Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers

District nurses experiences in providing terminal care in rural and more urban districts. A qualitative study from the Faroe Islands

OBJECTIVE

To explore district nurses' experiences in providing terminal care to patients and their families until death in a private home setting.

DESIGN, SETTING AND SUBJECTS

Qualitative study. Data derived from focus group discussions with primary nurses in The Faroe Islands.

RESULTS

Four themes were identified: 'Challenges in providing terminal care', 'The importance of supporting families', 'Collaborative challenges in terminal care' and 'Differences between rural districts and urban districts'. The nurses felt that terminal care could be exhausting, but they also felt the task rewarding. Involving the family was experienced as a prerequisite for making home death possible. Good collaboration with the local GPs was crucial, and support from a palliative care team was experienced as helpful. They pointed out that changes of GP and the limited services from the palliative care team were challenging. Structural and economic conditions differed between urban and rural districts, which meant that the rural districts needed to make private arrangements regarding care during night hours, while the urban districts had care services around the clock.

CONCLUSION

Our findings underline the complexity of terminal care. The nurses felt exhausted yet rewarded from being able to fulfil a patient's wish to die at home. Experience and intuition guided their practice. They emphasised that good collaboration with the GPs, the palliative care team and the families was important. Establishing an outgoing function for the palliative care team to support the nurses and the families would increase the scope for home deaths. Working conditions differed between rural and urban districts.

Supportive Services at End of Life can Help Reduce Acute Care Services: Observations From the Medicare Care Choices Model

OBJECTIVES

This study identifies the mechanisms through which supportive and palliative care services at the end-of-life helped prevent unnecessary use of acute care services.

BACKGROUND

From 2016 to 2021, the Medicare Care Choices Model (MCCM) tested whether offering Medicare beneficiaries the option to receive supportive and palliative care services through hospice providers, concurrently with treatments for their terminal conditions, improved patients' quality of life and care and reduced Medicare expenditures. Previous MCCM evaluation results showed that the model achieved its goals, but did not examine in depth the causal mechanisms leading to these results.

METHODS

Mixed-methods evaluation based on descriptive analysis of MCCM encounter data and qualitative analysis of interviews with staff from high-performing MCCM hospices.

RESULTS

MCCM hospices provided 217 156 encounters to 7263 enrollees over 6 years. Enrollees received on average 30 encounters with hospice staff while enrolled in the model, representing about 10 encounters per month enrolled. Most encounters were delivered by clinically trained staff in the patient's home. Hospice staff identified five services critical for keeping patients from seeking acute care services: early and frequent needs assessments, direct observation of patients in their homes, immediate responses to patients' medical complaints, round-the-clock telephone access to nursing staff, and communication and coordination of care with primary care physicians and specialists.

CONCLUSIONS

Palliative care approaches that are high-touch, employ clinically trained staff who visit patients in their homes, routinely evaluate how to manage patient symptoms, and are available when needs arise can improve outcomes and decrease costs at the end of life.

Quality of life for patients with advanced gastrointestinal cancer randomised to early specialised home-based palliative care: the ALLAN trial

BACKGROUND

The primary aim of specialised palliative care (SPC) is to improve the quality of life (QoL) for patients with a high symptom burden from a life-threatening disease. This randomised study aimed to assess the QoL impact of early integration of SPC alongside tumour-specific palliative treatment in patients with gastrointestinal (GI) cancers.

METHODS

We randomly assigned ambulatory patients with advanced GI cancer to early integration of SPC and palliative tumour-specific treatment or tumour-specific treatment alone. The primary endpoint was QoL assessed at baseline and every sixth week using the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire.

RESULTS

A total of 118 patients were randomised. The difference in total FACT-G score between patients assigned to early integration with SPC and controls was 5.2 points (95% CI: -0.1 to 10.5, p = 0.216), 6.7 points (95% CI: 0.2 to 13.3, p = 0.172), and 13 points (95% CI: 5.7 to 20.2, p = 0.004) at weeks 6, 12, and 24, respectively.

CONCLUSIONS

This prospective randomised trial strengthens the argument for early integration of SPC with tumour-specific treatment in patients with advanced GI cancers. We found an improved QoL for patients with advanced GI cancer 24 weeks after randomisation to early integration of home-based SPC.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (ref: NCT02246725).

Updating a conceptual model of effective symptom management in palliative care to include patient and carer perspective: a qualitative study

BACKGROUND

A conceptual model of effective symptom management was previously developed from interviews with multidisciplinary healthcare professionals (HCP) working in English hospices. Here we aimed to answer the question; does a HCP data-derived model represent the experience of patients and carers of people with advanced cancer?

METHODS

Semi-structured interviews were undertaken with six patients with advanced cancer and six carers to gain an in-depth understanding of their experience of symptom management. Analysis was based on the framework method; transcription, familiarisation, coding, applying analytical framework (conceptual model), charting, interpretation. Inductive framework analysis was used to align data with themes in the existing model. A deductive approach was also used to identify new themes.

RESULTS

The experience of patients and carers aligned with key steps of engagement, decision making, partnership and delivery in the HCP-based model. The data aligned with 18 of 23 themes. These were; Role definition and boundaries, Multidisciplinary team decision making, Availability of services/staff, Clinician-Patient relationship/rapport, Patient preferences, Patient characteristics, Quality of life versus treatment need, Staff time/burden, Psychological support -informal, Appropriate understanding, expectations, acceptance and goals- patients, Appropriate understanding, expectations, acceptance and goals-HCPs, Appropriate understanding, expectations, acceptance and goals- family friends, carers, Professional, service and referral factors, Continuity of care, Multidisciplinary team working, Palliative care philosophy and culture, Physical environment and facilities, Referral process and delays. Four additional patient and carer-derived themes were identified: Carer Burden, Communication, Medicines management and COVID-19. Constructs that did not align were Experience (of staff), Training (of staff), Guidelines and evidence, Psychological support (for staff) and Formal psychological support (for patients).

CONCLUSIONS

A healthcare professional-based conceptual model of effective symptom management aligned well with the experience of patients with advanced cancer and their carers. Additional domains were identified. We make four recommendations for change arising from this research. Routine appraisal and acknowledgement of carer burden, medicine management tasks and previous experience in healthcare roles; improved access to communication skills training for staff and review of patient communication needs. Further research should explore the symptom management experience of those living alone and how these people can be better supported.

A palliative care approach for adult non-cancer patients with life-limiting illnesses is cost-saving or cost-neutral: a systematic review of RCTs

BACKGROUND

Patients living with life-limiting illnesses other than cancer constitute the majority of patients in need of palliative care globally, yet most previous systematic reviews of the cost impact of palliative care have not exclusively focused on this population. Reviews that tangentially looked at non-cancer patients found inconclusive evidence. Randomised controlled trials (RCTs) are the gold standard for treatment efficacy, while total health care costs offer a comprehensive measure of resource use. In the sole review of RCTs for non-cancer patients, palliative care reduced hospitalisations and emergency department visits but its effect on total health care costs was not assessed. The aim of this study is to review RCTs to determine the difference in costs between a palliative care approach and usual care in adult non-cancer patients with a life-limiting illness.

METHODS

A systematic review using a narrative synthesis approach. The protocol was registered with PROSPERO prospectively (no. CRD42020191082). Eight databases were searched: Medline, CINAHL, EconLit, EMBASE, TRIP database, NHS Evidence, Cochrane Library, and Web of Science from inception to January 2023. Inclusion criteria were: English or German; randomised controlled trials (RCTs); adult non-cancer patients (> 18 years); palliative care provision; a comparator group of standard or usual care. Quality of studies was assessed using Drummond's checklist for assessing economic evaluations.

RESULTS

Seven RCTs were included and examined the following diseases: neurological (3), heart failure (2), AIDS (1) and mixed (1). The majority (6/7) were home-based interventions. All studies were either cost-saving (3/7) or cost-neutral (4/7); and four had improved outcomes for patients or carers and three no change in outcomes.

CONCLUSIONS

In a non-cancer population, this is the first systematic review of RCTs that has demonstrated a palliative care approach is cost-saving or at least cost-neutral. Cost savings are achieved without worsening outcomes for patients and carers. These findings lend support to calls to increase palliative care provision globally.

Palliative care for patients with heart failure and family caregivers in rural Appalachia: a randomized controlled trial

BACKGROUND

Heart failure (HF) is a debilitating disease with worsening symptoms and family caregiving burden. HF affects more than 8 million Americans. West Virginia has the highest HF death rate in the U.S. and limited healthcare services. This study tested whether the family HF palliative and end-of-life care intervention (FamPALcare) improved patient and caregiver outcomes at 3- and 6-month study endpoints.

METHODS

This study used a randomized controlled trial design. Patients with HF and their caregivers were randomly assigned together to the intervention (n = 21) or control (n = 18) group. The intervention included five telephone coaching sessions on the HF home, palliative, and end-of-life care. The outcome data collected at baseline and at 3 and 6 months were from the patients' (a) HF-related health status and depression/anxiety scale scores; and from caregivers' (b) caregiving burden and depression/anxiety scale scores; and (c) anonymous ratings on the 11-item FamPALcare helpfulness scale, completed by the intervention participants.

RESULTS

The mean age of the patients was 65.66 (SD = 13.72) years, and 67% were White males. The mean age of the caregivers was 62.05 (SD = 13.14) years, and 77% were White females. Compared to the controls, patients in the intervention group had significantly greater scores for HF-related health status (p < .05) and lower depression/anxiety scores at 6 months, the study endpoint. The family caregivers in the intervention group had significantly lower scores on caregiving burden (p < .05) and depression/anxiety (p < .01) at 3 months. The mean helpfulness rating was M = 4.46 out of 5 (SD = 0.49).

CONCLUSIONS

The FamPALcare intervention was found to be effective at improving patient HF-related health status and reducing caregiver burden and improving both patient and caregiver depression and anxiety scores. The FamPALcare HF intervention was found feasible and consistently delivered (fidelity). The FamPALcare intervention's cost-effectiveness and helpfulness ratings information will be used to plan for subsequent clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04153890, Registered on 4 November 2019, https://clinicaltrials.gov/ct2/show/NCT04153890 .

Tele-Assisted Home-Based Palliative Care Reduces Health Care Costs for Terminal Cancer Patients: Real-World Evidence From a Regional Hospital in Taiwan

Background: Tele-assisted home-based palliative care (THPC) usually fulfills the desire of terminal patients to pass away at home. The overall costs of such a service deserve evaluation. Objectives: This study aims to determine health care utilization and costs for cancer patients at the end of life, stratified by THPC service. Design: Patients who received THPC were matched 1:1 based on age, gender, year of death, and propensity score with those who did not receive THPC. Setting/Subjects: A total of 773 cancer patients passed away in a regional hospital in Taiwan during the period of 2012-2020, of which 293 received THPC. Measurements: We measured the rates and costs of outpatient clinic visits, emergency department (ED) visits, hospitalizations, and intensive care unit (ICU) admissions during the last week, the last two weeks and the last month before death. In addition, we estimated the driving times and expenses required for transportation from each cancer patient's home to the hospital using Google Maps. National Health Insurance (NHI) reimbursements and out-of-pocket expenses were also calculated. Results: In comparison with patients without THPC, those who received THPC had a 50% lower likelihood of visiting the ED or being hospitalized, a more than 90% reduced chance of ICU admission, but were four times more likely to obtain their medicines from outpatient clinics. THPC patients had similar out-of-pocket expenditures, approximately half of the NHI costs, and lower rates and costs for ambulance transportation to the ED. Conclusions: THPC reduced health care costs for terminal cancer patients in the last week, the last two weeks, and the last month before death, while also increasing the likelihood of patients being able to rest and pass away at home.

Developing research priorities for palliative care in Colombia: a priority setting partnership approach

BACKGROUND

A recent Lancet commission called for more research on palliative care in low- and middle-income (LMIC) countries such as Colombia. A research priority setting approach has been recommended by The Global Forum for Health Research to address the huge gap in research output between LMIC and high-income countries, with influential health service bodies recommending the active involvement of non-research expert stakeholders in establishing research priorities to address service user needs.

METHOD

Priority setting partnership (PSP) following the four stages of the James Lind Alliance methodology; establishing the partnership, identifying evidence uncertainties, refining questions and uncertainties, and prioritization. Data from MS forms were analysed using descriptive statistics.

RESULTS

A total of 33 stakeholders attended an online PSP workshop and completed the Mentimeter exercise in Microsoft Teams. A total of 48 attended the subsequent in person prioritisation exercise in urban Bogota (n = 22) and rural Popayan (n = 25). The stakeholders were a diverse group of health professionals (physicians, medical students, nurses, dentists, physiotherapists, nutritionist, occupational and speech therapists), financial and administrative staff and patients with life-limiting illness and caregivers. Top research priorities included patient and caregiver needs, service provider education and training, and better integration of palliative care with cancer and non-cancer services. The key challenges included a lack of interest in palliative care research, along with funding, time and resource constraints. Key solutions included collaboration across disciplines and settings, highlighting benefits of palliative research to help secure adequate resources, and multicentre, mixed method research, with patient involvement from the research development stage.

CONCLUSION

The findings of this PSP should be disseminated among palliative care associations worldwide to inform international multicentre studies, and among governmental and nongovernmental organisations that promote research in Colombia. A focus on patient and family caregiver palliative care needs in Colombia should be prioritised.

The cancer caregiving burden trajectory over time: varying experiences of perceived versus objectively measured burden

INTRODUCTION

The objective of this study was to comprehensively understand the burden experienced by caregivers (CGs) providing home-based, end-of-life care to patients with cancer. We examined the relationship between objective and subjective burden including whether and how burden changes over time.

METHODS

A case series of terminal cancer patient-caregiver dyads (n = 223) were recruited from oncology clinics and followed for 12 months or until patient death. Data were collected every other week and in-person from CGs in their homes using quantitative surveys, diaries, and monthly structured observations.

RESULTS

Bivariate correlations revealed a significant association between subjective burden and activities of daily living (ADLs), instrumental activities of daily living (IADL), high-intensity tasks, and time spent on ADLs; these correlations varied over time. Models examining the slope of subjective burden revealed little systematic change; spouse caregiver and patient functional limitations were positively, and Black caregiver was negatively associated with subjective burden. Generally, the slopes for measures of objective burden were significant and positive. Models showed subjective burden was positively associated with most measures of objective burden both within caregiver (concurrent measures were positively associated) and between CGs (those with higher subjective also had higher objective).

CONCLUSIONS

Cancer caregiving is dynamic; CGs must adjust to the progression of the patient's disease. We found an association between subjective and objective burden both within and between CGs. Black CGs were more likely to report lower subjective burden compared to their White counterparts. More detailed investigation of the sociocultural components that affect caregiver experience of burden is needed to better understand how and where to best intervene with targeted supportive care services.

Quality indicators for integrating oncology and home palliative care in Japan: modified Delphi study

CONTEXT

Home palliative care service increases the chance of dying at home, particularly for patients with advanced cancer, but late referrals to home palliative care services still exist. Indicators for evaluating programs that can facilitate the integration of oncology and home palliative care have not been defined.

OBJECTIVES

This study developed quality indicators for the integration of oncology and home palliative care in Japan.

METHODS

We conducted a systematic literature review (Databases included CENTRAL, MEDLINE, EMBASE, and Emcare) and a modified Delphi study to develop the quality indicators. Panelists rated a potential list of indicators using a 9-point scale over three rounds according to two criteria: appropriateness and feasibility. The criterion for the adoption of candidate indicators was set at a total mean score of 7 or more. Final quality indicators with no disagreement were included.

RESULTS

Of the 973 publications in our initial search, 12 studies were included. The preliminary list of quality indicators by systematic literature review comprised 50 items. In total, 37 panelists participated in the modified Delphi study. Ultimately, 18 indicators were identified from the following domains: structure in cancer hospitals, structure in home palliative care services, the process of home palliative care service delivery, less aggressive end-of-life care, patient's psychological comfort, caregiver's psychological comfort, and patient's satisfaction with home palliative care service.

CONCLUSION

Comprehensive quality indicators for the integration of oncology and home palliative care were identified. These indicators may facilitate interdisciplinary collaboration between professional healthcare providers in both cancer hospitals and home palliative care services.

Is palliative care a utopia for older patients with organ failure, dementia or frailty? A qualitative study through the prism of emergency department admission

BACKGROUND

Nearly three out of four older people will use the emergency department (ED) during their last year of life. However, most of them do not benefit from palliative care. Providing palliative care is a real challenge for ED clinicians who are trained in acute, life-saving medicine. Our aim is to understand the ED's role in providing palliative care for this population.

METHODS

We designed a qualitative study based on 1) interviews - conducted with older patients (≥ 75 years) with a palliative profile and their informal caregivers - and 2) focus groups - conducted with ED and primary care nurses and physicians. Palliative profiles were defined by the Supportive and Palliative Indicators tool (SPICT). Qualitative data was collected in French-speaking Belgium between July 2021 and July 2022. We used a constant inductive and comparative analysis.

RESULTS

Five older patients with a palliative profile, four informal caregivers, 55 primary and ED caregivers participated in this study. A priori, the participants did not perceive any role for the ED in palliative care. In fact, there is widespread discomfort with caring for older patients and providing palliative care. This is explained by multiple areas of tensions. Palliative care is an approach fraught with pitfalls, i.e.: knowledge and know-how gaps, their implementation depends on patients'(co)morbidity profile and professional values, experiences and type of practice. In ED, there are constant tensions between emergency and palliative care requirements, i.e.: performance, clockwork and needs for standardised procedures versus relational care, time and diversity of palliative care projects. However, even though the ED's role in palliative care is not recognised at first sight, we highlighted four roles assumed by ED caregivers: 1) Investigator, 2) Objectifier, 3) Palliative care provider, and 4) Decision-maker on the intensity of care. A common perception among participants was that ED caregivers can assist in the early identification of patients with a palliative profile.

CONCLUSIONS

Currently, there is widespread discomfort regarding ED caregivers caring for older patients and providing palliative care. Nonetheless, ED caregivers play four roles in palliative care for older patients. In the future, ED caregivers might also perform the role of early identifier.

Unrealistic expectations and disclosure of incurability in patients with non-small cell lung cancer

PURPOSE

Determining whether patients' unrealistic expectations of chemotherapy as a cure were associated with their perception of the disclosure of incurability.

METHODS

This prospective study included consecutive patients with pretreated non-small cell lung cancer from four study sites. Patients and their oncologists were asked whether they perceived the disclosure of cancer incurability. Patients were also asked if they thought that chemotherapy was curative. We followed up on whether the deceased patients received specialized palliative care 14 months after their last enrollment. Multiple regression analyses were conducted to examine the association between the expectation of chemotherapy as a cure and patient/oncologist-reported perceptions of the disclosure of incurability.

RESULTS

We analyzed 200 patients, 77 (38.5%) of whom had unrealistic expectations of a cure. Based on patients' perceptions, incurability was disclosed to 138 (69.0%) patients, and based on their oncologists' perceptions, incurability was disclosed to 185 (92.5%) patients (patient/oncologist agreements, κ = 0.19). Patients without a perception of the oncologist's disclosure of incurability-regardless of their oncologist's perception-were more likely to have unrealistic expectations of a cure than patients for whom both patient and oncologist perceptions were present. Patients who had unrealistic expectations of chemotherapy as a cure were shown to be significantly less likely to have received specialized palliative care, after adjusting for covariates (adjusted OR, 0.45; 95% CI, 0.23-0.91; p = .027).

CONCLUSION

Oncologists' disclosure of incurability was not fully recognized by patients, and expectations of chemotherapy as a cure were associated with patients' perception of the disclosure of incurability.

Resilience and related factors in caregivers of adult cancer patients: a systematic review

Background

This systematic review aimed to investigate resilience and its related factors in caregivers of adult patients with cancer.

Materials and methods

A systematic search of online electronic databases including Scopus, PubMed, Web of Science, Iranmedex, and Scientific Information Database (SID) was performed using keywords extracted from Medical Subject Headings such as "Psychological Resilience", "Caregiver", and "Cancer" from the earliest to 6 June 2023. The quality of the studies included in this review was evaluated using the appraisal tool for cross-sectional studies (AXIS tool).

Results

A total of 2735 caregivers of cancer patients participated in 15 studies. The majority of the studies found that caregivers of cancer patients had high levels of resilience. Factors related to the resilience of cancer patients' caregivers included caregivers' social support, caregivers' quality of life, patients' resilience, caregivers' family function, patients' performance, caregivers' age, caregivers' health status, caregivers' self-esteem, caregivers post-traumatic growth, caregivers religious, caregivers hope, caregivers positive affect, patients age, patients social support, patients resilience support, patients quality of life, caregivers' anxiety, caregivers' depression, caregivers' burden, caregivers level of education, caregivers financial problem, caregivers memory, caregivers negative affect, caregivers post-traumatic stress disorder, maternal distress, and patients post-traumatic stress disorder.

Conclusion

Therefore, healthcare administrators and policymakers can enhance the resilience of caregivers and the quality of care they provide by instituting ongoing training initiatives focused on evaluating mental well-being and implementing coping strategies for managing stress and depression.

Home emergency response team for the seriously ill palliative care patient: feasibility and effectiveness

OBJECTIVES

To characterise trajectories associated with a new team organisation combining critical care and palliative care approaches at home.

METHODS

We describe the pattern of an emergency response team 24/7 directed to patients with advanced illness presenting a distressing symptom at home, who wanted to stay at home and for whom hospitalisation was considered inappropriate by a shared medical decision-making process in an emergency situation. To assess preliminary impact of this Programme, we conducted a descriptive study on all consecutive patients receiving this intervention during the first year (between 6 September 2021 and 5 September 2022).

RESULTS

Among the 352 patients included, main advanced illnesses were cancer (41%), dementia (28%) or chronic organ failure (10%). They were critically ill with acute failures: respiratory (52%), neurological (48%) or circulatory (20%). Main distressing symptoms were breathlessness (43%) and pain (17%). Median response time from call to home-visit (IQR) was 140 (90-265) min. Median length of follow-up (IQR) was 4 (2-7) days. Main outcomes were death at home (72%), improvement (19%) or hospitalisation (9%) including three visits to emergency department (1%).

CONCLUSIONS

Our study supports that shared decision-making process and urgent care at home are feasible and might prevent undesired hospitalisations.

Exploring End-of-Life Care for Patients with Breast Cancer, Dementia or Heart Failure: A Register-Based Study of Individual and Institutional Factors

OBJECTIVE

To examine variations in end-of-life care for breast cancer, heart failure, and dementia patients.

DATA AND METHODS

Data from four Norwegian health registries were linked using a personal identification number. Longitudinal trends over 365 days and the type of care on the final day of life were analyzed using descriptive techniques and logistic regression analysis.

RESULTS

Patients with dementia were more commonly placed in nursing homes than patients in the two other groups, while patients with heart failure and breast cancer were more frequently hospitalized than the dementia patients. Breast cancer and heart failure patients had a higher likelihood of dying at home than dementia patients. The higher the number of general practitioners, the higher was the probability of home-based end-of-life care for cancer patients, while an increasing non-physician healthcare workers increased the likelihood of home-based care for the other patient groups.

CONCLUSIONS

Diagnoses, individual characteristics, and service availability are all associated with the place of death in end-of-life care. The higher the availability of health care services, the higher also is the probability of ending the life at home.

Appropriate use of medication among home care adult cancer patients at end of life: a retrospective observational study

BACKGROUND

Medications are commonly used for symptom control in cancer patients at the end of life. This study aimed to evaluate medication utilization among home care palliative patients with cancer at the end of life and assess the appropriateness of these medications.

METHOD

This retrospective observational study included adult cancer patients who received home care in 2020. Medications taken during the last month of the patient's life were reviewed and classified into three major categories: potentially avoidable, defined as medications that usually have no place at the end of life because the time to benefit is shorter than life expectancy; medications of uncertain appropriateness, defined as medications that need case-by-case evaluation because they could have a role at the end of life; and potentially appropriate, defined as medications that provide symptomatic relief.

RESULTS

In our study, we enrolled 353 patients, and 2707 medications were analyzed for appropriateness. Among those, 1712 (63.2%) were classified as potentially appropriate, 755 (27.9%) as potentially avoidable, and 240 (8.9%) as medications with uncertain appropriateness. The most common potentially avoidable medications were medications for peptic ulcers and gastroesophageal reflux disease (30.5%), vitamins (14.6%), beta-blockers (9.8%), anticoagulants (7.9%), oral antidiabetics (5.4%) and insulin products (5.3%). Among the potentially appropriate medications, opioid analgesics were the most frequently utilized medications (19.5%), followed by laxatives (19%), nonopioid analgesics (14.4%), gamma-aminobutyric acid analog analgesics (7.7%) and systemic corticosteroids (6%).

CONCLUSION

In home care cancer patients, approximately one-third of prescribed medications were considered potentially avoidable. Future measures to optimize medication use in this patient population are essential.

Effects of Telemedicine on Informal Caregivers of Patients in Palliative Care: Systematic Review and Meta-Analysis

Background

Telemedicine technology is a rapidly developing field that shows immense potential for improving medical services. In palliative care, informal caregivers assume the primary responsibility in patient care and often face challenges such as increased physical and mental stress and declining health. In such cases, telemedicine interventions can provide support and improve their health outcomes. However, research findings regarding the use of telemedicine among informal caregivers are controversial, and the efficacy of telemedicine remains unclear.

Objective

This study aimed to evaluate the impacts of telemedicine on the burden, anxiety, depression, and quality of life of informal caregivers of patients in palliative care.

Methods

A systematic literature search was conducted using the PubMed, Embase, Web of Science, CENTRAL, PsycINFO, CINAHL Plus with Full Text, CBM, CNKI, WanFang, and VIP databases to identify relevant randomized controlled trials published from inception to March 2023. Two authors independently screened the studies and extracted the relevant information. The methodological quality of the included studies was assessed using the Cochrane risk-of-bias tool. Intervention effects were estimated and sensitivity analysis was conducted using Review Manager 5.4, whereas 95% prediction intervals (PIs) were calculated using R (version 4.3.2) and RStudio.

Results

A total of 9 randomized controlled trials were included in this study. The meta-analysis indicated that telemedicine has reduced the caregiving burden (standardized mean differences [SMD] -0.49, 95% CI -0.72 to -0.27; P<.001; 95% PI -0.86 to -0.13) and anxiety (SMD -0.23, 95% CI -0.40 to -0.06; P=.009; 95% PI -0.98 to 0.39) of informal caregivers; however, it did not affect depression (SMD -0.21, 95% CI -0.47 to 0.05; P=.11; 95% PI -0.94 to 0.51) or quality of life (SMD 0.35, 95% CI -0.20 to 0.89; P=.21; 95% PI -2.15 to 2.85).

Conclusions

Although telemedicine can alleviate the caregiving burden and anxiety of informal caregivers, it does not significantly reduce depression or improve their quality of life. Further high-quality, large-sample studies are needed to validate the effects of telemedicine. Furthermore, personalized intervention programs based on theoretical foundations are required to support caregivers.

Identification of Nursing Outcomes and Quality Indicators for Home Health Care in Older Adults with End-Stage Cancer

OBJECTIVE

This study aimed to identify nursing outcomes and quality indicators for older adults with end-stage cancer receiving home health care.

METHODS

Nineteen experts and professional caregivers, including palliative doctors, nursing faculty, advanced practice nurses, and registered nurses, participated in the Delphi technique. Final medians and interquartile ranges were calculated.

RESULT

Seven components with 43 nursing outcomes and quality indicators for older adults with end-stage cancer were developed, encompassing physical pain relief, symptom management, physical well-being, complication prevention, psychosocial support, caregiver and family roles in end-of-life care, and advance care planning.

CONCLUSION

The caregiver and family's role in end-of-life care had the most indicators, reflecting the significance of family involvement in Thailand's cultural context. Consistent implementation of these indicators is crucial, and correlational analysis of indicator scores can enhance their validity.

Symptom burden and relief in palliative care units of German Comprehensive Cancer Center and other hospitals

PURPOSE

The National Hospice and Palliative Registry contains patient data from German hospice and palliative care facilities about symptoms. The aim of the study at hand is to differentiate symptom burden of patients in palliative care units between Comprehensive Cancer Center (CCC) and other hospitals regarding symptom burden and relief of patients in palliative care units.

METHODS

The registry analysis provided data of patients in palliative care units (2014-2018). We analyzed characteristic and symptom-related data on 18 symptoms, with considerable symptom-burdened patients (moderate or severe). We followed a cancer (yes/no) and facility-specific descriptive analysis (f, %, μ, Mdn, SD, V, r) using SPSS.

RESULTS

We evaluated 10,447 patient records (CCC: 4234 pts/non CCC 6,213 pts), 82% with a cancer diagnosis. For cancer patients, the mean age in CCC-affiliated palliative care units was 68 (SD 19-99) years, in others 73 (SD 23-104) years (p < 0.05; V = 0.2). The proportion of patients with significant symptom burden is lower in CCC-affiliated than in other palliative care units. The difference between facilities shows a significant weak effect in pain, vomiting and constipation, depressiveness, anxiety, and tension. The proportion of cases which symptom burden could be alleviated is higher in CCC-affiliated palliative care units with significant weak/medium effect in pain, nausea, vomiting, shortness of breath, constipation, wound care problems, depressiveness, anxiety, tension, confusion, and problems in organizing care.

CONCLUSION

We found differences in symptom burden and symptom relief between CCC-affiliated and other palliative care units. CCCs should continue to feel responsible for sharing knowledge about symptom relief, such as through standard operating procedures and education.

Palliative Care Costs in Different Ambulatory-Based Settings: A Systematic Review

BACKGROUND

Cost-of-illness studies in palliative care are of growing interest in health economics. There is no standard methodology to capture direct and non-direct healthcare and non-healthcare expenses incurred by health services, patients and their caregivers in the course of the ambulatory palliative care process.

OBJECTIVE

We aimed to describe the type of healthcare and non-healthcare expenses incurred by patients with cancer and non-cancer patients and their caregivers for palliative care in ambulatory-based settings and the methodology used to capture the data.

METHODS

We conducted a systematic review of studies on the costs of ambulatory-based palliative care in patients with cancer (breast, lung, colorectal) and non-cancer conditions (chronic heart failure, chronic obstructive pulmonary disease, dementia) found in six bibliographic databases (PubMed, EMBASE [via Ovid], Cochrane Database of Systematic Reviews, EconLit, the National Institute for Health Research Health Technology Assessment Database and the National Health Service Economic Evaluation Database at the University of York, and Google Scholar). The studies were published between January 2000 and December 2022. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology for study selection and assessed study quality using the Quality of Health Economic Studies instrument. The study was registered in PROSPERO (CRD42021250086).

RESULTS

Of 1434 identified references, 43 articles met the inclusion criteria. The primary data source was databases. More than half of the articles presented data from public healthcare systems (65.12%) were retrospective (60.47%), and entailed a bottom-up costing analysis (93.2%) made from a healthcare system perspective (53.49%). The sociodemographic characteristics of patients and families/caregivers were similar across the studies. Cost outcomes reports were heterogeneous; almost all of the studies collected data on direct healthcare costs (97.67%). The main driver of costs was inpatient care (55.81%), which increased during the end-of-life period. Nine studies (20.97%) recorded costs due to productivity losses for caregivers and three recorded such costs for patients. Caregiving costs were explored through an opportunity cost analysis in all cases, based on interviews conducted with and questionnaires administered to patients and caregivers, mainly via telephone calls (23.23%).

CONCLUSIONS

This systematic review reveals that studies on the costs of ambulatory-based palliative care are increasing. These studies are mostly conducted from a healthcare system perspective, which leaves out costs related to patients'/caregivers' economic burden. There is a need for prospective studies to assess this financial burden and evaluate, with strong evidence, the interventions and actions designed to improve the quality of life of palliative care patients. Future studies should propose cost calculation approaches using a societal perspective to better estimate the economic burden imposed on patients in ambulatory-based palliative care.

Integrated palliative care in oncology: a protocol for a realist synthesis

INTRODUCTION

Emerging evidence suggests improved quality of life, reduced symptom burden and lower health services costs when integrated palliative care and cancer care are implemented. Integrated palliative care aims to achieve care continuity by integrating organisational, administrative and clinical services involved in patient care networks. However, integrated palliative care for cancer is not common practice. This project, therefore, aims to understand how integrated palliative care and cancer care works in different healthcare settings (inpatient/outpatient), and for which groups of people (at what stage of the cancer journey), so we can develop guidance for optimal delivery.

METHODS AND ANALYSIS

We will conduct a realist synthesis to develop a programme theory of how integrated palliative care in cancer works, for whom and in what contexts to achieve improved symptom management and quality of life for patients and their families.This realist synthesis will follow the five stages outlined by Pawson: (1) locating existing theories, (2) searching for evidence, (3) article selection, (4) extracting and organising data and (5) synthesising the evidence and drawing conclusions. We will work closely with our expert stakeholder group, which includes health and social care professionals providing palliative care and oncology; management and policy groups and members of the public and patients. We will adhere to RAMESES quality standards for undertaking a realist synthesis.

ETHICS AND DISSEMINATION

Ethics approval for this project is not required.The realist synthesis will develop a programme theory that provides clarity on the optimal delivery of palliative care for adults with cancer. We will use the programme theory to coproduce guidance and user-friendly outputs, working with stakeholders to inform delivery of best practice. Findings will inform further research in integrated palliative care and cancer. Stakeholder engagement will assist in the dissemination of our findings.

PROSPERO REGISTRATION NUMBER

CRD42023389791.

Perspectives of nursing home executives on collaboration with GPs and specialist palliative care teams

Background: Nursing home (NH) staff, general practitioners (GPs) and specialist outpatient palliative care teams are expected to cooperate to ensure adequate palliative care for NH residents in Germany. Aim: The aim of this study was to investigate the perspective of NH executives concerning collaboration with GPs and specialist outpatient palliative care teams. Methods: We conducted semi-structured telephone interviews with executives of NHs in the federal state of Baden-Wuerttemberg, Germany. Interviews were analysed by means of structured content analyses. Results: Executives of 20 NHs participated in the study, eight NHs cooperate with specialist outpatient palliative care teams. Content analysis resulted in two main categories: 'general palliative care by primary carers' and 'collaboration with SAPV in NHs', each with three first-order subcategories. The main barriers to adequate palliative care were reported to be lack of palliative care knowledge in GPs and NH staff, refusal of some GPs to cooperate with specialist outpatient palliative care teams and staff shortage in NHs. Specialist palliative care involvement was described to result in improved palliative care. Conclusion: Solutions seem obvious, e.g., further education in palliative care or round tables to discuss collaboration. However, studies show that even comprehensive educational and management interventions to implement palliative care do not always result in long-term effects and further research is needed.

Palliative care in a rural subdistrict in South Africa: A 4-year critical review

BACKGROUND

Palliative care (PC) is a priority in South Africa, focussing on integrating PC into primary health care. Few examples exist showing how this is done. In 2018, a rural PC project was implemented, which subsequently evolved into an integrated service between the hospital and the community.

AIM

The aim was to review the PC project over 4 years.

SETTING

The setting was the George subdistrict of the Garden Route district in South Africa. Community-based services were offered to all patients with PC needs by three non-governmental organisations who deliver home community-based care via community health workers. They were supplemented by primary health care clinics, an intermediate care facility and two hospitals.

METHODS

This was a retrospective descriptive study. Inpatient ward round data and patient referrals between 2018 and 2022 were analysed using descriptive statistics. Variables included patient demographics, diagnosis, home visits and place of death.

RESULTS

A total of 819 patients were referred. Inpatients were reviewed on weekly ward rounds by a multidisciplinary team. The most common diagnosis was cancer (57%). Home visits enabled patient follow-ups, of which 152 were recorded.

CONCLUSION

The programme has become sustainable and integrated in the public healthcare system. Contributing factors included dedicated staff, using simple tools and continuous training. The findings may be useful to PC programmes in similar contexts elsewhere.Contribution: This work adds new knowledge to the field of PC in an underresourced rural healthcare environment in sub-Saharan Africa, by describing how system-wide integration of a new service was navigated to become sustainable.

Palliative sedation and time to death in home palliative care: retrospective analysis

OBJECTIVES

We described time to death and rates of palliative sedation during home palliative care leveraging a retrospective cohort of patients with advanced cancer.

METHODS

The cohort consists of 143 patients with solid or haematological malignancies admitted to home palliative care in the Tuscany region in central Italy. Only patients for whom a date of death was available were included. The outcome measures were time from admission to home palliative care to death and receipt of palliative sedation.

RESULTS

143 patients were included in this report. Lower Eastern Cooperative Oncology Group (ECOG) performance status (PS) scores were significantly associated with anticancer treatment at admission, as was younger age. Increasing ECOG PS scores were associated with lower survival time. Women and patients on anticancer treatment had longer survival time. Thirty-eight per cent of patients underwent palliative sedation at home; palliative sedation was more frequent among younger patients and among patients with brain or lung cancer. The most common reasons for palliative sedation were delirium and dyspnoea.

CONCLUSIONS

ECOG PS, sex and anticancer treatment had a significant impact on survival time. Thirty-eight per cent of patients in our cohort underwent home palliative sedation for refractory symptoms, most often delirium and dyspnoea.

Comparing quality indicator rates for home care clients receiving palliative and end-of-life care before and during the Covid-19 pandemic

BACKGROUND

The consensus among Canadians with regards to end-of-life preferences is that with adequate support the majority prefer to live and die at home.

PURPOSE

To compare quality indicator (QI) rates for home care clients receiving palliative and end-of-life care prior to and after the onset of the COVID-19 pandemic.

METHODS

A retrospective population-based cohort design was used. Sixteen QIs informed by existing literature and a preliminary set of QIs recently evaluated by a modified Delphi panel were compared. Data were obtained from the interRAI Palliative Care instrument for Ontario home care clients for two separate cohorts: the pre-COVID (January 14, 2019 to March 16, 2020) and COVID cohort (March 17, 2020 to May 18, 2021). A propensity score analysis was used to match (using nearest neighbour matching) on 21 covariates, resulting in a sample size of 2479 unique interRAI Palliative Care assessments in each cohort. Alternative propensity score methods were explored as part of a sensitivity analysis.

RESULTS

After matching the pre-COVID and COVID cohorts, five of the 16 QIs had statistically significant differences in the QI rates (change from pre-COVID to COVID): decrease in prevalence of severe or excruciating daily pain (p = 0.03, effect size=-0.08), decrease in prevalence of caregiver distress (p = 0.02, effect size=-0.06), decrease in prevalence of negative mood (p = 0.003, effect size=- 0.17), decrease in prevalence of a delirium-like syndrome (p = 0.001, effect size=-0.25) and decrease in prevalence of nausea or vomiting (p = 0.04, effect size=-0.06). While the alternative propensity score methods produced slightly different results, no clinically meaningful differences were seen between the cohorts when effect sizes were examined. All methods were in agreement regarding the highest QI rates, which included the prevalence of shortness of breath with activity, no advance directives, and fatigue.

CONCLUSION

This study is the first to examine differences in QI rates for home care clients receiving palliative and end-of-life care before and during COVID in Ontario. It appears that QI rates did not change over the course of the pandemic in this population. Future work should be directed to understanding the temporal variation in these QI rates, risk-adjusting the QI rates for further comparison among jurisdictions, provinces, and countries, and in creating benchmarks for determining acceptable rates of different QIs.

Trend analysis of quality indicators in palliative home care among terminally ill cancer and non-cancer patients in Taiwan: a 6-year observational study

PURPOSE

Palliative home care services (PHCS) have been emerging for years. However, limited data exist regarding quality indicators for pain control, unplanned hospital readmissions, and household deaths among terminal cancer and non-cancer patients receiving PHCS.

METHODS

We conducted a retrospective collection and recording of data from 1242 terminally ill cancer and non-cancer patients receiving PHCS. The data were obtained from the Hospice-Palliative Clinical Database (HPCD) of Taichung Veterans General Hospital (TCVGH) for the period from 2016 to 2021. T test and chi-square test were applied for characteristics and the quality indicators among cancer and non-cancer groups. Chi-square test was used for trend analysis of the number of patients receiving PHCS and the quality indicators among cancer and non-cancer groups throughout the study period.

RESULTS

A total of 1242 terminally ill cancer and non-cancer patients who had received PHCS were documented by TCVGH from the years 2016 to 2021, including 221 non-cancer patients and 1021 cancer patients having an average age of 70. The number of terminally ill cancer and non-cancer patients receiving PHCS has increased annually since 2016. Another finding was that age was a statistically significant factor impacting quality indicators. On the other hand, compared to non-cancer patients, cancer patients had a higher likelihood of receiving treatment with analgesics when needed. Their odds of needing analgesics more than three times within 4 days after PHCS enrollment were significantly elevated [OR 4.188, 95% CI (1.002, 17.51)].

CONCLUSION

The results of this 6-year observational study indicate a substantial increase in the number of terminal cancer and non-cancer patients receiving PHCS over the past decade. Furthermore, aging plays an important role in life quality of terminal cancer and non-cancer patients.

Introduction of Various Models of Palliative Oncology Care: A Systematic Review

BACKGROUND

The aim of this study is to synthesize the existing evidence on various palliative care (PC) models for cancer patients. This effort seeks to discern which facets of PC models are suitable for various patient cohorts, elucidate their mechanisms, and clarify the circumstances in which these models operate.

METHODS

A comprehensive search was performed using MeSH terms related to PC and cancer across various databases. The Preferred Reporting Items for Systematic Reviews and a comprehensive evidence map were also applied.

RESULTS

Thirty-three reviews were published between 2009 and 2023. The conceptual PC models can be classified broadly into time-based, provider-based, disease-based, nurse-based, issue-based, system-based, team-based, non-hospice-based, hospital-based, community-based, telehealth-based, and setting-based models. The study argues that the outcomes of PC encompass timely symptom management, longitudinal psychosocial support, enhanced communication, and decision-making. Referral methods to specialized PC services include oncologist-initiated referral based on clinical judgment alone, via referral criteria, automatic referral at the diagnosis of advanced cancer, or referral based on symptoms or other triggers.

CONCLUSION

The gold standard for selecting a PC model in the context of oncology is a model that ensures broad availability of early PC for all patients and provides well-timed, scheduled, and specialized care for patients with the greatest requirement.

Effects of early exposure to palliative care on end-of-life outcomes in patients with cancer in a community setting

OBJECTIVE

Although prior studies show that exposure to early outpatient palliative care (OPC) versus no exposure is associated with improved outcomes at the end of life (EoL) for patients with cancer, few examined the impact of exposure to OPC prior to home-based palliative care (HBPC) on EoL outcomes. This study compares the effect of OPC prior to HBPC versus HBPC alone on EoL outcomes in patients with cancer.

METHODS

A secondary analysis of data from a trial comparing two models of HBPC was performed on patients with primary cancer diagnoses. Adjusted negative binomial and logistic regression models were used to compare days in acute care and intensive care unit stays in the last 30 days, chemotherapy administration in the last 14 days and in-hospital deaths between patients who received standard-dose (4+ encounters) and low-dose (<4 encounters) OPC plus HBPC versus HBPC alone.

RESULTS

A total of 1187 patients, 483 (40.1%) of whom had OPC+HBPC and 704 (59.3%) who had HBPC alone were included in the analyses. Compared with patients who had HBPC alone, patients who had standard-dose OPC spent fewer days in acute care (4.29 vs 4.19, p=0.04) and fewer days inpatient (3.45 vs 3.09, p=0.03) in the last 30 days of life. No difference was seen in EoL outcomes in patients exposed to low-dose OPC compared with those with HBPC alone. Receipt of hospice after HBPC was strongly associated with improved EoL outcomes.

CONCLUSION

Future research is needed to examine the modality, timing and intensity of palliative care necessary to effect EoL outcomes.

University hospital center for palliative and supportive care

The Center for Palliative Care and Supportive Care opened in 2019 with the aim of contributing to the implementation of general palliative care in all departments of the Geneva University Hospitals. Built with the aim of supporting care professionals in the management of patients with palliative trajectories and enhancing their professional skills, depending on their specialisation, the centre has laid out recommendations for the palliative management of people with a life-limiting disease. The results of the centre's actions, carried out in collaboration with these professionals, are encouraging and show a growing use of the recommended tools for the evaluation and management of patients in general palliative care.

Early Integrated Palliative Care Within a Surgical Oncology Clinic

Importance

Advance directive (AD) designation is an important component of advance care planning (ACP) that helps align care with patient goals. However, it is underutilized in high-risk surgical patients with cancer, and multiple barriers contribute to the low AD designation rates in this population.

Objective

To assess the association of early palliative care integration with changes in AD designation among patients with cancer who underwent surgery.

Design, Setting, and Participants

This cohort study was a retrospective analysis of a prospectively maintained registry of adult patients who underwent elective surgery for advanced abdominal and soft tissue malignant tumors at a surgical oncology clinic in a comprehensive cancer center with expertise in regional therapeutics between June 2016 and May 2022, with a median (IQR) postoperative follow-up duration of 27 (15-43) months. Data analysis was conducted from December 2022 to April 2023.

Exposure

Integration of ACP recommendations and early palliative care consultations into the surgical workflow in 2020 using electronic health records (EHR), preoperative checklists, and resident education.

Main Outcomes and Measures

The primary outcomes were AD designation and documentation. Multivariable logistic regression was performed to assess factors associated with AD designation and documentation.

Results

Among the 326 patients (median [IQR] age 59 [51-67] years; 189 female patients [58.0%]; 243 non-Hispanic White patients [77.9%]) who underwent surgery, 254 patients (77.9%) designated ADs. The designation rate increased from 72.0% (131 of 182 patients) before workflow integration to 85.4% (123 of 144 patients) after workflow integration in 2020 (P = .004). The AD documentation rate did not increase significantly after workflow integration in 2020 (48.9% [89 of 182] ADs documented vs 56.3% [81 of 144] ADs documented; P = .19). AD designation was associated with palliative care consultation (odds ratio [OR], 41.48; 95% CI, 9.59-179.43; P < .001), palliative-intent treatment (OR, 5.12; 95% CI, 1.32-19.89; P = .02), highest age quartile (OR, 3.79; 95% CI, 1.32-10.89; P = .01), and workflow integration (OR, 2.05; 95% CI, 1.01-4.18; P = .048). Patients who self-identified as a race or ethnicity other than non-Hispanic White were less likely to have designated ADs (OR, 0.36; 95% CI, 0.17-0.76; P = .008). AD documentation was associated with palliative care consulation (OR, 4.17; 95% CI, 2.57- 6.77; P < .001) and the highest age quartile (OR, 2.41; 95% CI, 1.21-4.79; P = .01).

Conclusions and Relevance

An integrated ACP initiative was associated with increased AD designation rates among patients with advanced cancer who underwent surgery. These findings demonstrate the feasibility and importance of modifying clinical pathways, integrating EHR-based interventions, and cohabiting palliative care physicians in the surgical workflow for patients with advanced care.

Systematic Review of Models of Effective Community Specialist Palliative Care Services for Evidence of Improved Patient-Related Outcomes, Equity, Integration, and Health Service Utilization

Background: The benefits of palliative care programs are well documented. However, the effectiveness of specialist palliative care services is not well established. The previous lack of consensus on criteria for defining and characterizing models of care has restrained direct comparison between these models and limited the evidence base to inform policy makers. A rapid review for studies published up to 2012 was unable to find an effective model. Aim: To identify effective models of community specialist palliative care services. Design: A mixed-method synthesis design reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Prospero: CRD42020151840. Data sources: Medline, PubMed, EMBASE, CINAHL and the Cochrane Database of Systematic Reviews were searched in September 2019 for primary research and review articles from 2012 to 2019. Supplementary search was conducted on Google in 2020 for policy documents to identify additional relevant studies. Results: The search yielded 2255 articles; 36 articles satisfied the eligibility criteria and 6 additional articles were identified from other sources. Eight systematic reviews and 34 primary studies were identified: observational studies (n = 24), randomized controlled trials (n = 5), and qualitative studies (n = 5). Community specialist palliative care was found to improve symptom burden/quality of life and to reduce secondary service utilization across cancer and noncancer diagnoses. Much of this evidence relates to face-to-face care in home-based settings with both round-the-clock and episodic care. There were few studies addressing pediatric populations or minority groups. Findings from qualitative studies revealed that care coordination, provision of practical help, after-hours support, and medical crisis management were some of the factors contributing to patients' and caregivers' positive experience. Conclusion: Strong evidence exists for community specialist palliative care to improve quality of life and reducing secondary service utilization. Future research should focus on equity outcomes and the interface between generalist and specialist care.

Changes in the Place of Death of Patients With Cancer After the Introduction of Insurance-Covered, Home-Based Hospice Care in Korea

Importance

Although hospice care has been covered by health insurance for the purpose of improving the quality of life of patients with terminal cancer as well as their caregivers, few studies have evaluated the outcomes of the policy to cover home-based hospice care services.

Objective

To investigate the changes in the place of death of patients with cancer after the introduction of insurance-covered, home-based hospice care services in Korea.

Design, Setting, and Participants

This cohort study used data from February 1, 2018, to December 31, 2021, from the Causes of Death Statistics database, released annually by Statistics Korea, which contains information on all deaths in the country. Individuals who died of cancer, a representative hospice-eligible disease, were assigned to the case group, and those who died of dementia, a non-hospice-eligible disease, were assigned to the control group. A total of 218 522 individuals constituted the study population.

Exposure

Because the Korean Health Insurance Service had begun covering home-based hospice care services on September 1, 2020, and the last follow-up date was December 31, 2021, the follow-up periods for before and after intervention were 31 months and 16 months, respectively (preintervention period: February 1, 2018, to August 31, 2020; postintervention period: September 1, 2020 to December 31, 2021).

Main Outcomes and Measures

The place of death was categorized as a binary variable according to whether it was the person's own home or not. Comparative interrupted time-series models with segmented regression were applied to analyze the time trend and its change in outcomes.

Results

Of the 218 522 deaths eligible for the analysis (mean [SD] age at death, 78.6 [8.8] years; 130 435 men [59.7%]), 207 459 were due to cancer, and 11 063 were due to dementia. Immediately after the introduction of home-based hospice care, the rate of home deaths was 24.5% higher for patients with cancer than for those with dementia (estimate, 1.245 [95% CI, 1.030-1.504]; P = .02). The difference in the level change between cancer deaths and dementia deaths, on intervention, was more pronounced for those living in rural areas (estimate, 1.320 [95% CI, 1.118-1.558]; P = .001). In addition, a higher educational level was associated with a larger difference in the immediate effect size due to home-based hospice care (low educational level: estimate, 1.205 [95% CI, 1.025-1.416]; P = .02; middle educational level: estimate, 1.307 [95% CI, 0.987-1.730], P = .06; high educational level: estimate, 1.716 [95% CI, 0.932-3.159]; P = .08).

Conclusions and Relevance

In this cohort study exploring the changes in the place of death for patients with cancer after the insurance mandates for home-based hospice care in Korea, the probability of patients with cancer dying in their own homes increased after the intervention. This finding suggests the need to broaden the extent of home-based hospice care to honor the autonomy of individuals with terminal illness and improve their quality of death.

Factors associated with emergency admission for people dying from cancer in Northern Ireland: an observational data linkage study

BACKGROUND

Many people living with cancer are admitted as an emergency, some just prior to diagnosis and others in their last year of life. Factors associated with accessing emergency care for people dying of cancer are complex and not well understood. This can make it difficult to have the resources and staffing in place to best care for individuals in their last year of life and their families.

METHODS

This study uses routinely collected administrative data from people who died of cancer in N. Ireland (NI) during 2015 and explores how personal characteristics (e.g., gender, age) and disease related factors (e.g., tumour site, cancer stage at initial diagnosis) were associated with having an emergency admission to hospital in the last year and the last 28 days of their lives, using multivariate logistic regression.

RESULTS

Almost three in four people had at least one emergency admission in the last year of life, and over one in three had an emergency admission the last 28 days of life. Patterns were similar for both time outcomes with males, people with haematological, lung or brain cancers, younger persons, those diagnosed with late-stage cancer, and people diagnosed close to time of death, being significantly more likely to have an emergency admission. While there was no significant association between deprivation and emergency admission rates, those living in urban areas were more likely to have an emergency admission in their last month of life compared to rural dwellers. Late diagnosis was evident with 538 people (12.8% of all deaths from cancer) being diagnosed within one month of death and 1242 (29%) within 3 months of death.

CONCLUSION

The high level of emergency admissions points to gaps in routine end-of-life care, and the need for additional training for hospital staff including frontline emergency department (ED) staff who are often the 'gatekeepers' to emergency inpatient care for people living with cancer. The levels of late diagnosis indicate a need for increased population awareness of cancer symptoms and system change to promote earlier diagnosis.

Barriers and facilitators to palliative care for patients with non-curable cancer in Colombia: perspectives of allied health and social care professionals

BACKGROUND

Palliative care aims to improve the quality of life of people with life-limiting illness and their families by addressing physical, psychological, social and spiritual suffering. Allied Health and Social Care Professionals (AHSCP) are key to delivering comprehensive, high quality palliative care. In recent years, Colombia has developed changes in the legal, and regulatory framework for access to palliative care but barriers and facilitators to palliative care for patients with non-curable cancer have not been explored from the perspective of AHSCP.

METHOD

This study aims to address this knowledge gap in two cities in Colombia: one in a medium-sized city in a rural area (Popayan) and one in a highly urbanized area (Bogota). Two focus groups with AHSCP were conducted using the World Cafe method, and a subsequent thematic analysis was performed to establish the main barriers and facilitators.

RESULTS

A wide range of 18 AHSCPs attended the two World Cafe groups in Popayan and Bogota. As a result of this iterative process, we established five thematic areas: (i) Humanizing care, (ii) Normalizing palliative care: referral at the time of diagnosis, (iii) Misunderstandings related to palliative care, (iv) Barriers within the health system, and (v) Geographic barriers.

CONCLUSION

This study provided the perspectives of AHSCPs in Colombia in relation to barriers and facilitators in the framework of comprehensive palliative care attention. Participants identified misconceptions about palliative care, which are explained by the lack of inclusion of this area in the educational programs of health professionals and AHSCPs, along with the limited supply and access to palliative care, especially in rural areas.

[A regional comparison of outcomes quality and costs of general and specialized palliative care in Germany: a claims data analysis]

BACKGROUND

The main framework conditions for palliative care are set at the regional level. The scope of the forms of care used (outpatient, inpatient, general, specialized) varies widely. What is the quality of outcomes achieved by the palliative care provided on a federal states level? What are the associated costs of care?

METHOD

Retrospective observational study using BARMER claims data from 145,372 individuals who died between 2016 and 2019 and had palliative care in the last year of life. Regional comparison with regard to the following outcomes: proportion of palliative care patients who died in the hospital, potentially burdensome care in the last 30 days of life (ambulance calls, [intensive care] hospitalizations, chemotherapy, feeding tubes, parenteral nutrition), total cost of care (last three months), cost of palliative care (last year), and cost-effectiveness ratios. Calculation of patient/resident characteristic adjusted rates, costs, and ratios.

RESULTS

Federal states vary significantly with respect to the outcomes (also adjusted) of palliative care. Palliative care costs vary widely, most strongly for specialized outpatient palliative care (SAPV). Across all indicators and the cost-effectiveness ratio of total cost of care to at-home deaths, Westphalia-Lippe shows favorable results.

CONCLUSION

Regions with better quality and more favorable cost (ratios) can provide guidance for other regions. The extent to which the new federal SAPV agreement can incorporate the empirical findings should be reviewed. Patient-relevant outcome parameters should be given greater weight than parameters aiming at structures of care.

Using volunteers to improve access to community rehabilitation in palliative care: the St Christopher's Living Well at Home Team

Background

UK hospices often provide outpatient rehabilitation services for people with advanced progressive illness. However, some people are unable to travel, leading to inequity in rehabilitation access.

Objectives

The Living Well at Home Team (LWAHT) at St Christopher's Hospice aimed to evaluate whether using volunteers to support rehabilitation in peoples' homes improved the reach of rehabilitation for people living in underserved localities and if it supported people to optimise their functional independence.

Methods

This service improvement project evaluated hospice rehabilitation uptake during the implementation of volunteer-supported community rehabilitation. Following assessment by an LWAHT therapist, eligible people were matched with a trained volunteer who supported four to eight rehabilitation sessions in the person's home. The evaluation assessed uptake of the rehabilitation sessions. Mobility, wellbeing, and goal attainment outcomes were assessed by the Life-Space Assessment (LSA), General Health Questionnaire (GHQ), and Goal Attainment Scale (GAS), respectively.

Results

In the first year, 183 patients were referred to the LWAHT; 123 were assessed and 96 received rehabilitation including 56 who were matched with a volunteer. Following volunteer support, patients reported significant improvements in mobility [LSA median 20 (IQR, 3.5-27.8)], general health [GHQ -2 (-5.25 to 0)], and achievement of goals [GAS T-score +8 (0-18.4)].

Conclusions

It was feasible to support community rehabilitation using hospice volunteers for people with advanced progressive illness. The LWAHT service also increased the uptake of hospice centre-based rehabilitation. Further work should test efficacy and identify patients requiring additional professional input.

Key message

This is the first known study reporting on the use of trained rehabilitation volunteers to extend the reach of hospice rehabilitation services. People with limited access to the hospice, because of geographical location or personal circumstances, valued and benefited from tailored rehabilitation supported by the volunteers in their own homes.

Need of community-based palliative care in rural India and factors that influence its sustainability: a comprehensive exploration using qualitative methodology in rural Puducherry, India

Background

The existing palliative care services in India are concentrated in urban areas, attached to tertiary care hospitals. This poses issues relating to access and equity for people in rural locations and with low socioeconomic status. A Community-Based Palliative Care (CBPC) service named Sanjeevan has been initiated in Puducherry, a union territory of India to provide physical, social, psychological, and emotional support to incurably ill people, including older adults living in rural areas.

Objectives

To understand the social mechanisms that underpin the implementation of CBPC in rural parts of India and the challenges to its sustainability.

Design

Qualitative research using focus group discussions (FGDs) and key informant interviews (KIIs).

Methods

Community-based participatory research (CBPR) approach was used in this study, and descriptive analysis was done. Through CBPR it was possible to document and interpret local knowledge on the community concerns and assets along with the experiences of the community members. Purposive sampling was used to identify vocal participants involved in patient care and areas of the Sanjeevan program such as financial management, administration, and community mobilization. Seven KIIs and four FGDs were conducted, with 7-8 participants in each.

Results

The analysis indicated the need for a CBPC and the factors enabling its establishment. The findings revealed capacity building, resources for palliative care services, and the existing social structure of the community being the main challenges that need to be overcome for better penetration of CBPC services into society. Demand generation through sensitization and administration of services based on the need and regular follow-up remains the key strategies for the sustainability of the program.

Conclusion

The CBPC program like 'Sanjeevan' adopted in the rural area of Puducherry can be cited as an example and can be replicated in other rural settings with similar sociocultural characteristics to support people living with end-stage diseases.

Comparison of home-based palliative care delivered by community health workers versus usual care: research protocol for a pilot randomized controlled trial

BACKGROUND

Research studies demonstrate that palliative care can improve patient outcomes such as quality of life, symptom burden and patient satisfaction with care (Gomes B, et al. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. 2013(6):CD00776) (World Health Organization. Palliative Care. Published 2020.). While 76% of patients who need palliative care live in limited-resource countries, access to high quality palliative services in these countries is minimal (Worldwide Hospice and Palliative Care Association and World Health Organization. Global Atlas of Palliative Care (2nd ed). 2020.). In 2014 the Worldwide Hospice Palliative Care Alliance, with strong endorsement by the WHO, released the Palliative Care Toolkit to provide a training and implementation toolkit for empowering community members to deliver palliative care in resource poor settings (Worldwide Hospice and Palliative Care Association and World Health Organization. Global Atlas of Palliative Care at the End of Life. Geneva, Switzerland 2014.). They encouraged researchers and public health practitioners to conduct rigorous evaluation of the toolkit in diverse settings and contexts. To address this need, we will conduct a pilot randomized controlled trial (RCT) to examine implementation and explore potential effect of an intervention based upon the Palliative Care Toolkit, as adapted and used by community health workers (CHWs) working with a cancer center in Kolkata, India to deliver home-based palliative care for rural patients.

METHODS

Utilizing a randomized controlled trial design, intervention patients (n = 45) receive home-based palliative services (Pal-Care) delivered by community health workers (CHWs), with comparison against a control group of patients (n = 45) who receive usual cancer-center-based palliative services. Primary outcome measures include evaluation of CHW training outcomes, roles and responsibilities of the CHWS and how they assist patients, trial recruitment, stakeholder perceptions of the intervention, and fidelity to study protocol. Secondary outcomes measure patient self-report of health-related quality of life, symptom burden, palliative needs and patient care experience, outcomes The RE-AIM framework guides our evaluation plan to measure the reach, effectiveness, adoption, implementation and maintenance of the Pal-Care intervention (Gaglio B, et al. The RE-AIM framework: a systematic review of use over time. Am J Public Health. 2013;103(6):e38?46.). Data will be analyzed in SAS. All measures will be evaluated overall and by patient age, gender and cancer type and by CHW caseload.

DISCUSSION

Pal-Care is a RCT funded by the NCI to explore utilization of CHWs to deliver a home-based palliative care intervention built upon the WHO Palliative Care toolkit (PCT), as compared to a usual care control group. The long-term goal of this research is to develop an effective and sustainable model for delivering home-based palliative care for cancer patients in underserved areas.

TRIAL REGISTRATION (TRN)

ClinicalTrials.gov ID# NCT04972630.

Caregivers' experiences of end-of-life caregiving to severely ill relatives with cancer dying at home: A qualitative study in the Faroe Islands

BACKGROUND AND AIM

It is common among people with advanced cancer to wish to die at home, but only a few succeed in doing so. The willingness of family members to care for a person, who wants to die at home, is crucial This qualitative study aimed to provide insight into conditions that make dying at home possible in a small-scale society and to describe family caregivers' experiences of providing end-of-life care in a private home setting.

METHODS

Thirteen caregivers were interviewed, their ages varying from 39 to 84 years. A phenomenological approach, inspired by Giorgi, was applied.

RESULTS

Two essential structures captured the experience of caring at home until death: 'Managing end-of-life care' and 'meaningfulness in a time of impending death'. It was mainly the family, and especially family members with a healthcare background, together with the district nurses, who supported the caregivers in managing the care of a dying relative at home. Being able to fulfil their relative's wish to die at home and to come closer together as a family made the caregivers feel their efforts meaningful.

CONCLUSION

Our findings point to the importance of having access to home care day and night for the caregivers to feel secure during the night-time. As of now, this is only an option in larger towns in the Faroe Islands, which might also be the case in outskirts areas in other countries. Our findings also showed an unmet need for support to ease the mental load on caregivers. Establishing an outgoing interdisciplinary palliative team would help to increase the number of people who want to die at home and succeed in doing so by giving the caregivers emotional and advisory support.

Exploring the challenges and roles of nurses in delivering palliative care for cancer patients and co-morbidities in Ghana

BACKGROUND

Patients suffering from chronic and life-threatening diseases receive inadequate palliative care in low-income countries, eventually leading to poor quality of life for these patients. Little is known about the experience of delivering palliative care in a low-resource country such as Ghana in comparison to higher-income countries. This study, therefore, aimed to assess the roles and challenges of nurses providing palliative care services for patients with cancer and life-limiting conditions at tertiary Hospitals in Ghana.

METHODS

Thirty oncology nurses at a tertiary Hospital in Ghana participated. All nurses were providing end-of-life care to patients with cancer. A qualitative exploratory-descriptive design and a semi-structured interview guide developed by the researchers were used. Interviews lasted on average forty minutes to 1 h were audio-recorded, and transcribed verbatim. Content analysis was carried out to generate themes and sub-themes.

FINDINGS

Participants were between the ages of 25 and 40 years. A higher percentage of females (n = 17, 57%) participated in the study than males (n = 13, 43%). Two main themes were generated which were the delivery of palliative care and the provision of home care services. The current roles of nurses were centered around pain management, home care services, spiritual needs, and psychological care. Challenges that hindered the implementation of palliative care included distress over expected and unexpected patient mortality, difficulty delivering bad news to patients and families, and frustration with health system resource shortages that negatively impacted patient care.

CONCLUSION

Palliative care is one of the essential services provided for patients with life-limiting conditions, and nurses play an active role in the provision of this care. Further research is needed to determine the most effective ways to deliver this care, particularly in developing nations like Ghana.

Evaluating the Potential of Machine Learning and Wearable Devices in End-of-Life Care in Predicting 7-Day Death Events Among Patients With Terminal Cancer: Cohort Study

BACKGROUND

An accurate prediction of mortality in end-of-life care is crucial but presents challenges. Existing prognostic tools demonstrate moderate performance in predicting survival across various time frames, primarily in in-hospital settings and single-time evaluations. However, these tools may fail to capture the individualized and diverse trajectories of patients. Limited evidence exists regarding the use of artificial intelligence (AI) and wearable devices, specifically among patients with cancer at the end of life.

OBJECTIVE

This study aimed to investigate the potential of using wearable devices and AI to predict death events among patients with cancer at the end of life. Our hypothesis was that continuous monitoring through smartwatches can offer valuable insights into the progression of patients at the end of life and enable the prediction of changes in their condition, which could ultimately enhance personalized care, particularly in outpatient or home care settings.

METHODS

This prospective study was conducted at the National Taiwan University Hospital. Patients diagnosed with cancer and receiving end-of-life care were invited to enroll in wards, outpatient clinics, and home-based care settings. Each participant was given a smartwatch to collect physiological data, including steps taken, heart rate, sleep time, and blood oxygen saturation. Clinical assessments were conducted weekly. The participants were followed until the end of life or up to 52 weeks. With these input features, we evaluated the prediction performance of several machine learning-based classifiers and a deep neural network in 7-day death events. We used area under the receiver operating characteristic curve (AUROC), F1-score, accuracy, and specificity as evaluation metrics. A Shapley additive explanations value analysis was performed to further explore the models with good performance.

RESULTS

From September 2021 to August 2022, overall, 1657 data points were collected from 40 patients with a median survival time of 34 days, with the detection of 28 death events. Among the proposed models, extreme gradient boost (XGBoost) yielded the best result, with an AUROC of 96%, F1-score of 78.5%, accuracy of 93%, and specificity of 97% on the testing set. The Shapley additive explanations value analysis identified the average heart rate as the most important feature. Other important features included steps taken, appetite, urination status, and clinical care phase.

CONCLUSIONS

We demonstrated the successful prediction of patient deaths within the next 7 days using a combination of wearable devices and AI. Our findings highlight the potential of integrating AI and wearable technology into clinical end-of-life care, offering valuable insights and supporting clinical decision-making for personalized patient care. It is important to acknowledge that our study was conducted in a relatively small cohort; thus, further research is needed to validate our approach and assess its impact on clinical care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05054907; https://classic.clinicaltrials.gov/ct2/show/NCT05054907.

Interventions to improve outcomes for caregivers of patients with advanced cancer: a meta-analysis

BACKGROUND

Family caregivers of patients with advanced cancer often have poor quality of life (QOL) and mental health. We examined the effectiveness of interventions offering support for caregivers of patients with advanced cancer on caregiver QOL and mental health outcomes.

METHODS

We searched Ovid MEDLINE, EMBASE, Cochrane CENTRAL, and Cumulative Index to Nursing and Allied Health Literature databases from inception through June 2021. Eligible studies reported on randomized controlled trials for adult caregivers of adult patients with advanced cancer. Meta-analysis was conducted for primary outcomes of QOL, physical well-being, mental well-being, anxiety, and depression, from baseline to follow-up of 1-3 months; secondary endpoints were these outcomes at 4-6 months and additional caregiver burden, self-efficacy, family functioning, and bereavement outcomes. Random effects models were used to generate summary standardized mean differences (SMD).

RESULTS

Of 12 193 references identified, 56 articles reporting on 49 trials involving 8554 caregivers were eligible for analysis; 16 (33%) targeted caregivers, 19 (39%) patient-caregiver dyads, and 14 (29%) patients and their families. At 1- to 3-month follow-up, interventions had a statistically significant effect on overall QOL (SMD = 0.24, 95% confidence interval [CI] = 0.10 to 0.39); I2 = 52.0%), mental well-being (SMD = 0.14, 95% CI = 0.02 to 0.25; I2 = 0.0%), anxiety (SMD = 0.27, 95% CI = 0.06 to 0.49; I2 = 74.0%), and depression (SMD = 0.34, 95% CI = 0.16 to 0.52; I2 = 64.4) compared with standard care. In narrative synthesis, interventions demonstrated improvements in caregiver self-efficacy and grief.

CONCLUSIONS

Interventions targeting caregivers, dyads, or patients and families led to improvements in caregiver QOL and mental health. These data support the routine provision of interventions to improve well-being in caregivers of patients with advanced cancer.

When should Home-visit nurses initiate end-of-life discussions for patients with Organ failure and family caregivers? A qualitative study

BACKGROUND

End-of-life (EOL) discussions for organ-failure patients with family caregivers are important factors for successful EOL care. However, identifying the appropriate time to initiate these discussions is difficult owing to the unpredictability of the disease trajectory. No practical tools or clinical indicators currently exist that can help identify non-cancer patients receiving home care who need EOL discussions.

METHODS

The survey was conducted from February 2020 to June 2021. To identify the appropriate time at which to initiate EOL discussions for patients with organ failure and their caregivers, we determined the time when home-visit nurses initiated EOL discussions. We interviewed 19 home-visit nurses (mean total home-visit nursing experience: 6.7 ± 5.9 years) and analyzed the data using Hsieh and Shannon's qualitative content approach.

RESULTS

Three themes related to home-visit nurses' experiences of identifying the appropriate time to start EOL discussions were identified: symptomatic worsening, lack of patients' and family caregivers' EOL awareness, and decline in activities of daily living.

CONCLUSIONS

It is necessary to develop a tool that will enable home-visit nurses to implement EOL discussions at the appropriate time.

Factors Associated With Mode of Separation for People With Palliative Diagnoses With Preference for Home Death Receiving Care From a Nurse-Led End of Life (Palliative Extended and Care at Home) Program

Palliative Extended and Care at Home (PEACH) is a rapid response nurse-led package of care mobilized for palliative care patients who have an expressed preference to die at home. This study aimed to identify the demographic and clinical predictors of home death for patients receiving the package. Deidentified data were used from administrative and clinical information systems. Univariate and multivariate analyses were conducted to assess association of sociodemographic factors with mode of separation. Furthermore, 1754 clients received the PEACH package during the study period. Mode of separation was home death (75.7%), hospital/palliative care unit admission (13.5%), and alive/discharged from the PEACH Program (10.8%). Of participants with clear preference to die at home, 79% met their wish. Multivariate analysis demonstrated cancer diagnosis, patients who wished to be admitted when death was imminent, and patients with undecided preference for location of death were associated with an increased likelihood of being admitted to the hospital. Compared with those with spousal caregivers, those cared for by their child/grandchild and other nonspouse caregivers were significantly associated with a decreased likelihood of being admitted to the hospital/palliative care unit. Our results show that opportunities to tailor home care based on referral characteristics to meet patient preference to die at home, at individual, system, and policy levels, exist.

SPICT as a predictive tool for risk of 1-year health degradation and death in older patients admitted to the emergency department: a bicentric cohort study in Belgium

BACKGROUND

Older patients are increasingly showing multi-comorbidities, including advanced chronic diseases. When admitted to the emergency department (ED), the decision to pursue life-prolonging treatments or to initiate a palliative care approach is a challenge for clinicians. We test for the first time the diagnostic accuracy of the Supportive and Palliative Care Indicators Tool (SPICT) in the ED to identify older patients at risk of deteriorating and dying, and timely address palliative care needs.

METHODS

We conducted a prospective bicentric cohort study on 352 older patients (≥ 75 years) admitted to two EDs in Belgium between December 2019 and March 2020 and between August and November 2020. SPICT (French version, 2019) variables were collected during the patients' admission to the ED, along with socio-demographic, medical and functional data. The palliative profile was defined as a positive SPICT assessment. Survival, symptoms and health degradation (≥ 1 point in ADL Katz score or institutionalisation and death) were followed at 12 months by phone. Main accuracy measures were sensitivity, specificity and likelihood ratios (LR) as well as cox regression, survival analysis using the Kaplan Meier method, and ordinal regression.

RESULTS

Out of 352 patients included in the study (mean age 83 ± 5.5 years, 43% male), 167 patients (47%) had a positive SPICT profile. At one year follow up, SPICT positive patients presented significantly more health degradation (72%) compared with SPICT negative patients (35%, p < 0.001). SPICT positivity was correlated with 1-year health degradation (OR 4.9; p < 0.001). The sensitivity and specificity of SPICT to predict health degradation were 0.65 (95%CI, 0.57-0.73) and 0.72 (95%CI, 0.64-0.80) respectively, with a negative LR of 0.48 (95%CI, 0.38-0.60) and a positive LR of 2.37 (1.78-3.16). The survival time was shorter in SPICT positive patients than in SPICT negative ones (p < 0.001), the former having a higher 1-year mortality rate (HR = 4.21; p < 0.001).

CONCLUSIONS

SPICT successfully identifies older patients at high risk of health degradation and death. It can support emergency clinicians to identify older patients with a palliative profile and subsequently initiate a palliative care approach with a discussion on goals of care.

Comparison of Symptom Severity and Progression in Advanced Cancer Patients Among Different Care Settings: A Secondary Analysis

Background

Most people in Japan wish to spend their final days at home, but the majority fail to do so; earlier studies indicated a more pronounced worsening of symptoms if treated at home.

Objectives

This study compared the prevalence of symptom worsening and explored associated factors between patients with advanced cancer receiving palliative care in palliative care units (PCUs) and at home.

Design

We conducted a secondary analysis of two multicenter, prospective cohort studies involving patients with advanced cancer receiving palliative care in PCUs or at home.

Setting/Subjects

One study was conducted at 23 PCUs (January to December 2017) and the other on 45 palliative home care services (July to December 2017) in Japan.

Measurements

Symptom changes were categorized as stable, improved, or worse.

Results

Of the 2998 registered patients, 2877 were analyzed. Among them, 1890 patients received palliative care in PCUs, and 987 at home. Patients receiving palliative care at home were more likely to have worsening of pain (17.1% vs. 3.8%; p < 0.001) and drowsiness (32.6% vs. 22.2%; p < 0.001) than those in PCUs. By multivariate logistic regression analysis, palliative care at home was significantly associated with worsening of the Palliative Prognostic Index dyspnea subscale in the unadjusted model (odds ratio, 1.42 [95% confidence interval, 1.08-1.88]; p = 0.014) but not for any symptoms in the adjusted model.

Conclusions

After adjusting for patient background, the prevalence of symptom worsening was not different between patients with advanced cancer receiving palliative care at home and in PCUs.

Survival Outcome and Prognostic Factors Among Patients With Hepatocellular Carcinoma: A Hospital-Based Study

Background

Hepatocellular carcinoma (HCC) is a leading cancer with very high incidence and mortality and low survival rate in Vietnam and worldwide. This study aimed to investigate the survival outcome and its prognostic factors among HCC patients.

Methods

This is a retrospective descriptive study on patients newly diagnosed with HCC at Hanoi Oncology Hospital, Vietnam from January 2018 to December 2020. Overall survival (OS) was calculated by the Kaplan-Meier method. Log-rank test and Cox regression were used to investigate the association among patients' OS and their diagnosis and treatment factors.

Results

A total of 674 patients were included. The median OS was 10.0 months. The survival rates at 6, 12, 24, and 36 months were 57.3%, 46.6%, 34.8%, and 29.7%, respectively. The initial performance status (PS), Child-Pugh score, and Barcelona Clinic Liver Cancer (BCLC) stage at the time of diagnosis are prognostic factors of HCC OS. A total of 451 (66.8%) patients have died, most of them (375 equally 83.1%) died at home, and only 76 (16.9%) died at hospital. Hepatocellular carcinoma patients living in the rural area more likely died at home than those living in the urban area (85.9% vs 74.8%, P = .007).

Conclusions

Hepatocellular carcinoma has a poor prognosis with low OS. Performance status, Child-Pugh score, and BCLC stage were the independent prognostic factors for the survival outcome of HCC patients. The fact that most HCC patients died at home suggested that home-based hospice care needs to be paid special attention.

Frequencies and reasons for unplanned emergency department return visits by older adults: a cohort study

BACKGROUND

As unplanned Emergency Department (ED) return visits (URVs) are associated with adverse health outcomes in older adults, many EDs have initiated post-discharge interventions to reduce URVs. Unfortunately, most interventions fail to reduce URVs, including telephone follow-up after ED discharge, investigated in a recent trial. To understand why these interventions were not effective, we analyzed patient and ED visit characteristics and reasons for URVs within 30 days for patients aged ≥ 70 years.

METHODS

Data was used from a randomized controlled trial, investigating whether telephone follow-up after ED discharge reduced URVs compared to a satisfaction survey call. Only observational data from control group patients were used. Patient and index ED visit characteristics were compared between patients with and without URVs. Two independent researchers determined the reasons for URVs and categorized them into: patient-related, illness-related, new complaints and other reasons. Associations were examined between the number of URVs per patient and the categories of reasons for URVs.

RESULTS

Of the 1659 patients, 222 (13.4%) had at least one URV within 30 days. Male sex, ED visit in the 30 days before the index ED visit, triage category "urgent", longer length of ED stay, urinary tract problems, and dyspnea were associated with URVs. Of the 222 patients with an URV, 31 (14%) returned for patient-related reasons, 95 (43%) for illness-related reasons, 76 (34%) for a new complaint and 20 (9%) for other reasons. URVs of patients who returned ≥ 3 times were mostly illness-related (72%).

CONCLUSION

As the majority of patients had an URV for illness-related reasons or new complaints, these data fuel the discussion as to whether URVs can or should be prevented.

TRIAL REGISTRATION

For this cohort study, we used data from a randomized controlled trial (RCT). This trial was pre-registered in the Netherlands Trial Register with number NTR6815 on the 7^th of November 2017.

Home Care Use and Out-of-Hospital Death in Pancreatic Cancer Patients: A Retrospective Cohort Study

Objective: This study aimed to determine the factors associated with usage of home care, including palliative home care, in patients with pancreatic cancer in Ontario. In addition, this study attempted to investigate factors associated with early-onset palliative home care as well as the impact of home care services on survival and out-of-hospital death. Methods: The Ontario Cancer Registry (OCR) was used to identify and capture basic patient/cancer characteristics of index cases of pancreatic cancer diagnosed between April first, 2010 and March 31st, 2016. Patients that received home care were identified using the Home Care Database (HCD) and stratified into general, transition-to-palliative, and early-onset palliative home care. Logistic regressions were used to describe determinants of home care use and determinants of out-of-hospital death. Results: A total of 6888 pancreatic cancer patients met eligibility criteria for this study. A high proportion of patients (83.7%) received home care, including palliative home care (56.8%). In general, older patients (OR = 3.07) and those with more advanced malignancy (OR = 4.98) for stage 4 versus stage 1) had greater odds of receiving palliative home care. Patients receiving home care (P < .01) and those residing in rural regions (P < .01) had greater odds of out-of-hospital death. Conclusion: A large proportion of patients with pancreatic cancer are directed to home care and those that do are more likely to die outside of hospital. Age and stage at diagnosis are significant predictors of home care use. Differences exist in the healthcare experience of patients depending on if they receive home care services and the type of home care.

Needs-based triggers for timely referral to palliative care for older adults severely affected by noncancer conditions: a systematic review and narrative synthesis

BACKGROUND

Older people with noncancer conditions are less likely to be referred to palliative care services due to the inherent uncertain disease trajectory and a lack of standardised referral criteria. For older adults with noncancer conditions where prognostic estimation is unpredictable, needs-based criteria are likely more suitable. Eligibility criteria for participation in clinical trials on palliative care could inform a needs-based criteria. This review aimed to identify and synthesise eligibility criteria for trials in palliative care to construct a needs-based set of triggers for timely referral to palliative care for older adults severely affected by noncancer conditions.

METHODS

A systematic narrative review of published trials of palliative care service level interventions for older adults with noncancer conditions. Electronic databases Medline, Embase, CINAHL, PsycINFO, CENTRAL, and ClinicalTrials.gov. were searched from inception to June 2022. We included all types of randomised controlled trials. We selected trials that reported eligibility criteria for palliative care involvement for older adults with noncancer conditions, where > 50% of the population was aged ≥ 65 years. The methodological quality of the included studies was assessed using a revised Cochrane risk-of-bias tool for randomized trials. Descriptive analysis and narrative synthesis provided descriptions of the patterns and appraised the applicability of included trial eligibility criteria to identify patients likely to benefit from receiving palliative care.

RESULTS

27 randomised controlled trials met eligibility out of 9,584 papers. We identified six major domains of trial eligibility criteria in three categories, needs-based, time-based and medical history-based criteria. Needs-based criteria were composed of symptoms, functional status, and quality of life criteria. The major trial eligibility criteria were diagnostic criteria (n = 26, 96%), followed by medical history-based criteria (n = 15, 56%), and physical and psychological symptom criteria (n = 14, 52%).

CONCLUSION

For older adults severely affected by noncancer conditions, decisions about providing palliative care should be based on the present needs related to symptoms, functional status, and quality of life. Further research is needed to examine how the needs-based triggers can be operationalized as referral criteria in clinical settings and develop international consensus on referral criteria for older adults with noncancer conditions.