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Grant M, McCarthy D, Kearney C, Collins A, Sundararajan V, Rhee J, Philip J, Emery J. Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data. Support Care Cancer 2024; 32:273. [PMID: 38587665 PMCID: PMC11001688 DOI: 10.1007/s00520-024-08458-7] [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: 11/10/2023] [Accepted: 03/25/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage. METHODS Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017. RESULTS A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month. CONCLUSION This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.
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Affiliation(s)
- M Grant
- Palliative Nexus Research Group, Department of Medicine, University of Melbourne, Melbourne, Australia.
- Department of Palliative Medicine, St Vincent's Hospital Melbourne, Melbourne, Australia.
- Centre of Expertise in Palliative Care Utrecht, Department of General Practice, Julius Centre, UMC Utrecht, Universiteitsweg 100, 3584CG, Utrecht, The Netherlands.
| | - D McCarthy
- Dept of General Practice and Primary Care, Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - C Kearney
- Dept of General Practice and Primary Care, Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - A Collins
- Palliative Nexus Research Group, Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Palliative Medicine, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - V Sundararajan
- La Trobe University, Public Health, Melbourne, Australia
| | - J Rhee
- Discipline of General Practice, School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - J Philip
- Palliative Nexus Research Group, Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Palliative Medicine, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - J Emery
- Centre of Expertise in Palliative Care Utrecht, Department of General Practice, Julius Centre, UMC Utrecht, Universiteitsweg 100, 3584CG, Utrecht, The Netherlands
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Leach I, Mayland CR, Turner N, Mitchell S. Understanding patient views and experiences of the IDENTIfication of PALLiative care needs (IDENTI-PALL): a qualitative interview study. Br J Gen Pract 2024; 74:e88-e95. [PMID: 38191566 PMCID: PMC10792441 DOI: 10.3399/bjgp.2023.0071] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 09/13/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Palliative care improves quality of life for people with life-threatening illnesses. There are longstanding inequalities in access to palliative care, with many people never identified as having palliative care needs, particularly frail older people, those with non-malignant disease, and people from ethnic minority backgrounds. Little is known about the process of identification of palliative care needs from a patient perspective. AIM To provide new understanding into patient views and experiences of the process of identification of palliative care needs, and to explore the impact of identification on health care, if any, from a patient perspective. DESIGN AND SETTING A qualitative interview study undertaken with patients and family carers in a major UK city. METHOD Semi-structured interviews were carried out with patients (and/or family carers) identified as being on general practice palliative care registers. An inductive thematic analysis was conducted to explore the data. RESULTS Eleven participants were recruited: eight patients and three family carers. The following three interrelated themes were identified: 1) misconceptions about palliative care and unshared prognostic uncertainty hinder the identification of palliative care needs; 2) a compassionate, timely approach is required for identification of palliative care needs, with or without an identification tool; and 3) identification of palliative care needs is beneficial where it leads to proactive holistic care. CONCLUSION A compassionate approach, sharing of prognostic uncertainty, and proactive primary care are key to timely, beneficial identification of palliative care needs. Future policy should ensure that identification is an adaptable, personalised process to meet the individual needs of people with advanced serious illnesses.
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Affiliation(s)
- Isabel Leach
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield
| | - Catriona R Mayland
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield
| | - Nicola Turner
- School of Health Sciences, University of Nottingham, Nottingham
| | - Sarah Mitchell
- Division of Primary Care, Palliative Care and Public Health, University of Leeds, Leeds
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Bergman H, Borson S, Jessen F, Krolak-Salmon P, Pirani A, Rasmussen J, Rodrigo J, Taddeo D. Dementia and comorbidities in primary care: a scoping review. BMC PRIMARY CARE 2023; 24:277. [PMID: 38097969 PMCID: PMC10720181 DOI: 10.1186/s12875-023-02229-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND People with dementia (PwD) are known to have more chronic conditions compared to those without dementia, which can impact the clinical presentation of dementia, complicate clinical management and reduce overall quality of life. While primary care providers (PCPs) are integral to dementia care, it is currently unclear how PCPs adapt dementia care practices to account for comorbidities. This scoping review maps recent literature that describes the role for PCPs in the prevention, detection/diagnosis and management of dementia in the context of comorbidities, identifies critical knowledge gaps and proposes potential avenues for future research. METHODS We searched for peer-reviewed literature published between 2017-2022 in MEDLINE, Cochrane Library, and Scopus using key terms related to dementia, primary care, and comorbidity. The literature was screened for relevance by title-abstract screening and subsequent full-text screening. The prioritized papers were categorized as either 'Risk Assessment and Prevention', 'Screening, Detection, and Diagnosis' or 'Management' and were further labelled as either 'Tools and Technologies', 'Recommendations for Clinical Practice' or 'Programs and Initiatives'. RESULTS We identified 1,058 unique records in our search and respectively excluded 800 and 230 publications during title-abstract and full-text screening. Twenty-eight articles were included in our review, where ~ 50% describe the development and testing of tools and technologies that use pre-existing conditions to assess dementia risk. Only one publication provides official dementia screening guidelines for PCPs in people with pre-existing conditions. About 30% of the articles discuss managing the care of PwD, where most were anchored around models of multidisciplinary care and mitigating potentially inappropriate prescribing. CONCLUSION To our knowledge, this is the first scoping review that examines the role for PCPs in the prevention, detection/diagnosis and management of dementia in the context of comorbidities. Given our findings, we recommend that future studies: 1) further validate tools for risk assessment, timely detection and diagnosis that incorporate other health conditions; 2) provide additional guidance into how comorbidities could impact dementia care (including prescribing medication) in primary care settings; 3) incorporate comorbidities into primary care quality indicators for dementia; and 4) explore how to best incorporate dementia and comorbidities into models/frameworks of holistic, person-centred care.
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Affiliation(s)
- Howard Bergman
- Department of Family Medicine, McGill University, 5858 Ch. de La Côte-Des-Neiges, Suite 300, Montreal, QC, H3S 1Z1, Canada.
| | - Soo Borson
- Department of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Frank Jessen
- Department of Psychiatry, Medical Faculty, University of Cologne, Cologne, Germany
| | | | | | | | - Jesus Rodrigo
- Spanish Alzheimer's Confederation (Confederación Española de Alzheimer), Pamplona, Spain
| | - Daiana Taddeo
- Italian College of General Practitioners and Primary Care (SIMG - Società Italiana Di Medicina Genrale E Cure Primarie), Florence, Italy
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Hosie A, Agar M. Critical care admission rates for people with dementia: too high, too low, or just right? Age Ageing 2023; 52:afad200. [PMID: 37902682 DOI: 10.1093/ageing/afad200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Indexed: 10/31/2023] Open
Affiliation(s)
- Annmarie Hosie
- School of Nursing & Midwifery, University of Note Dame Australia, Darlinghurst, Australia
- Palliative Care, St Vincent's Health Network Sydney, Darlinghurst, Australia
- Faculty of Health, IMPACCT - Improving Palliative, Aged and Chronic Care through Research and Translation, University of Technology Sydney, Sydney, Australia
| | - Meera Agar
- Faculty of Health, IMPACCT - Improving Palliative, Aged and Chronic Care through Research and Translation, University of Technology Sydney, Sydney, Australia
- South West Sydney Clinical School, University of New South Wales, Randwick, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
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Yorganci E, Sleeman KE, Sampson EL, Stewart R. Survival and critical care use among people with dementia in a large English cohort. Age Ageing 2023; 52:afad157. [PMID: 37678881 PMCID: PMC10484725 DOI: 10.1093/ageing/afad157] [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: 12/02/2022] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Admitting people with dementia to critical care units may not always lead to a clear survival benefit. Critical care admissions of people with dementia vary across countries. Little is known about the use and trends of critical care admissions of people with dementia in England. OBJECTIVE To investigate critical care use and survival among people with dementia in a large London catchment area. METHODS A retrospective cohort study using data from dementia assessment services in south London, UK (2007-20) linked with national hospitalisation data to ascertain critical care admissions. Outcomes included age-sex-standardised critical care use and 1-year post-critical care admission survival by dementia severity (binary: mild versus moderate/severe). We used logistic regression and Kaplan-Meier survival plots for investigating 1-year survival following a critical care admission and linear regressions for time trends. RESULTS Of 19,787 people diagnosed with dementia, 726 (3.7%) had ≥1 critical care admission at any time after receiving their dementia diagnosis. The overall 1-year survival of people with dementia, who had a CCA, was 47.5% (n = 345). Dementia severity was not associated with 1-year survival following a critical care admission (mild dementia versus moderate-severe dementia odds of 1-year mortality OR: 0.90, 95% CI [0.66-1.22]). Over the 12-year period from 2008 to 2019, overall critical care use decreased (β = -0.05; 95% CI = -0.01, -0.0003; P = 0.03), while critical care admissions occurring during the last year of life increased (β = 0.11, 95% CI = 0.01, 0.20, P = 0.03). CONCLUSIONS In this cohort, while critical care use among people with dementia declined overall, its use increased among those in their last year of life. Survival remains comparable to that observed in general older populations.
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Affiliation(s)
- Emel Yorganci
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, London SE5 9PJ, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, London SE5 9PJ, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, University College London, London W1T 7NF, UK
- Liaison Psychiatry, Royal London Hospital, East London NHS Foundation Trust, London E1 1FR, UK
| | - Robert Stewart
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AB, UK
- South London and Maudsley NHS Foundation Trust, London SE5 8AB, UK
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Yorganci E, Sleeman KE. Palliative care can benefit people with dementia. BMJ 2023; 380:754. [PMID: 37001899 DOI: 10.1136/bmj.p754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Emel Yorganci
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Williamson LE, Leniz J, Chukwusa E, Evans CJ, Sleeman KE. A population-based retrospective cohort study of end-of-life emergency department visits by people with dementia: multilevel modelling of individual- and service-level factors using linked data. Age Ageing 2023; 52:afac332. [PMID: 36861183 PMCID: PMC9978317 DOI: 10.1093/ageing/afac332] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/12/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND emergency department (ED) visits have inherent risks for people with dementia yet increase towards the end-of-life. Although some individual-level determinants of ED visits have been identified, little is known about service-level determinants. OBJECTIVE to examine individual- and service-level factors associated with ED visits by people with dementia in the last year of life. METHODS retrospective cohort study using hospital administrative and mortality data at the individual-level, linked to health and social care service data at the area-level across England. The primary outcome was number of ED visits in the last year of life. Subjects were decedents with dementia recorded on the death certificate, with at least one hospital contact in the last 3 years of life. RESULTS of 74,486 decedents (60.5% women; mean age 87.1 years (standard deviation: 7.1)), 82.6% had at least one ED visit in their last year of life. Factors associated with more ED visits included: South Asian ethnicity (incidence rate ratio (IRR) 1.07, 95% confidence interval (CI) 1.02-1.13), chronic respiratory disease as the underlying cause of death (IRR 1.17, 95% CI 1.14-1.20) and urban residence (IRR 1.06, 95% CI 1.04-1.08). Higher socioeconomic position (IRR 0.92, 95% CI 0.90-0.94) and areas with higher numbers of nursing home beds (IRR 0.85, 95% CI 0.78-0.93)-but not residential home beds-were associated with fewer ED visits at the end-of-life. CONCLUSIONS the value of nursing home care in supporting people dying with dementia to stay in their preferred place of care must be recognised, and investment in nursing home bed capacity prioritised.
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Affiliation(s)
| | - Javiera Leniz
- Departamento de Salud Pública, Escuela de Medicina, Pontificia Universidad Católica de, Santiago, Chile
| | - Emeka Chukwusa
- King’s College London, Cicely Saunders Institute, London SE5 9PJ, UK
| | - Catherine J Evans
- King’s College London, Cicely Saunders Institute, London SE5 9PJ, UK
- Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton BN2 3EW, UK
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Chambers RL, Pask S, Higginson IJ, Barclay S, Murtagh FE, Sleeman KE. Inclusion of palliative and end of life care in health strategies aimed at integrated care: a documentary analysis. HEALTH OPEN RESEARCH 2023; 4:19. [PMID: 36987529 PMCID: PMC7614372 DOI: 10.12688/amrcopenres.13079.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background: In England, Integrated Care Systems have been established to improve integration of care, as part of the NHS Long Term Plan. For people near the end of life, palliative care can improve integration of care. We aimed to understand whether and how palliative and end of life care was included in Integrated Care System strategies, and to consider priorities for strengthening this. Methods: Documentary analysis of Integrated Care System (ICS) strategies, using summative content analysis, was performed. Google searches were used to identify NHS Trust, Clinical Commissioning Group or ICS websites. We searched these websites to identify strategies. Key terms were used to identify relevant content. Themes were mapped onto an adapted logic model for integrated care. Results: 23 Integrated Care System strategy documents were identified. Of these, two did not mention any of the key terms, and six highlighted palliative and end of life care as either a priority, area of focus, or an ambition. While most (19/23) strategies included elements that could be mapped onto the adapted logic model for integrated care, the thread from enablers and components, to structures, processes, outcomes, and impact was incomplete. Conclusions: Greater prioritisation of palliative and end of life care within recently established Integrated Care Systems could improve outcomes for people near the end of life, as well as reduce reliance on acute hospital care. Integrated Care Systems should consider involving patients, the public and palliative care stakeholders in the ongoing development of strategies. For strategies to be effective, our adapted logic model can be used to outline how different components of care fit together to achieve defined outcomes and impact.
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Affiliation(s)
- Rachel L. Chambers
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College, London, SE5 9PJ, UK
| | - Sophie Pask
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Irene J. Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College, London, SE5 9PJ, UK
- King’s College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Stephen Barclay
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fliss E.M. Murtagh
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College, London, SE5 9PJ, UK
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Katherine E. Sleeman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College, London, SE5 9PJ, UK
- King’s College Hospital NHS Foundation Trust, Denmark Hill, London, UK
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