Prevalence and characteristics of patients with advanced chronic conditions in need of palliative care in the general population: a cross-sectional study

A refined ICD-10 diagnoses-based approach for retrospective analysis of potential palliative care need and coverage in claims data of deceased

Objectives

ICD-10-based approaches often provide the basis for retrospective estimation of potential palliative care need. Applying the ICD-10-based Murtagh et al. classification from 2014 (Murtagh classification), developed using mortality data, to administrative claims data leads to inconsistencies in estimating palliative care need. The aim of the study was to refine the classification for palliative care need estimation in deceased individuals with cancer and non-cancer diagnosis.

Methods

A retrospective population-based study comparing Murtagh classification to a new ICD-10-based classification (revised by expert opinion) was conducted using outpatient and inpatient claims data, including billing codes for palliative care. Palliative care need was estimated for diagnoses groups and was contrasted with palliative care utilization rates in the last year of life. Our dataset included records of 417,405 individuals who deceased in 2016-2019.

Results

Out of individuals deceased in 2019 (n = 117,436), 81.4% had at least one diagnosis from the new classification, while 97.0% had at least one diagnosis from the Murtagh classification. Classification revision thus identified fewer individuals as potentially in need of palliative care. Among individuals with cancer, 70.7% (vs. 55.7% via Murtagh classification) received palliative care. In non-cancer subgroups, the utilization rate was considerably lower, with a maximum of 36.7% (vs. 33.7% via Murtagh classification) in 2019. Similar results were observed for the other years.

Conclusion

Compared to the ICD10-based Murtagh classification, the revised ICD-10-based classification enables more realistic estimations if the cause of death is unavailable and reveals higher rates of palliative care coverage and differences especially in cancer versus non-cancer diseases. German Clinical Trials Register (DRKS00024133).

Dementia patients in palliative care according to data from the German National Hospice and Palliative Care Register (2009-2021)

BACKGROUND

People with dementia are less in focus of palliative care research than other patient groups even though the awareness of their palliative and end-of-life care needs is rising. Empirical data analyses on people with dementia in palliative care services are lacking.

AIM

To explore the prevalence of dementia diagnoses as per the ICD criteria among users of various palliative care settings and to compare use of palliative services, care pathways, and outcomes in people with and without a dementia diagnosis.

DESIGN

We conducted retrospective analysis of dementia diagnoses as per ICD (F00-F03/G30) in the German National Hospice and Palliative Care Register between 2009 and 2021. The analysis used methods of descriptive and inferential statistics, including the Bonferroni correction for alpha error inflation.

SETTING/PARTICIPANTS

We limited the analysis to the subsample of people aged over 64.

RESULTS

The prevalence of dementia in the different settings of palliative care was lower than in the age-comparable population: Of the 69,116 data sets included in the analysis, a small minority (3.3%) was coded with dementia as the principal diagnosis. Among patients on inpatient palliative care wards, 0.8% (148 of 19,161) had a dementia diagnosis, as did 2.2% (52 of 2,380) of those under hospital palliative care support teams and 4.3% (2,014 of 46,803) of those receiving specialized palliative care at home.

CONCLUSIONS

The records of the German National Hospice and Palliative Care Register suggest that the prevalence of dementia is lower than one might expect from general population data, though numbers are in line with international studies on proportion of dementia patients receiving palliative care. Future research could usefully examine whether this discrepancy stems either from omissions in coding dementia as patients' principal diagnosis respectively from lapses in documentation of a dementia diagnosis previously made, or from barriers to accessing palliative care services or even displays being excluded from palliative care when trying to access it.

TRIAL REGISTRATION

No registration.

Prognostic Role of NECPAL CCOMS-ICO Tool on One-Year Mortality in a Hospitalized Older Population

Background: It is essential to establish both the appropriateness of palliative care (PC) and the prognosis in daily clinical practice to guide decision making in the management of older people with multiple advanced chronic diseases. Objectives: We assessed patients who were appropriate for PC using the NECPAL tool in a hospitalized older population and then we investigated its predictive validity on one-year mortality compared with the multidimensional prognostic index (MPI), a validated geriatric prognostic tool. Design: Prospective cohort study. Setting/Subjects: We enrolled 103 older adults hospitalized for acute medical and surgical conditions in a geriatric hospital in Italy. Measurements: The variables of interest were obtained at baseline through interviews of the ward medical staff and by consulting the computerized medical records. Long-term mortality (one-year) was assessed through the analysis of data acquired from hospital or territorial databases or through telephone contact with caregivers. Results: Mean age was 86.8 ± 7.2 years, with a female prevalence of 54.4%. Prevalence of NECPAL+ patients was 65.1%. MPI low risk: 30.1%; moderate risk: 41.7%; severe risk: 28.2%. Patients deceased during follow-up were 54.4%. NECPAL+ patients were more likely to die, even after adjusting for age, sex, and MPI score (hazard ratio [HR] 2.7, p = 0.020). All the NECPAL categories were associated with one-year mortality. MPI showed a better predictive power than NECPAL (area under the curve [AUC] 0.85 vs. 0.75, p = 0.030). After the exclusion of "Comorbidity: ≥2 concurrent diseases" item from NECPAL, its AUC increased to 0.78 with no statistically significant differences from MPI (p = 0.122). Conclusions: NECPAL is useful to identify the appropriateness of PC in hospitalized older adults, also allowing to predict long-term mortality with a performance similar to that of a validated geriatric prognostic tool.

[Palliative Care Needs in Primary Health Care: Characteristics of Patients with Advanced Cancer and Dementia]

INTRODUCTION

The increase in life expectancy brought a higher prevalence of chronic diseases, with an emphasis on those who reached advanced stages and required palliative care. We aimed to characterize patients diagnosed with advanced neoplasms and/or dementia accompanied in primary health care and to test the sensitivity of two tools for identifying patients with palliative needs.

METHODS

We recruited three voluntary family physicians who provided data relative to 623 patients with active codification for neoplasm and/or dementia on the MIM@UF platform. We defined 'patient with palliative needs' as any patient with this codification in advanced stadium and made their clinical and sociodemographic characterization. Assuming the existence of advanced-stage disease as the gold standard, we calculated and compared the sensitivities of each of the tools under study: the surprise question, the question 'do you think this patient has palliative needs?' and an instrument that corresponded to identification by at least one of the questions.

RESULTS

Among the analyzed data, there were 559 (89.7%) active codifications of neoplasm and 64 (10.3%) of dementia; the prevalence of advanced neoplasm and dementia was 1.0% in the studied sample. The subgroup of patients with advanced dementia showed female sex predominance, an older age, and less access to health care. In both subgroups there was a scarcity of data related to education and income, and we observed polypharmacotherapy and multimorbidity. The sensitivity of the surprise question was 33.3% for neoplasia and 69.3% for dementia; of the new tool 50.0% for neoplasia and 92.3% for dementia; and, when used together, 55.6% for neoplasia and 92.3% for dementia.

CONCLUSION

Our results help characterize two subpopulations of patients in need of palliative care and advance with a possible tool for their identification, to be confirmed in a representative sample.

Machine Learning Model for Predicting Mortality Risk in Patients With Complex Chronic Conditions: Retrospective Analysis

Background

The health care system is undergoing a shift toward a more patient-centered approach for individuals with chronic and complex conditions, which presents a series of challenges, such as predicting hospital needs and optimizing resources. At the same time, the exponential increase in health data availability has made it possible to apply advanced statistics and artificial intelligence techniques to develop decision-support systems and improve resource planning, diagnosis, and patient screening. These methods are key to automating the analysis of large volumes of medical data and reducing professional workloads.

Objective

This article aims to present a machine learning model and a case study in a cohort of patients with highly complex conditions. The object was to predict mortality within the following 4 years and early mortality over 6 months following diagnosis. The method used easily accessible variables and health care resource utilization information.

Methods

A classification algorithm was selected among 6 models implemented and evaluated using a stratified cross-validation strategy with k=10 and a 70/30 train-test split. The evaluation metrics used included accuracy, recall, precision, F1-score, and area under the receiver operating characteristic (AUROC) curve.

Results

The model predicted patient death with an 87% accuracy, recall of 87%, precision of 82%, F1-score of 84%, and area under the curve (AUC) of 0.88 using the best model, the Extreme Gradient Boosting (XGBoost) classifier. The results were worse when predicting premature deaths (following 6 months) with an 83% accuracy (recall=55%, precision=64% F1-score=57%, and AUC=0.88) using the Gradient Boosting (GRBoost) classifier.

Conclusions

This study showcases encouraging outcomes in forecasting mortality among patients with intricate and persistent health conditions. The employed variables are conveniently accessible, and the incorporation of health care resource utilization information of the patient, which has not been employed by current state-of-the-art approaches, displays promising predictive power. The proposed prediction model is designed to efficiently identify cases that need customized care and proactively anticipate the demand for critical resources by health care providers.

[Prevalence and clinical characteristics of pain in patients with advanced chronic disease]

OBJECTIVES

Determine pain prevalence and clinical characteristics in patients with advanced chronic disease and identify breakthrough pain frequency.

DESIGN

Observational, descriptive, cross-sectional study.

LOCATION

Three primary care teams and one intermediate care hospital.

PARTICIPANTS

All patients with advanced chronic disease.

MAIN MEASUREMENTS

A semi-structured interview was performed to collect demographic, clinical, and specific variables of pain using validated scales. Patient location (home, nursing home or hospital) and advanced chronicity trajectory (organ failure, oncological disease, dementia, or multimorbidity) were recorded. Pain was assessed based on the Brief Pain Inventory (BPI) and, in cases of disabling dementia, using the Pain Assessment in Advanced Dementia (PAINAD). A statistical descriptive, comparative analysis between variables was performed using the R software.

RESULTS

Of all patients selected, 223 (60.4%) were included. Prevalence of pain: 83.9% (n=187), with no differences based on location or trajectory. Significant differences in pain intensity based on location (P=.0046) (moderate-severe in patients at home, moderate in hospital patients, and mild in nursing home patients) and on trajectory (P<.0001) (moderate-severe in patients with organ failure and multimorbidity, moderate in patients with cancer, and mild in patients with dementia). Global functional impact of pain was mild-moderate, emotional impact was severe in 41.5% of patients (n=51), and breakthrough pain was observed in 8.6% (n=13).

CONCLUSIONS

Pain must always be explored and assessed in patients with advanced chronicity, since it was highly prevalent in all locations and trajectories, being particularly intense in patients at home with organ failure and multimorbidity. Breakthrough pain was found in non-oncological trajectories.

The prognostic value of the NECPAL instrument, Palliative Prognostic Index, and PROFUND index in elderly residents of nursing homes with advanced chronic condition

BACKGROUND

It is essential to assess the need for palliative care and the life prognosis of elderly nursing home residents with an advanced chronic condition, and the NECPAL ICO-CCOMS©4.0 prognostic instrument may be adequate for both purposes. The objective of this study was to examine the predictive capacity of NECPAL, the Palliative Prognosis Index, and the PROFUND index in elderly residents with advanced chronic condition with and without dementia, comparing their results at different time points.

METHODS

This prospective observational study was undertaken in eight nursing homes, following the survival of 146 residents with advanced chronic condition (46.6% with dementia) at 3, 6, 12, and 24 months. The capacity of the three instruments to predict mortality was evaluated by calculating the area under the receiver operating characteristic curve (AUC), with 95% confidence interval, for the global population and separately for residents with and without dementia.

RESULTS

The mean age of residents was 84.63 years (± 8.989 yrs); 67.8% were female. The highest predictive capacity was found for PROFUND at 3 months (95%CI: 0.526-0.756; p = 0.016), for PROFUND and NECPAL at 12 months (non-significant; AUC > 0.5), and NECPAL at 24 months (close-to-significant (AUC = 0.624; 95% CI: 0.499-0.750; p = 0.053). The highest capacity at 12 months was obtained using PROFUND in residents with dementia (AUC = 0.698; 95%CI: 0.566-0.829; p = 0.003) and NECPAL in residents without dementia (non-significant; AUC = 0.649; 95%CI: 0.432-0.867; p = 0.178). Significant differences in AUC values were observed between PROFUND at 12 (p = 0.017) and 24 (p = 0.028) months.

CONCLUSIONS

PROFUND offers the most accurate prediction of survival in elderly care home residents with advanced chronic condition overall and in those with dementia, especially over the short term, whereas NECPAL ICO-CCOMS©4.0 appears to be the most useful to predict the long-term survival of residents without dementia. These results support early evaluation of the need for palliative care in elderly care home residents with advanced chronic condition.

Cultural adaptation and validation of the Quality of Dying in Long-term Care (QoD-LTC and QoD-LTC-C) scales by caregivers in nursing homes

BACKGROUND

There is a lack of tools that can evaluate quality of dying in nursing homes from the perspective of deceased patients' caregivers. The aim of this study was to adapt and validate the caregivers' versions of the Quality of Dying in Long-Term Care (QoD-LTC) and Quality of Dying in Long-Term Care Complete (QoD-LTC-C) scales in the Spanish context.

METHODS

This was a cultural adaptation and validation study. The scales were translated from English to Spanish and vice versa, and 13 experts in end-of-life care participated in a two-round Delphi panel. Caregivers of 69 deceased residents from seven nursing homes in southern Spain completed both scales. Reliability, feasibility, and concurrent validity with global quality of dying perception and symptom burden (Edmonton Symptom Assessment Scale), were evaluated.

RESULTS

Spanish caregivers' version of the QoD-LTC scale showed good internal consistency for the total scale (α = 0.74) and each of its three factors, and good inter-rater reliability (ICC = 0.50) and test-retest reliability (ICC = 0.81). The Spanish QoD-LTC-C scale for caregivers showed good internal consistency for the total scale (α = 0.81) and for its component factors, and good test-retest reliability (ICC = 0.89) and inter-rater reliability (ICC = 0.66). Both scales correlated with family caregivers' global perception of deceased residents' quality of dying (r = 0.39; r = 0.32), but not with the ESAS score.

CONCLUSIONS

Both scales presented an adequate factorial structure, internal consistency, and reliability to assess caregivers' perception of the quality of dying in Spanish nursing homes.

Advance Care Planning in Spain

In the last decade in Spain, an important push has been given to the development of health policies that define the framework of action in the care of people with advanced chronic diseases. Respect for the autonomy of the patient, shared decision-making processes and advance care planning (ACP) are recognized into health plans as a key aspect in chronic care, frailty, and palliative care. A few but significant number of institutions, local governments, and healthcare professionals from different regions of Spain have started a rationale and roadmap for a new twist in Spain's theoretical, ethical and policy development, promoting ACP implementation into public health care systems. In 2020, a working group founded in 2017, evolved into the "Spanish Association of Shared Care Planning" (AEPCA). The Shared Care Planning (SCP) concept grows up after the two international consensus Delphi studies in 2017 and pretends to shift from the framework of ACP programs to a person-centred care approach. In the last years, several experiences show how professionals are more sensible and interested on the ACP process, but it cannot be said, for now, that it has taken effect in the global Spanish health system. Even both ACP and SCP are being used simultaneously in Spain, each day more people and autonomous communities embrace renewed concept and foundations of SCP, supporting the work of AEPCA on spreading the value of this process into the care of people who are coping with chronic diseases, vulnerability, and frailty.

Analysis of palliative care needs in hospitalized patients

AIM

To determine the prevalence of palliative care needs in patients in an acute care hospital and to analyze the profile of these patients.

DESIGN

We conducted a prospective cross-sectional study in an acute care hospital, in April 2018. The study population consisted of all patients over 18 years of age admitted to hospital wards and intensive care units. Variables were collected on a single day by six micro-teams using the NECPAL CCOMS-ICO© instrument. The descriptive analysis, on patient mortality and length of stay, was performed at a one-month follow-up.

RESULTS

We assessed 153 patients, of whom 65 (42.5%) were female, with a mean age of 68.17±17.03 years. A total of 45 patients (29.4%) were found to be SQ+, of which 42 were NECPAL+ (27.5%), with a mean age of 76.64±12.70 years. According to the disease indicators, 33.35% had cancer, 28.6% had heart disease, and 19% had COPD, resulting in a ratio of 1:3 between patients with cancer and non-cancer disease. Half of the inpatients in need of palliative care were in the Internal Medicine Unit.

CONCLUSIONS

Almost 28% of patients were identified as NECPAL+, most of them not identified as under palliative care in clinical records. Greater awareness and knowledge from healthcare professionals would facilitate the early identification of these patients and avoid overlooking palliative care needs.

Identifying Nursing Home Residents with Unmet Palliative Care Needs: A Systematic Review of Screening Tool Measurement Properties

OBJECTIVES

Despite common use of palliative care screening tools in other settings, the performance of these tools in the nursing home has not been well established; therefore, the purpose of this review is to (1) identify palliative care screening tools validated for nursing home residents and (2) critically appraise, compare, and summarize the quality of measurement properties.

DESIGN

Systematic review of measurement properties consistent with Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines.

SETTINGS AND PARTICIPANTS

Embase (Ovid), MEDLINE (PubMed), CINAHL (EBSCO), and PsycINFO (Ovid) were searched from inception to May 2022. Studies that (1) reported the development or evaluation of a palliative care screening tool and (2) sampled older adults living in a nursing home were included.

METHODS

Two reviewers independently screened, selected, extracted data, and assessed risk of bias.

RESULTS

We identified only 1 palliative care screening tool meeting COSMIN criteria, the NECesidades Paliativas (NEC-PAL, equivalent to palliative needs in English), but evidence for use with nursing home residents was of low quality. The NEC-PAL lacked robust testing of measurement properties such as reliability, sensitivity, and specificity in the nursing home setting. Construct validity through hypothesis testing was adequate but only reported in 1 study. Consequently, there is insufficient evidence to guide practice. Broadening the criteria further, this review reports on 3 additional palliative care screening tools identified during the search and screening process but which were excluded during full-text review for various reasons.

CONCLUSION AND IMPLICATIONS

Given the unique care environment of nursing homes, we recommend future studies to validate available tools and develop new instruments specifically designed for nursing home use. In the meantime, we recommend that clinicians consider the evidence presented here and choose a screening instrument that best meets their needs.

Medication Assessment in an Older Population during Acute Care Hospitalization and Its Effect on the Anticholinergic Burden: A Prospective Cohort Study

(1) Background: Anticholinergic and sedative drugs (ASDs) contribute to negative health outcomes, especially in the frail population. In this study, we aimed to assess whether frailty increases with anticholinergic burden and to evaluate the effects of medication reviews (MRs) on ASD regimens among patients attending an acute care for the elderly (ACE) unit. (2) Methods: A cohort study was conducted between June 2019 and October 2020 with 150 consecutive patients admitted to our ACE unit. Demographic, clinical, and pharmacological data were assessed. Frailty score was determined using the Frail-VIG index (FI-VIG), and ASD burden was quantified using the drug burden index (DBI). In addition, the MR was performed using the patient-centered prescription (PCP) model. We used a paired T-test to compare the DBI pre- and post-MR and univariate and multivariate regression to identify the factors associated with frailty. (3) Results: Overall, 85.6% (n = 128) of participants showed some degree of frailty (FI-VIG > 0.20) and 84% (n = 126) of patients received treatment with ASDs upon admission (pre-MR). As the degree of frailty increased, so did the DBI (p < 0.001). After the implementation of the MR through the application of the PCP model, a reduction in the DBI was noted (1.06 ± 0.8 versus 0.95 ± 0.7) (p < 0.001). After adjusting for covariates, the association between frailty and the DBI was apparent (OR: 11.42, 95% (CI: 2.77-47.15)). (4) Conclusions: A higher DBI was positively associated with frailty. The DBI decreased significantly in frail patients after a personalized MR. Thus, MRs focusing on ASDs are crucial for frail older patients.

Simulation-based learning in palliative care in postgraduate nursing education: a scoping review

BACKGROUND

Nurses require advanced competence in palliative care, but they face wide variations in education and a shortage in opportunities for clinical placement. Simulation-based learning (SBL) can enable students to develop clinical skills, critical thinking and confidence. No scoping reviews to date have mapped the use of SBL in palliative care within postgraduate nursing education.

METHODS

The aim of this scoping review was to systematically map published studies on the use of SBL in palliative care in postgraduate nursing education. A scoping review was conducted using Arksey and O'Malley's (Int J Soc Res Meth 8(1):19-32, 2005) methodological framework. A systematic and comprehensive search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resources Information Center (ERIC), Ovid MEDLINE, Ovid EMBASE, Allied and Complementary Medicine and PsycINFO was performed for studies published between January 2000 and April 2022. Two authors independently assessed papers for inclusion and extracted data. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. The protocol was registered on the Open Science Framework.

RESULTS

This review includes 10 studies. Three thematic groupings were identified: enhanced understanding of the importance of teamwork, interdisciplinarity and interpersonal skills; preparedness and confidence in one's ability to communicate during emotionally challenging situations; and impact and relevance to one's own clinical practice.

CONCLUSIONS

The use of SBL in palliative care in postgraduate nursing education seems to enhance students' understanding of the importance of teamwork and interdisciplinarity. The review shows contradictory results regarding whether SBL in palliative care increases students' confidence in their communication skills. Postgraduate nursing students experienced personal growth after participating in SBL. Because our findings indicate that limited research has been conducted within this field, future research should (1) explore postgraduate nursing students' experiences with SBL in palliative care with a focus on more practical content such as symptom management, (2) examine the relevance and application of SBL in clinical practice, and (3) be reported in line with recommendations on the reporting of simulation research.

Screening versus multidimensional assessment of symptoms and psychosocial distress in cancer patients from the time of incurability

Objective

Previous symptom prevalence studies show a diverse spectrum of symptoms and a large diversity in symptom intensities in patients being just diagnosed as having incurable cancer. It is unclear, how physical symptoms and psychosocial burden should be recorded in order to determine the variable need for palliative care and further support. Therefore, we compared two different strategies for detecting physical symptoms and psychosocial burden of patients with newly diagnosed incurable cancer and their effects on the further course of the disease.

Methods

SCREBEL is a controlled, randomized, non-blinded, longitudinal study of the research network of the Palliative Medicine Working Group (APM) of the German Cancer Society (DKG). We compared: a less complex repeated brief screening for symptoms and burden in patients using the NCCN Distress Thermometer and IPOS questionnaire versus a multidimensional comprehensive assessment using the FACT-G and their entity-specific questionnaires, the PHQ4 scales, SCNS-34-SF, IPOS and NCCN Distress Thermometer. The primary study endpoint was quality of life (QoL), measured using FACT-G, after six months. Secondary study endpoints were QoL by using evaluation of secondary scores (NCCN DT, IPOS, PHQ4, SCNS-SF-34G) at time 6 months, the number of hospital days, the utilization of palliative care, emergency services, and psychosocial care structures. To assess effects and differences, multiple linear regression models were fitted and survival analyses were conducted.

Results

504 patients were included in the study. 262 patients were lost to follow-up, including 155 fatalities. There were no significant differences between the low-threshold screening approach and a comprehensive assessment with respect to symptoms and other aspects of QoL. Using the IPOS, we were able to measure an improvement in the quality of life in the low-threshold screening arm by a decrease of 0.67 points (95%-CI: 0.34 to 0.99) every 30 days. (p<0.001). Data on the involvement of emergency facilities and on supportive services were insufficient for analysis.

Conclusion

A comprehensive, multidimensional assessment did not significantly differ from brief screening in preserving several dimensions of quality of life. These findings may positively influence the implementation of structured low-threshold screening programs for supportive and palliative needs in DKG certified cancer centers.DRKS -No. DRKS00017774 https://drks.de/search/de/trial/DRKS00017774.

Information and Advance Care Directives for End-of-Life Residents with and without Dementia in Nursing Homes

BACKGROUND

Communication and advance care directives may be affected by the presence of dementia. We sought to describe the information and end-of-life preferences provided to nursing homes residents and their families.

METHODS

Trained nurses collected information from 124 residents randomly selected with palliative care needs from eight nursing homes.

RESULTS

A total of 54.4% of the residents with dementia had been provided with information about their state of health, compared to 92.5% of the residents without dementia (p < 0.01); family members exhibited no differences regarding information (p = 0.658), regardless of whether the resident was cognitively impaired. Most advance care interventions remained unexplored, except for cases where a transfer to hospital (81.5%) or serotherapy (69.4%) was desired. Decisions regarding palliative sedation (p = 0.017) and blood transfusion (p = 0.019) were lower among residents with dementia.

CONCLUSIONS

Residents, especially residents with dementia, are provided with limited information and their preferences are inadequately explored.

Screening versus multidimensional assessment of symptoms and psychosocial distress in cancer patients from the time of incurability

OBJECTIVE

Previous symptom prevalence studies show a diverse spectrum of symptoms and a large diversity in symptom intensities in patients being just diagnosed as having incurable cancer. It is unclear, how physical symptoms and psychosocial burden should be recorded in order to determine the variable need for palliative care and further support. Therefore, we compared two different strategies for detecting physical symptoms and psychosocial burden of patients with newly diagnosed incurable cancer and their effects on the further course of the disease.

METHODS

SCREBEL is a controlled, randomized, non-blinded, longitudinal study of the research network of the Palliative Medicine Working Group (APM) of the German Cancer Society (DKG). We compared: a less complex repeated brief screening for symptoms and burden in patients using the NCCN Distress Thermometer and IPOS questionnaire versus a multidimensional comprehensive assessment using the FACT-G and their entity-specific questionnaires, the PHQ4 scales, SCNS-34-SF, IPOS and NCCN Distress Thermometer. The primary study endpoint was quality of life (QoL), measured using FACT-G, after six months. Secondary study endpoints were QoL by using evaluation of secondary scores (NCCN DT, IPOS, PHQ4, SCNS-SF-34G) at time 6 months, the number of hospital days, the utilization of palliative care, emergency services, and psychosocial care structures. To assess effects and differences, multiple linear regression models were fitted and survival analyses were conducted.

RESULTS

504 patients were included in the study. 262 patients were lost to follow-up, including 155 fatalities. There were no significant differences between the low-threshold screening approach and a comprehensive assessment with respect to symptoms and other aspects of QoL. Using the IPOS, we were able to measure an improvement in the quality of life in the low-threshold screening arm by a decrease of 0.67 points (95%-CI: 0.34 to 0.99) every 30 days. (p<0.001). Data on the involvement of emergency facilities and on supportive services were insufficient for analysis.

CONCLUSION

A comprehensive, multidimensional assessment did not significantly differ from brief screening in preserving several dimensions of quality of life. These findings may positively influence the implementation of structured low-threshold screening programs for supportive and palliative needs in DKG certified cancer centers.DRKS -No. DRKS00017774 https://drks.de/search/de/trial/DRKS00017774.

What Palliative Patients and their Carers Need at Home and what a Primary Health Care Team can Offer - First Pilot Study in Slovenia

Introduction

Spending one's last days and dying at home is a common wish of people with a life-limiting illness. Home-based palliative care is essentially organised at the primary level to meet the needs of palliative patients and their carers. The aim of this study was to identify the characteristics of home-based palliative care, focusing on those who identify palliative patients, what their needs are and how this affects their length of life and site of death.

Methods

This retrospective cohort study analysed routinely collected notes of patients enrolled in home-based palliative care between 2015 and 2021. Palliative care was provided by a primary health care team in a predominantly rural area.

Results

This study included 107 palliative patients, aged 71±11.4 years, 94% of whom had cancer. They were enrolled in palliative care by their primary care team or by hospital staff. The enrolment by hospital staff (3%) resulted in significantly shorter survival (p=0.008). Patients lived an average of 66 days, and 65% of patients died at home. Home-based palliative care was found to respond to both basic and complex palliative medical needs, but was weaker in addressing socio-economic, psychological or spiritual issues.

Conclusion

This exemplary primary-level palliative team provided home-based palliative care that has improved over the years in terms of all the observed quality indicators: early enrolment, the proportion of patients dying at home and the ability to address needs. Specialised mobile palliative teams, hospitals and other palliative care settings complement home-based palliative care.

Prevalence and clinical characteristics of patients with Advanced Chronic Illness and Palliative Care needs, identified with the NECPAL CCOMS-ICO© Tool at a Tertiary Care Hospital

BACKGROUND

The identification of patients with advanced chronic conditions and palliative care needs is essential since their care represents one of the main challenges for public health systems. The study aimed to determine the prevalence and characteristics of inpatients with palliative care needs in different services of a tertiary care hospital using the NECPAL CCOMS-ICO© tool.

METHODS

A descriptive, cross-sectional cohort study was conducted in a tertiary hospital. The NECPAL tool identifies patients who require palliative care. Any patient with the Surprise Question with the answer "NO" and at least another question of the tool with a positive answer is considered a positive identification. Patients were classified as Non-NECPAL, NECPAL I-II, and NECPAL III, depending on the NECPAL tool criteria they met. The presence of physical symptoms, emotional distress, and social risk factors was assessed.

RESULTS

Of the 602 inpatients, 236 (39.2%) were enrolled. Of them, 34 (14.4%) non-NECPAL, 202 (85.6%) NECPAL+ [105 (44.5%) NECPAL I-II, and 97 (41.1%) NECPAL III]. Physical symptom burden was high (pain intensity ≥ 1 in 68.3% of patients; tiredness ≥ 1 in 83.5%; somnolence ≥ 1 in 50.6%; dyspnea ≥ 1 in 37.9%; anorexia ≥ 1 in 59.5%). 64.1% had emotional distress, and 83.6% had social risk factors. The NECPAL-III group contained a higher percentage of cancer patients, higher demand for palliative care, and greater need for palliative care (p < 0.001). In 50.8% of cases, no referrals were made to psychology, social work, or hospital palliative and supportive care teams. The three services with the higher number of patients with palliative care needs were: Palliative Care Unit (100%), Oncology (54.54%), and Emergency Short-stay Unit (54.16%).

CONCLUSION

A high percentage of patients admitted to tertiary care hospitals presented palliative care needs, with multiple unmet physical, emotional, and social needs. Less than 50% are referred to specialized care teams, such as hospital palliative and supportive care teams.

[DNVF Memorandum: Health Services Research in the Last Year of Life]

This memorandum outlines current issues concerning health services research on seriously ill and dying people in the last year of their lives as well as support available for their relatives. Patients in the last phase of life can belong to different disease groups, they may have special characteristics (e. g., people with cognitive and complex impairments, economic disadvantage or migration background) and be in certain phases of life (e. g., parents of minor children, (old) age). The need for a designated memorandum on health services research in the last year of life results from the special situation of those affected and from the special features of health services in this phase of life. With reference to these special features, this memorandum describes methodological and ethical specifics as well as current issues in health services research and how these can be adequately addressed using quantitative, qualitative and mixed methods. It has been developed by the palliative medicine section of the German Network for Health Services Research (DNVF) according to the guidelines for DNVF memoranda.

Addressing inequity in palliative care provision for older people living with multimorbidity. Perspectives of community-dwelling older people on their palliative care needs: A scoping review

BACKGROUND

Older people living with multimorbidity are projected to become the main recipients of palliative care in the coming decades, yet there is limited evidence regarding their expressed palliative care needs to inform person-centred care.

AIM

To understand the palliative care needs of community-dwelling people aged ⩾60 living with multimorbidity in the last 2 years of life.

DESIGN

A scoping review following Arksey and O'Malley.

DATA SOURCES

Three international electronic databases (CINAHL, Ovid Medline, PsycINFO) were searched from March 2018 to December 2021. Reference lists were hand searched. Eligible papers were those reporting empirical data on older people's needs.

RESULTS

From 985 potential papers, 28 studies were included, published between 2002 and 2020; sixteen quantitative, nine qualitative and three mixed methods. Data were extracted and presented under the holistic palliative care domains of need: physical, psychological, social, spiritual, and additionally practical needs. Different measurement tools (n = 29) were used, of which 20 were multidimensional. Primacy in reporting was given to physical needs, most commonly pain and function. Social and practical needs were often prioritised by older people themselves, including maintaining social connections and accessing and receiving individualised care.

CONCLUSION

Identifying the palliative care needs that matter most to older people with multimorbidity requires the recognition of their concerns, as well as their symptoms, across a continuum of living and dying. Available evidence is superficial. Supporting end of life provision for this growing and underserved population necessitates a shift to tailored multidimensional tools and community focussed integrated care services.

Effectiveness of a specialist palliative home care nurse-patient consultation followed by an interprofessional telephone case conference compared with usual care among patients with non-oncological palliative care needs: protocol for the multicentre KOPAL cluster-randomised controlled trial

INTRODUCTION

Progressive chronic, non-malignant diseases (CNMD) like congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are of growing relevance in primary care. Most of these patients suffer from severe symptoms, reduced quality of life and increased numbers of hospitalisations. Outpatient palliative care can help to reduce hospitalisation rate by up to 50%. Due to the complex medical conditions and prognostic uncertainty of the course of CNMD, early interprofessional care planning among general practitioners who provide general palliative care and specialist palliative home care (SPHC) teams seems mandatory. The KOPAL study (a concept for strenghtening interprofessional collaboration for patients with palliative care needs) will test the effectiveness of a SPHC nurse-patient consultation followed by an interprofessional telephone case conference.

METHODS AND ANALYSIS

Multicentre two-arm cluster randomised controlled trial KOPAL with usual care as control arm. The study is located in Northern Germany and aims to recruit 616 patients in 56 GP practices (because of pandemic reasons reduced to 191 participants). Randomisation will take place on GP practice level immediately after inclusion (intervention group/control group). Allocation concealment is carried out on confirmation of participation. Patients diagnosed with CHF (New York Heart Association (NYHA) classification 3-4), COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage classification 3-4, group D) or dementia GDS stage 4 or above). Primary outcome is a reduced hospital admission within 48 weeks after baseline, secondary outcomes include symptom burden, quality of life and health costs. The primary analysis will follow the intention-to-treat principle. Intervention will be evaluated after the observation period using qualitative methods.

ETHICS AND DISSEMINATION

The responsible ethics committees of the cooperating centres approved the study. All steps of data collection, quality assurance and data analysis will continuously be monitored. The concept of KOPAL could serve as a blueprint for other regions and meet the challenges of geographical equity in end-of-life care.

TRIAL REGISTRATION NUMBER

DRKS00017795; German Clinical Trials Register.

Perfil de pacientes con cronicidad avanzada y necesidades paliativas: un cambio que no llega

Objetivo: estudiar los posibles cambios en el perfil de pacientes con cronicidad avanzada entre dos cohortes en el momento de su inclusión en un equipo de soporte de atención paliativa domiciliaria (ESAPD) en el marco de la implementación de estrategias de cronicidad. Método: estudio observacional retrospectivo con enfoque analítico de pacientes no oncológicos derivados a un ESAPD de la Comunidad de Madrid, divididos en dos cohortes (2014 y 2019) definidas por el momento de inclusión en programa. Las variables principales fueron: tiempo de permanencia en programa (TPP), carga sintomática (CS) y situación funcional (SF). Se recogieron variables sociodemográficas y clínicas. Se comparó globalmente y por sexo el efecto de la cohorte (bruto y ajustado) sobre las variables principales mediante LogRank y Cox para el TPP, t-Student para la CS y SF y Modelo Lineal Generalizado para la SF. Resultados: las cohortes 2014 y 2019 constaron, respectivamente, de 98 y 116 pacientes, 63% y 52% de mujeres, 48% y 35% del ámbito rural y 43% y 27% de institucionalizados, con una media de edad y lugar de fallecimiento similares. En el TPP no se evidenciaron diferencias entre ambas cohortes (p=0,098); el análisis de Cox tampoco mostró asociación (HR = 1,01 [0,75; 1,36]). En la CS no se encontraron diferencias clínicamente relevantes. No se observaron diferencias en la SF una vez ajustada por las variables edad, sexo e institucionalización. Conclusión: no se observaron diferencias en el perfil de pacientes con cronicidad avanzada incluidos en el programa del ESAPD entre los años 2014 y 2019 en el marco de la implementación de estrategias de cronicidad. Palabras clave: cuidados paliativos, Atención Primaria, enfermedad crónica, diagnóstico precoz, anciano frágil.

Perfil de pacientes con cronicidad avanzada y necesidades paliativas: un cambio que no llega

Objetivo: estudiar los posibles cambios en el perfil de pacientes con cronicidad avanzada entre dos cohortes en el momento de su inclusión en un equipo de soporte de atención paliativa domiciliaria (ESAPD) en el marco de la implementación de estrategias de cronicidad. Método: estudio observacional retrospectivo con enfoque analítico de pacientes no oncológicos derivados a un ESAPD de la Comunidad de Madrid, divididos en dos cohortes (2014 y 2019) definidas por el momento de inclusión en programa. Las variables principales fueron: tiempo de permanencia en programa (TPP), carga sintomática (CS) y situación funcional (SF). Se recogieron variables sociodemográficas y clínicas. Se comparó globalmente y por sexo el efecto de la cohorte (bruto y ajustado) sobre las variables principales mediante LogRank y Cox para el TPP, t-Student para la CS y SF y Modelo Lineal Generalizado para la SF. Resultados: las cohortes 2014 y 2019 constaron, respectivamente, de 98 y 116 pacientes, 63% y 52% de mujeres, 48% y 35% del ámbito rural y 43% y 27% de institucionalizados, con una media de edad y lugar de fallecimiento similares. En el TPP no se evidenciaron diferencias entre ambas cohortes (p=0,098); el análisis de Cox tampoco mostró asociación (HR = 1,01 [0,75; 1,36]). En la CS no se encontraron diferencias clínicamente relevantes. No se observaron diferencias en la SF una vez ajustada por las variables edad, sexo e institucionalización. Conclusión: no se observaron diferencias en el perfil de pacientes con cronicidad avanzada incluidos en el programa del ESAPD entre los años 2014 y 2019 en el marco de la implementación de estrategias de cronicidad. Palabras clave: cuidados paliativos, Atención Primaria, enfermedad crónica, diagnóstico precoz, anciano frágil.

Palliative Care for Patients with End-Stage, Non-Oncologic Diseases-A Retrospective Study in Three Public Palliative Care Departments in Northern Italy

Patients with irreversible malignant and non-malignant diseases have comparable mortality rates, symptom burdens, and quality of life issues; however, non-cancer patients seldom receive palliative care (PC) or receive it late in their disease trajectory. To explore the characteristics of non-cancer patients receiving PC in northern Italy, as well as the features and outcomes of their care, we retrospectively analyzed the charts of all non-cancer patients initiating PC regimens during 2019 in three publicly funded PC departments in Italy’s populous Lombardy region. We recorded the baseline variables (including data collected with the NECPAL CCOMS-ICO-derived questionnaire used since 2018 to evaluate all admissions to the region’s PC network), as well as treatment features (setting and duration) and outcomes (including time and setting of death). Of the 2043 patients admitted in 2019, only 12% (243 patients—131 females; mean age 83.5 years) had non-oncological primary diagnoses (mainly dementia [n = 78], heart disease [n = 55], and lung disease [n = 30]). All 243 had Karnofsky performance statuses ≤ 40% (10−20% in 64%); most (82%) were malnourished, 92% had ≥2 comorbidities, and 61% reported 2−3 severe symptoms (pain, dyspnea, and fatigue). Fifteen withdrew or were discharged from the study PCN; the other 228 remained in the PCN and died in hospice (n = 133), at home (n = 9), or after family-requested transfer to an emergency department (n = 1). Most deaths (172/228, 75%) occurred <3 weeks after PC initiation. These findings indicate that the PCN network we studied cares for few patients with life-limiting non-malignant diseases. Those admitted have advanced-stage illness, heavy symptom burdens, low performance statuses, and poor survival. Additional efforts are needed to improve PCN accessibility for non-cancer patients.

Improving individualized prescription in patients with multimorbidity through medication review

Background

Older patients tend to have multimorbidity, represented by multiple chronic diseases or geriatric conditions, which leads to a growing number of prescribed medications. As a result, pharmacological prescription has become a major concern because of the increased difficulties to ensure appropriate prescription in older adults. The study’s main objectives were to characterize a cohort of older adults with multimorbidity, carry out a medication review and compare the pharmacological data before and after the medication review globally and according to the frailty index.

Methods

This was a quasi-experimental (uncontrolled pre-post) study with a cohort of patients ≥ 65 years old with multimorbidity. Data were collected from June 2019 to October 2020. Variables assessed included demographic, clinical, and pharmacological data, degree of frailty (Frail-VIG index), medication regimen complexity index, anticholinergic and or sedative burden index, and monthly drug expenditure. Finally, a medication review was carried out by an interdisciplinary team (primary care team and a consultant team with a geriatrician and a clinical pharmacist) by applying the Patient-Centered Prescription model to align the treatment with care goals.

Results

Four hundred twenty-eight patients were recruited [66.6% women; mean age 85.5 (SD 7.67)]. The mean frail index was 0.39 (SD 0.13), corresponding with moderate frailty. Up to 90% of patients presented at least one inappropriate prescription, and the mean of inappropriate prescriptions per patient was 3.14 (SD 2.27). At the three-month follow-up [mortality of 17.7% (n = 76)], the mean chronic medications per patient decreased by 17.96%, varying from 8.13 (SD 3.87) to 6.67 (SD 3.72) (p < 0.001). The medication regimen complexity index decreased by 19.03%, from 31.0 (SD 16.2) to 25.1 (SD 15.1), and the drug burden index mean decreased by 8.40%, from 1.19 (SD 0.82) to 1.09 (SD 0.82) (p < 0.001). A decrease in polypharmacy, medication regimen complexity index, and drug burden index was more frequent among frail patients, especially those with severe frailty (p < 0.001).

Conclusions

An individualized medication review in frail older patients, applying the Patient-Centered Prescription model, decreases pharmacological parameters related to adverse drug effects, such as polypharmacy, therapeutical complexity, and anticholinergic and, or sedative burden. The benefits are for patients with frailty.

How Many Cancer Patients Need Palliative Care? A Population-Based Study

BACKGROUND

The number of cancer patients potentially amenable to palliative care is conventionally estimated from cancer deaths, as reported in the death certificates. However, a more representative population should also include cancer patients who die from causes other than cancer, as they may develop other life-limiting chronic conditions leading to terminal prognosis.

AIM

This study aimed at refining the assessment of the number of cancer patients potentially in need of palliative care, by linked hospital and death data.

DESIGN

Retrospective study.

SETTING/PARTICIPANTS

Residents in the Emilia Romagna Region in Italy, who died between 2009 and 2017.

RESULTS

We identified a potential palliative care population of 157,547 cancer patients. The use of different administrative data sources enhanced the sensitivity of our selection. Starting from a standard estimate of 129,212 patients based on cancer as the primary cause of death, we showed that the additional use of hospital records identified a further 11.4% of possible palliative care patients 14,687. Also considering cancer as secondary cause of death, the estimate further increased by 10.6% (13,648 new cases). Notably, the proportion of cancer patients selected by the additional data sources were characterized by more advanced age and higher prevalence of comorbidity.

CONCLUSION

Healthcare services addressing the issue of estimating palliative care needs of cancer patients at a population level should consider that relying on the death certificate alone may lead to underestimating these needs of about 22%.

Individualized Medication Review in Older People with Multimorbidity: A Comparative Analysis between Patients Living at Home and in a Nursing Home

(1) Background: aging is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. A periodic medication review (MR) in frail older people leads to optimizing medication use. The aims of the study were to perform a comparative analysis of the impact of place of residence (own home versus nursing home) in a cohort of older patients on the characteristics of the baseline therapeutic plan and characteristics of the therapeutic plan after an MR; (2) Methods: Study with paired pre- and post-MR data based on person-centred prescription, with a follow-up assessment at three months. Patients who lived either in their own home or in a nursing home were recruited. We selected patients of 65 years or more with multimorbidity whose General Practitioner identified difficulties with the prescription management and the need for an MR. Each patient’s treatment was analysed by applying the Patient-Centred Prescription (PCP) model; (3) Results: 428 patients. 90% presented at least one inappropriate prescription (IP) in both settings. In nursing homes, a higher number of implemented optimization proposals was detected (81.6% versus 65.7% (p < 0.001)). After the MR, nursing-home patients had a greater decrease in their mean number of medications, polypharmacy prevalence, therapeutic complexity, and monthly drug expenditure (p < 0.001); (4) Conclusions: PCP model detected a high number of IP in both settings. However, after an individualized MR, nursing-home patients presented a greater decrease in some pharmacological parameters related to adverse events, such as polypharmacy and therapeutic complexity, compared to those living at home. Nursing homes may be regarded as a highly suitable scenario to carry out a periodic MR, due to its high prevalence of frail people and its feasibility to apply the recommendations of an MR. Prospective studies with a robust design should be performed to demonstrate this quasi-experimental study along with a longitudinal follow-up on clinical outcomes.

Palliative and prognostic approach in cancer patients identified in the multicentre NECesidades PALiativas 2 study in Argentina

Background

Early identification of palliative needs has proven benefits in quality of life, survival and decision-making. The NECesidades PALiativas (NECPAL) Centro Coordinador Organización Mundial de la Salud - Instituto Catalán de Oncología (CCOMS-ICO©) tool combines the physician’s insight with objective disease progression parameters and advanced chronic conditions. Some parameters have been independently associated with mortality risk in different populations. According to the concept of the ‘prognostic approach’ as a companion of the ‘palliative approach’, predictive models that identify individuals at high mortality risk are needed.

Objective

We aimed to identify prognostic factors of mortality in cancer in our cultural context.

Method

We assessed cancer patients with palliative needs until death using this validated predictive tool at three hospitals in Buenos Aires City. This multifactorial, quantitative and qualitative non-dichotomous assessment process combines subjective perception (the surprise question: Would you be surprised if this patient dies in the next year?) with other parameters, including the request (and need) for palliative care (PC), the assessment of disease severity, geriatric syndromes, psychosocial factors and comorbidities, as well as the use of healthcare resources.

Results

2,104 cancer patients were identified, 681 were NECPAL+ (32.3%). During a 2-year follow-up period, 422 NECPAL+ patients died (61.9%). The mean overall survival was 8 months. A multivariate model was constructed with significant indicators in univariate analysis. The best predictors of mortality were: nutritional decline (p < 0.000), functional decline (p < 0.000), palliative performance scale (PPS) ≤ 50 (p < 0.000), persistent symptoms (p < 0.002), functional dependence (p < 0.000), poor treatment response (p < 0.000), primary cancer diagnosis (p = 0.024) and condition (in/outpatients) (p < 0.000). Only three variables remained as survival predictors: low response to treatment (p < 0.001), PPS ≤ 50 (p < 0.000) and condition (in/outpatients) (p < 0.000).

Conclusion

This prospective model aimed to improve cancer survival prediction and timely PC referral in Argentinian hospitals.

Comparing the Clinical Characteristics and Mortality of Residential and Non-Residential Older People with COVID-19: Retrospective Observational Study

Nursing homes have accounted for a significant part of SARS-CoV-2 mortality, causing great social alarm. Using data collected from electronic medical records of 1,319,839 institutionalised and non-institutionalised persons ≥ 65 years, the present study investigated the epidemiology and differential characteristics between these two population groups. Our results showed that the form of presentation of the epidemic outbreak, as well as some risk factors, are different among the elderly institutionalised population with respect to those who are not. In addition to a twenty-fold increase in the rate of adjusted mortality among institutionalised individuals, the peak incidence was delayed by approximately three weeks. Having dementia was shown to be a risk factor for death, and, unlike the non-institutionalised group, neither obesity nor age were shown to be significantly associated with the risk of death among the institutionalised. These differential characteristics should be able to guide the actions to be taken by the health administration in the event of a similar infectious situation among institutionalised elderly people.

End-of-life and hospice care for neurologic illness

Systems for end of life care around the world vary in availability, structure, and funding. When available, most end of life care is in the hospice model with an interdisciplinary team approach to care of people who are expected to die within months and whose primary goal is to maximize quality of life. Symptom management near the end of life is guided by prognosis and individual priorities. People dying with neurologic disease are likely to have impaired communication or mobility that adds to the complexity of prognostication and symptom management. Neurologic specialists have important roles to play in end of life care due to their unique understanding of disease prognosis as well as end of life symptom burden and management. Neurologic specialists need to become strong advocates for the importance of end of life care by being actively involved in the hospice movement and by addressing current disparities in access to care.

Assessing a care programme for complex and advanced chronic patients: Use of resources and costs

INTRODUCTION

The Public Health System of the Balearic Islands (IB-Salut) implemented between 2016 and 2019 the Chronic Patient Care Plan to properly manage complex chronicity and provide quality care attention. The goal of this study is assessing the use of healthcare services and their associated costs before and after the implementation of the programme.

METHODS

Descriptive analyses of resources destined to complex and advanced chronic patients (CCP and ACP).

RESULTS

After entering the programme: the frequency of CCP admissions to acute hospitals reduced by 6.9%, the frequency of CCP visits to emergency departments reduced by 8.4%, while the frequency of ACP admitted to intermediate care hospitals increased. Both the frequencies of ACP admitted to acute hospitals and emergency visits decreased to 16.7% and to 27.3%, respectively. Total cost before and after the implementation of the programme was €60,884,241 and €46,889,693, respectively. Taking into account the 1011 admissions avoided, the result is a negative incremental cost-effectiveness ratio (€-396.57) per acute hospital admission that was avoided.

CONCLUSION

The Chronic Patient Care Plan might be interpreted as a cost-effective intervention. This first assessment would benefit from further research including control groups.

Prevalence and characteristics of patients with heart failure needing palliative care

Background

Few hospitals and heart failure (HF) clinics offer concurrent palliative care (PC) together with life-prolonging therapies. To know the prevalence of patients in HF clinics needing PC and useful tools to recognize them are the first steps to extending PC in those settings. However, it is still unknown whether tools commonly used to identify patients with HF needing PC can correctly distinguish them. Two systematic reviews found that the NECesidades PALiativas (NECPAL) tool was one of the two most commonly used tools to asses PC needs in HF patients. Therefore, we assessed 1) the prevalence of PC needs in HF clinics according to the NECPAL tool, and 2) the characteristics of the patients identified as having PC; mainly, their quality of life (QoL), symptom burden, and psychosocial problems.

Methods

This cross-sectional study was conducted at two HF clinics in Colombia. We assessed the prevalence of PC in the overall sample and in subgroups according to clinical and demographic variables. We assessed QoL, symptom burden, and psychosocial problems using the 12-Item Short-Form Health Survey (SF-12), the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Edmonton Symptom Assessment System (ESAS). We compared the results of these tools between patients identified as having PC needs (+NECPAL) and patients identified as not having PC needs (–NECPAL).

Results

Among the 178 patients, 78 (44%) had PC needs. The prevalence of PC needs was twice as nigh in patients NYHA III/IV as in patients NYHA I/II and almost twice as high in patients older than 70 years as in patients younger than 70 years. Compared to –NECPAL patients, +NECPAL patients had worse QoL, more severe shortness of breath, tiredness, drowsiness, and pain, and more psychosocial problems.

Conclusion

The prevalence of PC needs in outpatient HF clinics is high and is even higher in older patients and in patients at more advanced NYHA stages. Compared to patients identified as not having PC needs, patients identified as having PC needs have worse QoL, more severe symptoms, and greater psychosocial problems. Including a PC provider in the multidisciplinary team of HF clinics may help to assess and cover these needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00850-y.

The Online Representation of Palliative Care by Practice, Policy, and Advocacy Organizations: Definitional Variations and Discursive Tensions

Negative beliefs and a lack of clarity surrounding the meaning of palliative care have been widely reported as obstacles to its uptake. Information available to the public possibly contributes to this. A descriptive and discourse-theoretical analysis was conducted of information spread online by palliative care policy, advocacy, and practice organizations. Discrepancies were found in the way palliative care was defined in relation to curative, end-of-life, terminal, and supportive care. Beyond these definitional variations, meaning was generated through the representation of palliative care as a culture, connected to total care, compassion, and openness. Tensions arose around the concepts of autonomy, a natural death, and an emphasis on the quality of life away from death and dying. Overall, this study showed that the online information of palliative care is a potential source of confusion and might even contribute to its stigmatization. Insights are provided that may help improve clarity toward the public.

Factors Associated with the Detection of Inappropriate Prescriptions in Older People: A Prospective Cohort

(1) Background: Ageing is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. The main objectives were to study an older community-dwelling cohort, to detect inappropriate prescriptions (IP) applying the Patient-Centred Prescription model, and to evaluate the most associated factors. (2) Methods: This was a prospective, descriptive, and observational study conducted from June 2019 to October 2020 on patients ≥ 65 years with multimorbidity who lived in the community. Demographic, clinical and pharmacological data were assessed. Variables assessed were: degree of frailty, using the Frail-VIG index; therapeutical complexity and anticholinergic and sedative burden; and the number of chronic drugs to determine polypharmacy or excessive polypharmacy. Finally, a medication review was carried out through the application of the Patient-Centred Prescription model. We used univariate and multivariate regression to identify the factors associated with IP. (3) Results: We recruited 428 patients (66.6% women; mean age 85.5, SD 7.67). A total of 50.9% of them lived in a nursing home; the mean Barthel Index was 49.93 (SD 32.14), and 73.8% of patients suffered some degree of cognitive impairment. The prevalence of frailty was 92.5%. Up to 90% of patients had at least one IP. An increase in IP prevalence was detected when the Frail-VIG index increased (p < 0.05). With the multivariate model, the relationship of polypharmacy with IP detection stands out above all. (4) Conclusions: 90% of patients presented one IP or more, and this situation can be detected through the PCP model. Factors with higher association with IP were frailty and polypharmacy.

Frommelt Attitude Toward Care of the Dying Scale Form B: Validation for Spanish health professionals

Objective

The aim of this study is to culturally adapt and validate the Frommelt Attitude Toward Care of the Dying Scale Form B (FATCOD-B) in Spanish health professionals.

Method

A cultural adaptation and scale validation was carried out to evaluate the validity of appearance, content and construct, reliability and feasibility. The psychometric validation of the FATCOD-B was carried out on a sample of 2,446 Spanish physicians, nurses, psychologists, and social workers and students of these disciplines, between January 2017 and December 2018. This sample was selected by intentional sampling. Descriptive statistics were used to characterize the sample. An exploratory multi-group factor analysis was performed, internal consistency was evaluated by calculating Cronbach's α and stability by test–retest.

Results

A total of 2,446 people participated in the study, 1,134 students and 1,312 professionals. The exploratory multi-group factor analysis revealed a two-dimensional factor structure, with a total of 17 items retained in the model from the 30 of the original scale. The results showed that this version has adequate reliability (α = 0.79) and for each subscale, and stability (ICC = 0.843, p < 0.001).

Significance of results

FATCOD has been used with physicians and nurses from different countries. However, no reports have been found in the literature of its use with psychologists and social workers. It is important to have an instrument that allows us to know the attitudes of these professionals since they are all directly involved in the care of patients at the end of their lives and their families. The Spanish version of FATCOD-B has proven to be a reliable and valid instrument for its use in Spanish health professionals while allowing comparisons between disciplines.

End-stage organ disease-Healthcare utilisation: Impact of palliative medicine

OBJECTIVES

Although patients living with end-stage organ disease (ESOD) suffer unmet needs from the physical and emotional burdens of living with chronic illness, they are less likely to receive palliative care.The aims of the study were to determine if palliative care referrals reduced healthcare utilisation and if impact on healthcare utilisation was dependent on the timing of the referral.

METHODS

Patients with ESOD who received palliative care support were matched with those who did not using coarsened exact matching and propensity score matching, and compared in this retrospective cohort study. Primary outcomes of interests were reduction in all-cause emergency department (ED) visits and costs, reduction in all-cause tertiary hospital admissions, length of hospital stay and inpatient hospital costs.

RESULTS

Patients with ESOD referred to palliative care experienced a reduction in the frequency of all cause ED visits and inpatient hospital admissions. Significant impact of a palliative care referral was at 3 months, rather than 1 month prior to death with a greater reduction in the frequency of ED visits, inpatient hospital admissions, length of stay and charges (p all <0.05). The most common ESOD referred to palliative care for 1110 matched patients was end-stage renal failure (57.7%), and least commonly for respiratory failure (7.6%).

CONCLUSION

Palliative care can reduce healthcare utilisation, with reduction greatest when the referral is timed earlier in the disease trajectory. Cost savings can be judiciously redirected to the development of palliative care resources for integrated support of patients and caregivers.

Characteristics and Service Utilization by Complex Chronic and Advanced Chronic Patients in Catalonia: A Retrospective Seven-Year Cohort-Based Study of an Implemented Chronic Care Program

The Chronic Care Program introduced in Catalonia in 2011 focuses on improving the identification and management of complex chronic (CCPs) and advanced chronic patients (ACPs) by implementing an individualized care model. Its first stage is their identification based on chronicity, difficult clinical management (i.e., complexity), and, in ACPs, limited life prognosis. Subsequent stages are individual evaluation and implementation of a shared personalized care plan. This retrospective study, including all CCPs and ACPs identified in Catalonia between 2013 and 2019, was aimed at describing the characteristics and healthcare service utilization among these patients. Data were obtained from an administrative database and included sociodemographic, clinical, and service utilization variables and morbidity-associated risk according to the Adjusted Morbidity Groups (GMA) stratification. During the study period, CCPs’ and ACPs’ prevalence increased and was higher in lower-income populations; most cases were women. CCPs and ACPs had all comorbidities at higher frequencies, higher utilization of healthcare services, and were more frequently at high risk (63% and 71%, respectively) than age-, sex-, and income level-adjusted non-CCP (23%) and non-ACP populations (30%). These results show effective identification of the program’s target population and demonstrate that CCPs and ACPs have a higher burden of multimorbidity and healthcare needs.

Primary Care Professionals' Self-Efficacy Surrounding Advance Care Planning and Its Link to Sociodemographics, Background and Perceptions: A Cross-Sectional Study

Primary care (PC) professionals have been considered the most appropriate practitioners for leading Advance care planning (ACP) processes with advanced chronic patients. Aim: To explore how PC doctors’ and nurses’ self-efficacy surrounding ACP is linked to their sociodemographic characteristics, background and perceptions of ACP practices. Methods: A cross-sectional study was performed. Sociodemographics, background and perceptions about ACP in practice were collected using an online survey. The Advance Care Planning Self-Efficacy Spanish (ACP-SEs) scale was used for the self-efficacy measurement. Statistical analysis: Bivariate, multivariate and backward stepwise logistic regression analyses were performed to identify variables independently related to a higher score on the ACP-SEs. Results: N = 465 participants, 70.04% doctors, 81.47% female. The participants had a mean age of 46.45 years and 66.16% had spent >15 years in their current practice. The logistic regression model showed that scoring ≤ 75 on the ACP-SEs was related to a higher score on feeling sufficiently trained, having participated in ACP processes, perceiving that ACP facilitates knowledge of preferences and values, and perceiving that ACP improves patients’ quality of life. Conclusion: Professionals with previous background and those who have a positive perception of ACP are more likely to feel able to carry out ACP processes with patients.

Therapeutic optimization through goal-oriented prescription in nursing homes

Background People living in nursing homes are highly vulnerable and frail. Polypharmacy and inappropriate prescription (IP) are also common problems. Objectives The objectives of the study are (i) to study the baseline situation and calculate the frailty index (FI) of the residents, (ii) to assess the results of routine clinical practice to do a pharmacotherapy review (patient-centred prescription (PCP) model) (Molist Brunet et al., Eur Geriatr Med. 2015;6:565-9) and (iii) to study the relationship between IP and frailty, functional dependence, advanced dementia and end-of-life situation. Setting Two nursing homes in the same geographical area in Catalonia (Spain). Method This was a prospective, descriptive and observational study of elderly nursing home residents. Each patient's treatment was analysed by applying the PCP model, which centres therapeutic decisions on the patient's global assessment and individual therapeutic goal. Main outcome measure Prevalence of polypharmacy and IP. Results 103 patients were included. They were characterized by high multimorbidity and frailty. Up to 59.2% were totally dependent. At least one IP was identified in 92.2% of residents. Prior to the pharmacological review, the mean number of chronic medications prescribed per resident was 6.63 (SD 2.93) and after this review it was 4.97 (SD 2.88). Polypharmacy decreased from 72.55% to 52.94% and excessive polypharmacy fell from 18.62% to 5.88%.The highest prevalence of IP was detected in people with a higher FI, in those identified as end-of-life, and also in more highly dependent residents (p < 0.05). Conclusions People who live in nursing homes have an advanced frailty. Establishing individualized therapeutic objectives with the application of the PCP model enabled to detect 92.2% of IP. People who are frailer, are functionally more dependent and those who are end-of-life are prescribed with inappropriate medication more frequently.

Use of antithrombotics at the end of life: an in-depth chart review study

BACKGROUND

Antithrombotics are frequently prescribed for patients with a limited life expectancy. In the last phase of life, when treatment is primarily focused on optimizing patients' quality of life, the use of antithrombotics should be reconsidered.

METHODS

We performed a secondary analysis of a retrospective review of 180 medical records of patients who had died of a malignant or non-malignant disease, at home, in a hospice or in a hospital, in the Netherlands. All medication prescriptions and clinical notes of patients using antithrombotics in the last three months of life were reviewed manually. We subsequently developed case vignettes based on a purposive sample, with variation in setting, age, gender, type of medication, and underlying disease.

RESULTS

In total 60% (n=108) of patients had used antithrombotics in the last three months of life. Of all patients using antithrombotics 33.3 % died at home, 21.3 % in a hospice and 45.4 % in a hospital. In total, 157 antithrombotic prescriptions were registered; 30 prescriptions of vitamin K antagonists, 60 of heparins, and 66 of platelet aggregation inhibitors. Of 51 patients using heparins, 32 only received a prophylactic dose. In 75.9 % of patients antithrombotics were continued until the last week before death. Case vignettes suggest that inability to swallow, bleeding complications or the dying phase were important factors in making decisions about the use of antithrombotics.

CONCLUSIONS

Antithrombotics in patients with a life limiting disease are often continued until shortly before death. Clinical guidance may support physicians to reconsider (dis)continuation of antithrombotics and discuss this with the patient.

Family Physicians' Perspectives on Their Role in Palliative Care: A Double Focus Group in Portugal

Background: Aggravated by the COVID-19 pandemic, the provision of palliative care for patients with palliative care needs emerges as a necessity more than ever. Most are managed in primary care by their family physicians (FP). This study aimed to understand the perspectives of specialist and trainee FPs about their role in palliative care. Methods: we conducted a double focus-group study consisting of two separate online focus-groups, one with FP specialists (n = 9) and one with FP trainees (n = 10). Results: FPs already gather two fundamental skills for the provision of palliative care: the capacity to identify patients’ needs beyond physical symptoms and the recognition that the patient belongs to a familiar, psychosocial, and even spiritual environment. They perceive their role in palliative care to be four-fold: early identification of patients with palliative care needs, initial treatment, symptom management, and patient advocacy. Participants recognized the need for palliative care training and provided suggestions for training programs. Conclusion: FPs share a holistic approach and identify multiple roles they can play in palliative care, from screening to care and advocacy. Organizational barriers must be addressed. Short training programs that combine theory, practice, and experiential learning may further the potential for FPs to contribute to palliative care.

Projecting palliative and end-of-life care needs in Central Lancashire up to 2040: an integrated palliative care and public health approach

OBJECTIVES

A collaborative study was undertaken by palliative care and public health on behalf of Chorley & South Ribble and Greater Preston Clinical Commissioning Groups. Going beyond a traditional needs assessment by providing projections of local palliative and end-of-life care needs in all conditions over 20 years, the study will support locality commissioning and development of appropriate health care services.

STUDY DESIGN

Population-based needs assessment involving secondary analysis of routinely available regional mortality and population data for Central Lancashire (2017). Palliative care need was estimated using three different recognised methods.

METHODS

These estimates were combined with routinely available population and mortality projections and observed trends in palliative care need to provide projections up to 2040.

RESULTS

Palliative care need in 2017 in Chorley & South Ribble and Greater Preston is estimated to be between 75% (1292) and 97% (1670), and 74.9% (1337) and 95.7% (1710) of all deaths, respectively. By 2040, the annual need is projected to increase compared with 2017 figures, by 24.2-55.9% (314-729 more deaths) in Chorley & South Ribble and by 13.4-41.4% (180-554 more deaths) in Greater Preston. The numbers of deaths from dementia are forecast to increase by three-fold in both localities.

CONCLUSION

This study demonstrates practical application of public health data to support the development of locally responsive palliative care services. Dissemination of findings from this needs assessment on rising palliative care need, including numbers of deaths in different disease groups, provides direction to plan appropriate, equitable and sustainable services. Rapidly growing dementia deaths deserve particular attention in the planning of care. Collaborative work between public health and palliative care in other settings is encouraged, and will likely increase in significance as the full impact of COVID-19 is felt.

Reliability, Validity, and Feasibility of the Frail-VIG Index

The study aimed to assess the reliability of the scores, evidence of validity, and feasibility of the Frail-VIG index. A validation study mixing hospitalized and community-dwelling older people was designed. Intraclass correlation coefficient (ICC) was used to assess the inter-rater agreement and the reliability. The construct validity of the Frail-VIG index with respect to the Frailty Phenotype (FP) was evaluated by calculating the area under the receiver operating characteristic curve (AUC-ROC). Convergent validity with the Clinical Frailty Scale (CFS) was assessed using Pearson's correlation coefficients. The feasibility was evaluated by calculating the average time required to administer the Frail-VIG index and the percentage of unanswered responses. A sample of 527 older people (mean age of 81.61, 56.2% female) was included. The inter-rater agreement and test-retest reliability were very strong: 0.941 (95% CI, 0.890 to 0.969) and 0.976 (95% CI, 0.958 to 0.986), respectively. Results indicated adequate convergent validity of the Frail-VIG index with respect to the FP, AUC-ROC 0.704 (95% CI, 0.622 to 0.786), and a moderate to strong positive correlation between the Frail-VIG index and CFS (r = 0.635, 95% CI, 0.54 to 0.71). The Frail-VIG index administration required an average of 5.01 min, with only 0.34% of unanswered responses. The Frail-VIG index is a reliable, feasible, and valid instrument to assess the degree of frailty in hospitalized and community-dwelling older people.

Physicians' Opinions on Anticoagulant Therapy in Patients with a Limited Life Expectancy

Patients with a limited life expectancy have an increased risk of thromboembolic and bleeding complications. Anticoagulants are often continued until death, independent of their original indication. We aimed to identify the opinions of physicians about the use of anticoagulants at the end of life. A mixed-method research design was used. A secondary analysis was performed on data from a vignette study and an interview study. Participants included general practitioners and clinical specialists. Physicians varied in their opinions: some would continue and others would stop anticoagulants at the end of life because of the risk of thromboembolic or bleeding complications. The improvement or preservation of patients' quality of life was a reason for both stopping and continuing anticoagulants. Other factors considered in the decision-making were the types of anticoagulant, the indication for which the anticoagulant was prescribed, underlying diseases, and the condition and life expectancy of the patient. Factors that made decision-making difficult were the lack of evidence on either strategy, uncertainty about patients' life expectancy, and the fear of harming patients. Which decision was eventually made seems largely dependent on the choice of the patient. In conclusion, there is a substantial variation in physicians' opinions regarding the use of anticoagulants in patients with a limited life expectancy. Physicians agree that the primary goal of medical care at end of life is the improvement or preservation of patients' quality of life. An important barrier to decision-making is the lack of evidence about the risks and benefits of stopping anticoagulants.

Frailty degree and illness trajectories in older people towards the end-of-life: a prospective observational study

OBJECTIVES

To assess the degree of frailty in older people with different advanced diseases and its relationship with end-of-life illness trajectories and survival.

METHODS

Prospective, observational study, including all patients admitted to the Acute Geriatric Unit of the University Hospital of Vic (Spain) during 12 consecutive months (2014-2015), followed for up to 2 years. Participants were identified as end-of-life people (EOLp) using the NECPAL (NECesidades PALiativas, palliative care needs) tool and were classified according to their dominant illness trajectory. The Frail-VIG index (Valoración Integral Geriátrica, Comprehensive Geriatric Assessment) was used to quantify frailty degree, to calculate the relationship between frailty and mortality (Receiver Operating Characteristic (ROC) curves), and to assess the combined effect of frailty degree and illness trajectories on survival (Cox proportional hazards model). Survival curves were plotted using the Kaplan-Meier estimator with participants classified into four groups (ie, no frailty, mild frailty, moderate frailty and advanced frailty) and were compared using the log-rank test.

RESULTS

Of the 590 persons with a mean (SD) age of 86.4 (5.6) years recruited, 260 (44.1%) were identified as EOLp, distributed into cancer (n=31, 11.9%), organ failure (n=79, 30.4%), dementia (n=86, 33.1%) and multimorbidity (n=64, 24.6%) trajectories. All 260 EOLp had some degree of frailty, mostly advanced frailty (n=184, 70.8%), regardless of the illness trajectory, and 220 (84.6%) died within 2 years. The area under the ROC curve (95% CI) after 2 years of follow-up for EOLp was 0.87 (0.84 to 0.92) with different patterns of survival decline in the different end-of-life trajectories (p<0.0001). Cox regression analyses showed that each additional deficit of the Frail-VIG index increased the risk of death by 61.5%, 30.1%, 29.6% and 12.9% in people with dementia, organ failure, multimorbidity and cancer, respectively (p<0.01 for all the coefficients).

CONCLUSIONS

All older people towards the end-of-life in this study were frail, mostly with advanced frailty. The degree of frailty is related to survival across the different illness trajectories despite the differing survival patterns among trajectories. Frailty indexes may be useful to assess end-of-life older people, regardless of their trajectory.

[VIG-Express: Consensus on an express multidimensional/geriatric assessment system in Catalonia]

OBJECTIVE

To reach a consensus on an rapid multidimensional/geriatric assessment (RMGA) tool for all health and social professionals of Catalonia as a shared and universal system to assess patients with multimorbidities, frailty, complexity or advanced conditions.

DESIGN

Three-phase consensus of professionals, combining in-person sessions with telematics.

LOCATION

Catalonia.

PARTICIPANTS

A group of 27 interdisciplinary professionals from different care settings.

METHOD

The Design Thinking methodology for an initial consensus on the characteristics of the RMGA tool (Phase 1) has been combined with the Lean Startup methodology to create a new RMGA tool (Phase 2), and then tested in a group of patients (Phase 3).

RESULTS

In Phase 1, a consensus was reached that the perfect RMGA tool should allow for an ad hoc assessment of patients, be fast and flexible (<10 min), identify altered dimensions using trigger questions and facilitate the diagnosis of the condition (ideally quantified). In Phase 2, a prototype of a new RMGA tool containing 15 + 2 questions (VIG-Express) was developed, which was then tested in 35 patients in Phase 3.

CONCLUSIONS

Based on preliminary results, the VIG-Express tool seems to facilitate a simple, rapid multidimensional assessment and the customization of interventions, as well as provide a unique look and shared narrative between professionals from different care settings. More studies will be required to corroborate these findings.

[Adaptation and validation in Chile of the patient identification instrument needing palliative care: NECPAL-CCOMS-ICO 3.1©]

OBJECTIVE

Adapt and validate the NECPAL instrument in Chile.

DESIGN

Prospective, longitudinal, analytical study for validation of the instrument in 5 stages: cultural adaptation, content validation, pilot test, application, and statistical analysis.

PLACE

Four primary care centers of the South East Metropolitan Health Service, in Santiago, Chile.

PARTICIPANTS

Primary health care physicians and nurses for cultural adaptation and application, and palliative care experts for content validation.

MAIN MEASUREMENTS

Cultural adaptation was carried out through cognitive interviews. Content validity was measured using Delphi method and the Lawshe content validity ratio (CVR) was obtained. In the pilot test, we measured stability (test-retest), inter judge harmony and application time in 14 chronic advanced patients (CAP). The test was applied to this same group, calculating the sample according to Nunally's recommendation.

RESULTS

A sample of 118 CAP was obtained. The CVR was 0.75 and the average testing time was 6.7 min (SD = 4.01). The test-retest obtained a Kappa test concordance index between 0.632 and 1.0; and the interjudge harmony agreement between 0.192 and 0.692. The surprise question (PS) was positive in 20.3% of the sample. The main conditions associated with the disease-specific severity item, were fragility (23.7%), chronic heart disease (21.2%) and chronic lung disease (12.7%). The demand group and specific severity indicators obtained a greater predictive capacity of PS+, with an area under the curve of 0.808 (95% CI: 0.697-0.918).

CONCLUSIONS

NECPAL is feasible to be used in Chile, has adequate psychometric properties and will allow early detection of patients in need of palliative care.