An in-hospital clinical care pathway with integrated decision support for cancer pain management reduced pain intensity and needs for hospital stay

Standardizing Integrated Oncology and Palliative Care Across Service Levels: Challenges in Demonstrating Effects in a Prospective Controlled Intervention Trial

INTRODUCTION

Patients with cancer often want to spend their final days at home. In Norway, most patients with cancer die in institutions. We hypothesized that full integration of oncology and palliative care services would result in more time spent at home during end-of-life.

METHODS

A prospective non-randomized intervention trial was conducted in two rural regions of Mid-Norway. The hospitals' oncology and palliative care outpatient clinics and surrounding communities participated. An intervention including information, education, and a standardized care pathway was developed and implemented. Adult non-curative patients with cancer were eligible. Proportion of last 90 days of life spent at home was the primary outcome.

RESULTS

We included 129 patients in the intervention group (I) and 76 patients in the comparison group (C), of whom 82% of patients in I and 78% of patients in C died during follow-up. The mean proportion of last 90 days of life spent at home was 0.62 in I and 0.72 in C (p = 0.044), with 23% and 36% (p = 0.073), respectively, dying at home. A higher proportion died at home in both groups compared to pre-study level (12%). During the observation period the comparison region developed and implemented an alternative intervention to the study intervention, with the former more focused on end-of-life care.

CONCLUSION

A higher proportion of patients with cancer died at home in both groups compared to pre-study level. Patients with cancer in I did not spend more time at home during end-of-life compared to those in C. The study intervention focused on the whole disease trajectory, while the alternative intervention was more directed towards end-of-life care. "Simpler" and more focused interventions on end-of-life care may be relevant for future studies on integration of palliative care into oncology.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02170168.

Breakthrough and Episodic Cancer Pain from a Palliative Care Perspective

Cancer pain intensity (PI) fluctuates, but the relationship between pain flares and background pain with respect to pain management is not settled. We studied how flare and background PIs corresponded with treatment results for background cancer pain. Patients admitted to an acute palliative care unit with average and/or worst PI ≥ 1 on the 11-point numeric rating scale were included. Average and worst PI at admission and average PI at discharge were collected. We examined how the difference and ratio between worst and average PI and average PI at admission, were associated with average PI development during hospitalization. Positive differences between worst and average PI at admission were defined as pain flares. Ninety out of 131 patients had pain flares. The reduction in average PI for patients with flares was 0.9 and for those without, 1.9 (p = 0.02). Patients with large worst minus average PI differences reported the least improvement, as did those with large worst/average PI ratios. Patients with pain flares and average PI ≤ 4 at admission had unchanged average PI during hospitalization, while those with pain flares and average PI > 4 experienced pain reduction (2.1, p < 0.001). Large pain flares, in absolute values and compared to background PI, were associated with inferior pain relief.

The effects of cancer clinical decision support systems on patient-reported outcomes: A systematic review

PURPOSE

The implementation of high-quality decision-making support are integral to ensuring the delivery of quality cancer care and subsequently achieving positive patient outcomes. Decision Support Systems (DSS) are increasingly used, however it is not known what the effects are beyond supporting the decision-making process. We aimed to identify and synthesize the available literature regarding the effects of DSS on patient-reported outcomes both during and after cancer treatment.

METHODS

A systematic review was conducted using dual processes to identify empirical literature that reported an evaluation of DSS interventions and patient-reported outcomes. We appraised study quality using the Mixed Methods Appraisal Tool (MMAT). Data were narratively synthesized.

RESULTS

We included 15 studies, categorized as symptom assessment interventions or interactive educational interventions. Findings were mixed regarding the effectiveness of DSS interventions in improving total symptom distress and severity, whereas the majority were effective in reducing mean scores for worst and usual pain. Interventions were not effective in improving other health-related patient-reported outcomes including quality of life, global distress, depression, or self-efficacy and there were mixed effects for reducing decisional conflict. There was moderate to high patient adherence to the interventions and generally high satisfaction and acceptability, yet minimal evidence for the effect of DSS interventions in clinician adherence to intervention recommendations.

CONCLUSIONS

Including patient-reported outcomes in the evaluation of DSS is critical to understand their impact. Inconsistencies in reporting of interventions may, however, be a contributing factor to heterogeneous effects of clinical DSS regarding a broad range of patient-reported outcomes.

Antibiotic Therapy in Integrated Oncology and Palliative Cancer Care: An Observational Study

Simple Summary

Approximately one-quarter of the patients with advanced cancer acutely admitted to the Palliative Care Unit at St. Olav’s University Hospital received intravenous antibiotics. We observed that physiological variables and paraclinical findings in patients with and without infections differed at admission but observed no differences in patient-reported outcome measures. Patients admitted for infection had no shorter life expectancy than patients without infections. We did not observe any difference in the prescription of antibiotics to patients with ongoing anti-cancer therapy (integrated pathway) compared to patients with no ongoing cancer therapy (palliative care pathway). This information increases the knowledge about the use of antibiotic therapy in palliative cancer care.

Abstract

Decision-making for antibiotic therapy in palliative cancer care implies avoiding futile interventions and to identify patients who benefit from treatment. We evaluated patient-reported outcome-measures (PROMs), physiological findings, and survival in palliative cancer care patients hospitalized with an infection. All acute admissions during one year, directly to a University Hospital unit that provided integrated services, were included. Serious infection was defined as a need to start intravenous antibiotics. PROMs, clinical and paraclinical variables, and survival were obtained. Sixty-two of 257 patients received intravenous antibiotic treatment. PROMs were generally similar in the infection group and the non-infection group, both in respect to intensities at admission and improvements during the stay. There were more physiological and paraclinical deviations at admission in patients in the infection group. These deviations improved during the stay. Survival was not poorer in the infection group compared to the non-infection group. Patients in integrated cancer care were as likely to be put on intravenous antibiotics but had longer survival. In integrated oncology and palliative cancer services, patients with an infection had similar outcomes as those without an infection. This argues that the use of intravenous antibiotics is appropriate in many patients admitted to palliative care.

Implementing a Standardized Care Pathway Integrating Oncology, Palliative Care and Community Care in a Rural Region of Mid-Norway

INTRODUCTION

To improve quality across levels of care, we developed a standardized care pathway (SCP) integrating palliative and oncology services for hospitalized and home-dwelling palliative cancer patients in a rural region.

METHODS

A multifaceted implementation strategy was directed towards a combination of target groups. The implementation was conducted on a system level, and implementation-related activities were registered prospectively. Adult patients with advanced cancer treated with non-curative intent were included and interviewed. Healthcare leaders (HCLs) and healthcare professionals (HCPs) involved in the development of the SCP or exposed to the implementation strategy were interviewed. In addition, HCLs and HCPs exposed to the implementation strategy answered standardized questionnaires. Hospital admissions were registered prospectively.

RESULTS

To assess the use of the SCP, 129 cancer patients were included. Fifteen patients were interviewed about their experiences with the patient-held record (PHR). Sixty interviews were performed among 1320 HCPs exposed to the implementation strategy. Two hundred and eighty-seven HCPs reported on their training in and use of the SCP. Despite organizational cultural differences, developing an SCP integrating palliative and oncology services across levels of care was feasible. Both HCLs and HCPs reported improved quality of care in the wake of the implementation process. Two and a half years after the implementation was launched, 28% of the HCPs used the SCP and 41% had received training in its use. Patients reported limited use and benefit of the PHR.

CONCLUSION

An SCP may be a usable tool for integrating palliative and oncology services across care levels in a rural region. An extensive implementation process resulted in improvements of process outcomes, yet still limited use of the SCP in clinical practice. HCLs and HCPs reported improved quality of cancer care following the implementation process. Future research should address mandatory elements for usefulness and successful implementation of SCPs for palliative cancer patients.

Breakthrough cancer pain in 2020

PURPOSE OF REVIEW

An overview on breakthrough cancer pain (BTCP), including inherent limitations of the terminology, assessment, clinical presentation, and treatment options.

RECENT FINDINGS

The estimated prevalence of BTCP is dependent on the defined cutoffs for controlled background pain and the magnitude of the pain flare. In addition, pain flares outside the definition of BTCP are prevalent. In the 11th Revision of the International Classification of Diseases, the temporal characteristics of cancer pain are described as continuous background pain and intermittent episodic pain. BTCP should be assessed by validated methods, and the patient perspective should be included. The pain may be related to neoplastic destruction of bone, viscera, or nerve tissue and is characterized by rapid onset, high intensity, and short duration. Treatment directed towards painful metastases must be considered. Due to pharmacological properties mirroring the pain characteristics, transmucosal fentanyl formulations are important for the treatment of BTCP. Oral immediate release opioids can be used for slow-onset or predictable BTCP. For more difficult pain conditions, parenteral, or even intrathecal pain medication, may be indicated.

SUMMARY

All clinically relevant episodic pains must be adequately treated in accordance with the patient's preferences. Transmucosal fentanyl formulations are effective for BTCP.

Interventions and symptom relief in hospital palliative cancer care: results from a prospective longitudinal study

PURPOSE

To study the use of interventions and symptom relief for adult patients with incurable cancer admitted to an acute palliative care unit providing integrated oncology and palliative care services.

METHODS

All admissions during 1 year were assessed. The use of interventions was evaluated for all hospitalizations. Patients with assessments for worst and average pain intensity, tiredness, drowsiness, nausea, appetite, dyspnea, depression, anxiety, well-being, constipation, and sleep were evaluated for symptom development during hospitalization. Descriptive statistics was applied for the use of interventions and the paired sample t-test to compare symptom intensities (SIs).

RESULTS

For 451 admissions, mean hospital length of stay was 7.0 days and mean patient age 69 years. More than one-third received systemic cancer therapy. Diagnostic imaging was performed in 66% of the hospitalizations, intravenous rehydration in 45%, 37% received antibiotics, and 39% were attended by the multidisciplinary team. At admission and at discharge, respectively, 55% and 44% received oral opioids and 27% and 45% subcutaneous opioids. For the majority, opioid dose was adjusted during hospitalization. Symptom registrations were available for 180 patients. Tiredness yielded the highest mean SI score (5.6, NRS 0-10) at admission and nausea the lowest (2.2). Significant reductions during hospitalization were reported for all assessed SIs (p ≤ 0.01). Patients receiving systemic cancer therapy reported symptom relief similar to those not on systemic cancer therapy.

CONCLUSION

Clinical practice and symptom relief during hospitalization were described. Symptom improvements were similar for oncological and palliative care patients.