The impact of conducting a regional palliative care clinical study

Using the 'Social Marketing Mix Framework' to explore recruitment barriers and facilitators in palliative care randomised controlled trials? A narrative synthesis review

BACKGROUND

Effective recruitment to randomised controlled trials is critically important for a robust, trustworthy evidence base in palliative care. Many trials fail to achieve recruitment targets, but the reasons for this are poorly understood. Understanding barriers and facilitators is a critical step in designing optimal recruitment strategies.

AIM

To identify, explore and synthesise knowledge about recruitment barriers and facilitators in palliative care trials using the '6 Ps' of the 'Social Marketing Mix Framework'.

DESIGN

A systematic review with narrative synthesis.

DATA SOURCES

Medline, CINAHL, PsycINFO and Embase databases (from January 1990 to early October 2016) were searched. Papers included the following: interventional and qualitative studies addressing recruitment, palliative care randomised controlled trial papers or reports containing narrative observations about the barriers, facilitators or strategies to increase recruitment.

RESULTS

A total of 48 papers met the inclusion criteria. Uninterested participants (Product), burden of illness (Price) and 'identifying eligible participants' were barriers. Careful messaging and the use of scripts/role play (Promotion) were recommended. The need for intensive resources and gatekeeping by professionals were barriers while having research staff on-site and lead clinician support (Working with Partners) was advocated. Most evidence is based on researchers' own reports of experiences of recruiting to trials rather than independent evaluation.

CONCLUSION

The 'Social Marketing Mix Framework' can help guide researchers when planning and implementing their recruitment strategy but suggested strategies need to be tested within embedded clinical trials. The findings of this review are applicable to all palliative care research and not just randomised controlled trials.

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

BACKGROUND

Extensive evidence shows that well over 50% of people prefer to be cared for and to die at home provided circumstances allow choice. Despite best efforts and policies, one-third or less of all deaths take place at home in many countries of the world.

OBJECTIVES

1. To quantify the effect of home palliative care services for adult patients with advanced illness and their family caregivers on patients' odds of dying at home; 2. to examine the clinical effectiveness of home palliative care services on other outcomes for patients and their caregivers such as symptom control, quality of life, caregiver distress and satisfaction with care; 3. to compare the resource use and costs associated with these services; 4. to critically appraise and summarise the current evidence on cost-effectiveness.

SEARCH METHODS

We searched 12 electronic databases up to November 2012. We checked the reference lists of all included studies, 49 relevant systematic reviews, four key textbooks and recent conference abstracts. We contacted 17 experts and researchers for unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITSs) evaluating the impact of home palliative care services on outcomes for adults with advanced illness or their family caregivers, or both.

DATA COLLECTION AND ANALYSIS

One review author assessed the identified titles and abstracts. Two independent reviewers performed assessment of all potentially relevant studies, data extraction and assessment of methodological quality. We carried out meta-analysis where appropriate and calculated numbers needed to treat to benefit (NNTBs) for the primary outcome (death at home).

MAIN RESULTS

We identified 23 studies (16 RCTs, 6 of high quality), including 37,561 participants and 4042 family caregivers, largely with advanced cancer but also congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), HIV/AIDS and multiple sclerosis (MS), among other conditions. Meta-analysis showed increased odds of dying at home (odds ratio (OR) 2.21, 95% CI 1.31 to 3.71; Z = 2.98, P value = 0.003; Chi(2) = 20.57, degrees of freedom (df) = 6, P value = 0.002; I(2) = 71%; NNTB 5, 95% CI 3 to 14 (seven trials with 1222 participants, three of high quality)). In addition, narrative synthesis showed evidence of small but statistically significant beneficial effects of home palliative care services compared to usual care on reducing symptom burden for patients (three trials, two of high quality, and one CBA with 2107 participants) and of no effect on caregiver grief (three RCTs, two of high quality, and one CBA with 2113 caregivers). Evidence on cost-effectiveness (six studies) is inconclusive.

AUTHORS' CONCLUSIONS

The results provide clear and reliable evidence that home palliative care increases the chance of dying at home and reduces symptom burden in particular for patients with cancer, without impacting on caregiver grief. This justifies providing home palliative care for patients who wish to die at home. More work is needed to study cost-effectiveness especially for people with non-malignant conditions, assessing place of death and appropriate outcomes that are sensitive to change and valid in these populations, and to compare different models of home palliative care, in powered studies.

Interventions to improve continuity of care in the follow-up of patients with cancer

BACKGROUND

Care from the family physician is generally interrupted when patients with cancer come under the care of second-line and third-line healthcare professionals who may also manage the patient's comorbid conditions. This situation may lead to fragmented and uncoordinated care, and results in an increased likelihood of not receiving recommended preventive services or recommended care.

OBJECTIVES

To classify, describe and evaluate the effectiveness of interventions aiming to improve continuity of cancer care on patient, healthcare provider and process outcomes.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organization of Care Group (EPOC) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, CINAHL, and PsycINFO, using a strategy incorporating an EPOC Methodological filter. Reference lists of the included study reports and relevant reviews were also scanned, and ISI Web of Science and Google Scholar were used to identify relevant reports having cited the studies included in this review.

SELECTION CRITERIA

Randomised controlled trials (including cluster trials), controlled clinical trials, controlled before and after studies and interrupted time series evaluating interventions to improve continuity of cancer care were considered for inclusion. We included studies that involved a majority (> 50%) of adults with cancer or healthcare providers of adults with cancer. Primary outcomes considered for inclusion were the processes of healthcare services, objectively measured healthcare professional, informal carer and patient outcomes, and self-reported measures performed with scales deemed valid and reliable. Healthcare professional satisfaction was included as a secondary outcome.

DATA COLLECTION AND ANALYSIS

Two reviewers described the interventions, extracted data and assessed risk of bias. The authors contacted several investigators to obtain missing information. Interventions were regrouped by type of continuity targeted, model of care or interventional strategy and were compared to usual care. Given the expected clinical and methodological diversity, median changes in outcomes (and bootstrap confidence intervals) among groups of studies that shared specific features of interest were chosen to analyse the effectiveness of included interventions.

MAIN RESULTS

Fifty-one studies were included. They used three different models, namely case management, shared care, and interdisciplinary teams. Six additional interventional strategies were used besides these models: (1) patient-held record, (2) telephone follow-up, (3) communication and case discussion between distant healthcare professionals, (4) change in medical record system, (5) care protocols, directives and guidelines, and (6) coordination of assessments and treatment.Based on the median effect size estimates, no significant difference in patient health-related outcomes was found between patients assigned to interventions and those assigned to usual care. A limited number of studies reported psychological health, satisfaction of providers, or process of care measures. However, they could not be regrouped to calculate median effect size estimates because of a high heterogeneity among studies.

AUTHORS' CONCLUSIONS

Results from this Cochrane review do not allow us to conclude on the effectiveness of included interventions to improve continuity of care on patient, healthcare provider or process of care outcomes. Future research should evaluate interventions that target an improvement in continuity as their primary objective and describe these interventions with the categories proposed in this review. Also of importance, continuity measures should be validated with persons with cancer who have been followed in various settings.

Formal feasibility studies in palliative care: why they are important and how to conduct them

The concept of clinical trial feasibility is of great interest to the community of palliative care researchers, clinicians, and granting agencies. Significant allocation of resources is required in the form of funding, time, intellect, and motivation to carry out clinical research, and understandably, clinical investigators, institutions, and granting agencies are disappointed when funded trials are unsuccessfully conducted. We argue that for many trials conducted in palliative care, the feasibility of conducting the proposed trial should be formally explored before implementation. There is substantial information available within the literature on the topic of study feasibility but no singular guide on how one can pragmatically apply this advice in the palliative care setting. We suggest that a Formal Feasibility Study for palliative care trials should be commonly conducted before development of a larger pivotal trial, to prospectively identify barriers to research, develop strategies to address these barriers, and predict whether the larger study is feasible. If a Formal Feasibility Study is not required, elements of feasibility can be specifically tested before launching clinical trials. The purpose of this article is to offer a draft framework for the design and conduct of a Formal Feasibility Study that, if implemented, could concretely support successful completion of high-quality research in a timely fashion. Additionally, we hope to foster dialogue within the palliative care research community regarding the relevance of establishing feasibility before initiation of definitive trials in the palliative care population.

Methodological challenges in supportive and palliative care cancer research

As a growing medical field, palliative and supportive care should incorporate evidence-based medical practice. The gold standard research method continues to be the randomized clinical trial. This has been pursued with regard to cancer trials focused on cure. It has specific operational and methodological challenges in advanced disease. There are numerous reasons why effective research in palliative and supportive care is difficult. A consensus on the best research strategies and design is lacking. We will discuss the principles of palliative and supportive care research, examine the inherent challenges particularly in randomized controlled trials, and offer some suggestions to overcome them.

A proposed taxonomy of terms to guide the clinical trial recruitment process

CONTEXT

The successful conduct of clinical trials in palliative care is challenged by low accrual rates, high attrition of study patients during trials, difficulties managing comorbidity, and other factors. But what has been learned about improving the feasibility of palliative care research studies?

OBJECTIVE

To develop standard terms to describe patient accrual, and using these terms, describe an approach to allow investigators to predict trial feasibility.

METHODS

We proposed a standard language and definitions for specific elements of feasibility within clinical trial design and conduct. We then developed an approach to apply data generated from the use of these terms to allow researchers to predict feasibility at the design stage of a clinical trial's development.

RESULTS

We developed a taxonomy and then retrospectively applied the approach to four trials selected from our library of completed studies, to provide preliminary validity evidence. The approach includes a framework to help predict the number of patients needed to be assessed to achieve a study's accrual targets, as part of ongoing operational oversight to monitor the conduct and feasibility of a clinical trial.

CONCLUSION

Challenges to successful completion of palliative care trials are prevalent and serious. A taxonomy to characterize the eligible patient pool, and an approach by which feasibility is systematically investigated, hold the promise to enhance the effectiveness of scarce resources applied to palliative and end-of-life research.

PRISMA: a pan-European co-ordinating action to advance the science in end-of-life cancer care

INTRODUCTION

The epidemiology of progressive cancer and associated mortality in Europe underlines the essential need for high quality palliative and end-of-life care for its citizens. Currently, care of patients at the end-of-life is under-researched and under-funded. This is due to a lack of prioritisation, challenges in defining end-of-life, lack of a common research strategy for Europe that identifies and implements best practice and highest scientific principles, and the need for common use of appropriate well-validated tools to measure and improve the end-of-life cancer experience in Europe.

METHODS

PRISMA is a pan-European co-ordinating action funded under Framework Programme 7 of the European Commission. With 12 partners in 9 countries, it is delivering a series of 8 Work Packages with the common aim of promoting best practice in the measurement of end-of-life care, setting an agenda and guidance that reflects European cultural diversity, and is informed by both public and clinical priorities. Guidance in the selection, adaptation and use of core tools is informed by experts in public health and clinical research.

DISCUSSION

PRISMA is currently producing a series of outputs to be accessible to the wider community of researchers, policy makers, funders and clinicians. We encourage new partnerships to build on the work of PRISMA and to lead high quality work informed by our deliverables. PRISMA, we hope, is redressing the current lack of co-ordination of cancer end-of-life research across Europe, and will catalyse the conduct of evidence-based care that reflects European populations and priorities.

Changes in anticholinergic load from regular prescribed medications in palliative care as death approaches

Although there is an understandable emphasis on the side effects of individual medications, the cumulative effects of medications have received little attention in palliative care prescribing. Anticholinergic load reflects a cumulative effect of medications that may account for several symptoms and adverse health outcomes frequently encountered in palliative care. A secondary analysis of 304 participants in a randomised controlled trial had their cholinergic load calculated using the Clinician-Rated Anticholinergic Scale (modified version) longitudinally as death approached from medication data collected prospectively by study nurses on each visit. Mean time from referral to death was 107 days, and mean 4.8 visits were conducted in which data were collected. Relationships to key factors were explored. Data showed that anticholinergic load rose as death approached because of increasing use of medications for symptom control. Symptoms significantly associated with increasing anticholinergic load included dry mouth and difficulty concentrating (P < 0.05). There were also significant associations with increasing anticholinergic load and decreasing functional status (Australia-modified Karnofsky Performance Scale; and quality of life (P < 0.05). This study has documented in detail the longitudinal anticholinergic load associated with medications used in a palliative care population between referral and death, demonstrating the biggest contributor to anticholinergic load in a palliative care population is from symptom-specific medications, which increased as death approached.

The project ENABLE II randomized controlled trial to improve palliative care for rural patients with advanced cancer: baseline findings, methodological challenges, and solutions

OBJECTIVE

There is a paucity of randomized controlled trials (RCTs) to evaluate models of palliative care. Although interventions vary, all have faced a variety of methodological challenges including adequate recruitment, missing data, and contamination of the control group. We describe the ENABLE II intervention, methods, and sample baseline characteristics to increase intervention and methodological transparency, and to describe our solutions to selected methodological issues.

METHODS

Half of the participants recruited from our rural U.S. comprehensive cancer center and affiliated clinics were randomly assigned to a phone-based, nurse-led educational, care coordination palliative care intervention model. Intervention services were provided to half of the participants weekly for the first month and then monthly until death, including bereavement follow-up call to the caregiver. The other half of the participants were assigned to care as usual. Symptoms, quality of life, mood, and functional status were assessed every 3 months until death.

RESULTS

Baseline data of 279 participants were similar to normative samples. Solutions to methodological challenges of recruitment, missing data, and "usual care" control group contamination are described.

SIGNIFICANCE OF RESULTS

It is feasible to overcome many of the methodological challenges to conducting a rigorous palliative care RCT.

Preference for place of care and place of death in palliative care: are these different questions?

Place of death is at times suggested as an outcome for palliative care services. This study aimed to describe longitudinal preferences for place of care and place of death over time for patients and their caregivers. Longitudinal paired data of patient/caregiver dyads from a prospective unblinded cluster randomised control trial were used. Patients and caregivers were separately asked by the palliative care nurse their preference at that time for place of care and place of death. Longitudinal changes over time for both questions were mapped; patterns of agreement (patient and caregiver; and preference for place of death when last asked and actual placed of death) were analysed with kappa statistics. Seventy-one patient/caregiver dyads were analysed. In longitudinal preferences, preferences for both the place of care (asked a mean of >6 times) and place of death (asked a mean of >4 times) changed for patients (28% and 30% respectively) and caregivers (31% and 30%, respectively). In agreement between patients and caregivers, agreement between preference of place of care and preferred place of death when asked contemporaneously for patients and caregivers was low [56% (kappa 0.33) and 36% (kappa 0.35) respectively]. In preference versus actual place of death, preferences were met for 37.5% of participants for home death; 62.5% for hospital; 76.9% for hospice and 63.6% for aged care facility. This study suggests that there are two conversations: preference for current place of care and preference for care at the time of death. Place of care is not a euphemism for place of death; and further research is needed to delineate these. Patient and caregiver preferences may not change simultaneously. Implications of any mismatch between actual events and preferences need to be explored.