Prevalence, severity and impacts of breathlessness in Indian adults: An exploratory, nationally representative, cross-sectional online survey

There are no known estimates of the prevalence, severity and impacts from breathlessness in low- and middle-income countries. This study aimed to explore the prevalence, severity, self-attributed underlying conditions and impacts of breathlessness limiting exertion in community-dwelling adults in India. This exploratory, population-based online survey recruited a pre-planned sample of 3,000 adult respondents stratified by age, sex and rurality (quotas as per the 2011 Indian National Census). Measures included: demographics; breathlessness limiting exertion (modified Medical Research [mMRC] scale); health-related quality of life (EQ-5D-5L); and disability (World Health Organisation's Disability Assessment Schedule 2.0 12-item questionnaire [WHODAS-12]). Respondents (n = 3,046) had a mean age of 38 years (SD 15); 57% were male, 59% lived in rural areas and 33% had completed 12th grade. Breathlessness limiting exertion (mMRC ≥1) was reported by 44%, mostly attributed to poor nutrition (28%), lung conditions excluding tuberculosis (17%) or anaemia (13%). Compared to those without breathlessness, a higher proportion of people with breathlessness (mMRC ≥1) reported problems across all EQ-5D-5L dimensions. Most people reporting breathlessness (81%) indicated the symptom had adversely affected their normal activities. Disability scores (WHODAS-12 total and individual domains) increased as breathlessness worsened. To conclude, in India, conservative estimates indicate 626 million people live with breathlessness of whom 52 million people live with severe breathlessness. The symptom is associated with poorer health-related quality of life and marked disability, including reduced ability to perform daily activities.

Breast cancer screening participation in women using mental health services in NSW, Australia: a population study

PURPOSE

Population screening programs have contributed to reduced breast cancer mortality, but disadvantaged or vulnerable groups may not have shared these improvements. In North American and European studies, women living with mental health conditions have reduced breast screening rates. There are no current Australasian data to support health system planning and improvement strategies.

METHODS

The New South Wales (NSW) BreastScreen program offers free screening to NSW women aged 50-74. We compared 2-year breast screening rates for mental health service users (n = 33,951) and other NSW women (n = 1,051,495) in this target age range, after standardisation for age, socioeconomic status and region of residence. Mental health service contacts were identified through linkage to hospital and community mental health data.

RESULTS

Only 30.3% of mental health service users participated in breast screening, compared with 52.7% of other NSW women (crude incidence rate ratio 0.57, 95% CI 0.56-0.59). Standardisation for age, socioeconomic disadvantage or rural residence did not alter this screening gap. Around 7000 fewer women received screening than would be expected from comparable population rates. Screening gaps were largest in women over 60 and in socioeconomically advantaged areas. Women with severe or persistent mental illness had slightly higher screening rates than other mental health service users.

CONCLUSIONS

Low breast cancer screening participation rates for NSW mental health service users suggest significant risk of later detection, possibly leading to more extensive treatment and premature mortality. Focussed strategies are needed to support greater breast screening participation for NSW women who use mental health services.

Oxycodone initiation in Australia (2014-2018): Sociodemographic factors and preceding health service use

AIMS

Oxycodone is the most commonly prescribed strong opioid in Australia. This study describes health service antecedents and sociodemographic factors associated with oxycodone initiation.

METHODS

Population-based new user cohort study linking medicine dispensings, hospitalizations, emergency department visits, medical services and cancer notifications from New South Wales (NSW) for 2014-2018. New users had no dispensings of any opioid in the preceding year. We analysed health service use in the 5 days preceding initiation and proportion of people on treatment over 1 year and fitted an area-based, multivariable initiation model with sociodemographic covariates.

RESULTS

Oxycodone accounted for 30% of opioid initiations. Annually, 3% of the NSW population initiated oxycodone, and 5-6% were prevalent users; the new user cohort comprised 830 963 people. Discharge from hospital (39.3%), therapeutic procedures (21.4%) and emergency department visits (19.7%) were common; a hospital admission for injury (6.0%) or a past-year history of cancer (7.2%) were less common. At 1 year after initiation, 4.6% of people were using oxycodone. In the multivariable model, new use of oxycodone increased with age and was higher for people outside major cities, for example, an incidence rate ratio of 1.43 (95% confidence interval 1.36-1.51) for inner regional areas relative to major cities; there was no evidence of variation in rates of new use by social disadvantage.

CONCLUSION

About half of new oxycodone use in NSW was preceded by a recent episode of hospital care or a therapeutic procedure. Higher rates of oxycodone initiation in rural and regional areas were not explained by sociodemographic factors.

Pregnancy-associated gynecological cancer in New South Wales, Australia 1994-2013: A population-based historical cohort study

INTRODUCTION

Pregnancy-associated gynecological cancer (PAGC) refers to cancers of the ovary, uterus, fallopian tube, cervix, vagina, and vulva diagnosed during pregnancy or within 12 months postpartum. We aimed to describe the incidence of, and perinatal outcomes associated with, invasive pregnancy-associated gynecological cancer.

MATERIAL AND METHODS

We conducted a population-based historical cohort study using linked data from New South Wales, Australia. We included all women who gave birth between 1994 and 2013, with a follow-up period extending to September 30, 2018. Three groups were analyzed: a gestational PAGC group (women diagnosed during pregnancy), a postpartum PAGC group (women diagnosed within 1 year of giving birth), and a control group (women with control diagnosis during pregnancy or within 1 year of giving birth). We used generalized estimation equations to compare perinatal outcomes between study groups.

RESULTS

There were 1 786 137 deliveries during the study period; 70 women were diagnosed with gestational PAGC and 191 with postpartum PAGC. The incidence of PAGC was 14.6/100 000 deliveries and did not change during the study period. Women with gestational PAGC (adjusted odds ratio [aAOR] 6.81, 95% confidence interval [CI] 2.97-15.62) and with postpartum PAGC (aOR 2.65, 95% CI 1.25-5.61) had significantly increased odds of a severe maternal morbidity outcome compared with the control group. Babies born to women with gestational PAGC were more likely to be born preterm (aOR 3.11, 95% CI 1.47-6.59) and were at increased odds of severe neonatal complications (aOR 3.47, 95% CI 1.45-8.31) compared with babies born to women without PAC.

CONCLUSIONS

The incidence of PAGC has not increased over time perhaps reflecting, in part, the effectiveness of cervical screening and early impacts of human papillomavirus vaccination programs in Australia. The higher rate of preterm birth among the gestational PAGC group is associated with adverse outcomes in babies born to these women.

Assessment and Management of Sleep Disturbance in Palliative Care Settings

Background: Sleep disturbances, including insomnia, sleep-disordered breathing, and circadian rhythm disorders with potential consequences including excessive daytime somnolence and worsening fatigue, are prevalent yet largely under-measured and therefore under-managed problems in people receiving palliative care. This has the potential to negatively affect the person's functioning and quality of life. Objectives: We aimed to review the current practice of assessment and management of sleep disturbances in people with life-limiting illnesses in Australian and New Zealand palliative care settings, and to define areas for improvement in assessment and management of sleep disturbances and further research. Design: A cross-sectional, online survey was conducted with palliative care health professionals (PCHPs) to explore current approaches to routine assessment of sleep disturbances and PCHPs' awareness of, and perceived access to, evidence-based resources for assessing and managing sleep disturbances in their local settings. Results: Fifty-four PCHPs responded to the survey, including allied health professionals (44%), palliative care nurses (26%), and physicians (19%). Over 70% of PCHPs endorsed routine verbal screening of sleep symptoms, and >90% recommended management with basic behavioral strategies. However, none of PCHPs used validated patient-reported outcome measures for sleep, and <10% of PCHPs demonstrated awareness or use of sleep-specific interventions (including medications). Only 40% reported they had access to sleep specialist services for patients. Conclusion: Our findings provide a useful snapshot of current approaches to managing sleep disturbances in palliative care. Gaps in current practice are highlighted, including the lack of structured, clinical assessment, referral pathways, and PCHPs' perceived lack of access to targeted interventions for sleep disturbances.

Australian population norms for health-related quality of life measured using the EQ-5D-5L, and relationships with sociodemographic characteristics

BACKGROUND

Measuring health related quality-of-life (HRQoL) of the general population is essential to establish a reference for health outcome evaluations. This study sought to establish EQ-5D-5L population norms in Australia and to investigate the heterogeneity of HRQoL between sociodemographic variables.

METHODS

A cross-sectional study comprising of a representative sample of Australia's general population (n = 9958) aged 18 or older. Recruitment quotas were set for the Australian census population by age, sex, state/territory of residence and rurality. Participants were recruited by Qualtrics through its database of over 800,000 registered panel members and asked to value their own state of health using the EQ-5D-5L domains and the EuroQol-Visual Analogue Scale (EQ-VAS). An Australian value set developed using Discreet Choice Experiment was used to calculate utility scores.

RESULTS

The estimated mean EQ-5D-5L index for Australia's general population was 0.86 (standard deviation [SD] 0.19), and the EQ-VAS score was estimated as 73.2 (SD 21.7). 23.9% of the study population reported being in the best health state (11,111). Younger people, current smokers, people who are unemployed and people with more financial stress reported a lower EQ-5D-5L index score (p < 0.001). Residents in the major cities, inner regional and outer regional Australia reported higher health utility scores than those residing in remote and very remote Australia.

CONCLUSIONS

This is the first Australian study to apply the EQ-5D-5L in a nationally representative sample. The EQ-5D-5L Australian population norms obtained can be used as reference scores for future population health evaluations and comparisons. The findings facilitate a national reference for clinical, economic, and policy decision-making processes and provide a fuller understanding of the Australian population's HRQoL.

Factors most strongly associated with breathlessness in a population aged 50-64 years

Background

Breathlessness is a troublesome and prevalent symptom in the population, but knowledge of related factors is scarce. The aim of this study was to identify the factors most strongly associated with breathlessness in the general population and to describe the shapes of the associations between the main factors and breathlessness.

Methods

A cross-sectional analysis was carried out of the multicentre population-based Swedish CArdioPulmonary bioImage Study (SCAPIS) of adults aged 50 to 64 years. Breathlessness was defined as a modified Medical Research Council breathlessness rating ≥2. The machine learning algorithm extreme gradient boosting (XGBoost) was used to classify participants as either breathless or nonbreathless using 449 factors, including physiological measurements, blood samples, computed tomography cardiac and lung measurements, lifestyle, health conditions and socioeconomics. The strength of the associations between the factors and breathlessness were measured by SHapley Additive exPlanations (SHAP), with higher scores reflecting stronger associations.

Results

A total of 28 730 participants (52% women) were included in the study. The strongest associated factors for breathlessness were (in order of magnitude): body mass index ( SHAP score 0.39), forced expiratory volume in 1 s (0.32), physical activity measured by accelerometery (0.27), sleep apnoea (0.22), diffusing lung capacity for carbon monoxide (0.21), self-reported physical activity (0.17), chest pain when hurrying (0.17), high-sensitivity C-reactive protein (0.17), recent weight change (0.14) and cough (0.13).

Conclusion

This large population-based study of men and women aged 50-64 years identified the main factors related to breathlessness that may be prevented or amenable to public health interventions.

Gabapentin for Pain in Pediatric Palliative Care

OBJECTIVE

Gabapentin is commonly used to treat pain in children receiving pediatric palliative care. This study describes the real-world use of gabapentin and the associated benefits and adverse effects/events (AEs).

METHODS

A prospective, multicenter cohort of standardized data collection after a clinical decision was made to use gabapentin for managing neuropathic or nociplastic pain in children attended on by a pediatric palliative care service. It was conducted across 11 sites in seven countries including hospital, inpatient, and outpatient services. Clinical outcomes were graded using pain scales validated for age and cognitive ability and the National Cancer Institute Common Terminology Criteria for Adverse Events (NCICTCAE) at baseline, 14 days, 28 days, six weeks and 12 weeks after initiation of gabapentin. Ad-hoc safety reporting continued throughout the study.

RESULTS

Data were collected from 127 children with a median age of 4.7 years (IQR 0.1-17.9); 61% had a neurological disorder, 21% advanced cancer and the cohort had a high level of disability (Lansky/Karnofsky performance score 37.1). Gabapentin was prescribed at standard pediatric doses. On average, 76% of children had a reduction in pain and 42% experienced a potential AE. The mean pain score decreased from 6.0 (SD 2.6) at baseline to 3.3 (SD 2.4) at 14 days and 1.8 (SD 1.8) after 12-weeks of gabapentin therapy. Ten percent had increased pain at each time point. AEs did not increase when individual changes over time were accounted for except for somnolence (7%). Serious AEs attributable to gabapentin were possible or probable in 3% of children.

CONCLUSIONS

Gabapentin prescribed at standard doses for advanced cancer and severe neurological injury in children under a pediatric palliative care service was associated with generally improved pain intensity at previously described levels of adverse effects.

Nurses' encounters with patients having end-of-life dreams and visions in an acute care setting - A cross-sectional survey study

AIM

This study aimed to estimate the proportion of acute care nurses witnessing end-of-life dreams and visions or having these reported by a patient or relative, and to canvass their related attitudes and beliefs.

DESIGN

A cross-sectional survey study was conducted from February 2023 to May 2023.

SETTING/PARTICIPANTS

Participants were medical and surgical nurses from a 200-bed acute care hospital in metropolitan Australia.

RESULTS

Fifty-seven nurses participated from a workforce of 169 (34% response rate), of whom 35 (61%) reported they had encountered end-of-life dreams and visions. The nature of end-of-life dreams and visions encountered was similar to those reported in previous studies by patients and clinicians. Nurses generally held positive attitudes towards end-of-life dreams and visions but identified an unmet need for education and training on this aspect of end-of-life care.

CONCLUSION

Our results suggest that nurses in acute care encounter end-of-life dreams and visions in a similar proportion to oncology and long-term care but lower than in palliative care settings. Education and training regarding end-of-life dreams and visions are needed to ensure the provision of comprehensive, patient-centred end-of-life care.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

IMPACT

Research in sub-acute and long-term care settings suggests that end-of-life dreams and visions are a common accompaniment to the dying process. No research has yet focused on the acute care setting, despite this being the place of death for the majority of people in most high-income countries. This study demonstrates that acute care nurses encounter end-of-life dreams and visions in similar proportions to oncology and long-term care nurses but lower than palliative care nurses. Acute care nurses would benefit from education and training regarding end-of-life dreams and visions to enable the provision of holistic person-centred end-of-life care.

REPORTING METHOD

This study was reported using the STROBE Checklist for cross-sectional studies.

What Aspects of Quality of Life are Important from Palliative Care Patients' Perspectives? A Framework Analysis to Inform Preference-Based Measures for Palliative and End-of-Life Settings

BACKGROUND AND OBJECTIVE

Preference-based outcome measures are commonly applied in economic analyses to inform healthcare resource allocation decisions. Few preference-based outcome measures have been specifically developed for palliative and end-of-life settings. This study aimed to identify which quality-of-life domains are most important to Australians receiving specialised palliative care services to help determine if the development of a new condition-specific preference-based outcome measure is warranted.

METHODS

In-depth face-to-face interviews were conducted with 18 participants recruited from palliative care services in South Australia. Data were analysed using a framework analysis drawing on findings from a systematic review of international qualitative studies investigating the quality-of-life preferences of patients receiving palliation (domains identified included cognitive, emotional, healthcare, personal autonomy, physical, preparatory, social, spiritual). Participants identified missing or irrelevant domains in the EQ-5D and QLU-C10D questionnaires and ranked the importance of domains.

RESULTS

A priori domains were refined into cognitive, environmental, financial, independence, physical, psychological, social and spiritual. The confirmation of the eight important quality-of-life domains across multiple international studies suggests there is a relatively high degree of convergence on the perspectives of patients in different countries. Four domains derived from the interviews are not covered by the EQ-5D and QLU-C10D (cognitive, environmental, financial, spiritual), including one of the most important (spiritual).

CONCLUSIONS

Existing, popular, preference-based outcome measures such as the EQ-5D do not incorporate the most important, patient-valued, quality-of-life domains in the palliative and end-of-life settings. Development of a new, more relevant and comprehensive preference-based outcome measure could improve the allocation of resources to patient-valued services and have wide applicability internationally.

Breast screening participation and degree of spread of invasive breast cancer at diagnosis in mental health service users: A population linkage study

BACKGROUND

Women living with mental health conditions may not have shared in improvements in breast cancer screening and care. No studies have directly examined the link between reduced screening participation and breast cancer spread in women using mental health (MH) services.

METHODS

Population-wide linkage of a population cancer register, BreastScreen register, and mental health service data set in women aged 50 to 74 years in New South Wales, Australia, from 2008 to 2017. Incident invasive breast cancers were identified. Predictors of degree of spread (local, regional, metastatic) at diagnosis were examined using partial proportional odds regression, adjusting for age, socioeconomic status, rurality, and patterns of screening participation.

RESULTS

A total of 29 966 incident cancers were identified and included 686 (2.4%) in women with MH service before cancer diagnoses. More than half of MH service users had regional or metastatic spread at diagnosis (adjusted odds ratio, 1.63; 95% CI, 1.41-1.89). MH service users had lower screening participation; however, advanced cancer was more common even when adjusting for screening status (adjusted odds ratio, 1.53; 95% CI, 1.32-1.77). Advanced cancer was more common in women with severe or persistent MH conditions.

CONCLUSIONS

Low screening participation rates explain only small part of the risk of more advanced breast cancer in women who use MH services. More study is needed to understand possible mechanisms contributing to more advanced breast cancer in women living with MH conditions. Health systems need strategies to ensure that women living with MH conditions enjoy population gains in breast cancer outcomes.

Which breathlessness dimensions associate most strongly with fatigue?-The population-based VASCOL study of elderly men

BACKGROUND

Breathlessness and fatigue are common symptoms in older people. We aimed to evaluate how different breathlessness dimensions (overall intensity, unpleasantness, sensory descriptors, emotional responses) were associated with fatigue in elderly men.

METHODS

This was a cross-sectional analysis of the population-based VAScular disease and Chronic Obstructive Lung Disease (VASCOL) study of 73-year old men. Breathlessness dimensions were assessed using the Dyspnoea-12 (D-12), Multidimensional Dyspnoea Profile (MDP), and the modified Medical Research Council (mMRC) scale. Fatigue was assessed using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire. Clinically relevant fatigue was defined as FACIT-F≤ 30 units. Scores were compared standardized as z-scores and analysed using linear regression, adjusted for body mass index, smoking, depression, cancer, sleep apnoea, prior cardiac surgery, respiratory and cardiovascular disease.

RESULTS

Of 677 participants, 11.7% had clinically relevant fatigue. Higher breathlessness scores were associated with having worse fatigue; for D-12 total, -0.35 ([95% CI] -0.41 to -0.30) and for MDP A1, -0.24 (-0.30 to -0.18). Associations were similar across all the evaluated breathlessness dimensions even when adjusting for the potential confounders.

CONCLUSION

Breathlessness assessed using D-12 and MDP was associated with worse fatigue in elderly men, similarly across different breathlessness dimensions.

Age-specific differences in cervical cancer screening rates in women using mental health services in New South Wales, Australia

OBJECTIVE

Women living with mental health conditions have lower cervical cancer screening rates and higher mortality. More evidence is needed to target health system improvement efforts. We describe overall and age-specific cervical cancer screening rates in mental health service users in New South Wales.

METHODS

Cervical cancer screening registers were linked to New South Wales hospital and community mental health service data. Two-year cervical screening rates were calculated for New South Wales mental health service users aged 20-69 years (n = 114,022) and other New South Wales women (n = 2,110,127). Rate ratios were compared for strata of age, socio-economic disadvantage and rural location, and overall rates compared after direct standardisation.

RESULTS

Only 40.3% of mental health service users participated in screening, compared with 54.3% of other New South Wales women (incidence rate ratio = 0.74, 95% confidence interval = [0.74, 0.75]). Differences in age, social disadvantage or rural location did not explain screening gaps. Screening rates were highest in mental health service users aged <35 years (incidence rate ratios between 0.90 and 0.95), but only 15% of mental health service users aged >65 years participated in screening (incidence rate ratio = 0.27, 95% confidence interval = [0.24, 0.29]).

CONCLUSION

Women who use mental health services are less likely to participate in cervical cancer screening. Rates diverged from population rates in service users aged ⩾35 years and were very low for women aged >65 years. Intervention is needed to bridge these gaps. New screening approaches such as self-testing may assist.

Assessing Patient-Reported Outcomes in Routine Cancer Clinical Care Using Electronic Administration and Telehealth Technologies: Realist Synthesis of Potential Mechanisms for Improving Health Outcomes

BACKGROUND

The routine measurement of patient-reported outcomes in cancer clinical care using electronic patient-reported outcome measures (ePROMs) is gaining momentum worldwide. However, a deep understanding of the mechanisms underpinning ePROM interventions that could inform their optimal design to improve health outcomes is needed.

OBJECTIVE

This study aims to identify the implicit mechanisms that underpin the effectiveness of ePROM interventions and develop program theories about how and when ePROM interventions improve health outcomes.

METHODS

A realist synthesis of the literature about ePROM interventions in cancer clinical care was performed. A conceptual framework of ePROM interventions was constructed to define the scope of the review and frame the initial program theories. Literature searches of Ovid MEDLINE, Ovid Embase, Scopus, and CINAHL, supplemented by citation tracking, were performed to identify relevant literature to develop, refine, and test program theories. Quality appraisal of relevant studies was performed using the Mixed Methods Appraisal Tool.

RESULTS

Overall, 61 studies were included in the realist synthesis: 15 (25%) mixed methods studies, 9 (15%) qualitative studies, 13 (21%) descriptive studies, 21 (34%) randomized controlled trials, and 3 (5%) quasi-experimental studies. In total, 3 initial program theories were developed regarding the salient components of ePROM interventions-remote self-reporting, real-time feedback to clinicians, and clinician-patient telecommunication. The refined theories posit that remote self-reporting enables patients to recognize and report symptoms accurately and empowers them to communicate these to clinicians, real-time feedback prompts clinicians to manage symptoms proactively, and clinician-patient telephone interactions and e-interactions between clinic encounters improve symptom management by reshaping how clinicians and patients communicate. However, the intervention may not achieve the intended benefit if ePROMs become a reminder to patients of their illness and are not meaningful to them and when real-time feedback to clinicians lacks relevance and increases the workload.

CONCLUSIONS

The key to improving health outcomes through ePROM interventions is enabling better symptom reporting and communication through remote symptom self-reporting, promoting proactive management of symptoms through real-time clinician feedback, and facilitating clinician-patient interactions. Patient engagement with self-reporting and clinician engagement in responding to feedback are vital and may reinforce each other in improving outcomes. Effective ePROM interventions might fundamentally alter how clinicians and patients interact between clinic encounters.

Factors important for health-related quality of life in men and women: The population based SCAPIS study

INTRODUCTION

Health-related quality of life (HRQoL) is essential for human wellbeing, influenced by a complex interplay of factors, and is reported lower in women than men. We aimed to evaluate which factors were the most important for HRQoL in a middle-aged general population.

METHODS

This was a cross-sectional, multi-centre study of 29,212 men (48%) and women (52%) aged 50-64 in the general population in Sweden. Physical and mental HRQoL (0-100) was assessed using the Short Form 12 questionnaire, and association was evaluated for 356 variables including demographics, lifestyle, symptoms, physiological measurements, and health conditions. Using machine learning, each variable´s importance for HRQoL was measured by an importance score, comparable to effect size, and summarised in 54 factors, in men and women separately.

RESULTS

Men and women had similar mean and standard deviation (SD) scores for physical HRQoL (53.4 [SD 8.1] vs 51.4 [9.7]) and mental HRQoL (37.1 [5.0] vs 37.3 [5.4]). The most important factors for physical HRQoL were (importance score) physical activity (40), employment (36), pain (33), sleep (33), and sense of control (26). The most important factors for mental HRQoL were sense of control (18), physical activity (12), depression (12), pain (6), and employment (5).

CONCLUSIONS

The factors important for HRQoL identified by this study are likely to be amenable to interventions, and our findings can support prioritising interventions. The identified factors need to be a target even before middle-age to lay the foundation for long and happy lives.

Vaccine-preventable hospitalisations in adult mental health service users: a population study

BACKGROUND

Vaccine-preventable conditions cause preventable illness and may increase mortality in people living with mental illness. We examined how risks of hospitalisation for a wide range of vaccine-preventable conditions varied by age and sex among mental health (MH) service users.

METHODS

Linked population data from New South Wales (NSW), Australia were used to identify vaccine-preventable hospitalisations (VPH) for 19 conditions from 2015 to 2020. Adult MH service users (n = 418 915) were compared to other NSW residents using incidence rates standardised for age, sex and socioeconomic status. Secondary analyses examined admissions for COVID-19 to September 2021.

RESULTS

We identified 94 180 VPH of which 41% were influenza, 33% hepatitis B and 10% herpes zoster. MH service users had more VPH admissions [adjusted incidence rate ratio (aIRR) 3.2, 95% CI 3.1-3.3]. Relative risks were highest for hepatitis (aIRR 4.4, 95% CI 4.3-4.6), but elevated for all conditions including COVID-19 (aIRR 2.0, 95% CI 1.9-2.2). MH service users had a mean age of 9 years younger than other NSW residents at first VPH admission, with the largest age gap for vaccine-preventable pneumonias (11-13 years younger). The highest relative risk of VPH was among MH service users aged 45-65.

CONCLUSIONS

MH service users have increased risk of hospitalisation for many vaccine-preventable conditions. This may be due to reduced vaccination rates, more severe illness requiring hospitalisation, greater exposure to infectious conditions or other factors. People living with mental illness should be prioritised in vaccination strategies.

The effect of general practice contact on cancer stage at diagnosis in Aboriginal and non-Aboriginal residents of New South Wales

PURPOSE

Older age, risks from pre-existing health conditions and socio-economic disadvantage are negatively related to the prospects of an early-stage cancer diagnosis. With older Aboriginal Australians having an elevated prevalence of these underlying factors, this study examines the potential for the mitigating effects of more frequent contact with general practitioners (GPs) in ensuring local-stage at diagnosis.

METHODS

We compared the odds of local vs. more advanced stage at diagnosis of solid tumours according to GP contact, using linked registry and administrative data. Results were compared between Aboriginal (n = 4,084) and non-Aboriginal (n = 249,037) people aged 50 + years in New South Wales with a first diagnosis of cancer in 2003-2016.

RESULTS

Younger age, male sex, having less area-based socio-economic disadvantage, and fewer comorbid conditions in the 12 months before diagnosis (0-2 vs. 3 +), were associated with local-stage in fully-adjusted structural models. The odds of local-stage with more frequent GP contact (14 + contacts per annum) also differed by Aboriginal status, with a higher adjusted odds ratio (aOR) of local-stage for frequent GP contact among Aboriginal people (aOR = 1.29; 95% CI 1.11-1.49) but not among non-Aboriginal people (aOR = 0.97; 95% CI 0.95-0.99).

CONCLUSION

Older Aboriginal Australians diagnosed with cancer experience more comorbid conditions and more socioeconomic disadvantage than other Australians, which are negatively related to diagnosis at a local-cancer stage. More frequent GP contact may act to partly offset this among the Aboriginal population of NSW.

Association of participants who screened positive for night eating syndrome with physical health, sleep problems, and weight status in an Australian adult population

BACKGROUND

Night eating syndrome (NES) is a unique eating disorder characterised by evening hyperphagia and nocturnal ingestions which cause significant distress and/or impairment in functioning. Despite the growing literature, NES remains poorly understood and under diagnosed. As such, this study aims to compare the prevalence of physical health conditions in participants with NES when compared to participants without an eating disorder (ED) and participants with other eating disorders (including anorexia nervosa (AN), binge eating disorder (BED) and bulimia nervosa (BN)) in a general population Australian sample of adults.

METHODS

The data for this study were obtained from the 2017 Health Omnibus Survey (HOS) a multi-stage, cross-sectional survey, conducted by Harrison Research in South Australia. This current study focused on 2547 participants over 18 years of age and specific questions from this population survey including those related to participant demographics and health.

RESULTS

This study identified that participants who screened positive for night eating syndrome (spNES) when compared to participants with other eating disorders (ED) or no ED diagnosis, were significantly more likely to have an increased age, be female, have lower levels of education and have lower household income. Additionally, the spNES group was significantly associated with sleep apnoea (p = 0.031), insomnia or other sleep problems (p < 0.0001), increased BMI (p < 0.0001), increased levels of pain/discomfort and lower physical health-related quality of life. Hypertension, hypercholesterolemia, and diabetes were not significantly associated with the spNES group or the "other ED" group which included participants with AN, BED, BN.

CONCLUSIONS

Several physical health problems were found to be significantly associated with the spNES group including sleep problems, increased BMI, increased levels of pain and lower self-reported physical health-related quality of life. Consequently, future research exploring the complex interaction between NES and these medical conditions may provide further insight into the diagnosis, screening tools and management of NES. Additionally, this study highlights the need for future studies which use larger population-based samples.

LEVEL OF EVIDENCE

Level III. Evidence obtained from well-designed cohort or case-control analytic studies.

Opioid prescribing patterns among medical practitioners in New South Wales, Australia

INTRODUCTION

Prescriber behaviour is important for understanding opioid use patterns. We described variations in practitioner-level opioid prescribing in New South Wales, Australia (2013-2018).

METHODS

We quantified opioid prescribing patterns among medical practitioners using population-level dispensing claims data, and used partitioning around medoids to identify clusters of practitioners who prescribe opioids based on prescribing patterns and patient characteristics identified from linked dispensing claims, hospitalisations and mortality data.

RESULTS

The number of opioid prescribers ranged from 20,179 in 2013 to 23,408 in 2018. The top 1% of practitioners prescribed 15% of all oral morphine equivalent (OME) milligrams dispensed annually, with a median of 1382 OME grams (interquartile range [IQR], 1234-1654) per practitioner; the bottom 50% prescribed 1% of OMEs dispensed, with a median of 0.9 OME grams (IQR 0.2-2.6). Based on 63.6% of practitioners with ≥10 patients filling opioid prescriptions in 2018, we identified four distinct practitioner clusters. The largest cluster prescribed multiple analgesic medicines for older patients (23.7% of practitioners) accounted for 76.7% of all OMEs dispensed and comprised 93.0% of the top 1% of practitioners by opioid volume dispensed. The cluster prescribing analgesics for younger patients with high rates of surgery (18.7% of practitioners) prescribed only 1.6% of OMEs. The remaining two clusters comprised 21.2% of prescribers and 20.9% of OMEs dispensed.

DISCUSSION AND CONCLUSION

We observed substantial variation in opioid prescribing among practitioners, clustered around four general patterns. We did not assess appropriateness but some prescribing patterns are concerning. Our findings provide insights for targeted interventions to curb potentially harmful practices.

Population-level, patient-reported outcomes: a case study regarding a public health intervention that involves patients with life-limiting illnesses

Introduction

Dying and death are public health concerns, but little is known about public health interventions that target populations living with life-limiting illnesses. This gap makes it difficult to identify best-practice public health interventions for this population and to achieve public health objectives. The study aimed to describe a public health intervention that intends to improve population-level outcomes using point-of-care and patient-reported outcomes.

Methods

A case study approach, informed by the Organization for Economic Co-operation and Development's (OECD) Best-Practice Public Health Framework, was used to describe coverage, effectiveness, and equity using mixed methods. Data from 2012 to 2022 were analyzed.

Results

Over the 10-year period, the number of deaths recorded in the programme (n = 16,358 to 32,421, +98.2%) as well as the percentage of the population that might benefit from palliative care increased (14.8% to 25.1%). The median age of those admitted for care (74 to 77 years) and the proportion of services participating in the programme located in outer regional and remote areas of Australia increased (2012: 59; 2022: 94; +5.4%). The access by patients that experience the greatest socioeconomic disadvantage decreased (2012: 18.2% n = 4,918; 2022: 15.9% n = 9,525). Improvements in relation to moderate distress related to pain were identified (2012: 63% n = 8,751, 2022: 69% n = 13,700), and one in five instances of severe distress related to pain did not improve (2012: 20% n = 781; 2022: 19% n = 635).

Conclusion

Population-level, patient-reported outcome data are useful and necessary in addressing public health objectives in populations with life-limiting illnesses. Our application of the OECD's Best-Practice Public Health Framework has helped to identify and describe a national intervention that may be transferred to other settings to address health promotion objectives. This may help improve the targeting of treatments to improve pain and issues related to equity.

Modified-release morphine or placebo for chronic breathlessness: the MABEL trial protocol

Chronic breathlessness, a persistent and disabling symptom despite optimal treatment of underlying causes, is a frightening symptom with serious and widespread impact on patients and their carers. Clinical guidelines support the use of morphine for the relief of chronic breathlessness in common long-term conditions, but questions remain around clinical effectiveness, safety and longer term (>7 days) administration. This trial will evaluate the effectiveness of low-dose oral modified-release morphine in chronic breathlessness. This is a multicentre, parallel group, double-blind, randomised, placebo-controlled trial. Participants (n=158) will be opioid-naïve with chronic breathlessness due to heart or lung disease, cancer or post-coronavirus disease 2019. Participants will be randomised 1:1 to 5 mg oral modified-release morphine/placebo twice daily and docusate/placebo 100 mg twice daily for 56 days. Non-responders at Day 7 will dose escalate to 10 mg morphine/placebo twice daily at Day 15. The primary end-point (Day 28) measure will be worst breathlessness severity (previous 24 h). Secondary outcome measures include worst cough, distress, pain, functional status, physical activity, quality of life, and early identification and management of morphine-related side-effects. At Day 56, participants may opt to take open-label, oral modified-release morphine as part of usual care and complete quarterly breathlessness and toxicity questionnaires. The study is powered to be able to reject the null hypothesis and an embedded normalisation process theory-informed qualitative substudy will explore the adoption of morphine as a first-line pharmacological treatment for chronic breathlessness in clinical practice if effective.

Expanding health technology assessment towards broader value: Ireland as a case study

Healthcare innovations often represent important improvements in population welfare, but at what cost, and to whom? Health technology assessment (HTA) is a multidisciplinary process to inform resource allocation. HTA is conventionally anchored on health maximization as the only relevant output of health services. If we accept the proposition that health technologies can generate value outside the healthcare system, resource allocation decisions could be suboptimal from a societal perspective. Incorporating "broader value" in HTA as derived from social values and patient experience could provide a richer evaluative space for informing resource allocation decisions. This article considers how HTA is practiced and what its current context implies for adopting "broader value" to evaluating health technologies. Methodological challenges are highlighted, as is a future research agenda. Ireland serves as an example of a healthcare system that both has an explicit role for HTA and is evolving under a current program of reform to offer universal, single-tier access to public services. There are various ways in which HTA processes could move beyond health, including considering the processes of care delivery and/or expanding the evaluative space to some broader concept of well-being. Methods to facilitate the latter exist, but their adaptation to HTA is still emerging. We recommend a multi-stakeholder working group to develop and advance an international agenda for HTA that captures welfare/benefit beyond health.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Progressive pulmonary fibrosis: an expert group consensus statement

This expert group consensus statement emphasises the need for standardising the definition of progressive fibrosing interstitial lung diseases (F-ILDs), with an accurate initial diagnosis being of paramount importance in ensuring appropriate initial management. Equally, case-by-case decisions on monitoring and management are essential, given the varying presentations of F-ILDs and the varying rates of progression. The value of diagnostic tests in risk stratification at presentation and, separately, the importance of a logical monitoring strategy, tailored to manage the risk of progression, are also stressed. The term "progressive pulmonary fibrosis" (PPF) exactly describes the entity that clinicians often face in practice. The importance of using antifibrotic therapy early in PPF (once initial management has failed to prevent progression) is increasingly supported by evidence. Artificial intelligence software for high-resolution computed tomography analysis, although an exciting tool for the future, awaits validation. Guidance is provided on pulmonary rehabilitation, oxygen and the use of non-invasive ventilation focused specifically on the needs of ILD patients with progressive disease. PPF should be differentiated from acute deterioration due to drug-induced lung toxicity or other forms of acute exacerbations. Referral criteria for a lung transplant are discussed and applied to patient needs in severe diseases where transplantation is not realistic, either due to access limitations or transplantation contraindications. In conclusion, expert group consensus guidance is provided on the diagnosis, treatment and monitoring of F-ILDs with specific focus on the recognition of PPF and the management of pulmonary fibrosis progressing despite initial management.

Lidocaine for Neuropathic Cancer Pain (LiCPain): study protocol for a mixed-methods pilot study

INTRODUCTION

Many patients experience unrelieved neuropathic cancer-related pain. Most current analgesic therapies have psychoactive side effects, lack efficacy data for this indication and have potential medication-related harms. The local anaesthetic lidocaine (lignocaine) has the potential to help manage neuropathic cancer-related pain when administered as an extended, continuous subcutaneous infusion. Data support lidocaine as a promising, safe agent in this setting, warranting further evaluation in robust, randomised controlled trials. This protocol describes the design of a pilot study to evaluate this intervention and explains the pharmacokinetic, efficacy and adverse effects evidence informing the design.

METHODS AND ANALYSIS

A mixed-methods pilot study will determine the feasibility of an international first, definitive phase III trial to evaluate the efficacy and safety of an extended continuous subcutaneous infusion of lidocaine for neuropathic cancer-related pain. This study will comprise: a phase II double-blind randomised controlled parallel-group pilot of subcutaneous infusion of lidocaine hydrochloride 10% w/v (3000 mg/30 mL) or placebo (sodium chloride 0.9%) over 72 hours for neuropathic cancer-related pain, a pharmacokinetic substudy and a qualitative substudy of patients' and carers' experiences. The pilot study will provide important safety data and help inform the methodology of a definitive trial, including testing proposed recruitment strategy, randomisation, outcome measures and patients' acceptability of the methodology, as well as providing a signal of whether this area should be further investigated.

ETHICS AND DISSEMINATION

Participant safety is paramount and standardised assessments for adverse effects are built into the trial protocol. Findings will be published in a peer-reviewed journal and presented at conferences. This study will be considered suitable to progress to a phase III study if there is a completion rate where the CI includes 80% and excludes 60%. The protocol and Patient Information and Consent Form have been approved by Sydney Local Health District (Concord) Human Research Ethics Committee 2019/ETH07984 and University of Technology Sydney ETH17-1820.

TRIAL REGISTRATION NUMBER

ANZCTR ACTRN12617000747325.

Pregnancy associated cancer, timing of birth and clinical decision making-a NSW data linkage study

BACKGROUND

The incidence of pregnancy-associated cancer (PAC), comprising cancer diagnosed during pregnancy or within one year postpartum, is increasing. We investigated the obstetric management and outcomes of women with PAC and their babies.

METHODS

A population-based observational study of all women who gave birth between 1994 and 2013 in New South Wales, Australia. Women were stratified into three groups: those diagnosed during pregnancy (gestational cancer group), those diagnosed within one year of giving birth (postpartum cancer group), and a no-PAC group. Generalized estimating equations were used to examine the association between PAC and adverse maternal and neonatal outcomes.

RESULTS

One million seven hundred eighty-eight thousand four hundred fifty-onepregnancies were included-601 women (614 babies) were in the gestational cancer group, 1772 women (1816 babies) in the postpartum cancer group, and 1,786,078 women (1,813,292 babies) in the no-PAC group. The overall crude incidence of PAC was 132.7/100,000 women giving birth. The incidence of PAC increased significantly over the twenty-year study period from 93.5/100,000 in 1994 to 162.5/100,000 in 2013 (2.7% increase per year, 95% CI 1.9 - 3.4%, p-value < 0.001). This increase was independent of maternal age. The odds of serious maternal complications (such as acute abdomen, acute renal failure, and hysterectomy) were significantly higher in the gestational cancer group (adjusted odds ratio (AOR) 5.07, 95% CI 3.72 - 6.90) and the postpartum cancer group (AOR 1.55, 95% CI 1.16 - 2.09). There was no increased risk of perinatal mortality in babies born to women with PAC. However, babies of women with gestational cancer (AOR 8.96, 95% CI 6.96 - 11.53) or postpartum cancer (AOR 1.36, 95% CI 1.05 - 1.81) were more likely to be planned preterm birth. Furthermore, babies of women with gestational cancer had increased odds of a severe neonatal adverse outcome (AOR 3.13, 95% CI 2.52 - 4.35).

CONCLUSION

Women with PAC are more likely to have serious maternal complications. While their babies are not at increased risk of perinatal mortality, they are more likely to experience poorer perinatal outcomes associated with preterm birth. The higher rate of birth intervention among women with gestational cancers reflects the complexity of clinical decision-making in this context.

"This is What Lies Ahead". Perspectives of Oxygen-Naïve COPD Patients on Long-Term Oxygen Use. A Qualitative Study

Purpose

Oxygen is commonly prescribed to patients with severe COPD. However, little is known about the perspectives COPD patients, who do not yet use oxygen, have on this treatment.

Patients and Methods

A total of 14 oxygen-naïve patients with COPD Gold stages 3-4 and a high symptom burden participated in semi-structured interviews, in which their beliefs and expectations regarding oxygen therapy were explored. We used conventional content analysis to process our qualitative data.

Results

Four main themes were identified: seeking information, expected impact on quality of life, expected social impact and stigma, and last phase of life.

Conclusion

The message that home oxygen should be started, was regarded as bad news by most participants. The rationale behind the therapy and the way it is delivered were unknown to most participants. Some participants anticipated smoking-related stigma and social isolation. Misconceptions such as tank explosions, becoming housebound, full dependency on oxygen and an imminent death were common amongst interviewees. Clinicians should be aware of these fears and assumptions when communicating with patients on this subject.

Country of birth and non-small cell lung cancer incidence, treatment, and outcomes in New South Wales, Australia: a population-based linkage study

Objective

To compare treatment within 12 months of diagnosis, and survival by country of birth for people diagnosed with invasive non-small cell lung cancer (NSCLC) in New South Wales (NSW), Australia.

Design, patients, and setting

A population-based cohort study of NSW residents diagnosed with NSCLC in 2003–2016 using de-identified linked data from the NSW Cancer Registry, NSW Admitted Patient Data collection, Emergency Departments, Medicare Benefits and Pharmaceutical Benefits Scheme, and National Death Index.

Main outcome measures

Odds of receiving any treatment, surgery, systemic therapy, or radiotherapy respectively, in the 12 months following diagnosis were calculated using multivariable logistic regression. The hazard of death (all-cause) at one- and five-years following diagnosis was calculated using multivariable proportional hazards regression.

Results

27,114 People were recorded with NSCLC in the 14-year study period. Higher percentages of older males from European countries applied in the earlier years, with a shift to younger people from South East Asia, New Zealand, and the Middle East. Adjusted analyses indicated that, compared with the Australian born, people from European countries were more likely to receive treatment, and, specifically surgery. Also, people from Asian countries were more likely to receive systemic therapy but less likely to receive radiotherapy. Survival at one- and five-years following diagnosis was higher for people born in countries other than Australia, New Zealand the United Kingdom and Germany.

Conclusions

Variations exist in treatment and survival by country of birth in NSW. This may be affected by differences in factors not recorded in the NSW Registry, including use of general health services, family histories, underlying health conditions, other intrinsic factors, and cultural, social, and behavioural influences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02163-z.

OP08 A feasibility cluster randomised controlled trial of a paramedic-administered breathlessness management intervention for acute-on-chronic breathlessness (BREATHE): study findings

Background

One-fifth of conveyances to the emergency department (ED) are due to acute-on-chronic breathlessness. Paramedic breathlessness management may ease distress quicker and/or reduce ED conveyances. We evaluated the feasibility of a full trial of a paramedic delivered intervention to reduce avoidable conveyances (recruitment, randomisation, consent, training and intervention acceptability, adherence, data quality, best primary outcome, sample size estimation). The intervention comprised evidence-based non-drug techniques and a self-management booklet.

Methods

This mixed-methods feasibility cluster randomised controlled trial (ISRCTN80330546) with embedded qualitative study about trial processes, training and intervention delivery, randomised paramedics to usual care or to intervention+usual care. Retrospective patient consent to use call-out data and prospective patient/carer consent for follow-up was sought. Potential primary outcomes were breathlessness intensity (numerical rating scale) and ED conveyance. Follow-up included an interview for patients/carers and questionnaires at 14 days, 1 and 6 months and paramedic focus groups and survey.

Results

Recruitment was during the COVID-19 pandemic, leading to high demands on paramedics and fewer call-outs by eligible patients. We enrolled 29 paramedics; 9 withdrew. Randomisation/trial procedures were acceptable. Paramedics recruited 13 patients; 8 were followed up. Data quality was good. The intervention did not extend call-out time, was delivered with fidelity and no contamination and was acceptable to patients, carers, and paramedics. There were no repeat call-outs < 48 hours. Recruitment stop-go criteria were not met. We had insufficient data for sample size estimation.

Conclusions

A full trial in the same circumstances is not feasible. However, valuable information was gained on recruitment, attrition, consent, training and intervention acceptability and adherence, and patient-reported data collection.

Colorectal cancer and country of birth in New South Wales, Australia: All-of-population data for prioritising health service delivery and research

INTRODUCTION

Cancer care and outcomes differ across cultural groups in Australia. Quantifying these differences facilitates prioritisation and targeting of services and research. All-of-population data are needed by health agencies to understand and fulfil their cancer-control responsibilities. Compiling these data can be challenging while maintaining privacy. We have used data linkage to gain population-wide colorectal cancer data on stage (degree of spread), treatment, and survival in New South Wales (NSW), Australia, by country of birth (COB), and consider service implications.

METHODS

We studied colon and rectal cancers diagnosed in 2003-2016 and recorded on the NSW Cancer Registry (n = 41,575), plus linked hospital data and data from Australian Medical and Pharmaceutical Benefits payments, other treatment data and death records. Outcomes for 12 COB categories were analysed using multiple logistic and proportional hazards regression, with Australia as the reference category.

RESULTS

Compared with Australian born, the adjusted odds ratio for distant spread of colon cancer was higher for people born in Lebanon and the United Kingdom. Treatment was less common for people born in China (surgery), Germany (systemic), Italy (surgery), New Zealand (any treatment) and Vietnam (all treatments), while treatment for rectal cancer was more common for people born in Italy (surgery), United Kingdom (radiotherapy, systemic therapy), and Vietnam (surgery), and less frequent for people born in China (radiotherapy). Adjusted 5-year survival was higher for people born in China, Italy, Vietnam, Greece (colon), Lebanon (colon) and other non-English speaking countries. More advanced stage was negatively related to having surgery and survival.

CONCLUSIONS

This study illustrates how linked data can enable comparisons of multiple outcomes for colorectal cancer by country of birth across an entire population. Results disclose "big picture" variations in population characteristics, stage, treatment and survival. This will enable better targeting and prioritisation of services and inform research priorities to address disparities.

End-of-life dreams and visions: A systematic integrative review

OBJECTIVES

End-of-life dreams and visions (ELDVs) have been reported throughout history. We aimed to synthesize the research literature on ELDVs to determine the proportions of patients, bereaved families, healthcare professionals, and volunteers reporting ELDVs; ELDV content, timing, and interpretation; and any evidence-based approaches to ELDV-related care.

METHODS

A systematic review protocol was registered with PROSPERO (CRD4021282929). CINAHL, Medline, Embase, Emcare, and APA PsycInfo were searched for peer-reviewed English language articles reporting qualitative, quantitative, or mixed methods studies that explored reports of ELDVs by patients, bereaved families, healthcare professionals, or volunteers. Synthesis used both meta-analysis and a narrative approach.

RESULTS

Of 2,045 papers identified by searches, 22 were included, describing 18 studies in a variety of settings. Meta-analyses indicated that 77% (95% confidence intervals [CIs] 69-84%) of patients (n = 119) reported an ELDV compared with 32% (95% CIs 21-44%) of bereaved relatives (n = 2,444) and that 80% (95% CIs 59-94%) of healthcare professionals (n = 171) reported either witnessing or being told of an ELDV in the preceding 5 years. Studies of volunteers reported 34% (95% CIs 20-48%) (n = 45) either witnessing or being told of an ELDV over their entire period of service, with 49% of volunteers (95% CIs 33-64%) (n = 39) reporting events occurring in the preceding year. ELDVs reported by patients, bereaved families, healthcare professionals, and volunteers were perceived as being a source of comfort. Healthcare professionals and volunteers expressed a need for further education on how to support patients experiencing ELDVs and their families.

SIGNIFICANCE OF RESULTS

ELDVs are experienced by the majority of dying patients and need consideration in delivering holistic end-of-life care. Little if any research has been conducted in acute care facilities.

The association between phase of illness and resource utilisation-a potential model for demonstrating clinical efficiency?

Background: Healthcare efficiency involves demonstrating flexible inter-relationships between resource utilisation and patient need. In palliative care, five phases of patient illness have been identified: stable, unstable, deteriorating, terminal and bereaved. Evaluating the association between phase of illness and nursing activities could demonstrate clinical efficiency. Aim: The aim of this study was to evaluate the association between the phase of illness and the intensity of nursing care in a specialist palliative care unit. Methods: This was a prospective, observational cohort study of consecutive admissions (n=400) to a specialist palliative care unit. Patient phase of illness was documented on admission and daily thereafter. A nursing activity tool was developed, which scored daily nursing interventions (physical, psychological, family care and symptom control). This score was called the nursing total score (NTS) and reflected the intensity of nursing activities. Data were entered into SPSS and descriptive statistics weregenerated. Results: A total of 342 (85%) patients had full data recorded on admission. Stable, unstable, deteriorating and terminal phases were associated with progressively increasing median NTSs on days 1, 2, 3 and 4 (all P<0.01). Phase stabilisation from the unstable to the stable phase during this timeframe resulted in reductions in physical care (p=0.038), symptom management (p=0.007) and near-significant reductions in family support (p=0.06). Conclusion: A significant association was demonstrated between phase of illness and intensity of nursing activities, which were sensitive to phase changes, from unstable to stable. This demonstrates technically efficient resource utilisation and identifies a potential efficiency model for future evaluations of inpatient palliative care.

Symptom burden and lived experiences of patients, caregivers and healthcare professionals on the management of malignant bowel obstruction: A qualitative systematic review

BACKGROUND

Malignant bowel obstruction occurs in up to 50% of people with advanced ovarian and 15% of people with gastrointestinal cancers. Evaluation and comparison of interventions to manage symptoms are hampered by inconsistent evaluations of efficacy and lack of agreed core outcomes. The patient perspective is rarely incorporated.

AIM

To synthesise the qualitative data regarding patient, caregiver and healthcare professionals' views and experience of malignant bowel obstruction to inform the development of a core outcome set for the evaluation of malignant bowel obstruction.

DESIGN

A qualitative systematic review was conducted, with narrative synthesis. The review protocol was registered prospectively (https://www.crd.york.ac.uk/prospero, CRD42020176393).

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO and Scopus databases were searched for studies published between 2010 and 2021. Reference lists were screened for further relevant publications, and citation tracking was performed.

RESULTS

Nine papers were included, reporting on seven studies which described the views and experiences of malignant bowel obstruction through the perspectives of 75 patients, 13 caregivers and 62 healthcare professionals. Themes across the papers included symptom burden, diverse experiences of interventions, impact on patient quality of life, implications and trajectory of malignant bowel obstruction, mixed experience of communication and the importance of realistic goals of care.

CONCLUSION

Some of the most devastating sequelae of malignant bowel obstruction, such as pain and psychological distress, are not included routinely in its clinical or research evaluation. These data will contribute to a wider body of work to ensure the patient and caregiver perspective is recognised in the development of a core outcome set.

Patients’ and their caregivers’ experiences with regular, low-dose, sustained-release morphine for chronic breathlessness associated with COPD: a qualitative study

Introduction

Regular, low-dose, sustained-release morphine is effective in reducing chronic breathlessness in people with advanced disease, particularly in patients with chronic obstructive pulmonary disease (COPD). Despite experiencing a reduction in breathlessness, some patients choose not to continue long-term treatment.

Aim

This study aimed to explore patients’ and caregivers’ experiences with regular, low-dose, sustained-release morphine for chronic breathlessness associated with COPD.

Methods

A qualitative study embedded in a randomised controlled trial (RCT) of regular low-dose, sustained-release morphine for chronic breathlessness for people with COPD and modified Medical Research Council breathlessness scale 3–4. After completing the RCT or withdrawing, patients and their caregivers were invited to participate in interviews in their homes focused on their experiences with the trial medication while still blinded to the arm to which they had been allocated. Data analysis used a constant comparative method informed by the principles of grounded theory.

Results

Thirteen patients and nine caregivers participated. Four themes were identified: (1) Receptivity and knowledge; (2) Function as a priority; (3) Harmful and helpful side effects; and (4) Therapy-centred aspects. The concept of ‘net effect’ emerged from the interplay between themes, subthemes and the decision to continue taking sustained-release morphine during the trial and after trial completion.

Conclusion

Clinicians’ support and preconceived ideas about morphine influence the decision to commence sustained-release morphine. The hope for functional improvement is the great driver influencing positively the decision to take sustained-release morphine in the long term. The degree of symptom reduction, improved function, side-effects’ severity and caregivers’ availability creates a net effect driving patients’ decisions to continue or discontinue the medication.

Persisting breathlessness and activities reduced or ceased: a population study in older men

Introduction

Breathlessness is debilitating and increases in prevalence with age, with people progressively reducing their everyday activities to ‘self-manage’ it. This study aimed to evaluate the impact of breathlessness on function in terms of activities that have been reduced or ceased (‘compromised’) in older men.

Methods

A cross-sectional postal survey of Swedish 73-year-old man in the VAScular and Chronic Obstructive Lung disease study self-reporting on demographics, breathlessness (modified Medical Research Council (mMRC) scale, Dyspnoea-12, Multidimensional Dyspnea Scale) and its duration, anxiety/depression (Hospital Anxiety and Depression Scale), performance status (WHO Performance Status), everyday activities reduced/ceased and exertion.

Results

148/828 (17.9%) respondents reported breathlessness (mMRC >2), of whom 51.9% had reduced/ceased activities compared with 9.6% who did not. Physical activity was the most common activity reduced/ceased (48.0%) followed by sexual activity (41.2%) and social activities (37.8%). Of 16.0% of respondents with mMRC 3–4 talking on the phone was affected compared with only 2.9% of respondents with mMRC 2. Worsening breathlessness was associated with increasingly sedentary lifestyles and more limited function, those reporting reduced/ceased activities had an associated increase in reporting anxiety and depression. In adjusted analyses, breathlessness was associated with increased likelihood of activities being ceased overall as well as physical and sexual activities being affected separately.

Conclusion

Worsening breathlessness was associated with decreasing levels of self-reported physical activity, sexual activity and function. Overall, the study showed that people with persisting breathlessness modify their lifestyle to avoid it by reducing or ceasing a range of activities, seeking to minimise their exposure to the symptom.

Population-level utilisation of neoadjuvant radiotherapy for the treatment of rectal cancer

PURPOSE

International clinical guidelines recommend long- or short-course neoadjuvant radiotherapy for locally advanced rectal cancer. This study aims to examine variation in the use of neoadjuvant radiotherapy for rectal cancer and identify patient and hospital factors that underpin this variation.

METHODS AND MATERIALS

We conducted a retrospective, consecutive cohort study using statewide hospitalisation and radiotherapy data from New South Wales, Australia, 2013-2018. Included participants had a primary rectal adenocarcinoma and underwent surgical resection. Factors associated with the use or not of any neoadjuvant radiotherapy, and short versus long-course were explored using multilevel logistic regression models.

RESULTS

Of the 2912 people included in the study, 43% received neoadjuvant radiotherapy. There was significant variation in the use of neoadjuvant radiotherapy depending on geographic location. Abdominoperineal excision (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.53-2.28) and having surgery in a public hospital (OR = 2.34, 95% CI = 1.92-2.87) were both predictors of use. Among those receiving neoadjuvant radiotherapy, 17% received short-course therapy, with short-course declining over the study period.

CONCLUSIONS

The use of neoadjuvant radiotherapy for rectal cancer is highly variable, with differences only partially explained by assessable patient-or hospital-level factors. Understanding neoadjuvant radiotherapy utilisation patterns may assist in identifying barriers and opportunities to improve adherence to clinical guidelines.

The complexities, coordination, culture and capacities that characterise the delivery of oncology services in the common areas of ambulatory settings

Background

Relatively little is understood about real-world provision of oncology care in ambulatory outpatient clinics (OPCs). This study aimed to: 1) develop an understanding of behaviours and practices inherent in the delivery of cancer services in OPC common areas by characterising the organisation and implementation of this care; and 2) identify barriers to, and facilitators of, the delivery of this care in OPC common areas.

Methods

A purpose-designed ethnographic study was employed in four public hospital OPCs. Informal field scoping activities were followed by in-situ observations, key informant interviews and document review. A view of OPCs as complex adaptive systems was used as a scaffold for the data collection and interpretation, with the intent of understanding ‘work as done’. Data were analysed using an adapted “Qualitative Rapid Appraisal, Rigorous Analysis” approach.

Results

Field observations were conducted over 135 h, interviews over 6.5 h and documents were reviewed. Analysis found six themes. Staff working in OPCs see themselves as part of small local teams and as part of a broader multidisciplinary care team. Professional role boundaries could be unclear in practice, as duties expanded to meet demand or to stop patients “falling through the cracks.” Formal care processes in OPCs were supported by relationships, social capital and informal, but invaluable, institutional expertise. Features of the clinic layout, such as the proximity of departments, affected professional interactions. Staff were aware of inter- and intra-service communication difficulties and employed strategies to minimise negative impacts on patients. We found that complexity, coordination, culture and capacity underpin the themes that characterise this care provision.

Conclusions

The study advances understanding of how multidisciplinary care is delivered in ambulatory settings and the factors which promote or inhibit effective care practice. Time pressures, communication challenges and competing priorities can pose barriers to care delivery. OPC care is facilitated by: self-organisation of participants; professional acumen; institutional knowledge; social ties and relationships between and within professional groups; and commitment to patient-centred care. An understanding of the realities of ‘work-as-done’ may help OPCs to sustain high-quality care in the face of escalating service demand.

Opioid-sparing effects of ketorolac in palliative care patients receiving opioids for chronic cancer-related pain: A systematic literature review

BACKGROUND

Standard of care in treatment of cancer-related pain involves opioids in combination with non-steroidal anti-inflammatory drugs (NSAID). Ketorolac, a NSAID, has demonstrated opioid-sparing effects in other clinical settings.

AIM

This systematic literature review investigated ketorolac's opioid-sparing effects in patients receiving opioids for chronic, cancer-related pain.

DESIGN

The primary outcome was total daily dose of opioids. Secondary outcomes included frequency of opioid use, use and frequency of 'rescue' medication and adverse events. Outcomes were described, and meta-analysed where possible. PROSPERO registration CRD42019130894.

DATA SOURCES

Articles included original research, from any study phase or methodology, published in English in a peer-reviewed journal or conference between 1990 and 2020; included subjects >18 years; had chronic cancer-related pain and described the use of opioid-sparing effect of ketorolac.

RESULTS

Nine articles were included. While there was significant heterogeneity, ketorolac may have an opioid-sparing effect, with significant reductions in total daily dose of morphine observed in a single randomised controlled trial (SMD -4.30 mg, 95% CI -5.36 to -3.25), but the changes in the before and after studies were not statistically significant -0.46 mg (95% CI -1.14 to 0.22). Ketorolac was associated with greater likelihood of complete pain relief, but the data were heterogeneous. Insufficient data were available to analyse frequency of opioid use, or rescue medication requirements.

CONCLUSIONS

Given the heterogeneity of the data, adequately powered, randomised controlled trials are required to establish any opioid-sparing effect of ketorolac. For patients not responding to conventional pain management, ketorolac may have a role in treatment augmentation.

Breathlessness dimensions association with physical and mental quality of life: the population based VASCOL study of elderly men

Background

Breathlessness is a multidimensional symptom prevalent in elderly affecting many aspects of life. We aimed to determine how different dimensions of breathlessness are associated with physical and mental quality of life (QoL) in elderly men.

Methods

This was a cross-sectional, population-based analysis of 672 men aged 73 years in a Swedish county. Breathlessness was assessed using Dyspnoea-12 (D-12) and Multidimensional Dyspnoea Profile (MDP), and QoL using the Short Form 12 physical and mental scores. Scores were compared as z-scores across scales and analysed using multivariable linear regression, adjusted for smoking, body mass index and the presence of respiratory and cardiovascular disease.

Results

Worse breathlessness was related to worse physical and mental QoL across all the D-12 and MDP dimension scores. Physical QoL was most strongly associated with perceptional breathlessness scores, D-12 total and physical scores (95% CI −0.45 to −0.30). Mental QoL was more strongly influenced by affective responses, MDP emotional response score (95% CI −0.61 to −0.48). Head-to-head comparison of the instruments confirmed that D-12 total and physical scores most influenced physical QoL, while mental QoL was mostly influenced by the emotional responses captured by the MDP.

Conclusion

Breathlessness dimensions and QoL measures are associated differently. Physical QoL was most closely associated with sensory and perceptual breathlessness dimensions, while emotional responses were most strongly associated with mental QoL in elderly men. D-12 and MDP contribute complimentary information, where affective and emotional responses may be related to function, deconditioning and QoL.

Cancer Profiles, Times to Treatment, and Survival for Adolescents and Young Adults: Comparisons with Children and Older Adults in New South Wales, Australia

Purpose: To compare cancer types, stages, times to treatment, and survival for adolescent and young adults (AYAs) 15-24 years of age with other cancer patients <40 years. Methods: New South Wales Cancer Registry and treatment data were linked to explore differences in cancer type, stage, time to treatment, and survival between AYAs, children, and adults. Multivariable logistic regression and competing-risk regression were adjusted for sociodemographic, diagnostic period, and clinical characteristics. Results: Most common cancers in AYAs and adults were carcinomas compared with leukemias in children. Advanced (regional and distant) stage applied to 33% of AYA solid cancers, which was similar to adult stages, but lower than the 40% for children (adjusted odds ratio 1.21, 95% confidence interval [CI] 1.01-1.47). Proportions starting treatment ≤60 days from diagnosis were 93% for AYAs and children, and 94% for adults, with higher adjusted odds of starting ≤60 days of 1.39 (95% CI 1.11-1.73) for children and 1.23 (95% CI 1.06-1.44) for adults. Five-year disease-specific survival was 90% for AYAs and adults, and 87% for children. The adjusted subhazard ratio for children compared with AYAs was 0.67 (95% CI 0.52-0.88). Age differences in cancer stage, treatment start, and cancer survival varied by cancer type. Conclusions: After adjusting for cancer type, diagnostic period, and sociodemographic characteristics, AYAs had less advanced solid tumors than children; fewer AYAs were treated within 60 days than children and adults; and AYA survival was lower than for children. The potential for residual confounding from leukemia type and other confounders needs further analysis with larger Australia-wide cohorts.

323Breast and cervical cancer screening and outcomes in NSW mental health service consumers

Focus of Presentation

This presentation describes methods and findings from the NSW Mental Health Living Longer (MHLL) Program. MHLL involves population-wide data linkage that combines records from nine NSW data collections. Our collection includes over 120 million records for more than nine million people. This presentation focuses on the use of linked data to develop indicators to support reporting on premature cancer mortality for people living with mental illness. We will use these indicators to identify variation in care, assess areas for targeted intervention, and evaluate the effectiveness of research translation into safer and more effective care.

Findings

This work will be finalised by August 2020. We will use regression techniques to examine predictors of participation in breast and cervical cancer screening for women who use mental health services in NSW. These results will be used to assess geographical variation in risk-adjusted screening participation rates. We will also present methods and results for measuring incidence and stage at presentation, as well as 12 month and 5 year survival for women who use mental health services compared to other women in NSW.

Conclusions/Implications

If cancer survival is a key measure of the effectiveness of healthcare systems, then reduced survival in people with mental health problems reflects less effective health care. Improving screening and treatment services is likely to be the most important strategy for reducing the cancer mortality gap for people with mental illness.

Key messages

Health systems must move from recognition to action if we are to reduce premature cancer mortality in people living with mental illness.

Providing outpatient cancer care for CALD patients: a qualitative study

OBJECTIVE

There have been few descriptions of how outpatient cancer care is provided to patients from culturally and linguistically diverse (CALD) communities. As populations who experience disparities in cancer care access and outcomes, deeper understanding is needed to help identify those factors which can shape the receipt of multidisciplinary care in ambulatory settings. This paper reports on data collected and analysed as part of a multicentre characterisation of care in Australian public hospital cancer outpatient clinics (OPCs).

RESULTS

Analysis of data from our ethnographic study of four OPCs identified three themes: "Identifying CALD patient language-related needs"; "Capacity and resources to meet CALD patient needs", and "Making it work for CALD communities." The care team comprises not only clinicians but also families and non-clinical staff; OPCs serve as "touchpoints" facilitating access to a range of therapeutic services. The findings highlight the potential challenges oncology professionals negotiate in providing care to CALD communities and the ways in which clinicians adapt their practices, formulate strategies and use available resources to support care delivery.

Is Neuropathic Pain a Good Marker of Peripheral Neuropathy in Hospice Patients with Advanced Cancer? The Single Center Pilot Study

Neuropathic pain (NP) affects approximately 30% of patients with advanced cancer. The prevalence of neuropathic pain related to peripheral neuropathy (NP-RPN) in these patients is not known. The aim of the study was to evaluate NP-RPN prevalence in hospice patients and to find out whether the absence of this pain is sufficient to rule out peripheral neuropathy. The study included a total of 76 patients with advanced cancer who were cared for at inpatient hospices. All patients were asked about shooting or burning pain (of the feet and hands), were examined systematically for sensory deficits and had a nerve conduction study performed. NP-RPN was found in 29% of the patients. Electrophysiologically-diagnosed peripheral neuropathy was found in 79% of patients, and the diagnostic electrophysiological criteria for neuropathy were met by one half of the patients without NP-RPN. The severity of NP-RPN was correlated with the clinically assessed severity of sensory neuropathy and the Karnofsky score, but was not correlated with the intensity of the clinical signs of motor neuropathy. The presence of NP-RPN did not reflect greater prevalence of motor and sensory abnormalities in neurological and electrophysiological examinations. The absence of NP-RPN did not rule out polyneuropathy in hospice patients.

Effect of mammography screening and sociodemographic factors on stage of female breast cancer at diagnosis in New South Wales

Objective The aims of this study were to assess the effects of screening through BreastScreen NSW on the stage of cancer at diagnosis, and differences in cancer stage at diagnosis according to sociodemographic factors. Methods Using linked BreastScreen NSW screening attendance records and NSW Cancer Registry data, the effects of screening participation and sociodemographic characteristics on stage at diagnosis were investigated using Kruskal-Wallis analysis of variance or the Mann-Whitney U-test for the 2002-13 diagnostic period. Multivariate logistic regression was used to investigate predictors of stage at diagnosis. Results The association between BreastScreen NSW participation and earlier stage at diagnosis was strongest when the last screening episode occurred within 24 months of the cancer diagnosis, with an odds ratio of localised versus non-localised cancer of 1.61 (95% confidence interval 1.51-1.72). Women aged ≥70 years, Aboriginal women, residents of major cities and women living in areas of socioeconomic disadvantage were more likely to have distant than non-distant stage at diagnosis. A trend towards more distant stage in more recent diagnostic years was evident after adjusting for screening participation. Conclusions The strongest and most consistent predictor of earlier stage at diagnosis was BreastScreen NSW participation. Continued efforts to increase screening participation are important to achieve earlier stage at diagnosis, particularly for sociodemographic groups with more advanced disease. What is known about the topic? Earlier cancer stage at diagnosis is a prerequisite for mortality reduction from screening. Past research indicated that screening participation in New South Wales (NSW) was strongly associated with early stage at diagnosis and mortality reduction. More contemporary data are needed to monitor screening performance in NSW and assess differences in cancer stage across sociodemographic subgroups. What does this paper add? Using data linkage, this paper indicates associations between screening, sociodemographic factors and stage at diagnosis for the NSW population in 2002-13. Contrary to expectations, major city residents tended to have a lower proportion of early stage breast cancer at diagnosis, which may be indicative of lower screening coverage and barriers to screening. Compared with past research, similar effects of screening and other sociodemographic factors on the stage of breast cancer at diagnosis were observed. This paper compares screening histories across sociodemographic groups, indicating statistically significant differences. What are the implications for practitioners? Increasing screening participation is particularly important for sociodemographic groups who are diagnosed at more advanced stages, including women from lower socioeconomic areas, Aboriginal and Torres Strait Islander women and residents of major cities. In particular, the results reinforce the need to further develop targeted strategies to increase screening participation among NSW women from lower socioeconomic areas and Aboriginal and Torres Strait Islander women. Further investigation into screening coverage and barriers to screening for residents in major cities is needed.

Developing clinical indicators for oncology: the inaugural cancer care indicator set for the Australian Council on Healthcare Standards

INTRODUCTION

The Australian Council on Healthcare Standards (ACHS) sponsored an expert-led, consensus-driven, four-stage process, based on a modified Delphi methodology, to determine a set of clinical indicators as quality measures of cancer service provision in Australia. This was done in response to requests from institutional health care providers seeking accreditation, which were additional and complementary to the existing radiation oncology set. The steering group members comprised multidisciplinary key opinion leaders and a consumer representative. Five additional participants constituted the stakeholder group, who deliberated on the final indicator set.

METHODS AND RECOMMENDATIONS

An initial meeting of the steering group scoped the high level nature of the desired set. In stage 2, 65 candidate indicators were identified by a literature review and a search of international metrics. These were ranked by survey, based on ease of data accessibility and collectability and clinical relevance. The top 27 candidates were debated by the stakeholder group and culled to a final set of 16 indicators. A user manual was created with indicators mapped to clinical codes. The indicator set was ratified by the Clinical Oncology Society of Australia and is now available for use by health care organisations participating in the ACHS Clinical Indicator Program. This inaugural cancer clinical indicator set covers high level assessment of various critical processes in cancer service provision in Australia. Regular reviews and updates will ensure usability.

CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT

This is the inaugural indicator set for cancer care for use across Australia and internationally under the ACHS Clinical Indicator Program. Multidisciplinary involvement through a modified Delphi process selected indicators representing both generic and specific aspects of care across the cancer journey pathway and will provide a functional tool to compare health care delivery across multiple settings. It is anticipated that this will drive continual improvement in cancer care provision.

Population-Level Uptake of Moderately Hypofractionated Definitive Radiation Therapy in the Treatment of Prostate Cancer

PURPOSE

Recent evidence shows the noninferiority of hypofractionated radiation therapy regimens compared with conventional regimens in the treatment of prostate cancer (PCa). Hypofractionation has benefits for both the patient and health care system, because of the shorter treatment duration. Despite this advantage, the uptake of hypofractionation can be slow. Here we investigate the factors influencing the changing use of moderate hypofractionation (HypoRT) for the treatment of PCa.

METHODS AND MATERIALS

We conducted a population-based, retrospective, consecutive cohort study using the 2014 to 2018 Outpatient Radiation Oncology Data from public and private treatment facilities in New South Wales, Australia. Included participants had a PCa diagnosis of any risk, and they completed curative-intent external beam radiation therapy without treatment to lymph nodes. Factors potentially affecting use of HypoRT were examined using a 3-level hierarchical logistic regression model. The effects were reported using adjusted, median, or interval odds ratios.

RESULTS

The study included 4915 patients. Of these, 4053 patients (82.5%) received conventional fractionation, and 862 patients (17.5%) received HypoRT. HypoRT utilization increased from 5.2% in 2014 to 40.3% in 2018. The treating radiation oncologist, treatment facility, and increasing distance to treatment centers had the greatest influence on HypoRT uptake. The main limitation was the lack of stratification by PCa risk categorization.

CONCLUSIONS

Although HypoRT uptake has considerably increased between 2014 and 2018, it remains variable among facilities and treating radiation oncologists. Strategies are being explored to reduce inter-clinician variability.