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Kamal AH, Currow DC, Ritchie CS, Bull J, Abernethy AP. Community-based palliative care: the natural evolution for palliative care delivery in the U.S. J Pain Symptom Manage 2013; 46:254-64. [PMID: 23159685 DOI: 10.1016/j.jpainsymman.2012.07.018] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 07/21/2012] [Accepted: 07/28/2012] [Indexed: 12/25/2022]
Abstract
Palliative care in the U.S. has evolved from a system primarily reliant on community-based hospices to a combined model that includes inpatient services at most large hospitals. However, these two dominant approaches leave most patients needing palliative care-those at home (including nursing homes) but not yet ready for hospice-unable to access the positive impacts of the palliative care approach. We propose a community-based palliative care (CPC) model that spans the array of inpatient and outpatient settings in which palliative care is provided and links seamlessly to inpatient care; likewise, it would span the full trajectory of advanced illness rather than focusing on the period just before death. Examples of CPC programs are developing organically across the U.S. As our understanding of CPC expands, standardization is needed to ensure replicability, consistency, and the ability to relate intervention models to outcomes. A growing body of literature examining outpatient palliative care supports the role of CPC in improving outcomes, including reduction in symptom burden, improved quality of life, increased survival, better satisfaction with care, and reduced health care resource utilization. Furthermore the examination of how to operationalize CPC is needed before widespread implementation can be realized. This article describes the key characteristics of CPC, highlighting its role in longitudinal care across patient transitions. Distinguishing features include consistent care across the disease trajectory independent of diagnosis and prognosis; inclusion of inpatient, outpatient, long-term care, and at-home care delivery; collaboration with other medical disciplines, nursing, and allied health; and full integration into the health care system (rather than parallel delivery).
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Affiliation(s)
- Arif H Kamal
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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Schulz R. Research priorities in geriatric palliative care: informal caregiving. J Palliat Med 2013; 16:1008-12. [PMID: 23883146 DOI: 10.1089/jpm.2013.9483] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Informal care provided by family members is an essential feature of health care systems worldwide. Although caregiving often begins early in the disease process, over time informal caregivers must deal with chronic, debilitating, and life-threatening illnesses. Despite thousands of published studies on informal care, little is known about the intersection of informal caregiving and formal palliative care. OBJECTIVE The goal of this review is to identify research priorities that would enhance our understanding of the relationship between informal caregiving and palliative care. DESIGN To better understand palliative care in the context of caregiving, we provide an overview of the nature of a caregiving career from inception to care recipient placement and death and the associated tasks, challenges, and health effects at each stage of a caregiving career. This in turn leads to key unanswered questions designed to advance research in caregiving and palliative care. RESULTS Little is known about the extent to which and how palliative care uniquely affects the caregiving experience. This suggests a need for more fine-grained prospective studies that attempt to clearly delineate the experience of caregivers during palliative and end-of-life phases, characterize the transitions into and out of these phases from both informal and formal caregiver perspectives, identify caregiver needs at each phase, and identify effects on key caregiver and patient outcomes. CONCLUSIONS Inasmuch as most caregivers must deal with chronic, debilitating, and often life-threatening conditions, it is essential that we advance a research agenda that addresses the interplay between informal care and formal palliative care.
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Affiliation(s)
- Richard Schulz
- Department of Psychiatry, University of Pittsburgh , Pittsburgh, Pennsylvania
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Abernethy AP, Currow DC. Time for better integration of oncology and palliative care. J Oncol Pract 2013; 7:346-8. [PMID: 22379412 DOI: 10.1200/jop.2011.000467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2011] [Indexed: 11/20/2022] Open
Affiliation(s)
- Amy P Abernethy
- Duke University Medical Center, Durham, NC; Flinders University, Bedford Park, South Australia, Australia
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Burns CM, Abernethy AP, Dal Grande E, Currow DC. Uncovering an invisible network of direct caregivers at the end of life: a population study. Palliat Med 2013; 27:608-15. [PMID: 23587738 DOI: 10.1177/0269216313483664] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Most palliative care research about caregivers relies on reports from spouses or adult children. Some recent clinical reports have noted the assistance provided by other family members and friends. AIM This population study aims to define the people who actually provide care at the end of life. SETTING/PARTICIPANTS A South Australian study conducted an annual randomized health population survey (n=23,706) over a 7 year period. A sample was obtained of self-identifying people who had someone close to them die and 'expected' death in the last 5 years (n=7915). Data were standardised to population norms for gender, 10-year age group, socioeconomic status, and region of residence. RESULTS People of all ages indicated they provided 'hands on' care at the end of life. Extended family members (not first degree relatives) and friends accounted for more than half (n=1133/2028; 55.9%) of identified hands-on caregivers. These people came from the entire age range of the adult community. The period of time for which care was provided was shorter for this group of caregivers. People with extended family or friends providing care, were much more likely to be supported to die at home compared to having a spousal carer. CONCLUSION This substantial network of caregivers who are mainly invisible to the health team provide the majority of care. Hospice and palliative care services need to create specific ways of identifying and engaging this cohort in order to ensure they are receiving adequate support in the role. Relying on 'next-of-kin' status in research will not identify them.
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Affiliation(s)
- Catherine M Burns
- School of Humanities and Social Sciences, University of Newcastle, Newcastle upon Tyne, UK.
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Affiliation(s)
- Peter Hudson
- Centre for Palliative Care, c/o St Vincent’s Hospital, and The University of Melbourne, Victoria, Australia and School of Nursing, Queen’s University, Belfast, UK
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Glajchen M. Physical well-being of oncology caregivers: an important quality-of-life domain. Semin Oncol Nurs 2013; 28:226-35. [PMID: 23107180 DOI: 10.1016/j.soncn.2012.09.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To provide an overview of research and practice related to the physical well-being of oncology caregivers. DATA SOURCES Literature retrieved through the PubMed and CINAHL databases. CONCLUSION Caregivers play an important role in supporting people with cancer at every stage of the illness trajectory. Because caregiving is inherently stressful, caregivers should be routinely included in the assessment and treatment of patients with cancer. IMPLICATIONS FOR NURSING PRACTICE Oncology nurses are uniquely positioned to play a vital role in recognizing caregiver strain and intervening to break the cycle of unremitting physical and psychosocial burden.
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Affiliation(s)
- Myra Glajchen
- Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY 10003, USA.
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Currow DC, Agar M, Abernethy AP. Hospital Can Be the Actively Chosen Place for Death. J Clin Oncol 2013; 31:651-2. [DOI: 10.1200/jco.2012.46.2556] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- David C. Currow
- Flinders University, Bedford Park, South Australia, Australia
| | - Meera Agar
- Flinders University, Bedford Park, South Australia; Braeside Hospital, Hammond Care, Sydney, New South Wales, Australia
| | - Amy P. Abernethy
- Flinders University, Bedford Park, South Australia, Australia; Duke University Medical Center, Durham, NC
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Currow DC, Allingham S, Bird S, Yates P, Lewis J, Dawber J, Eagar K. Referral patterns and proximity to palliative care inpatient services by level of socio-economic disadvantage. A national study using spatial analysis. BMC Health Serv Res 2012; 12:424. [PMID: 23176397 PMCID: PMC3529682 DOI: 10.1186/1472-6963-12-424] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 10/22/2012] [Indexed: 12/25/2022] Open
Abstract
Background A range of health outcomes at a population level are related to differences in levels of social disadvantage. Understanding the impact of any such differences in palliative care is important. The aim of this study was to assess, by level of socio-economic disadvantage, referral patterns to specialist palliative care and proximity to inpatient services. Methods All inpatient and community palliative care services nationally were geocoded (using postcode) to one nationally standardised measure of socio-economic deprivation – Socio-Economic Index for Areas (SEIFA; 2006 census data). Referral to palliative care services and characteristics of referrals were described through data collected routinely at clinical encounters. Inpatient location was measured from each person’s home postcode, and stratified by socio-economic disadvantage. Results This study covered July – December 2009 with data from 10,064 patients. People from the highest SEIFA group (least disadvantaged) were significantly less likely to be referred to a specialist palliative care service, likely to be referred closer to death and to have more episodes of inpatient care for longer time. Physical proximity of a person’s home to inpatient care showed a gradient with increasing distance by decreasing levels of socio-economic advantage. Conclusion These data suggest that a simple relationship of low socioeconomic status and poor access to a referral-based specialty such as palliative care does not exist. Different patterns of referral and hence different patterns of care emerge.
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Affiliation(s)
- David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, 700 Goodwood Rd, Daw Park, South Australia, 5041, Australia.
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McGuire DB, Grant M, Park J. Palliative care and end of life: The caregiver. Nurs Outlook 2012; 60:351-356.e20. [DOI: 10.1016/j.outlook.2012.08.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 07/30/2012] [Accepted: 08/06/2012] [Indexed: 11/26/2022]
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Ferrell B, Hanson J, Grant M. An overview and evaluation of the oncology family caregiver project: improving quality of life and quality of care for oncology family caregivers. Psychooncology 2012; 22:1645-52. [PMID: 23065694 DOI: 10.1002/pon.3198] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 08/24/2012] [Accepted: 09/08/2012] [Indexed: 11/08/2022]
Abstract
OBJECTIVE With changes in health care, oncology family caregivers (FCs) provide the vast majority of patient care. Yet, FCs assume their role with little or no training and with limited resources within the cancer setting to support them. The purpose of this project is to develop and implement a curriculum to improve the quality of life and quality of care for FCs by strengthening cancer care settings in this area. METHODS A National Cancer Institute (NCI) R25 grant funded the development of an FC curriculum for professional healthcare providers. The curriculum, based on the City of Hope Quality-of-Life Model, is presented to professionals from cancer centers in national training courses. The project brings together the most current evidence-based knowledge and multiple resources to help improve FC support. Participants develop goals related to implementation and dissemination of the course content and resources in their home institution. Goal evaluation follows at 6, 12, and 18 months. RESULTS To date, three courses have been presented to 154 teams (322 individuals) representing 39 states. Course evaluations were positive, and participants have initiated institutional FC support goals. Although the goals are diverse, the broad categories include support groups, staff/FC/community education, resource development, assessment tools, and institutional change. CONCLUSIONS There is a critical need to improve support for cancer FCs. This FC training course for professionals is a first step in addressing this need.
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Affiliation(s)
- Betty Ferrell
- City of Hope National Medical Center, Duarte, CA 91010, USA
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Greene A, Aranda S, Tieman JJ, Fazekas B, Currow DC. Can assessing caregiver needs and activating community networks improve caregiver-defined outcomes? A single-blind, quasi-experimental pilot study: community facilitator pilot. Palliat Med 2012; 26:917-23. [PMID: 21930646 DOI: 10.1177/0269216311421834] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although the unit of care in palliative care is defined as the patient and their family, there are few rigorous studies on how to improve support for family and friends as they take on the role of caregiver for someone at the end of life. AIM Separate to patient evaluation and care, this pilot study aimed to define the feasibility and possible outcome measures to evaluate routine assessments and supports specifically for caregivers. DESIGN In a quasi-experimental design, two communities were included: one received standard specialist palliative care support and one additionally was allocated to a community network facilitator who assessed caregivers' needs and helped mobilize the caregiver's own support network or initiated contact with other community supports in three planned visits. Data were collected at baseline, 4 and 8 weeks using three caregiver assessment tools. Within group comparisons were made using Wilcoxon signed rank test and between group using the Mann-Whitney U-test. PARTICIPANTS Sixty-six caregivers participated. RESULTS At 8 weeks, participants in the intervention arm showed significant within-group improvement in caregiver fatigue, sufficient support from others, decreased resentment in the role, greater confidence in asking for assistance and were better able to find resources and support. No between-group changes were seen in this pilot study. CONCLUSIONS There were objective measures of improved support within the intervention group over time for caregivers through the active engagement of the community network facilitator. This pilot supports the case for an adequately powered study.
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Affiliation(s)
- Aine Greene
- Discipline, Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia
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Precious E, Haran S, Lowe D, Rogers S. Head and neck cancer patients’ perspective of carer burden. Br J Oral Maxillofac Surg 2012; 50:202-7. [DOI: 10.1016/j.bjoms.2011.04.072] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 04/21/2011] [Indexed: 11/16/2022]
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Abstract
Collecting reliable and valid data is an increasing expectation within palliative care. Data remain the crux for demonstrating value and quality of care, which are the critical steps to program sustainability. Parallel goals of conducting research and performing quality assessment and improvement can also ensure program growth, financial health, and viability in an increasingly competitive environment. Mounting expectations by patients, hospitals, and payers and inevitable pay-for-performance paradigms have transitioned data collection procedures from novel projects to expected standard operation within usual palliative care delivery. We present types of data to collect, published guides for data collection, and how data can inform quality, value, and research within a palliative care organization. Our experiences with the Quality Data Collection Tool (QDACT) in the Carolinas Palliative Care Consortium to collect data on quality have led to valuable lessons learned in creating a data collection system. Suggested steps in forming data-sharing collaborations and building data collection procedures are shared.
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64
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Currow DC, Farquhar M, Ward AM, Crawford GB, Abernethy AP. Caregivers' perceived adequacy of support in end-stage lung disease: results of a population survey. BMC Pulm Med 2011; 11:55. [PMID: 22117836 PMCID: PMC3262756 DOI: 10.1186/1471-2466-11-55] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 11/25/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND End-stage lung disease (ESLD) is a frequent cause of death. What are the differences in the supports needed by caregivers of individuals with ESLD at end of life versus other life-limiting diagnoses? METHODS The South Australian Health Omnibus is an annual, random, face-to-face, cross-sectional survey. In 2002, 2003 and 2005-2007, respondents were asked a range of questions about end-of-life care; there were approximately 3000 survey participants annually (participation rate 77.9%). Responses were standardised for the whole population. The families and friends who cared for someone with ESLD were the focus of this analysis. In addition to describing caring, respondents reported additional support that would have been helpful. RESULTS Of 1504 deaths reported, 145 (9.6%) were due to ESLD. The ESLD cohort were older than those with other 'expected' causes of death (> 65 years of age; 92.6% versus 70.6%; p < 0.0001) and were less likely to access specialised palliative care services (38.4% versus 61.9%; p < 0.0001). For those with ESLD, the mean caring period was significantly longer at 25 months (standard deviation (SD) 24) than for 'other diagnoses' (15 months; SD 18; p < 0.0001). Domains where additional support would have been useful included physical care, information provision, and emotional and spiritual support. CONCLUSIONS Caregiver needs were similar regardless of the underlying diagnosis although access to palliative care specialist services occurred less often for ESLD patients. This was despite significantly longer periods of time for which care was provided.
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Affiliation(s)
- David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia
| | - Morag Farquhar
- General Practice & Primary Care Research Unit, Department of Public Health & Primary Care, University of Cambridge, UK
| | - Alicia M Ward
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia
- Southern Adelaide Palliative Services, Repatriation General Hospital, Daw Park, South Australia, Australia
| | - Gregory B Crawford
- Discipline of Medicine, University of Adelaide, Adelaide. South Australia, Australia
| | - Amy P Abernethy
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia
- Division of Medical Oncology, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
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Kamal AH, Bull J, Kavalieratos D, Taylor DH, Downey W, Abernethy AP. Palliative care needs of patients with cancer living in the community. J Oncol Pract 2011; 7:382-8. [PMID: 22379422 PMCID: PMC3219466 DOI: 10.1200/jop.2011.000455] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2011] [Indexed: 12/25/2022] Open
Abstract
PURPOSE With improved effectiveness of early detection and treatment, many patients with cancer are now living with advanced disease and associated symptoms. As cancer becomes a chronic illness, adequate attention to patients' symptoms and psychosocial needs in the community setting requires positioning of palliative care alongside cancer care. This article describes the current palliative care needs of a population of community-dwelling patients with advanced cancer who are not yet ready for transition to hospice. METHODS This secondary analysis used quality-monitoring data collected in three community-based palliative care organizations. Analyses focused on people with cancer-related diagnoses who were receiving palliative care during 2008 to 2011. RESULTS The analytic data set included 4,980 people, 10% of whom had cancer. Median age was 71 years. Forty-eight percent had been hospitalized at least once in the 6 months before palliative care referral. Forty-nine percent had a Palliative Performance Score (PPS) of 40% to 60%; 40% had PPS ≤ 30%. Although 81% had an estimated prognosis of ≤ 6 months, 58% were expected to live weeks to months. Thirty-three percent had no identified healthcare surrogate; 59% had no do-not-resuscitate order despite declining functional status and limited prognosis. Ninety-five percent reported ≥ 1 symptom, and 67% reported ≥ 3 symptoms; a substantial proportion did not receive treatment for symptoms. CONCLUSIONS Patients referred to community-based palliative care experience multiple often-severe symptoms that have been insufficiently addressed. They tend to have declining performance status. Earlier palliative care intervention could improve outcomes but will require delivery models that better coordinate inpatient/outpatient oncology and community-based palliative care.
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Affiliation(s)
- Arif H. Kamal
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janet Bull
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Dio Kavalieratos
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Donald H. Taylor
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William Downey
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Amy P. Abernethy
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Currow DC. The PRISMA Symposium 3: lessons from beyond Europe. why invest in research and service development in palliative care? An Australian perspective. J Pain Symptom Manage 2011; 42:505-10. [PMID: 21963119 DOI: 10.1016/j.jpainsymman.2011.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 06/23/2011] [Indexed: 11/23/2022]
Abstract
Hospice and palliative care services need to be able to compete with finite health care resources. To compete for such funding, the sector needs to continuously improve the evidence base that demonstrates improved outcomes, or else funding will continue to be at the level of a "social good" rather than as services that deliver improved health outcomes. Three questions need to be answered for policy makers and health funders: 1) Why invest health care spending in hospice and palliative care?, 2) Why invest research monies in hospice and palliative care clinical research and health service development?, and 3) How can emerging evidence be more effectively implemented to improve patient outcomes? No single measure captures the net benefit of hospice and palliative care services. By patient-defined parameters, hospice and palliative care services have demonstrated benefits, including physical symptom control. To meet patients' concerns, greater emphasis needs to be placed on maintaining physical independence for a longer period of time. Targeted investment of research funding can deliver further improvements in patient outcomes and models of service delivery. Rigorous studies are feasible and necessary if each patient is going to receive the best possible support. Benchmarking and service development strategies can deliver improved patient outcomes. With routine point-of-care data collection and feedback loops to individual services, patient-valued outcomes and resourcing can be improved in hospice and palliative care. Public-good investments in hospice and palliative care research are vital to building the evidence base for improving the quality of care offered.
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Affiliation(s)
- David C Currow
- Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia.
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Abstract
Accompanying the ascendance of cancer as a leading cause of death worldwide is a new set of global health priorities focused on palliative care--the relief of symptoms and suffering, optimization of functional status, and quality of life for those with advanced, potentially life-limiting illnesses. In high-income countries, palliative care improves outcomes for patients, caregivers, provider organizations, and health systems. Data are not yet available to demonstrate similar benefits in low- and middle-income countries, where access to even the most basic palliative interventions (eg, opioids for pain management) is inadequate and unevenly distributed. This article describes current global disparities in the availability of palliative care. We make the case for international prioritization of palliative care as a critical strategy for improving outcomes for people with cancer and their caregivers worldwide.
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Affiliation(s)
- David C Currow
- Flinders University Discipline, Palliative and Supportive Services, Bedford Park, South Australia, Australia.
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Currow DC, Abernethy AP, Bausewein C, Johnson M, Harding R, Higginson I. Measuring the net benefits of hospice and palliative care: a composite measure for multiple audiences-palliative net benefit. J Palliat Med 2011; 14:264-5. [PMID: 21361829 DOI: 10.1089/jpm.2011.9722] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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69
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To THM, Greene AG, Agar MR, Currow DC. A point prevalence survey of hospital inpatients to define the proportion with palliation as the primary goal of care and the need for specialist palliative care. Intern Med J 2011; 41:430-3. [DOI: 10.1111/j.1445-5994.2011.02484.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Miller CL, Quester PG, Hill DJ, Hiller JE. Smokers' recall of Australian graphic cigarette packet warnings & awareness of associated health effects, 2005-2008. BMC Public Health 2011; 11:238. [PMID: 21496314 PMCID: PMC3096906 DOI: 10.1186/1471-2458-11-238] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 04/17/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2006, Australia introduced graphic cigarette packet warnings. The new warnings include one of 14 pictures, many depicting tobacco-related pathology. The warnings were introduced in two sets; Set A in March and Set B from November. This study explores their impact on smokers' beliefs about smoking related illnesses. This study also examines the varying impact of different warnings, to see whether warnings with visceral images have greater impact on smokers' beliefs than other images. METHODS Representative samples of South Australian smokers were interviewed in four independent cross-sectional omnibus surveys; in 2005 (n=504), 2006 (n=525), 2007 (n=414) and 2008 (n=464). RESULTS Unprompted recall of new graphic cigarette warnings was high in the months following their introduction, demonstrating that smokers' had been exposed to them. Smokers also demonstrated an increase in awareness about smoking-related diseases specific to the warning messages. Warnings that conveyed new information and had emotive images demonstrated greater impact on recall and smokers' beliefs than more familiar information and less emotive images. CONCLUSIONS Overall graphic pack warnings have had the intended impact on smokers. Some have greater impact than others. The implications for policy makers in countries introducing similar warnings are that fresh messaging and visceral images have the greatest impact.
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Affiliation(s)
- Caroline L Miller
- Cancer Council SA, 202 Greenhill Rd, Eastwood, South Australia, Australia
- Discipline of Public Health, School of Population Health and Clinical Practice, University of Adelaide, South Australia, Australia
| | | | - David J Hill
- The Cancer Council Victoria, 1 Rathdowne St, Carlton, Victoria, Australia
| | - Janet E Hiller
- Discipline of Public Health, School of Population Health and Clinical Practice, University of Adelaide, South Australia, Australia
- Australian Catholic University, Melbourne, Australia
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Currow DC, Burns C, Agar M, Phillips J, McCaffrey N, Abernethy AP. Palliative caregivers who would not take on the caring role again. J Pain Symptom Manage 2011; 41:661-72. [PMID: 21227632 DOI: 10.1016/j.jpainsymman.2010.06.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 06/25/2010] [Accepted: 07/08/2010] [Indexed: 10/18/2022]
Abstract
CONTEXT Health and social services rely heavily on family and friends for caregiving at the end of life. OBJECTIVES This study sought to determine the prevalence and factors associated with an unwillingness to take on the caregiving role again by interviewing former caregivers of palliative care patients. METHODS The setting for this study was South Australia, with a population of 1.6 million people (7% of the Australian population) and used the South Australian Health Omnibus, an annual, face-to-face, cross-sectional, whole-of-population, multistage, systematic area sampling survey, which seeks a minimum of 3000 respondents each year statewide. One interview was conducted per household with the person over the age of 15 who most recently had a birthday. Using two years of data (n=8377; 65.4% participation rate), comparisons between those who definitely would care again and those who would not was undertaken. RESULTS One in 10 people across the community provided hands-on care for someone close to them dying an expected death in the five years before being interviewed. One in 13 (7.4%) former caregivers indicated that they would not provide such care again irrespective of time since the person's death and despite no reported differences identified in unmet needs between those who would and would not care again. A further one in six (16.5%) would only "probably care again." The regression model identified that increasing age lessens the willingness to care again (odds ratio [OR] 3.94; 95% confidence interval [CI] 1.56, 9.95) and so does lower levels of education (OR 0.413; 95% CI 0.18, 0.96) controlling for spousal relationship. CONCLUSION These data suggest that assessment of willingness to care needs to be considered by clinical teams, especially in the elderly. Despite most active caregivers being willing to provide care again, a proportion would not.
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Affiliation(s)
- David C Currow
- Discipline of Palliative and Supportive Services, School of Medicine, Flinders University, Bedford Park, South Australia, Australia.
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Burns CM, LeBlanc TW, Abernethy A, Currow D. Young caregivers in the end-of-life setting: a population-based profile of an emerging group. J Palliat Med 2011; 13:1225-35. [PMID: 20858060 DOI: 10.1089/jpm.2010.0004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Little is known about young caregivers of people with advanced life-limiting illness. Better understanding of the needs and characteristics of these young caregivers can inform development of palliative care and other support services. METHODS A population-based analysis of caregivers was performed from piloted questions included in the 2001-2007 face-to-face annual health surveys of 23,706 South Australians on the death of a loved one, caregiving provided, and characteristics of the deceased individual and caregiver. The survey was representative of the population by age, gender, and region of residence. FINDINGS Most active care was provided by older, close family members, but large numbers of young people (ages 15-29) also provided assistance to individuals with advanced life-limiting illness. They comprised 14.4% of those undertaking "hands-on" care on a daily or intermittent basis, whom we grouped together as active caregivers. Almost as many young males as females participate in active caregiving (men represent 46%); most provide care while being employed, including 38% who work full-time. Over half of those engaged in hands-on care indicated the experience to be worse or much worse than expected, with young people more frequently reporting dissatisfaction thereof. Young caregivers also exhibited an increased perception of the need for assistance with grief. CONCLUSION Young people can be integral to end-of-life care, and represent a significant cohort of active caregivers with unique needs and experiences. They may have a more negative experience as caregivers, and increased needs for grief counseling services compared to other age cohorts of caregivers.
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Affiliation(s)
- Catherine Mary Burns
- Palliative & Supportive Service, School of Medicine, Flinders University, Adelaide, South Australia, Australia.
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Burns CM, Abernethy AP, Leblanc TW, Currow DC. What is the role of friends when contributing care at the end of life? Findings from an Australian population study. Psychooncology 2011; 20:203-12. [DOI: 10.1002/pon.1725] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Stajduhar K, Funk L, Toye C, Grande G, Aoun S, Todd C. Part 1: Home-based family caregiving at the end of life: a comprehensive review of published quantitative research (1998-2008). Palliat Med 2010; 24:573-93. [PMID: 20562171 DOI: 10.1177/0269216310371412] [Citation(s) in RCA: 205] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The changing context of palliative care over the last decade highlights the importance of recent research on home-based family caregiving at the end of life. This article reports on a comprehensive review of quantitative research (1998-2008) in this area, utilizing a systematic approach targeting studies on family caregivers, home settings, and an identified palliative phase of care (n = 129). Methodological challenges were identified, including: small, non-random, convenience samples; reliance on descriptive and bivariate analyses; and a dearth of longitudinal research. Robust evidence regarding causal relationships between predictor variables and carer outcomes is lacking. Findings suggest the need for knowledge regarding: family caregiving for patients with non-malignant terminal conditions; whether needs and outcomes differ between family caregivers at the end of life and comparison groups; and caregiver outcomes in bereavement. Clear definitions of 'family caregiving', 'end of life', and 'needs' are required as well as greater application and testing of theoretical and conceptual explanations.
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Affiliation(s)
- Ki Stajduhar
- School of Nursing, University of Victoria, British Columbia, Canada, Centre on Aging, University of Victoria, British Columbia, Canada.
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Currow DC. Even in death …. J Palliat Med 2009; 12:983-4. [DOI: 10.1089/jpm.2009.9944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Currow DC, Plummer JL, Crockett A, Abernethy AP. A community population survey of prevalence and severity of dyspnea in adults. J Pain Symptom Manage 2009; 38:533-45. [PMID: 19822276 DOI: 10.1016/j.jpainsymman.2009.01.006] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Revised: 01/20/2009] [Accepted: 02/19/2009] [Indexed: 11/28/2022]
Abstract
Given the progress in the symptomatic treatment of breathlessness, and the physical and psychological morbidity associated with chronic breathlessness, estimates of the size of the population that may benefit from better support become imperative. Prevalence estimates have varied widely (0.9% of clinical encounters to 32%) and have largely relied only on respondents who used clinical services. Whole-of-population approaches may be able to define better the "true" prevalence of chronic breathlessness and quantify exertion limited by breathlessness. The aim of this study was to estimate population levels of chronic breathlessness, severity of limits to exercise, and demographic predictors of the presence of breathlessness. A whole-of-population face-to-face survey method (n=8,396) in South Australia was used, directly standardized for age, gender, country of birth, and rurality. Respondents were asked about breathlessness and levels of exertion causing breathlessness for at least three of the last six months using a modified Medical Research Council dyspnea scale. Univariate and multivariate analyses identify the demographic characteristics of people more likely to experience chronic breathlessness. With a participation rate of 65.3%, 8.9% of respondents had breathlessness that chronically limited exertion. Significant associations with chronic breathlessness in multivariate analysis included female sex (P<0.001), not working full time (P<0.001), low income (P=0.007), and older age (P=0.031). There are significant levels of chronic breathlessness in the community. Given the prevalence, it is feasible to explore the onset of breathlessness, the underlying etiologies and subsequent health service utilization, and health consequences.
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Affiliation(s)
- David C Currow
- Department of Palliative and Supportive Services, Flinders University, Adelaide, Australia.
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Currow DC, Ward A, Clark K, Burns CM, Abernethy AP. Caregivers for people with end-stage lung disease: characteristics and unmet needs in the whole population. Int J Chron Obstruct Pulmon Dis 2009; 3:753-62. [PMID: 19281090 PMCID: PMC2650595 DOI: 10.2147/copd.s3890] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction End-stage lung disease (ESLD) (predominantly caused by chronic obstructive pulmonary disease and restrictive lung disease) is a significant cause of death. Little is known about community care for people with ESLD especially in the period leading to death. This paper describes demographic characteristics of caregivers, and key characteristics of the deceased irrespective of specialist service utilization. Methods The South Australian Health Omnibus is an annual, random, face-to-face, cross-sectional survey conducted statewide. For the last eight years questions about end of life have been asked of 3000 respondents annually (participation rate 77.9%). Directly standardized to the whole population, this study describes people who cared for someone with ESLD until death. Results One third (6370/18267) had someone die in the last five years from a terminal illness, 644 from ESLD (3.5% of respondents; 10.2% of deaths). One in five (20.8%) provided physical care: 43 respondents provided day-to-day and 63 provided intermittent hands-on care for an average of 40.1 months (SD 56.9). Caregivers were on average 51.2 years old (range 17–85; SD 16.5) and one in five was a spouse. Additional support to provide physical care was an unmet need by 17% of caregivers. The deceased were an average of 73.9 years old (range 47–92; SD 10.4). Only 31.1% were assessed as ‘comfortable’ or ‘very comfortable’ in the last fortnight of life. Discussion Given the health consequences of caregiving, caregivers of people with ESLD would benefit from prospectively defining their needs given the time for which intense caregiving is provided.
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Affiliation(s)
- David C Currow
- Department of Palliative and Supportive Services, Flinders University,Adelaide, Australia.
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Abernethy A, Burns C, Wheeler J, Currow D. Defining distinct caregiver subpopulations by intensity of end-of-life care provided. Palliat Med 2009; 23:66-79. [PMID: 18996981 DOI: 10.1177/0269216308098793] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Interventions designed to assist informal caregivers who serve individuals at or near the end of life have predominantly focused on caregiving spouses. Can we define other caregiver subpopulations--by intensity of care provided--so as to enable better a) identification of caregiver needs and b) targeting of support to caregivers? The Health Omnibus Survey, an annual face-to-face survey in South Australia, collects health-related data from a representative sample of 4400 households. Piloted questions included in the 2001-2005 Health Omnibus surveys addressed death of a loved one, caregiving provided, impact of caregiving and caregiver characteristics. Of 18,224 respondents, 5302 reported a loved one's death due to terminal illness in the previous 5 years. In all, 502 (10%) provided daily care [5-7 days/week], 619 (12%) provided intermittent care [2-4 days/week] and 425 (8%) provided rare care. Active (daily plus intermittent) caregivers, compared with non-active (rare) caregivers, were more often women (63% vs 50%; P < 0.0001). Daily caregivers were distinguishable from intermittent; daily caregivers were more often widowed (95% vs 7%; P < 0.0001) and >or=60 years (80% vs 64%; P < 0.0001); intermittent caregivers were more commonly children/parents (35%), other relatives (33%), or friends (26%; P < 0.0001) and were better educated, more active in paid work and wealthier. Financial burden, experience at time of death, ability to move on after the death and need for grief support also differed by intensity of caregiving. Caregiver subpopulations can be defined according to intensity of caregiving with distinct demographic features helping to distinguish them.
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Affiliation(s)
- A Abernethy
- Department of Medicine, Division of Medical Oncology, Duke University Medical Centre, Durham, North Carolina 27710, USA.
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Currow DC, Allen K, Plummer J, Aoun S, Hegarty M, Abernethy AP. Bereavement help-seeking following an 'expected' death: a cross-sectional randomised face-to-face population survey. BMC Palliat Care 2008; 7:19. [PMID: 19077297 PMCID: PMC2637838 DOI: 10.1186/1472-684x-7-19] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Accepted: 12/14/2008] [Indexed: 11/10/2022] Open
Abstract
Background This study examines the prevalence and nature of bereavement help-seeking among the population who experienced an "expected" death in the five years before their survey response. Such whole population data are not limited by identification through previous access to specific services nor practitioners. Methods In a randomised, cross-sectional, state-wide population-based survey, 6034 people over two years completed face-to-face interviews in South Australia by trained interviewers using piloted questions (74.2% participation rate). Respondent demographics, type of grief help sought, and circumstantial characteristics were collected. Uni- and multi-variate logistic regression models were created. Results One in three people (1965/6034) had experienced an 'expected' death of someone close to them in the last five years. Thirteen per cent sought help for their grief from one or more: friend/family members (10.7%); grief counselors (2.2%); spiritual advisers (1.9%); nurses/doctors (1.5%). Twenty five respondents (1.3%) had not sought, but would have valued help with their grief. In multi-variate regression modeling, those who sought professional help (3.4% of the bereaved) had provided more intense care (OR 5.39; CI 1.94 to14.98; p < 0.001), identified that they were less able to 'move on' with their lives (OR 7.08; CI 2.49 to 20.13; p = 0.001) and were more likely not to be in full- or part-time work (OR 3.75; CI 2.31 – 11.82; p = 0.024; Nagelkerke's R2 = 0.33). Conclusion These data provide a whole-of-population baseline of bereavement help-seeking. The uniquely identified group who wished they had sought help is one where potentially significant health gains could be made as we seek to understand better any improved health outcomes as a result of involving bereavement services.
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Affiliation(s)
- David C Currow
- Department of Palliative and Supportive Services, Flinders University, Sturt Road, Bedford Park, South Australia, 5042, Australia.
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Waller A, Girgis A, Currow D, Lecathelinais C. Development of the palliative care needs assessment tool (PC-NAT) for use by multi-disciplinary health professionals. Palliat Med 2008; 22:956-64. [PMID: 18952754 DOI: 10.1177/0269216308098797] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Needs assessment strategies can facilitate prioritisation of resources. To develop a needs assessment tool for use with advanced cancer patients and caregivers, to prompt early intervation. A convenience sample of 103 health professionals viewed three videotaped consultations involving a simulated patient, his/her caregiver and a health professional, completed the Palliative Care Needs Assessment Tool (PC-NAT) and provided feedback on clarity, content and acceptability of the PC-NAT. Face and content validity, acceptability and feasibility of the PC-NAT were confirmed. Kappa scores indicated adequate inter-rater reliability for the majority of domains; the patient spirituality domain and the caregiver physical and family and relationship domains had low reliability. The PC-NAT can be used by health professionals with a range of clinical expertise to identify individuals' needs, thereby enabling early intervention. Further psychometric testing and an evaluation to assess the impact of the systematic use of the PC-NAT on quality of life, unmet needs and service utilisation of patients and caregivers are underway.
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Affiliation(s)
- A Waller
- Centre for Health Research & Psycho-oncology, School of Medicine & Public Health, The Cancer Council NSW, University of Newcastle & Hunter Medical Research Institute, Newcastle, NSW, Australia.
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Currow DC, Eagar K, Aoun S, Fildes D, Yates P, Kristjanson LJ. Is it feasible and desirable to collect voluntarily quality and outcome data nationally in palliative oncology care? J Clin Oncol 2008; 26:3853-9. [PMID: 18688052 DOI: 10.1200/jco.2008.16.5761] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Hospice/palliative care is a critical component of cancer care. In Australia, more than 85% of people referred to specialized hospice/palliative care services (SHPCS) have a primary diagnosis of cancer, and 60% of people who die from cancer will be referred to SHPCS. The Palliative Care Outcomes Collaboration (PCOC) is an Australian initiative that allows SHPCS to collect nationally agreed-upon measures to better understand quality, safety, and outcomes of care. This article describes data (October 2006 through September 2007) from the first 22 SHPCS, with more than 100 inpatient admissions annually. Data include phase of illness, place of discharge, and, at each transition in place of care, the person's functional status, dependency, and symptom scores. Data are available for 5,395 people for 6,379 admissions. After categorizing by phase of illness and dependency, there remain at the end of each admission 12-fold differences (mean, 26%; range, 4% to 52%) in the percentage of patients who became stable after an unstable phase; seven-fold differences (mean, 22%; range, 6% to 41%) in the percentage of patients with improved symptom scores, five-fold differences (mean, 25%; range, 12% to 64%) in discharge back to the community, four-fold differences (mean, 10%; range, 4% to 16%) in improved function, and three-fold differences in the length of stay (mean, 14 days; range, 6 to 19 days). PCOC shows it is feasible to collect quality national palliative care outcome data voluntarily. Variations in outcomes justify continued enrollment of services. Benchmarking should include all patients whose cancer will cause death and explore observed variations.
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Affiliation(s)
- David C Currow
- Department of Palliative and Supportive Services, Flinders University, Adelaide, Australia.
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Currow DC, Agar M, Sanderson C, Abernethy AP. Populations who die without specialist palliative care: does lower uptake equate with unmet need? Palliat Med 2008; 22:43-50. [PMID: 18216076 DOI: 10.1177/0269216307085182] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In palliative care, the target population (all people with life-limiting illnesses and their family/caregivers) and the complexity of their needs from diagnosis to bereavement should define the subpopulation who access specialist palliative care services (SPCS). Have caregivers of patients who have not accessed SPCS had their needs met? METHODS As part of a broader state-wide randomized face-to-face population health survey over six years (18,224 interviews, 71% response), questions were asked of people bereaved in the previous five years when someone close to them died an ;expected' death (39% of respondents). Questions included respondent demographics, the diagnosis of the deceased and, for one year, whether SPCS was of benefit (if used) or needed (if not used). Differential uptake rates were calculated for diagnosis, income, country of birth and age and 2 x 2 tables reflecting the accuracy of match of service with caregiver needs were generated for each group (accuracy = true positives + true negatives/total) *100. RESULTS Uptake of SPCS was significantly lower in people with a non-cancer diagnosis (40% versus 62%; P = 0.0001), lower income (56% versus 61%; P = 0.0006) and people born where English was not the first language (52% versus 58%; P = 0.0096). The only subgroup where the accuracy of matching between palliative care service uptake and identified needs was lower than the overall average (83%) was where cancer was not the life-limiting illness (69%; cancer 86%). DISCUSSION SPCS under utilization has previously been described in the population subgroups explored in this study and assumed to equal unmet needs and poorer outcomes. Caregiver responses suggest that, except for people with a non-cancer diagnosis, lack of service uptake may not represent unmet needs. These results are limited to people with caregivers.
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Affiliation(s)
- David C Currow
- Department of Palliative and Supportive Services, Flinders University, Bedford Park, South Australia, Australia.
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