,GERAS Centre, Hamilton Health Sciences, Hamilton, ON, Canada. .,Departments of Pediatrics and Anesthesia, McMaster University, Hamilton, ON, Canada.
| |
Collapse
|
25
|
Halling CMB, Wolf RT, Sjøgren P, Von Der Maase H, Timm H, Johansen C, Kjellberg J. Cost-effectiveness analysis of systematic fast-track transition from oncological treatment to specialised palliative care at home for patients and their caregivers: the DOMUS trial. BMC Palliat Care 2020; 19:142. [PMID: 32933489 PMCID: PMC7493170 DOI: 10.1186/s12904-020-00645-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While hospitals remain the most common place of death in many western countries, specialised palliative care (SPC) at home is an alternative to improve the quality of life for patients with incurable cancer. We evaluated the cost-effectiveness of a systematic fast-track transition process from oncological treatment to SPC enriched with a psychological intervention at home for patients with incurable cancer and their caregivers. METHODS A full economic evaluation with a time horizon of six months was performed from a societal perspective within a randomised controlled trial, the DOMUS trial ( Clinicaltrials.gov : NCT01885637). The primary outcome of the health economic analysis was a incremental cost-effectiveness ratio (ICER), which is obtained by comparing costs required per gain in Quality-Adjusted Life Years (QALY). The costs included primary and secondary healthcare costs, cost of intervention and informal care from caregivers. Public transfers were analysed in seperate analysis. QALYs were measured using EORTC QLQ-C30 for patients and SF-36 for caregivers. Bootstrap simulations were performed to obtain the ICER estimate. RESULTS In total, 321 patients (162 in intervention group, 159 in control group) and 235 caregivers (126 in intervention group, 109 in control group) completed the study. The intervention resulted in significantly higher QALYs for patients when compared to usual care (p-value = 0.026), while being more expensive as well. In the 6 months observation period, the average incremental cost of intervention compared to usual care was €2015 per patient (p value < 0.000). The mean incremental gain was 0.01678 QALY (p-value = 0.026). Thereby, the ICER was €118,292/QALY when adjusting for baseline costs and quality of life. For the caregivers, we found no significant differences in QALYs between the intervention and control group (p-value = 0.630). At a willingness to pay of €80,000 per QALY, the probability that the intervention is cost-effective lies at 15% in the base case scenario. CONCLUSION This model of fast-track SPC enriched with a psychological intervention yields better QALYs than usual care with a large increase in costs. TRIAL REGISTRATION The trial was prospectively registered 25.6.2013. Clinicaltrials.gov Identifier: NCT01885637 .
Collapse
Affiliation(s)
| | - Rasmus Trap Wolf
- VIVE - The Danish Center for Social Science Research, Herluf Trolles Gade 11, 1052, København K, Denmark
| | - Per Sjøgren
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Hans Von Der Maase
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Helle Timm
- REHPA - The Danish Knowledge Centre for Rehabilitation and Palliative Care, Copenhagen, Denmark
| | - Christoffer Johansen
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,The Danish Cancer Society, Copenhagen, Denmark
| | - Jakob Kjellberg
- VIVE - The Danish Center for Social Science Research, Herluf Trolles Gade 11, 1052, København K, Denmark
| |
Collapse
|
26
|
Temel JS, Sloan J, Zemla T, Greer JA, Jackson VA, El-Jawahri A, Kamdar M, Kamal A, Blinderman CD, Strand J, Zylla D, Daugherty C, Furqan M, Obel J, Razaq M, Roeland EJ, Loprinzi C. Multisite, Randomized Trial of Early Integrated Palliative and Oncology Care in Patients with Advanced Lung and Gastrointestinal Cancer: Alliance A221303. J Palliat Med 2020; 23:922-929. [PMID: 32031887 PMCID: PMC7307668 DOI: 10.1089/jpm.2019.0377] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: We conducted a multicenter, randomized trial of early integrated palliative and oncology care in patients with advanced cancer to confirm the benefits of early palliative care (PC) seen in prior single-center studies. Methods: We randomly assigned patients with newly diagnosed incurable cancer to early integrated palliative and oncology care (n = 195) or usual oncology care (n = 196) at sites through the Alliance for Clinical Trials in Oncology. Patients assigned to the intervention were expected to meet with a PC clinician at least monthly until death, whereas usual care patients consulted PC on request. The primary endpoint was the change in quality of life from baseline to week 12 per the Functional Assessment of Cancer Therapy-General (FACT-G). Secondary outcomes included anxiety, depression, and communication about prognosis and end-of-life care. Results: Due to significant morbidity and a high proportion of measures that were not completed within the protocol window or for unknown reasons, the rate of missing data was high. We anticipated that 70% of patients (n = 280) would complete the FACT-G at baseline and week 12, but only 49.3% (n = 193/391) completed the measure. Delivery of the intervention was also suboptimal, as 14.9% (n = 29/195) of intervention patients had no PC visits by week 12. Intervention patients reported a mean 3.35 (standard deviation [SD] = 14.7) increase in FACT-G scores from baseline to week 12 compared with usual care patients who reported a 0.12 (SD = 12.7) increase from baseline (p = 0.10). Conclusion: This study highlights the difficulties of conducting multicenter trials of supportive care interventions in patients with advanced cancer. Clinical Trials Registration: NCT02349412.
Collapse
Affiliation(s)
- Jennifer S. Temel
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Address correspondence to: Jennifer S. Temel, MD, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | | | | | | | | | - Mihir Kamdar
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Arif Kamal
- Duke University Medical Center, Durham, North Carolina, USA
| | | | | | - Dylan Zylla
- Park Nicollet/HealthPartners, Metro-Minnesota Community Oncology Research Consortium, Minneapolis, Minnesota, USA
| | | | - Muhummad Furqan
- University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jennifer Obel
- NorthShore University HealthSystem CCOP, Evanston, Illinois, USA
| | - Mohammad Razaq
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Eric J. Roeland
- University of California San Diego Moores Cancer Center, La Jolla, California, USA
| | | |
Collapse
|
27
|
Fully Integrated Oncology and Palliative Care Services at a Local Hospital in Mid-Norway: Development and Operation of an Innovative Care Delivery Model. Pain Ther 2020; 9:297-318. [PMID: 32274655 PMCID: PMC7203320 DOI: 10.1007/s40122-020-00163-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction Early access to cancer palliative care is recommended. Descriptions of structures and processes of outpatient palliative care clinics operated within smaller hospitals are scarce. This paper presents the development and operation of a fully integrated cancer and palliative care outpatient clinic at a local hospital in a rural region of Mid-Norway offering palliative care concurrent with cancer treatment. A standardized care pathway was applied. Methods Palliative care is in Norway part of the public healthcare system. Official recommendations recent years point out action points to improve delivery of palliative care. An integrated cancer and palliative care outpatient clinic at a local hospital and an innovative care delivery model was developed and operated in this setting. Patients were recruited for a descriptive study of the patient population. Clinical data were collected by clinical staff and 13 symptom intensities were reported by the patients. Results Cancer and palliative care were provided by one team of healthcare professionals trained in both fields. There was a close collaboration with the other departments at the hospital, with its affiliated tertiary hospital, and with community health and care services to provide timely referral, enhanced continuity, and improved coordination of care. Eighty-eight patients were included. Mean age was 65.6 years, the most common cancer diagnoses were digestive organs (22.7%), male genital organs (20.5%) or breast (25.0%), 75.0% had metastatic or locally advanced cancer, 59.1% were treated with non-curative intention and 93.1% had Karnofsky Performance Status ≥ 80%. Median scores of individual symptoms ranged from 0 to 3 (numerical rating scale, 0–10) and 61.0% reported at least one clinically significant symptom rating (≥ 4). Conclusion This delivery model of integrated outpatient cancer and palliative care is particularly relevant in rural regions allowing cancer patients access to palliative care earlier in the disease trajectory and closer to home Palliative care is an important part of cancer care which aims at improving cancer patients’ symptom burden and quality of life and support their carers. Palliative care has traditionally been separated from cancer care. During the last decade, one has become aware of the benefits of introducing palliative care early and concurrent with cancer treatment. Most cancer patients are nowadays treated as outpatients. Availability of palliative care as a routine part of outpatient cancer clinics is therefore important. Most of the described models of early palliative care in cancer care are within large tertiary hospitals. Here it is described how early palliative care was delivered to cancer patients in an outpatient clinic in a smaller hospital in a rural region of Mid-Norway. In this integrated cancer and palliative care outpatient clinic, cancer and palliative care were provided by one team of healthcare professionals trained in both fields. The integrated outpatient clinic collaborated closely with the other hospital departments and with community health and care services. This was needed to be able to offer palliative care to all cancer patients in need of it, and closer to their home. Many of the patients attending the integrated outpatient clinic could not be cured for their cancer. They did not have many symptoms of their cancer, and they had a high functional status. This demonstrated that the integrated outpatient clinic in this local hospital was a relevant place to offer palliative care early and concurrent with cancer treatment before symptoms became severe.
Collapse
|
28
|
Hjermstad MJ, Aass N, Andersen S, Brunelli C, Dajani O, Garresori H, Hamre H, Haukland EC, Holmberg M, Jordal F, Krogstad H, Lundeby T, Løhre ET, Mjåland S, Nordbø A, Paulsen Ø, Schistad Staff E, Wester T, Kaasa S, Loge JH. PALLiON - PALLiative care Integrated in ONcology: study protocol for a Norwegian national cluster-randomized control trial with a complex intervention of early integration of palliative care. Trials 2020; 21:303. [PMID: 32241299 PMCID: PMC7118863 DOI: 10.1186/s13063-020-4224-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/02/2020] [Indexed: 12/11/2022] Open
Abstract
Background Several publications have addressed the need for a systematic integration of oncological care focused on the tumor and palliative care (PC) focused on the patient with cancer. The exponential increase in anticancer treatments and the high number of patients living longer with advanced disease have accentuated this. Internationally, there is now a persuasive argument that introducing PC early during anticancer treatment in patients with advanced disease has beneficial effects on symptoms, psychological distress, and survival. Methods This is a national cluster-randomized trial (C-RCT) in 12 Norwegian hospitals. The trial investigates effects of early, systematic integration of oncology and specialized PC in patients with advanced cancer in six intervention hospitals compared with conventional care in six. Hospitals are stratified on the size of local catchment areas before randomization. In the intervention hospitals, a three-part complex intervention will be implemented. The backbone of the intervention is the development and implementation of patient-centered care pathways that contain early, compulsory referral to PC and regular and systematic registrations of symptoms. An educational program must be completed before patient inclusion. A total of 680 patients with advanced cancer and one caregiver per patient are included when patients come for start of last line of chemotherapy, defined according to national treatment guidelines. Data registration, clinical variables, and patient- and caregiver-reported outcomes take place every 2 months for 1 year or until death. The primary outcome is use of chemotherapy in the last 3 months of life by comparing the proportion of patients who receive this in the intervention and control groups. Primary outcome is use of chemotherapy in the last 3 months before death, i.e. number of patients. Secondary outcomes are initiation, discontinuation and number of cycles, last 3 months of life, administration of other medical interventions in the last month of life, symptom burden, quality of life (QoL), satisfaction with information and follow-up, and caregiver health, QoL, and satisfaction with care. Discussion Results from this C-RCT will be used to raise the awareness about the positive outcomes of early provision of specialized palliative care using pathways for patients with advanced cancer receiving medical anticancer treatment. The long-term clinical objective is to integrate these patient-centered pathways in Norwegian cancer care. The specific focus on the patient and family and the organization of a predictable care trajectory is consistent with current Norwegian strategies for cancer care. Trial registration ClinicalTrials.gov, NCT03088202. Registered on 23 March 2017.
Collapse
Affiliation(s)
- Marianne Jensen Hjermstad
- Regional Advisory Unit in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway. .,European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Nina Aass
- Regional Advisory Unit in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway.,European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Sigve Andersen
- University Hospital of North Norway, Tromsø, Norway.,UiT, The Arctic University of Norway, Tromsø, Norway
| | - Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Olav Dajani
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Herish Garresori
- Department of Hematology and Oncology, Stavanger University Hospital, Stavanger, Norway
| | - Hanne Hamre
- Department of Oncology, Akershus University Hospital, Nordbyhagen, Norway
| | - Ellinor C Haukland
- Department of Oncology and Palliative Care, Nordland Hospital Trust, Bodø, Norway
| | - Mats Holmberg
- Department of Oncology and Palliative Care, Førde Hospital Trust, Førde, Norway
| | - Frode Jordal
- Department of Clinical Oncology, Østfold Hospital Trust, Grålum, Norway
| | - Hilde Krogstad
- Cancer Clinic, St. Olavs hospital, Trondheim university hospital, Trondheim, Norway
| | - Tonje Lundeby
- Regional Advisory Unit in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway.,European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erik Torbjørn Løhre
- Cancer Clinic, St. Olavs hospital, Trondheim university hospital, Trondheim, Norway
| | - Svein Mjåland
- Center for Cancer Treatment, Sorlandet Hospital, Kristiansand, Norway
| | - Arve Nordbø
- Department of Oncology and Palliative Care, Vestfold Hospital Trust, Tønsberg, Norway
| | - Ørnulf Paulsen
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Palliative Care Unit, Telemark Hospital Trust, Skien, Norway
| | | | - Torunn Wester
- Regional Advisory Unit in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Stein Kaasa
- Regional Advisory Unit in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway.,European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jon Håvard Loge
- Regional Advisory Unit in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| |
Collapse
|
29
|
Nakanishi M, Ogawa A, Nishida A. Availability of home palliative care services and dying at home in conditions needing palliative care: A population-based death certificate study. Palliat Med 2020; 34:504-512. [PMID: 31971075 DOI: 10.1177/0269216319896517] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Avoiding inappropriate care transition and enabling people with chronic diseases to die at home have become important health policy issues. Availability of palliative home care services may be related to dying at home. AIM After controlling for the presence of hospital beds and primary care physicians, we examined the association between availability of home palliative care services and dying at home in conditions requiring such services. DESIGN Death certificate data in Japan in 2016 were linked with regional healthcare statistics. SETTING/PARTICIPANTS All adults (18 years or older) who died from conditions needing palliative care in 2016 in Japan were included. RESULTS There were 922,756 persons included for analysis. Malignant neoplasm (37.4%) accounted for most decedents, followed by heart disease including cerebrovascular disease (31.4%), respiratory disease (14.7%) and dementia/Alzheimer's disease/senility (11.5%). Of decedents, 20.8% died at home or in a nursing home and 79.2% died outside home (hospital/geriatric intermediate care facility). Death at home was more likely in health regions with fewer hospital beds and more primary care physicians, in total and per condition needing palliative care. Number of home palliative care services was negatively associated with death at home. The adjustment for home palliative care services disappeared in heart disease including cerebrovascular disease and reversed in respiratory disease. CONCLUSION Specialised home palliative care services may be suboptimal, and primary care services may serve as a key access point in providing baseline palliative care to people with conditions needing palliative care. Therefore, primary care services should aim to enhance their palliative care workforce.
Collapse
Affiliation(s)
- Miharu Nakanishi
- Mental Health and Nursing Research Team, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Asao Ogawa
- Exploratory Oncology Research and Clinical Trial Center, National Cancer Center Hospital East, Chiba, Japan
| | - Atsushi Nishida
- Mental Health Promotion Project, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| |
Collapse
|
30
|
Currow DC, Agar MR, Phillips JL. Role of Hospice Care at the End of Life for People With Cancer. J Clin Oncol 2020; 38:937-943. [DOI: 10.1200/jco.18.02235] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Patient-defined factors that are important at the end of life include being physically independent for as long as possible, good symptom control, and spending quality time with friends and family. Hospice care adds to the quality of care and these patient-centered priorities for people with cancer and their families in the last weeks and days of life. Evidence from large observational studies demonstrate that hospice care can improve outcomes directly and support better and more appropriate health care use for people in the last stages of cancer. Team-based community hospice care has measurable benefits for patients, their family caregivers, and health services. In addition to improved symptom control for patients and a greater likelihood of time spent at home, caregiver outcomes are better when hospice care is accessed: informational needs are better met, and caregivers have an improved ability to move on with life after the patient’s death compared with people who did not have access to these services. Hospice care continues to evolve as its reach expands and the needs of patients continue to broaden. This is reflected in the transition from hospice being based on excellence in nursing to teams with a broad range of health professionals to meet the complex and changing needs of patients and their families. Additional integration of cancer services with hospice care will help to provide more seamless care for patients and supporting family caregivers during their caregiving and after the death of the patient.
Collapse
Affiliation(s)
- David C. Currow
- University of Technology Sydney, Ultimo, NSW, Australia
- University of Hull, Hull, United Kingdom
| | - Meera R. Agar
- University of Technology Sydney, Ultimo, NSW, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
| | | |
Collapse
|
31
|
Bjørnelv GMW, Edwin B, Fretland ÅA, Deb P, Aas E. Till death do us part: the effect of marital status on health care utilization and costs at end-of-life. A register study on all colorectal cancer decedents in Norway between 2009 and 2013. BMC Health Serv Res 2020; 20:115. [PMID: 32054492 PMCID: PMC7020544 DOI: 10.1186/s12913-019-4794-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/29/2019] [Indexed: 01/11/2023] Open
Abstract
Background Economic analyses of end-of-life care often focus on single aspects of care in selected cohorts leading to limited knowledge on the total level of care required to patients at their end-of-life. We aim at describing the living situation and full range of health care provided to patients at their end-of-life, including how informal care affects formal health care provision, using the case of colorectal cancer. Methods All colorectal cancer decedents between 2009 and 2013 in Norway (n = 7695) were linked to six national registers. The registers included information on decedents’ living situation (days at home, in short- or long-term institution or in the hospital), their total health care utilization and costs in the secondary, primary and home- and community-based care setting. The effect of informal care was assessed through marital status (never married, currently married, or previously married) using regression analyses (negative binominal, two-part models and generalized linear models), controlling for age, gender, comorbidities, education, income, time since diagnosis and year of death. Results The average patient spent four months at home, while he or she spent 27 days in long-term institutions, 16 days in short-term institutions, and 21 days in the hospital. Of the total costs (~NOK 400,000), 58, 3 and 39% were from secondary carers (hospitals), primary carers (general practitioners and emergency rooms) and home- and community-based carers (home care and nursing homes), respectively. Compared to the never married, married patients spent 30 more days at home and utilized less home- and community-based care, but more health care services at the secondary and primary health care level. Their total healthcare costs were significantly lower (−NOK 65,621) than the never married. We found similar, but weaker, patterns for those who had been married previously. Conclusion End-of-life care is primarily provided in the secondary and home-and community-based care level, and informal caregivers have a substantial influence on formal end-of-life care provision. Excluding aspects of care such as home and community-based care or informal care in economic analyses of end-of-life care provides a biased picture of the total resources required, and might lead to inefficient resource allocations.
Collapse
Affiliation(s)
- Gudrun Maria Waaler Bjørnelv
- The Intervention Centre, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway. .,Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Åsmund Avdem Fretland
- The Intervention Centre, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Partha Deb
- Department of Economics, Hunter College, CUNY and NBER, New York, USA
| | - Eline Aas
- Institute of Health and Society, University of Oslo, Oslo, Norway.,Health Service Research Unit, Akershus University Hospital, Lørenskog, Norway
| |
Collapse
|
32
|
Quigley DD, Parast L, Haas A, Elliott MN, Teno JM, Anhang Price R. Differences in Caregiver Reports of the Quality of Hospice Care Across Settings. J Am Geriatr Soc 2020; 68:1218-1225. [PMID: 32039474 DOI: 10.1111/jgs.16361] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To examine variation in reported experiences with hospice care by setting. DESIGN Consumer Assessment of Healthcare Providers and Systems Hospice (CAHPS®) Survey data from 2016 were analyzed. Multivariate linear regression analysis was used to examine differences in measure scores by setting of care (home, nursing home [NH], hospital, freestanding hospice inpatient unit [IPU], and assisted living facility [ALF]). SETTING A total of 2636 US hospices. PARTICIPANTS A total of 311 635 primary caregivers of patients who died in hospice. MEASUREMENTS Outcomes were seven hospice quality measures, including five composite measures that assess aspects of hospice care important to patients and families, including hospice team communication, timeliness of care, treating family member with respect, symptom management, and emotional and spiritual support, and two global measures of the overall rating of the hospice and willingness to recommend it to friends and family. Analyses were adjusted for mode of survey administration and differences in case-mix between hospices. RESULTS Caregivers of decedents who received hospice care in a NH reported significantly worse experiences than caregivers of those in the home for all measures. ALF scores were also significantly lower than home for all measures, except providing emotional and spiritual support. Differences in NH and ALF settings compared to home were particularly large for hospice team communication (ranging from -11 to -12 on a 0-100 scale) and getting help for symptoms (ranging from -7 to -10). Consistently across all care settings, hospice team communication, treating family member with respect, and providing emotional and spiritual support were most strongly associated with overall rating of care. CONCLUSIONS Important opportunities exist to improve quality of hospice care in NHs and ALFs. Quality improvement and regulatory interventions targeting the NH and ALF settings are needed to ensure that all hospice decedents and their family receive high-quality, patient- and family-centered hospice care. J Am Geriatr Soc 68:1218-1225, 2020.
Collapse
Affiliation(s)
- Denise D Quigley
- Department of Healthcare, RAND Corporation, Santa Monica, California
| | - Layla Parast
- Department of Healthcare, RAND Corporation, Santa Monica, California
| | - Ann Haas
- Department of Healthcare, RAND Corporation, Pittsburgh, Pennsylvania
| | - Marc N Elliott
- Department of Healthcare, RAND Corporation, Santa Monica, California
| | - Joan M Teno
- Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | | |
Collapse
|
33
|
Temel JS, Jacobsen PB. Palliative Care in Oncology: Continuing to Build the Evidence Base and Disseminate Effective Care Models. J Clin Oncol 2020; 38:849-851. [PMID: 32023160 DOI: 10.1200/jco.19.01069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
|
34
|
Avula S, LaFata M, Nabhan M, Allana A, Toprani B, Scheidel C, Suneja A. Heart failure mortality prediction using PRISM score and development of a classification and regression tree model to refer patients for palliative care consultation. IJC HEART & VASCULATURE 2020; 26:100440. [PMID: 31886404 PMCID: PMC6921143 DOI: 10.1016/j.ijcha.2019.100440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 01/03/2023]
Abstract
INTRODUCTION We sought to assess one-year mortality in heart failure (HF) patients by using (Placement Resource Indicator for Systems Management) PRISM, a disease nonspecific risk stratification score, and use it along with modified Seattle Heart Failure Model (SHFM) to guide patient selection for palliative care consultation. METHODS A retrospective study design was used to examine 1-year mortality in 689 HF patients admitted from 2012 to 2014. One-year mortality was calculated using Pmort30/PRISM and modified SHFM scores, and the predicted scores were validated using the area under the ROC curve. CART was used to develop an algorithm to classify patients based on their mortality risk. RESULTS The discriminatory ability of PRISM categorical score (AUC = 0.701) was not significantly different than the discriminatory ability of modified SHFM (AUC = 0.686) (DeLong's test p = 0.56) but improved significantly with the combination of PRISM (categorical) score + modified SHFM (AUC = 0.740) (p = 0.002). The predictive capability of the CART tree model after cross-validation was 72.2% (AUC 0.631). CONCLUSION Our study suggests PRISM score performed as well as modified SHFM for one-year mortality prediction. Moreover, the addition of modified SHFM to PRISM score increases discriminatory ability in predicting 1-year mortality in heart failure patients compared to either of the two models alone. Together, when combined in a CART model, they can be used to identify the population subset with the highest mortality risk and hence guide goals of care discussion.
Collapse
Affiliation(s)
- Sindhu Avula
- Mercy St. Vincent Medical Center, Toledo, OH, United States
| | - Michael LaFata
- St Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, United States
| | - Mohammed Nabhan
- St Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, United States
| | | | - Bhavana Toprani
- St Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, United States
| | | | - Anupam Suneja
- St Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, United States
| |
Collapse
|
35
|
Ernecoff NC, Check D, Bannon M, Hanson LC, Dionne-Odom JN, Corbelli J, Klein-Fedyshin M, Schenker Y, Zimmermann C, Arnold RM, Kavalieratos D. Comparing Specialty and Primary Palliative Care Interventions: Analysis of a Systematic Review. J Palliat Med 2019; 23:389-396. [PMID: 31644399 DOI: 10.1089/jpm.2019.0349] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Investigators have tested interventions delivered by specialty palliative care (SPC) clinicians, or by clinicians without palliative care specialization (primary palliative care, PPC). Objective: To compare the characteristics and outcomes of randomized clinical trials (RCTs) of SPC and PPC interventions. Design: Systematic review secondary analysis. Setting/Subjects: RCTs of palliative care interventions. Measurements: Interventions were classified SPC if delivered by palliative care board-certified or subspecialty trained clinicians, or those with extensive clinical experience; all others were PPC. We abstracted data for each intervention: delivery setting, delivery clinicians, outcomes measured, trial results, and Cochrane's Risk of Bias. We conducted narrative synthesis for quality of life, symptom burden, and survival. Results: Of 43 RCTs, 27 tested SPC and 16 tested PPC interventions. SPC interventions were more comprehensive (4.2 elements of palliative care vs. 3.1 in PPC, p = 0.02). SPC interventions were delivered in inpatient (44%) or outpatient settings (52%) by specialty physicians (44%) and nurses (44%); PPC interventions were delivered in inpatient (38%) and home settings (38%) by nurses (75%). PPC trials were more often of high risk of bias than SPC trials. Improvements were demonstrated on quality of life by SPC and PPC trials and on physical symptoms by SPC trials. Conclusions: Compared to PPC, SPC interventions were more comprehensive, were more often delivered in clinical settings, and demonstrated stronger evidence for improving physical symptoms. In the face of SPC workforce limitations, PPC interventions should be tested in more trials with low risk of bias, and may effectively meet some palliative care needs.
Collapse
Affiliation(s)
- Natalie C Ernecoff
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Devon Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Duke Cancer Institute, Durham, North Carolina
| | - Megan Bannon
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina.,Division of Geriatric Medicine & Palliative Care Program, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
| | | | - Jennifer Corbelli
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Camilla Zimmermann
- Division of Palliative Care, University Health Network, Toronto, Ontario, Canada.,School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
36
|
Webber C, Viola R, Knott C, Peng Y, Groome PA. Community Palliative Care Initiatives to Reduce End-of-Life Hospital Utilization and In-Hospital Deaths: A Population-Based Observational Study Evaluating Two Home Care Interventions. J Pain Symptom Manage 2019; 58:181-189.e1. [PMID: 31022443 DOI: 10.1016/j.jpainsymman.2019.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 01/08/2023]
Abstract
CONTEXT The end-of-life period is characterized by increased hospital utilization despite patients' preferences to receive care and die at home. OBJECTIVES To evaluate the impact of interventions aimed at planning for a home death (Yellow Folder) and managing symptoms in the home (Symptom Response Kit) on place of death and hospital utilization among palliative home care patients. METHODS This was an ecologic and retrospective cohort study of palliative home care patients in southeastern Ontario from April 2009 to March 2014. Linked health administrative and clinical databases were used to identify palliative home care patients and their receipt of the interventions, hospitalizations, emergency department visits, and place of death. Bivariable and multivariable regressions were used to evaluate outcomes according to patients' receipt of intervention(s). RESULTS The proportion of patients who died in the community increased after implementation of the interventions, from 42.8% to 48.5% (P < 0.0001). Compared with patients who received neither intervention, patients who received the Yellow Folder or Symptom Response Kit had an increased likelihood of dying in the community, with the largest relative risk observed in patients who received both interventions (relative risk = 2.20, 95% confidence interval 2.05-2.36). Receipt of these interventions was only associated with reductions in hospitalization or emergency department visit rates in the six months before death. CONCLUSION Patients who received the Yellow Folder or Symptom Response Kit were more likely remain at home at the end of life. This association was stronger when these interventions were used together.
Collapse
Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada.
| | - Raymond Viola
- Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Christine Knott
- Centre for Health Services and Policy Research, Queen's University, Kingston, Ontario, Canada; ICES, Kingston, Ontario, Canada
| | - Yingwei Peng
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
37
|
Borhan S, Mallick R, Pillay M, Kathard H, Thabane L. Sensitivity of methods for analyzing continuous outcome from stratified cluster randomized trials - an empirical comparison study. Contemp Clin Trials Commun 2019; 15:100405. [PMID: 31338480 PMCID: PMC6627034 DOI: 10.1016/j.conctc.2019.100405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/20/2019] [Accepted: 07/03/2019] [Indexed: 12/14/2022] Open
Abstract
The assessment of the sensitivity of statistical methods has received little attention in cluster randomized trials (CRTs), especially for stratified CRT when the outcome of interest is continuous. We empirically examined the sensitivity of five methods for analyzing the continuous outcome from a stratified CRT - aimed to investigate the efficacy of the Classroom Communication Resource (CCR) compared to usual care to improve the peer attitude towards children who stutter among grade 7 students. Schools – the clusters, were divided into quintile based on their socio-political resources, and then stratified by quintile. The schools were then randomized to CCR and usual care groups in each stratum. The primary outcome was Stuttering Resource Outcomes Measure. Five methods, including the primary method, were used in this study to examine the effect of CCR. The individual-level methods were: (i) linear regression; (ii) mixed-effects method; (iii) GEE with exchangeable correlation structure (primary method of analysis). And the cluster-level methods were: (iv) cluster-level linear regression; and (v) meta-regression. These methods were also compared with or without adjustment for stratification. Ten schools were stratified by quintile, and then randomized to CCR (223 students) and usual care (231 students) groups. The direction of the estimated differences was same for all the methods except meta-regression. The widths of the 95% confidence intervals were narrower when adjusted for stratification. The overall conclusion from all the methods was similar but slightly differed in terms of effect estimate and widths of confidence intervals. Trialregistration Clinicaltrials.gov, NCT03111524. Registered on 9 March 2017.
Collapse
Affiliation(s)
- Sayem Borhan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Biostatistics Unit, Research Institute of St Joseph's Healthcare, Hamilton, ON, Canada.,Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Rizwana Mallick
- University of Cape Town, Rondebosch, Cape Town, South Africa
| | | | - Harsha Kathard
- University of Cape Town, Rondebosch, Cape Town, South Africa
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Biostatistics Unit, Research Institute of St Joseph's Healthcare, Hamilton, ON, Canada.,Department of Pediatrics and Anesthesia, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
38
|
Saygili M, Çelik Y. An evaluation of the cost-effectiveness of the different palliative care models available to cancer patients in Turkey. Eur J Cancer Care (Engl) 2019; 28:e13110. [PMID: 31162760 DOI: 10.1111/ecc.13110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 01/14/2019] [Accepted: 05/14/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Three different models are commonly used to provide palliative care services to cancer patients in Turkey: comprehensive palliative care center (CPCC), hospital inpatient services (HIS) and home healthcare (HHC). OBJECTIVES The purpose of this study was to evaluate the cost-effectiveness of three alternative palliative care models for cancer patients. METHODS The study included a total of 160 patients diagnosed with cancer (CPCC:60, HIS:59, HHC:41). The patients' quality of life and their levels of satisfaction were used as the indicators of effectiveness, while direct and indirect costs incurred by service providers, patients and relatives were considered in estimating the costs of alternative models. The cost and effectiveness of the alternatives compared the "patient perspective" and "societal perspective" separately. RESULTS From a societal perspective, palliative care services provided the HIS model was found to be more cost-effective than the CPCC model. From a patient perspective, HHC was found to be more cost-effective compared to the other two models. CONCLUSIONS This study has the potential to provide substantial evidence to health managers and decision-makers with respect to health planning and the formulation of social security policies in Turkey.
Collapse
Affiliation(s)
- Meltem Saygili
- Department of Health Care Management, Faculty of Health Sciences, Kırıkkale University, Kırıkkale, Turkey
| | - Yusuf Çelik
- Department of Health Care Management, Faculty of Economics and Administrative Sciences, Hacettepe University, Ankara, Turkey
| |
Collapse
|
39
|
Palliative care needs of heart failure patients in China: putting people first. Curr Opin Support Palliat Care 2019; 12:10-15. [PMID: 29206703 DOI: 10.1097/spc.0000000000000315] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Recognizing the rising prevalence of heart failure in China, patients with heart failure have substantial palliative needs. This review highlights recent evidence on the epidemic of heart failure, identifies needs and potential benefit of palliative care in heart failure, and sets future strategic policy and research directions in China. RECENT FINDINGS Epidemiological studies demonstrate the prevalence of heart failure among women is higher than men in China and increases substantially with age. However, few studies have addressed the palliative needs of Chinese heart failure patients. The main themes from this review include: Healthcare providers should be culturally sensitive whenever assessing symptoms and needs. Locally validated, brief outcome measures are called for to identify symptoms and needs of Chinese heart failure patients. Palliative care should be better integrated into the management of heart failure through increased training for healthcare providers, policy development, financial support, and cultural acceptance of palliative care. SUMMARY Large-scale epidemiological studies are urgently needed to assess the current situation of heart failure in China, alongside interventional studies to drive the development of innovative palliative care services to address the needs of Chinese heart failure patients.
Collapse
|
40
|
Abstract
This study measures the proportion of cancer patients in Ontario, Canada, with intensive care unit (ICU) admissions, emergency room (ER) visits, or chemotherapy in the last two weeks of life. We used the Ontario Cancer Registry to identify a cohort of cancer patients who died in 2001. These cases were then linked to administrative sources of data to measure each indicator, and to describe the associated clinical and health service factors. In the cohort, 27% had at least one ER visit and 5% had an ICU visit in the last two weeks of life. Of those who received chemotherapy in the last six months, 16% received chemotherapy in the last two weeks of life. Receiving a home care visit in the last six months of life, or a physician house call or a palliative care assessment in the last two weeks of life was consistently associated with decreased odds of each of the indicators. Our results indicate that a significant proportion of Ontario cancer patients have indicators of poor quality end-of-life care. Certain health care factors may influence these indicators.
Collapse
Affiliation(s)
- Lisa Barbera
- Department of Radiation Oncology, University of Toronto, and the Institute for Clinical Evaluative Sciences
| | - Lawrence Paszat
- Institute for Clinical Evaluative Sciences and Department of Health Policy Management and Evaluation, University of Toronto
| | - Carole Charter
- Institute for Clinical Evaluative Sciences Cancer Care Ontario, Toronto, Ontario, Canada
| |
Collapse
|
41
|
Grande GE, Mckerral A, Addington-Hall JM, Todd CJ. Place of Death and Use of Health Services in the Last Year of Life. J Palliat Care 2019. [DOI: 10.1177/082585970301900408] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim To investigate whether health service input in the last year of life differs between cancer patients who die at home versus those dying in inpatient care. Methods Post hoc exploratory case-control study of 127 home deaths and 200 inpatient deaths. Retrospective electronic record linkage of patients’ community and inpatient care during the last year of life. Results Patients who died at home began their home nursing care closer to death than those who died as inpatients. Their first contact with inpatient hospice care began further from death. Before their final month, home death patients also had more specialist and district nursing than patients who died in inpatient care. Conclusions Patients who began their home nursing early were less likely to die at home than those who began such care late. This suggests that it may be difficult to sustain end-of-life care at home for an extended period. Further research incorporating assessment of informal care input and disease trajectory is required to investigate this issue.
Collapse
Affiliation(s)
- Gunn E. Grande
- School of Nursing, Midwifery and Health Visiting, University of Manchester, Manchester
| | | | | | - Chris J. Todd
- School of Nursing, Midwifery and Health Visiting, University of Manchester, Manchester, U.K
| |
Collapse
|
42
|
Pramesh CS, Chaturvedi H, Reddy VA, Saikia T, Ghoshal S, Pandit M, Babu KG, Ganpathy KV, Savant D, Mitera G, Sullivan R, Booth CM. Choosing Wisely India: ten low-value or harmful practices that should be avoided in cancer care. Lancet Oncol 2019; 20:e218-e223. [PMID: 30857957 DOI: 10.1016/s1470-2045(19)30092-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 12/14/2022]
Abstract
The Choosing Wisely India campaign was an initiative that was established to identify low-value or potentially harmful practices that are relevant to the Indian cancer health-care system. We undertook a multidisciplinary framework-driven consensus process to identify a list of low-value or harmful cancer practices that are frequently undertaken in India. A task force convened by the National Cancer Grid of India included Indian representatives from surgical, medical, and radiation oncology. Each specialty had representation from the private and public sectors. The task force included two representatives from national patient and patient advocacy groups. Of the ten practices that were identified, four are completely new recommendations, and six are revisions or adaptations from previous Choosing Wisely USA and Canada lists. Recommendations in the final list pertain to diagnosis and treatment (five practices), palliative care (two practices), imaging (two practices), and system-level delivery of care (two practices). Implementation of this list and reporting of concordance with its recommendations will facilitate the delivery of high-quality, value-based cancer care in India.
Collapse
Affiliation(s)
- C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
| | | | - Vijay Anand Reddy
- Department of Radiation Oncology, Apollo Hospitals, Hyderabad, India
| | - Tapan Saikia
- Department of Medical Oncology, Prince Aly Khan Hospital, Mumbai, India
| | - Sushmita Ghoshal
- Department of Radiation Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - K Govind Babu
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, India
| | - K V Ganpathy
- Jeet Association for Support to Cancer Patients, Mumbai, India
| | | | - Gunita Mitera
- Department of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, and King's Health Partners Comprehensive Cancer Centre, London, UK
| | - Christopher M Booth
- Department of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada
| | | |
Collapse
|
43
|
Philip RR, Venables E, Manima A, Tripathy JP, Philip S. "Small small interventions, big big roles"- a qualitative study of patient, care-giver and health-care worker experiences of a palliative care programme in Kerala, India. BMC Palliat Care 2019; 18:16. [PMID: 30717717 PMCID: PMC6362568 DOI: 10.1186/s12904-019-0400-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 01/23/2019] [Indexed: 11/29/2022] Open
Abstract
Background Home-based palliative care is an essential resource for many communities. We conducted a qualitative study to explore perceptions of a home-based palliative care programme in Kerala, India, from the perspective of patients, their care-givers and the doctors, nurses and volunteers running the intervention. Methods A descriptive qualitative study was carried out. One focus group discussion (FGD) was conducted with patients (n = 8) and two with male and female volunteers (n = 12); and interviews were conducted with doctors (n = 3), nurses (n = 3) and care-givers (n = 14). FGDs and interviews were conducted in Malayalam, audio-recorded, transcribed verbatim and translated into English. Transcripts were coded and analysed using manual content analysis. Results Doctors, nurses and volunteers have interdependent roles in providing palliative care to patients, including mentorship, training, patient care and advocating for patient needs. Volunteers also considered themselves to be mediators between families and the programme. Care-givers were mainly female and were caring for relatives. They have physically demanding, psychologically stressful and socially restrictive experiences of care-giving. They felt that the programme facilitated their role as care-givers by giving them training and support. Patients with long standing illnesses felt that the programme enabled them to become more independent and self-reliant. The local community supports the programme through economic contributions and offering practical assistance to patients. Conclusion The salient features of this programme include the provision of regular holistic care through a team of doctors, nurses and patients. The programme was perceived to have improved the lives of patients and their care-givers. The involvement of volunteers from the local community was perceived as a strength of the programme, whilst simultaneously being a challenge.
Collapse
Affiliation(s)
- Rekha Rachel Philip
- Department of Community Medicine, Government T.D Medical College Alappuzha, Vandanam P.O, Alappuzha, Kerala, India.
| | - Emilie Venables
- Médecins Sans Frontières - Operational Centre Brussels, Medical Department, Operational Research Unit (LuxOR), Luxembourg, Luxembourg.,Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Abdulla Manima
- Malappuram Initiative in Palliative care, Malappuram, Kerala, India
| | - Jaya Prasad Tripathy
- International Union Against Tuberculosis and Lung Disease, Paris, France.,Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, India
| | - Sairu Philip
- Department of Community Medicine, Government T.D Medical College Alappuzha, Vandanam P.O, Alappuzha, Kerala, India
| |
Collapse
|
44
|
Nordly M, Skov Benthien K, Vadstrup ES, Kurita GP, von Heymann-Horan AB, von der Maase H, Johansen C, Timm H, Kjellberg J, Sjøgren P. Systematic fast-track transition from oncological treatment to dyadic specialized palliative home care: DOMUS - a randomized clinical trial. Palliat Med 2019; 33:135-149. [PMID: 30415608 DOI: 10.1177/0269216318811269] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: The focus of specialized palliative care is to improve quality of life for patients with incurable cancer and their relatives including an increased opportunity to make their own choice of place of care and death. Aim: To investigate whether a systematic fast-track transition from oncological treatment to specialized palliative care at home for patients with incurable cancer reinforced with a psychological dyadic intervention could result in more time spent at home and death at home. Secondary aims were to investigate effects on quality of life, symptomatology and survival. Design: A prospective, single-centre, randomized controlled trial ( Clinicaltrials.gov : NCT01885637). Setting/participants: In all, 340 patients with incurable cancer and no or limited antineoplastic treatment options. Results: No statistically significant difference was found regarding number of deaths (4%, p = 0.460) and time spent at home (3%, p = 0.491). The secondary outcomes indicated that the intervention resulted in improved quality of life (−11.6 ± 25.5, p = 0.005, effect size = −0.44, 95% confidence interval = −0.77; −0.11), social functioning (−15.8 ± 31.4, p = 0.001, effect size = −0.50, 95% confidence interval = −0.84; −0.17) and emotional functioning (−9.1 ± 21.2, p = 0.039, effect size = −0.43, 95% confidence interval = −0.76; −0.10) after 6 months. A linear mixed-effect regression model confirmed a possible effect on emotional and social functioning at 6 months. Regarding survival, no differences were found between groups ( p = 0.605). No adverse effects were seen as consequence of the intervention. Conclusions: The main findings indicated that the intervention had no effect on time spent at home or place of death. However, the intervention resulted in a weak improvement of quality of life, social functioning and emotional functioning after 6 months.
Collapse
Affiliation(s)
- Mie Nordly
- 1 Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- 2 Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kirstine Skov Benthien
- 1 Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- 2 Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Eva S Vadstrup
- 1 Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Geana P Kurita
- 1 Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- 3 Multidisciplinary Pain Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Hans von der Maase
- 1 Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- 2 Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christoffer Johansen
- 1 Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- 2 Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- 4 Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Helle Timm
- 5 REHPA - Danish Knowledge Centre for Rehabilitation and Palliative Care, University of Southern Denmark, Copenhagen, Denmark
| | - Jakob Kjellberg
- 6 The Danish Institute for Local and Regional Government Research, Copenhagen, Denmark
| | - Per Sjøgren
- 1 Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- 2 Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
45
|
Steven B, Lange L, Schulz H, Bleich C. Views of psycho-oncologists, physicians, and nurses on cancer care-A qualitative study. PLoS One 2019; 14:e0210325. [PMID: 30650112 PMCID: PMC6334960 DOI: 10.1371/journal.pone.0210325] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 12/20/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND As worldwide cancer prevalence continues to increase, the challenges facing cancer care are also increasing. Various topics related to deficiencies in cancer care have been discussed repeatedly in the literature. The most frequently stated topics are the unmet psychosocial support needs of cancer patients, difficulties in multidisciplinary teamwork, difficulties in communication between physicians and patients, and issues in palliative care settings. However, there is little research regarding the views of health care providers on these topics. With the aim of gaining abundant information regarding the care of German cancer patients, this study explores the stances of psycho-oncologists, physicians, and nurses regarding the quality of cancer care. MATERIALS AND METHODS Semi-structured interviews were conducted at the University Medical Center Hamburg-Eppendorf (UKE) and in different oncological outpatient offices in Hamburg; twenty-five interviews in total were conducted with health care providers. Interviews were semi-structured to gain a broad range of information on cancer care. The data were analyzed using thematic analysis by Braun and Clarke with an inductive, constant comparison approach to identify themes and categorized codes. RESULTS The following five principle themes were identified in the interviews: "psycho-oncological care", "cooperation of health care providers", "palliative care", "health care provider-patient contact", and "coordination and organization of care". Participants seemed satisfied with the overall quality of cancer care in Germany. Nevertheless, the results showed deficiencies regarding communication among different health care providers and between health care providers and patients. Important findings in conjunction with these communication problems were a lack of psycho-oncological support, shortages in the oncology work force, language and cultural barriers, and deficient education in the communication of providers. CONCLUSIONS The statements of psycho-oncologists, physicians, and nurses on cancer care provide a suitable basis to conduct further focused research on the studied deficiencies in cancer care. In particular, communication in psycho-oncological care, communication within multidisciplinary teams, and health care provider-patient communication should be further explored with the aim of developing new ideas for improvements and thereby enhancing the quality of cancer care.
Collapse
Affiliation(s)
- Berenike Steven
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Lange
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Holger Schulz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christiane Bleich
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
46
|
Collier A, Hodgins M, Crawford G, Every A, Womsley K, Jeffs C, Houthuysen P, Kang S, Thomas E, Weller V, Van C, Farrow C, Dadich A. What does it take to deliver brilliant home-based palliative care? Using positive organisational scholarship and video reflexive ethnography to explore the complexities of palliative care at home. Palliat Med 2019; 33:91-101. [PMID: 30362898 DOI: 10.1177/0269216318807835] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Despite the increasing number of people requiring palliative care at home, there is limited evidence on how home-based palliative care is best practised. Aim: The aim of this participatory qualitative study is to determine the characteristics that contribute to brilliant home-based palliative care. Design: This study was inspired by the brilliance project – an initiative to explore how positive organisational scholarship in healthcare can be used to study brilliant health service management from the viewpoint of patients, families, and clinicians. The methodology of positive organisational scholarship in healthcare was combined with video-reflexive ethnography. Setting/participants: Home-based specialist palliative care services across two Australian states participated in the study. Clinicians were able to take part in the study at different levels. Pending their preference, this could involve video-recording of palliative care, facilitating and/or participating in reflexive sessions to analyse and critique the recordings, identifying the characteristics that contribute to brilliant home-based palliative care, and/or sharing the findings with others. Results: Brilliance in home-based palliative care is contingent on context and is conceptualised as a variety of actions, people, and processes. Care is more likely to be framed as brilliant when it is epitomised: anticipatory aptitude and action; a weave of commitment; flexible adaptability; and/or team capacity-building. Conclusion: This study is important because it verifies the characteristics of brilliant home-based palliative care. Furthermore, these characteristics can be adapted for use within other services.
Collapse
Affiliation(s)
- Aileen Collier
- 1 School of Nursing, Faculty of Medicine and Health Sciences The University of Auckland, Auckland, New Zealand.,2 College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia.,3 School of Health Sciences, University of Tasmania, Hobart, TAS, Australia
| | - Michael Hodgins
- 4 School of Business, Western Sydney University, Parramatta, NSW, Australia
| | - Gregory Crawford
- 5 Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia.,6 Northern Adelaide Palliative Care Service, Northern Adelaide Local Health Network, SA, Australia
| | - Alice Every
- 6 Northern Adelaide Palliative Care Service, Northern Adelaide Local Health Network, SA, Australia
| | - Kerrie Womsley
- 7 Community Health Nursing Services, Hoxton Park Community Health Centre South West Sydney Area Health Service, Hoxton Park, NSW, Australia
| | - Catherine Jeffs
- 6 Northern Adelaide Palliative Care Service, Northern Adelaide Local Health Network, SA, Australia
| | - Pat Houthuysen
- 6 Northern Adelaide Palliative Care Service, Northern Adelaide Local Health Network, SA, Australia
| | - Srey Kang
- 7 Community Health Nursing Services, Hoxton Park Community Health Centre South West Sydney Area Health Service, Hoxton Park, NSW, Australia
| | - Elizabeth Thomas
- 7 Community Health Nursing Services, Hoxton Park Community Health Centre South West Sydney Area Health Service, Hoxton Park, NSW, Australia
| | - Valerie Weller
- 7 Community Health Nursing Services, Hoxton Park Community Health Centre South West Sydney Area Health Service, Hoxton Park, NSW, Australia
| | - Cindy Van
- 7 Community Health Nursing Services, Hoxton Park Community Health Centre South West Sydney Area Health Service, Hoxton Park, NSW, Australia
| | - Caroline Farrow
- 6 Northern Adelaide Palliative Care Service, Northern Adelaide Local Health Network, SA, Australia
| | - Ann Dadich
- 4 School of Business, Western Sydney University, Parramatta, NSW, Australia
| |
Collapse
|
47
|
Seow H, Barbera L, Howell D, Dy SM. How End-Of-Life Home Care Services Are Used from Admission to Death: A Population-Based Cohort Study. J Palliat Care 2018. [DOI: 10.1177/082585971002600403] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim: Our goal was to describe the trajectories of end-of-life nursing and personal support worker (PSW) use from home care admission until death. Methods: We studied a historical prospective cohort of end-of-life home care patients in Ontario, Canada, linking administrative databases. We calculated the odds of using any nursing or PSW hours and the incidence rate ratio of services used for each week approaching death, controlling for confounders. Results: Among all patients (n=11,867), the odds of using any nursing and PSW hours increased by 4 percent and 10 percent, respectively, each week closer to death. Among patients using services, the ratio of nursing and PSW hours increased 20 percent and 11 percent, respectively, in the last 4 weeks of life compared to use at 24 weeks before death. Conclusion: Use of nursing and PSW hours increases slightly each week before death and sharply in the last month of life. Understanding the trajectory of home care services use can help decision makers design better end-of-life care.
Collapse
Affiliation(s)
- Hsien Seow
- H Seow (corresponding author): Department of Oncology, McMaster University, Hamilton, Ontario, Canada, and Juravinski Cancer Centre, 699 Concession St, 4th Floor, Room 4–229, Hamilton, Ontario, Canada L8V 5C2
| | - Lisa Barbera
- L Barbera: Departments of Radiation Oncology and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Doris Howell
- D Howell: Oncology Nursing Research, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Sydney M. Dy
- SM Dy: Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, United States
| |
Collapse
|
48
|
Masucci L, Guerriere DN, Cheng R, Coyte PC. Determinants of place of Death for recipients of Home-Based Palliative Care. J Palliat Care 2018. [DOI: 10.1177/082585971002600404] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Health system restructuring combined with the preferences of many terminally ill care recipients and their caregivers has led to an increase in home-based palliative care, yet many care recipients die within institutional settings such as hospitals. This study sought to determine the place of death and its predictors among palliative care patients with cancer. Methods: Study participants were re cruited from the Temmy Latner Centre for Palliative Care, a regional palliative care program based in Toronto, Canada. A total of 137 patients and their family caregivers participated in the study; application of various exclusion criteria restricted analysis to a sub-sample of 110. Bivariate (chi-square) and multivariate (logistic regression) analyses were conducted. Results: 66 percent of participants died at home. Chisquare analysis indicated that women were more likely to die at home than men; multivariate analysis indicated that women and those living with others were significantly more likely to die at home than men or those who lived alone. Conclusion: Place of death is influenced by the socio-demographic characteristics of patients, the characteristics of their caregivers, and health service factors. Palliative care programs need to tailor services to men and those living alone in order to reduce institutional deaths.
Collapse
Affiliation(s)
- Lisa Masucci
- L Masucci, DN Guerriere: Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Denise N. Guerriere
- L Masucci, DN Guerriere: Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Richard Cheng
- R Cheng: Life Sciences Program, University of Toronto, Toronto, Ontario, Canada
| | - Peter C. Coyte
- PC Coyte (corresponding author): Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, 155 College Street 4th Floor, Toronto, Ontario, Canada M5T 3M6
| |
Collapse
|
49
|
Atkins SR, Cunningham S. Multidisciplinary views towards the clinical pharmacist: a hospital palliative cancer care team perspective in Malta. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2018. [DOI: 10.1111/jphs.12267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sean Ryan Atkins
- Department of Pharmacy; Sir Anthony Mamo Oncology Centre - Mater Dei Hospital; Msida Malta
| | - Scott Cunningham
- Faculty of Health and Social Care; School of Pharmacy and Life Sciences; Robert Gordon University; Aberdeen UK
| |
Collapse
|
50
|
von Heymann-Horan A, Bidstrup P, Guldin MB, Sjøgren P, Andersen EAW, von der Maase H, Kjellberg J, Timm H, Johansen C. Effect of home-based specialised palliative care and dyadic psychological intervention on caregiver anxiety and depression: a randomised controlled trial. Br J Cancer 2018; 119:1307-1315. [PMID: 30425351 PMCID: PMC6265292 DOI: 10.1038/s41416-018-0193-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/29/2018] [Accepted: 07/04/2018] [Indexed: 12/25/2022] Open
Abstract
Background Specialised palliative care trials often fail to address intervention effects on caregiver anxiety and depression, particularly in bereavement. We evaluate effects of specialised palliative care and dyadic psychological intervention on caregiver anxiety and depression in a randomised controlled trial (RCT). Methods Patients with incurable cancer and limited antineoplastic treatment options and their caregivers, recruited from a university hospital oncology department, were randomised (1:1) to care as usual or accelerated transition from oncological treatment to home-based specialised palliative care. We assessed caregivers’ symptoms of anxiety and depression with the Symptom Checklist-92 up to six months after randomisation and 19 months into bereavement, and estimated intervention effects in mixed effects models. Results The ‘Domus’ trial enrolled 258 caregivers. The intervention significantly attenuated increases in caregivers’ symptoms of anxiety overall (estimated difference, −0.12; 95% confidence interval, −0.22 to −0.01, p = 0.0266), and symptoms of depression at eight weeks (−0.17; −0.33 to −0.02; p = 0.0314), six months (−0.27; −0.49 to −0.05; p = 0.0165), and in bereavement at two weeks (−0.28; −0.52 to −0.03; p = 0.0295) and two months (−0.24; −0.48 to −0.01; p = 0.0448). Conclusions This first RCT evaluating specialised palliative care with dyadic psychological support significantly attenuated caregiver anxiety and depression before and during bereavement. (Clinicaltrials.gov: NCT01885637)
Collapse
Affiliation(s)
| | | | - Mai-Britt Guldin
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Per Sjøgren
- Department of Oncology, Palliative Research Group, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Hans von der Maase
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jakob Kjellberg
- KORA, The Danish Institute for Local and Regional Government Research, Copenhagen, Denmark
| | - Helle Timm
- Knowledge Center for Rehabilitation and Palliative Care, University of Southern Denmark, Nyborg, Denmark
| | - Christoffer Johansen
- Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|