Does Care for Australians With Pancreatic Cancer Compare Favourably to a Consensus-Based Standard of Optimal Care?

Background: Pancreatic cancer has one of the lowest survival rates of all cancer types, with an incidence to mortality ratio approaching one. People with pancreatic cancer experience a rapid decline in health characterized by pain, nausea, fatigue and weight loss. For most people, the disease is detected at an advanced stage and the focus of treatment is palliative. In Victoria, Australia, knowledge regarding patterns of care for people with pancreatic cancer is out-of-date, but central to quality improvement initiatives targeting unwarranted variations in care and improvement in supports that are consistent with patient preferences. Aim: Our aim was to compare care received by patients with pancreatic cancer with a consensus-based standard representing optimal care to identify deviations from best practice and highlight processes that may improve the quality and safety of care provided. Methods: Eligible patients included those with pancreatic cancer, first treated in 2015, at one of three tertiary hospitals in Victoria, Australia. Once identified, dates and details of events indicated by the optimal care pathway were extracted from the medical record of each patient. Data were summarized using descriptive statistics and process maps: a visualization method that illuminates gaps, duplication, deviations from best practice and processes that may be amenable to improvement. Results: Thirty-two of 165 care pathways have been mapped to date. The nature and timing of care received appears highly variable. Only nine of 32 patients (28%) received all of their cancer care at a single institution; the remainder (n=23, 72%) received care in multiple tertiary and community facilities. Apart from four (13%) emergency presentations, referrals for specialist care came from general/primary practitioners (n=26, 81%). The timeframe for general/primary practitioner investigations ranged from one to 57 days. Once referred to a tertiary setting, most patients (n=23, 72%) were discussed at a multidisciplinary team meeting and received standard therapies. Only four had resectable disease. Nineteen patients (60%) had documented referrals to hospital- or community-based palliative care services. Where observed, deviations from the consensus-based standard tended to be related to the difficult nature of diagnosing pancreatic cancer, and determining appropriate care for patients with an advanced cancer with nonspecific symptoms. Conclusion: Process mapping provided a useful and efficient means of comparing care received with a consensus-based standard; however, the assessment of adherence to optimal timeframes and specific care events was complicated by missing data. Implications for quality improvement activities will be considered in the context of study limitations. We will also emphasize the importance of engaging patients and carers in setting improvement priorities.

Implementing practice change in chronic cancer pain management: clinician response to a phase III study of ketamine

BACKGROUND

An adequately powered, double-blind, multisite, randomised controlled trial has shown no net clinical benefit for subcutaneous ketamine over placebo in the management of cancer pain refractory to combination opioid and co-analgesic therapy. The results of the trial were disseminated widely both nationally and internationally.

AIM

To determine whether the trial had impacted on clinical practice in Australasia.

METHODS

Members of the Australia and New Zealand Society of Palliative Medicine were sent an online ketamine utilisation survey.

RESULTS

A total of 123/392 clinicians responded (31% response rate). The majority of respondents had practised for more than 10 years in a metropolitan hospital setting. Ketamine had been prescribed by 91% of respondents, and 92% were aware of the trial. As a result, 65% of respondents had changed practice (17% no longer prescribed ketamine, 46% used less and 2% more). Thirty-five per cent had not changed practice. Reasons for change included belief in the results of the study, concerns over the toxicity reported or because there were alternatives for pain control. Of those who prescribed less, over 80% were more selective and would now only use the drug in certain clinical situations or pain types, or when all other medications had failed.

CONCLUSIONS

Although two-thirds of respondents reported practice change as a result of the randomised controlled trial, a minority remained convinced of the benefit of the drug from their own observations and would require additional evidence.

Community-based palliative care for Bangladeshi patients in east London. Accounts of bereaved carers

The aim of this paper is to describe the palliative care experience of Bangladeshi patients and carers in the Tower Hamlets area in the east of London. Semi-structured interviews were carried out in Sylheti, the Bengali dialect of this community, with bereaved primary carers of 18 patients (10 male, eight female) referred to an east London community palliative care team between 1986 and 1993. It was found that patients were young, with a mean age of males of 55 years (range 34-65) and females of 40 years (range 28-57). Communication difficulties were common. The fluency in English of patients was low, with reliance on family members, especially children, for translation. The diagnosis was known by all patients, but only 56% of carers agreed with disclosure. Team dissatisfaction with communication was recorded in 16 cases. Fourteen patients died in London; however, 13 were buried in Bangladesh. Carers often reported symptoms as poorly controlled. Pain was said to be severe for 14 patients, and pain control said to be poor in 11. Family and friends provided most support during the illness and bereavement. Serious financial difficulties occurred in nine families. General practitioners were involved actively in six cases. In conclusion, there are ethno-specific needs in this particular community, many of which arise from socio-economic factors, recent migration and religious beliefs, and which are highlighted by terminal illness.

A comparison of the use of sedatives in a hospital support team and in a hospice

This study examines how frequently and for what indications sedatives are prescribed in a hospital support team and in a hospice. We also looked at the survival of sedated patients from the date of admission and from the start of sedation. Overall 26% of patients were prescribed sedatives in order to sedate them (31% at the hospice and 21% at the hospital) and 43% of patients were given sedatives for symptom control (67% at the hospice and 21% at the hospital). Sedated patients survived for a mean of 1.3 days after the start of sedation, and there was no detectable difference in survival from the date of admission between sedated and nonsedated patients.