Barriers to the development of pediatric palliative care in Italy

INTRODUCTION

In recent years the emergence of new types of patient, clinical situations, technological frontiers and "health" objectives have changed considerably the needs of ill children, this also concerns pediatric palliative care (PPC). In Italy, despite the introduction of legislation (Law 38/2010) stipulating the right of children and families to access appropriate services for pain control and pediatric palliative care, the availability of these services is still limited.

AIM

The aim of this study is to highlight, through a review of the existing data and published literature, the critical issues that obstacle the planning and development of PPC services in Italy.

RESULTS

Four main areas identified were: socio-cultural setting; types of patients and nature of diseases requiring PPC; training for PPC providers; regulatory and political issues.

CONCLUSIONS

This type of analysis can provide the rational for advancing proposals and developing supportive, corrective and implementation strategies.

Outpatient therapeutic chronic opioid consumption in Italy: a one-year survey

BACKGROUND

In Italy since the 38/2010 law concerning Palliative Care and pain therapy has been promulgated, the consumption of opioids started increasing. However, despite the availability of a large amount of data regarding opioid prescription, a database including all patients on chronic opioid therapy does not yet exist.

METHODS

Retrospective analysis of analgesic opioid consumption was performed between January 2013 and December 2013 using the data of national refunded medications for outpatients, collected by Italian Ministry of Health. We considered patients on chronic opioid therapy those patients with at least three opioids prescriptions in three consecutive months and/or six opioid prescriptions in six even not consecutive months in the observation period. We considered cancer patients those with neoplasm exemption code in the scheduled prescription and/or patients with at least one ROOs prescription (rapid onset opioids, approved in Italy for Break Through cancer Pain-BTcP- only). We also calculated the patient's morphine daily mean dose (MED) converting all prescribed opioids in equivalent of morphine using specific conversion tables.

RESULTS

This census revealed a total of 422,542 patients in chronic therapy with opioids, of those 369.961 with chronic non-cancer pain and 52,581 with chronic cancer pain. This represents about 4% of the estimated requirement in Italy for both groups based on previous surveys regarding the prevalence of chronic pain.

CONCLUSIONS

Relatively to MED, We found that in Italy chronic cancer pain patients receive doses similar to patients with cancer pain in other Literature reports, whereas patients with chronic non-cancer pain received lower dosages.

Use of a checklist to improve pain control in hospitalized cancer patients: the 38Checkpain project

AIM

Checklists may improve management of patients in different settings. However, no studies have been conducted to investigate the use of this tool to improve inpatient pain control. This study, conducted in Italy, aims to describe the experience, in terms of pain control, of the widespread introduction of a checklist for pain control in oncological patients, according to current Italian legislation.

MATERIALS & METHODS

In total, 92 Italian centers were randomly assigned to the use of the 38Checkpain to monitor pain management or to continue their standard practice without the use of this tool.

RESULTS

The 38Checkpain improved the control of pain compared with centers who did not use this tool.

CONCLUSION

Overall, the findings of this study suggest that the application of the 38Checkpain may help improve control of pain of hospitalized oncological patients.

Narrative medicine to highlight values of Italian pain therapists in a changing healthcare system

Until 2010 pain management in Italy was only partially covered and no structural and qualitative mapping had ever been realized. The VEDUTA project was designed to provide a tool to unite pain therapists in national cooperation. Quantitative questionnaires and narrative plots were sent to 350 Italian specialists; 184 therapists completed the first section and 87 also wrote their stories. Narratives were analyzed through transactional analysis and emotional intelligence. Overall, results show that a patient-centered approach is common in daily practice, but that bureaucracy is endangering quality of care. This cultural analysis, through both the application of quantitative assessment and narrative plots, provides a useful tool to improve those aspects of the system detrimental to the appropriate management of pain in Italy.

The frequency of apneas in very preterm infants is increased after non-acid gastro-esophageal reflux

BACKGROUND

To evaluate whether physical and/or chemical features of gastro-esophageal reflux (GER) influence its relationship with apnea of prematurity (AOP).

METHODS

Fifty-eight preterm newborns (GA ≤ 33 weeks) with recurrent apneas were studied by simultaneous polysomnography and combined impedance and pH monitoring, to analyze whether the correlation between GER and AOP varies according to the acidity, duration and height of GERs.

KEY RESULTS

The frequency of apnea (number apnea/min) occurring after-GER [median (range) 0.07 (0-0.25)] was higher than the one detected in GER-free period [0.06 (0.04-0.13), P = 0.015], and also than the one detected before-GER [0 (0-0.8), P = 0.000]. The frequency of apneas detected in the 30'' after pH-GER [median (range), 0 min(-1) (0-1.09)] was higher than the frequency detected in the 30'' before [0 (0-0.91), P = 0.04]; even more, the frequency of apneas detected after non-acid MII-GER episodes [0 (0-2)] was significantly higher than the one detected before [0 (0-1), P = 0.000], whereas the frequency of apneas detected before acid MII-GER episodes [0 (0-0.67)] did not differ from the one detected after [0 (0-2), P = 0.137]. The frequency of pathological apneas detected in the 30'' after-GER (0 min(-1), range 0-0.55) was higher than the frequency detected before (0, range 0-0.09; P = 0.001). No difference in mean height or in mean duration was found between GERs correlated and those non-correlated to apnea.

CONCLUSIONS & INFERENCES

Non-acid GER is responsible for a variable amount of AOP detected after-GER: this novel finding must be taken into consideration when a therapeutic strategy for this common problem is planned.

Pediatric palliative care

The WHO defines pediatric palliative care as the active total care of the child's body, mind and spirit, which also involves giving support to the family. Its purpose is to improve the quality of life of young patients and their families, and in the vast majority of cases the home is the best place to provide such care, but for cultural, affective, educational and organizational reasons, pediatric patients rarely benefit from such an approach. In daily practice, it is clear that pediatric patients experience all the clinical, psychological, ethical and spiritual problems that severe, irreversible disease and death entail. The international literature indicates a prevalence of incurable disease annually affecting 10/10,000 young people from 0 to 19 years old, with an annual mortality rate of 1/10,000 young people from birth to 17 years old. The needs of this category of patients, recorded in investigations conducted in various parts of the world, reveal much the same picture despite geographical, cultural, organizational and social differences, particularly as concerns their wish to be treated at home and the demand for better communications between the professionals involved in their care and a greater availability of support services. Different patient care models have been tested in Italy and abroad, two of institutional type (with children staying in hospitals for treating acute disease or in pediatric hospices) and two based at home (the so-called home-based hospitalization and integrated home-based care programs). Professional expertise, training, research and organization provide the essential foundations for coping with a situation that is all too often underestimated and neglected.