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Lo UC, Musa H, Li J, Gaon J, Hibbs DE, Ong JA. Patient beliefs associated with medication hesitancy in palliative care: A systematic review using the theory of planned behavior. Palliat Support Care 2024; 22:610-622. [PMID: 36503650 DOI: 10.1017/s1478951522001547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
CONTEXT The demand of palliative care is increasing due to the aging population and treatment hesitancy or intentional avoidance compromises symptom management. OBJECTIVES To identify patient beliefs associated with medication hesitancy by using the theory of planned behavior (TPB) namely, attitudes, subjective norms, behavioral intention, and perceived behavioral control associated with medication hesitancy or intentional noncompliance by avoidance. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guideline was followed to conduct a systematic literature search involving the CINAHL, Embase, MEDLINE, and PsycINFO databases from inception until March 2022. Hand-searched articles from reference lists and gray literature were included. Thematic analysis was conducted on qualitative data and triangulated with quantitative data. RESULTS About 554 articles were retrieved from the literature search and 17 articles were included based on the eligibility criteria. Three subthemes that were identified under TPB constructs were attitude: negative attitude toward medications, passive attitude toward illness and inaccurate information about disease or medication; one subtheme was identified under subjective norms: perceived negative opinions from others; and one subtheme was identified under perceived behavioral control: perception of manageable symptoms. Quantitative data provided triangulation of qualitative findings related to fear of addiction and side effects, feelings of hopelessness, unclear direction and information, social stigma, endurable symptoms, and illness as determinants for medication avoidance. SIGNIFICANCE OF RESULTS This systematic review highlighted some patient beliefs related to medication hesitancy or avoidance. Clinicians should take patient beliefs and concerns into consideration when creating treatment regimens for people receiving palliative care to optimize medication adherence and the quality of care.
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Affiliation(s)
- Un Cheng Lo
- School of Pharmacy, University of Sydney, Sydney, NSW, Australia
| | - Hala Musa
- Department of Pharmacy, Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - Jeffery Li
- Department of Pharmacy, Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - Janet Gaon
- Department of Pharmacy, Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - David E Hibbs
- School of Pharmacy, University of Sydney, Sydney, NSW, Australia
| | - Jennifer A Ong
- School of Pharmacy, University of Sydney, Sydney, NSW, Australia
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2
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Masumoto S, Hosoi T, Nakamura T, Hamano J. Polypharmacy and Potentially Inappropriate Medications in Patients With Advanced Cancer: Prevalence and Associated Factors at the End of Life. J Palliat Med 2024; 27:749-755. [PMID: 38354283 DOI: 10.1089/jpm.2023.0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Background: Polypharmacy and potentially inappropriate medications (PIMs) impose a burden on patients with advanced cancer near the end of their lives. However, only a few studies have addressed factors associated with PIMs in such patients. Objective: To examine polypharmacy and factors associated with PIMs in end-of-life patients with advanced cancer. Design: Retrospective chart review. Setting/Subjects: We analyzed 265 patients with advanced cancer who died in a palliative care unit (PCU) or at home in a home medical care (HMC) from April 2018 to December 2022 in Japan. Measurements: Sociodemographic, clinical, and prescription data at the time of PCU admission or HMC initiation were collected from electronic medical records. PIMs were assessed using OncPal Deprescribing Guidelines. Results: Patients with advanced cancer with an average age of 76.3 years and median survival days of 20 were included in the analyses. The average number of medications was 6.4 (standard deviation = 3.4), and PIMs were prescribed to 50.2%. Frequent PIMs included antihypertensive medications, peptic ulcer prophylaxis, and dyslipidemia medications. A multivariate logistic regression analysis revealed that age ≥75 years (adjusted odds ratio [aOR] = 2.30, 95% confidence interval [CI] = 1.30-4.05), referral from an outpatient setting compared with inpatient setting (aOR = 2.06, 95% CI = 1.12-3.80), more than two comorbidities (aOR = 1.88, 95% CI = 1.08-3.29), and more than five medications (aOR = 1.84, 95% CI = 1.03-3.28) were associated with PIMs. Conclusions: Medication reconciliation is recommended at the time of transition to a PCU or HMC, especially for older patients with advanced cancer who were referred from an outpatient setting and present more comorbidities and prescriptions.
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Affiliation(s)
- Shoichi Masumoto
- Department of Family Medicine, General Practice and Community Health, Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of General Medicine, Tsukuba Central Hospital, Ushiku, Ibaraki, Japan
| | - Takahiro Hosoi
- Department of General Medicine, Tsukuba Central Hospital, Ushiku, Ibaraki, Japan
| | - Toru Nakamura
- Department of Pharmacy, Tsukuba Central Hospital, Ushiku, Ibaraki, Japan
| | - Jun Hamano
- Department of Palliative and Supportive Care, Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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3
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van Merendonk LN, Peters BJM, Möhlmann JE, Hunting CB, Kastelijn EA, van den Broek MPH. The potential for deprescribing in a palliative oncology patient population: a cross-sectional study. Eur J Hosp Pharm 2023; 31:10-15. [PMID: 35197277 PMCID: PMC10800274 DOI: 10.1136/ejhpharm-2021-003143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 02/08/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The use of preventive medication in palliative oncology patients may be inappropriate due to limited life expectancy. Deprescribing tools are available but time-consuming and not always tailored to this specific population. Our primary goal was to identify potentially inappropriate medications (PIMs) in palliative oncology patients with a life expectancy of up to 2 years using an adapted deprescribing tool. Our secondary aim was to identify patient characteristics associated with the presence of PIMs. METHODS Oncology patients with a life expectancy of up to 2 years were included cross-sectionally. An adapted deprescribing tool was developed to identify PIMs. Logistic regression was used to identify factors associated with having PIMs. RESULTS A total of 218 patients were included in this study of which 56% had at least one PIM with a population mean of 1.1 PIM per patient. Most frequently defined PIMs were antihypertensive drugs and gastric acid inhibitors. Identification of PIMs by review took an estimated 5-10 min per patient. Polypharmacy, age >65 years and inpatient/outpatient status were found to be associated with having at least one PIM. CONCLUSIONS Deprescribing is possible in more than half of palliative oncology patients with a life expectancy of up to 2 years. The adapted deprescribing tool used is non-time consuming and suitable for palliative oncology patients, regardless of age.
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Affiliation(s)
| | - Bas J M Peters
- Clinical Pharmacy, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Julia E Möhlmann
- Clinical Pharmacy, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Cornelis B Hunting
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Elisabeth A Kastelijn
- Department of Pulmonary Diseases, Sint Antonius Hospital, Nieuwegein, The Netherlands
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Pethybridge R, Teleni L, Chan RJ. How do family-caregivers of patients with advanced cancer provide symptom self-management support? A qualitative study. Eur J Oncol Nurs 2020; 48:101795. [PMID: 32763841 DOI: 10.1016/j.ejon.2020.101795] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE The family-caregiver role is of critical importance to the success of symptom-related self-management of patients with advanced cancer. This study examined the perspectives of patients and family-caregivers regarding the role of the family-caregiver in symptom-related self-management support ( SMS). METHODS Semi-structured interviews were conducted in patients with advanced cancer experiencing significant symptom burden and their family-caregivers. An inductive content analysis approach was used to analyse data. RESULTS Eleven patients and ten family caregivers were included. Identified themes were 1) engaging in specific symptom-related SMS; 2) interacting with health care professionals; and 3) balancing patient need versus expectation. These themes were applicable to both the family-caregiver and patient cohorts, regardless of the individual symptom profile of each patient. CONCLUSIONS The role of family-caregivers of patients with advanced cancer is complex and varied in providing symptom-related SMS at home; often requiring family-caregivers to have diverse knowledge and skills in the management of a range of cancer-related symptoms. Health care professionals can support family-caregivers by anticipating needs, tailoring evidence-based information to those needs, and ensuring family-caregivers have an appropriate contact point for advice or help.
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Affiliation(s)
- Ruth Pethybridge
- School of Nursing and Cancer and Palliative Care Outcomes Centre, Queensland University of Technology, Brisbane, Australia; Princess Alexandra Hospital, Metro South Hospital and Health Services, Brisbane, Australia.
| | - Laisa Teleni
- School of Nursing and Cancer and Palliative Care Outcomes Centre, Queensland University of Technology, Brisbane, Australia.
| | - Raymond Javan Chan
- School of Nursing and Cancer and Palliative Care Outcomes Centre, Queensland University of Technology, Brisbane, Australia; Princess Alexandra Hospital, Metro South Hospital and Health Services, Brisbane, Australia.
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5
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van Dongen SI, de Nooijer K, Cramm JM, Francke AL, Oldenmenger WH, Korfage IJ, Witkamp FE, Stoevelaar R, van der Heide A, Rietjens JA. Self-management of patients with advanced cancer: A systematic review of experiences and attitudes. Palliat Med 2020; 34:160-178. [PMID: 32009565 PMCID: PMC7433395 DOI: 10.1177/0269216319883976] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with advanced cancer are increasingly expected to self-manage. Thus far, this topic has received little systematic attention. AIM To summarise studies describing self-management strategies of patients with advanced cancer and associated experiences and personal characteristics. Also, to summarise attitudes of relatives and healthcare professionals towards patient self-management. DESIGN A systematic review including non-experimental quantitative and qualitative studies. Data were analysed using critical interpretive synthesis. Included studies were appraised on methodological quality and quality of reporting. DATA SOURCES MEDLINE, Embase, Cochrane Central, PsycINFO, CINAHL, Web of Science and Google Scholar (until 11 June 2019). RESULTS Of 1742 identified articles, 31 moderate-quality articles describing 8 quantitative and 23 qualitative studies were included. Patients with advanced cancer used self-management strategies in seven domains: medicine and pharmacology, lifestyle, mental health, social support, knowledge and information, navigation and coordination and medical decision-making (29 articles). Strategies were highly individual, sometimes ambivalent and dependent on social interactions. Older patients and patients with more depressive symptoms and lower levels of physical functioning, education and self-efficacy might have more difficulties with certain self-management strategies (six articles). Healthcare professionals perceived self-management as desirable and achievable if based on sufficient skills and knowledge and solid patient-professional partnerships (three articles). CONCLUSION Self-management of patients with advanced cancer is highly personal and multifaceted. Strategies may be substitutional, additional or even conflicting compared to care provided by healthcare professionals. Self-management support can benefit from an individualised approach embedded in solid partnerships with relatives and healthcare professionals.
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Affiliation(s)
- Sophie I van Dongen
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Kim de Nooijer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jane M Cramm
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Anneke L Francke
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands.,Amsterdam Public Health (APH) Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Wendy H Oldenmenger
- Faculty of Nursing and Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frederika E Witkamp
- Faculty of Nursing and Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | - Rik Stoevelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Judith Ac Rietjens
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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Lundby C, Graabaek T, Ryg J, Søndergaard J, Pottegård A, Nielsen DS. Health care professionals' attitudes towards deprescribing in older patients with limited life expectancy: A systematic review. Br J Clin Pharmacol 2019; 85:868-892. [PMID: 30630219 DOI: 10.1111/bcp.13861] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS The aim of this systematic review was to explore health care professionals' attitudes towards deprescribing in older people with limited life expectancy. METHODS A systematic literature search was conducted from inception to December 2017 using MEDLINE, EMBASE and CINAHL. Studies were included if they specifically concerned older people (≥65 years) with limited life expectancy, including those residing in any type of aged care facility, or were based on representative patient profiles. Results were analyzed inspired by the Joanna Briggs Institute's method for synthesis of qualitative data. Studies were characterized using a checklist for reporting of qualitative research. RESULTS Eight studies were included. Six studies explored health care professionals' views on deprescribing in general, and two studies focused specifically on psychotropic agents. All eight studies explored the views of physicians, mostly general practitioners, while three studies also considered other health care professionals. Four themes related to health care professionals' attitudes towards deprescribing were identified: (i) patient and relative involvement; (ii) the importance of teamwork; (iii) health care professionals' self-assurance and skills; and (iv) the impact of organizational factors. Within each of these themes, 3-4 subthemes were identified and analysed. CONCLUSIONS Our results suggest that health care professionals' decisions to engage in deprescribing activities with older people with limited life expectancy depend on multiple factors which are highly interdependent. Consequently, there is an urgent need for more research on how to approach deprescribing in clinical practice within this population.
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Affiliation(s)
- Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Trine Graabaek
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense C, Denmark.,Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Dorthe Susanne Nielsen
- Migrant Health Clinic, Odense University Hospital, Odense C, Denmark.,Centre for Global Health, University of Southern Denmark, Odense C, Denmark.,Health Sciences Research Center, University College Lillebaelt, Odense M, Denmark
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7
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Paque K, Vander Stichele R, Elseviers M, Pardon K, Dilles T, Deliens L, Christiaens T. Barriers and enablers to deprescribing in people with a life-limiting disease: A systematic review. Palliat Med 2019; 33:37-48. [PMID: 30229704 DOI: 10.1177/0269216318801124] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND: Knowing the barriers/enablers to deprescribing in people with a life-limiting disease is crucial for the development of successful deprescribing interventions. These barriers/enablers have been studied, but the available evidence has not been summarized in a systematic review. AIM: To identify the barriers/enablers to deprescribing of medications in people with a life-limiting disease. DESIGN: Systematic review, registered in PROSPERO (CRD42017073693). DATA SOURCES: A systematic search of MEDLINE, Embase, Web of Science and CENTRAL was conducted and extended with a hand search. Peer-reviewed, primary studies reporting on barriers/enablers to deprescribing in the context of explicit life-limiting disease were included in this review. RESULTS: A total of 1026 references were checked. Five studies met the criteria and were included in this review. Three types of barriers/enablers were found: organizational, professional and patient (family)-related barriers/enablers. The most prominent enablers were organizational support (e.g. for standardized medication review), involvement of multidisciplinary teams in medication review and the perception of the importance of coming to a joint decision regarding deprescribing, which highlighted the need for interdisciplinary collaboration and involving the patient and his family in the decision-making process. The most important barriers were shortages in staff and the perceived difficulty or resistance of the nursing home resident's family - or the resident himself. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: The scarcity of findings in the literature highlights the importance of filling this gap. Further research should focus on deepening the knowledge on these barriers/enablers in order to develop sustainable multifaceted deprescribing interventions in palliative care.
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Affiliation(s)
- Kristel Paque
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Robert Vander Stichele
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Monique Elseviers
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,3 Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium
| | - Koen Pardon
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Tinne Dilles
- 3 Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium.,4 Department of Nursing and Midwifery, Thomas More University College, Lier, Belgium
| | - Luc Deliens
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,5 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Thierry Christiaens
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
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Jia Hao L, Omar MS, Tohit N. Polypharmacy and Willingness to Deprescribe Among Elderly with Chronic Diseases. INT J GERONTOL 2018. [DOI: 10.1016/j.ijge.2018.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Budhwani S, Wodchis WP, Zimmermann C, Moineddin R, Howell D. Self-management, self-management support needs and interventions in advanced cancer: a scoping review. BMJ Support Palliat Care 2018; 9:12-25. [PMID: 30121581 DOI: 10.1136/bmjspcare-2018-001529] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/29/2018] [Accepted: 07/11/2018] [Indexed: 12/25/2022]
Abstract
Patients with advanced cancer can experience illness trajectories similar to other progressive chronic disease conditions where undertaking self-management (SM) and provision of self-management support (SMS) becomes important. The main objectives of this study were to map the literature of SM strategies and SMS needs of patients with advanced cancer and to describe SMS interventions tested in this patient population. A scoping review of all literature published between 2002 and 2016 was conducted. A total of 11 094 articles were generated for screening from MEDLINE, Embase, PsychINFO, CINAHL and Cochrane Library databases. A final 55 articles were extracted for inclusion in the review. Included studies identified a wide variety of SM behaviours used by patients with advanced cancer including controlling and coping with the physical components of the disease and facilitating emotional and psychosocial adjustments to a life-limiting illness. Studies also described a wide range of SMS needs, SMS interventions and their effectiveness in this patient population. Findings suggest that SMS interventions addressing SMS needs should be based on a sound understanding of the core skills required for effective SM and theoretical and conceptual frameworks. Future research should examine how a patient-oriented SMS approach can be incorporated into existing models of care delivery and the effects of SMS on quality of life and health system utilisation in this population.
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Affiliation(s)
- Suman Budhwani
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada.,Health System Performance Research Network, University of Toronto, Toronto, ON, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada.,Health System Performance Research Network, University of Toronto, Toronto, ON, Canada
| | - Camilla Zimmermann
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Doris Howell
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
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Bennett MI, Mulvey MR, Campling N, Latter S, Richardson A, Bekker H, Blenkinsopp A, Carder P, Closs J, Farrin A, Flemming K, Gallagher J, Meads D, Morley S, O'Dwyer J, Wright-Hughes A, Hartley S. Self-management toolkit and delivery strategy for end-of-life pain: the mixed-methods feasibility study. Health Technol Assess 2018; 21:1-292. [PMID: 29265004 DOI: 10.3310/hta21760] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Pain affects most people approaching the end of life and can be severe for some. Opioid analgesia is effective, but evidence is needed about how best to support patients in managing these medicines. OBJECTIVES To develop a self-management support toolkit (SMST) and delivery strategy and to test the feasibility of evaluating this intervention in a future definitive trial. DESIGN Phase I - evidence synthesis and qualitative interviews with patients and carers. Phase II - qualitative semistructured focus groups and interviews with patients, carers and specialist palliative care health professionals. Phase III - multicentre mixed-methods single-arm pre-post observational feasibility study. PARTICIPANTS Phase I - six patients and carers. Phase II - 15 patients, four carers and 19 professionals. Phase III - 19 patients recruited to intervention that experienced pain, living at home and were treated with strong opioid analgesia. Process evaluation interviews with 13 patients, seven carers and 11 study nurses. INTERVENTION Self-Management of Analgesia and Related Treatments at the end of life (SMART) intervention comprising a SMST and a four-step educational delivery approach by clinical nurse specialists in palliative care over 6 weeks. MAIN OUTCOME MEASURES Recruitment rate, treatment fidelity, treatment acceptability, patient-reported outcomes (such as scores on the Brief Pain Inventory, Self-Efficacy for Managing Chronic Disease Scale, Edmonton Symptom Assessment Scale, EuroQol-5 Dimensions, Satisfaction with Information about Medicines Scale, and feasibility of collecting data on health-care resource use for economic evaluation). RESULTS Phase I - key themes on supported self-management were identified from evidence synthesis and qualitative interviews. Phase II - the SMST was developed and refined. The delivery approach was nested within a nurse-patient consultation. Phase III - intervention was delivered to 17 (89%) patients, follow-up data at 6 weeks were available on 15 patients. Overall, the intervention was viewed as acceptable and valued. Descriptive analysis of patient-reported outcomes suggested that interference from pain and self-efficacy were likely to be candidates for primary outcomes in a future trial. No adverse events related to the intervention were reported. The health economic analysis suggested that SMART could be cost-effective. We identified key limitations and considerations for a future trial: improve recruitment through widening eligibility criteria, refine the SMST resources content, enhance fidelity of intervention delivery, secure research nurse support at recruiting sites, refine trial procedures (including withdrawal process and data collection frequency), and consider a cluster randomised design with nurse as cluster unit. LIMITATIONS (1) The recruitment rate was lower than anticipated. (2) The content of the intervention was focused on strong opioids only. (3) The fidelity of intervention delivery was limited by the need for ongoing training and support. (4) Recruitment sites where clinical research nurse support was not secured had lower recruitment rates. (5) The process for recording withdrawal was not sufficiently detailed. (6) The number of follow-up visits was considered burdensome for some participants. (7) The feasibility trial did not have a control arm or assess randomisation processes. CONCLUSIONS A future randomised controlled trial is feasible and acceptable. STUDY AND TRIAL REGISTRATION This study is registered as PROSPERO CRD42014013572; Current Controlled Trials ISRCTN35327119; and National Institute for Health Research (NIHR) Portfolio registration 162114. FUNDING The NIHR Health Technology Assessment programme.
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Affiliation(s)
- Michael I Bennett
- Leeds Institute of Health Sciences, Faculty of Medicine, University of Leeds, Leeds, UK
| | - Matthew R Mulvey
- Leeds Institute of Health Sciences, Faculty of Medicine, University of Leeds, Leeds, UK
| | - Natasha Campling
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Sue Latter
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Alison Richardson
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Hilary Bekker
- Leeds Institute of Health Sciences, Faculty of Medicine, University of Leeds, Leeds, UK
| | - Alison Blenkinsopp
- School of Pharmacy, Faculty of Life Sciences, University of Bradford, Bradford, UK
| | | | - Jose Closs
- School of Healthcare, University of Leeds, Leeds, UK
| | - Amanda Farrin
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Kate Flemming
- Department of Health Science, University of York, York, UK
| | - Jean Gallagher
- Leeds Institute of Health Sciences, Faculty of Medicine, University of Leeds, Leeds, UK
| | - David Meads
- Leeds Institute of Health Sciences, Faculty of Medicine, University of Leeds, Leeds, UK
| | - Stephen Morley
- Leeds Institute of Health Sciences, Faculty of Medicine, University of Leeds, Leeds, UK
| | - John O'Dwyer
- Leeds Institute of Health Sciences, Faculty of Medicine, University of Leeds, Leeds, UK
| | | | - Suzanne Hartley
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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11
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Perspectives of patients, close relatives, nurses, and physicians on end-of-life medication management. Palliat Support Care 2017; 16:580-589. [DOI: 10.1017/s1478951517000761] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
ABSTRACTObjective:Our aim was to gain insight into the perspectives of patients, close relatives, nurses, and physicians on medication management for patients with a life expectancy of less than 3 months.Method:We conducted an empirical multicenter study with a qualitative approach, including in-depth interviews with patients, relatives, nurses, specialists, and general practitioners (GPs). We used the constant comparative method and ATLAS.ti (v. 7.1) software for our analysis.Results:Saturation occurred after 18 patient cases (76 interviews). Some 5 themes covering 18 categories were identified: (1) priorities in end-of-life care, such as symptom management and maintaining hope; (2) appropriate medication use, with attention to unnecessary medication and deprescription barriers; (3) roles in decision making, including physicians in the lead, relatives' advocacy, and pharmacists as suppliers; (4) organization and communication (e.g., transparency of tasks and end-of-life conversations); and (5) prerequisites about professional competence, accessibility and quality of medical records, and financial awareness. Patients, relatives, nurses, specialists, and GPs varied in their opinions about these themes.Significance of Results:This study adds to our in-depth understanding of the complex practice of end-of-life medication management. It provides knowledge about the diversity of the perspectives of patients, close relatives, nurses, and physicians regarding beliefs, attitudes, knowledge, skills, behavior, work setting, the health system, and cultural factors related to the matter. Our results might help to draw an interdisciplinary end-of-life medication management guide aimed at stimulating a multidisciplinary and patient-centered pharmacotherapeutic care approach.
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Ngwenya N, Kenten C, Jones L, Gibson F, Pearce S, Flatley M, Hough R, Stirling LC, Taylor RM, Wong G, Whelan J. Experiences and Preferences for End-of-Life Care for Young Adults with Cancer and Their Informal Carers: A Narrative Synthesis. J Adolesc Young Adult Oncol 2017; 6:200-212. [PMID: 28075655 PMCID: PMC5467142 DOI: 10.1089/jayao.2016.0055] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
To review the qualitative literature on experiences of and preferences for end-of-life care of people with cancer aged 16–40 years (young adults) and their informal carers. A systematic review using narrative synthesis of qualitative studies using the 2006 UK Economic and Social Research Council research methods program guidance. Seven electronic bibliographic databases, two clinical trials databases, and three relevant theses databases were searched from January 2004 to October 2015. Eighteen articles were included from twelve countries. The selected studies included at least 5% of their patient sample within the age range 16–40 years. The studies were heterogeneous in their aims, focus, and sample, but described different aspects of end-of-life care for people with cancer. Positive experiences included facilitating adaptive coping and receiving palliative home care, while negative experiences were loss of “self” and nonfacilitative services and environment. Preferences included a family-centered approach to care, honest conversations about end of life, and facilitating normality. There is little evidence focused on the end-of-life needs of young adults. Analysis of reports including some young adults does not explore experience or preferences by age; therefore, it is difficult to identify age-specific issues clearly. From this review, we suggest that supportive interventions and education are needed to facilitate open and honest communication at an appropriate level with young people. Future research should focus on age-specific evidence about the end-of-life experiences and preferences for young adults with cancer and their informal carers.
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Affiliation(s)
- Nothando Ngwenya
- 1 Cancer Clinical Trials Unit, University College Hospital , London, United Kingdom
| | - Charlotte Kenten
- 1 Cancer Clinical Trials Unit, University College Hospital , London, United Kingdom
| | - Louise Jones
- 2 Division of Psychiatry, Palliative Care Research Department, University College London , London, United Kingdom
| | - Faith Gibson
- 3 Centre for Outcomes and Experiences Research in Children's Health, Great Ormond Street Hospital for Children NHS Foundation Trust , London, United Kingdom .,4 School of Health Sciences, University of Surrey , London, United Kingdom
| | - Susie Pearce
- 5 Department of Oncology, University College Hospital , London, United Kingdom
| | | | - Rachael Hough
- 7 Children and Young Peoples Cancer Service, University College Hospital , London, United Kingdom
| | - L Caroline Stirling
- 8 Camden, Islington ELiPSe and UCLH & HCA Palliative Care Service, Central and North West London NHS Trust , London, United Kingdom
| | - Rachel M Taylor
- 5 Department of Oncology, University College Hospital , London, United Kingdom
| | - Geoff Wong
- 9 Nuffield Department of Primary Care Health Sciences, University of Oxford , Oxford, United Kingdom
| | - Jeremy Whelan
- 5 Department of Oncology, University College Hospital , London, United Kingdom
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The Development and Preliminary Testing of an Instrument for Assessing Fatigue Self-management Outcomes in Patients With Advanced Cancer. Cancer Nurs 2017; 40:48-57. [DOI: 10.1097/ncc.0000000000000347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chan R, Yates P, McCarthy A. Fatigue Self-Management Behaviors in Patients With Advanced Cancer: A Prospective Longitudinal Survey. Oncol Nurs Forum 2016; 43:762-771. [DOI: 10.1188/16.onf.762-771] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Hughes ND, Closs SJ, Flemming K, Bennett MI. Supporting self-management of pain by patients with advanced cancer: views of palliative care professionals. Support Care Cancer 2016; 24:5049-5057. [PMID: 27557834 DOI: 10.1007/s00520-016-3372-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 08/04/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of the study is to ascertain the views of specialist palliative care professionals on patient self-management of cancer pain in order to inform the development of a new educational intervention to support self-management. METHODS This is a qualitative research study using focus group interviews. RESULTS Participants viewed self-management of cancer pain as desirable and achievable but also as something that could be problematic. Challenges to self-management were perceived in patient attitudes and behaviours, professionals' own beliefs and actions and the wider social system. Practitioners showed awareness of potential tension between their espoused views (the desirability that patients manage pain autonomously) and their tacit views (the undesirability of patients managing pain in ways which conflict with professionals' knowledge and identity). CONCLUSIONS Practitioners espoused patient-centred professional practice which inclined them towards supporting self-management. They showed awareness of factors which might inhibit them from effectively incorporating education and support for self-management into routine practice.
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Affiliation(s)
- Nicholas D Hughes
- School of Healthcare, Baines Wing, University of Leeds, Leeds, LS2 9UT, UK.
| | - S José Closs
- School of Healthcare, Baines Wing, University of Leeds, Leeds, LS2 9UT, UK
| | - Kate Flemming
- Department of Health Sciences, University of York, York, UK
| | - Michael I Bennett
- Academic Unit of Palliative Care, School of Medicine, University of Leeds, Leeds, UK
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Todd A, Holmes H, Pearson S, Hughes C, Andrew I, Baker L, Husband A. 'I don't think I'd be frightened if the statins went': a phenomenological qualitative study exploring medicines use in palliative care patients, carers and healthcare professionals. BMC Palliat Care 2016; 15:13. [PMID: 26822776 PMCID: PMC4731932 DOI: 10.1186/s12904-016-0086-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/25/2016] [Indexed: 11/10/2022] Open
Abstract
Background There is a growing body of evidence suggesting patients with life-limiting illness use medicines inappropriately and unnecessarily. In this context, the perspective of patients, their carers and the healthcare professionals responsible for prescribing and monitoring their medication is important for developing deprescribing strategies. The aim of this study was to explore the lived experience of patients, carers and healthcare professionals in the context of medication use in life-limiting illness. Methods In-depth interviews, using a phenomenological approach: methods of transcendental phenomenology were used for the patient and carer interviews, while hermeneutic phenomenology was used for the healthcare professional interviews. Results The study highlighted that medication formed a significant part of a patient’s day-to-day routine; this was also apparent for their carers who took on an active role-as a gatekeeper of care-in managing medication. Patients described the experience of a point in which, in their disease journey, they placed less importance on taking certain medications; healthcare professionals also recognize this and refer it as a ‘transition’. This point appeared to occur when the patient became accepting of their illness and associated life expectancy. There was also willingness by patients, carers and healthcare professionals to review and alter the medication used by patients in the context of life-limiting illness. Conclusions There is a need to develop deprescribing strategies for patients with life-limiting illness. Such strategies should seek to establish patient expectations, consider the timing of the discussion about ceasing treatment and encourage the involvement of other stakeholders in the decision-making progress.
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Affiliation(s)
- Adam Todd
- Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, University Boulevard, Thornaby, Stockton-on-Tees, TS17 6BH, UK.
| | - Holly Holmes
- Division of Geriatric and Palliative Medicine, The University of Texas Health Science Center, Houston, TX, USA.
| | - Sallie Pearson
- Faculty of Pharmacy and School of Public Health, The University of Sydney, Sydney, Australia.
| | - Carmel Hughes
- School of Pharmacy, Queen's University, Belfast, UK.
| | - Inga Andrew
- St Benedict's Hospice and Centre for Specialist Palliative Care, Ryhope, Sunderland, UK.
| | - Lisa Baker
- St Benedict's Hospice and Centre for Specialist Palliative Care, Ryhope, Sunderland, UK.
| | - Andy Husband
- Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, University Boulevard, Thornaby, Stockton-on-Tees, TS17 6BH, UK.
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Todd A, Husband A, Andrew I, Pearson SA, Lindsey L, Holmes H. Inappropriate prescribing of preventative medication in patients with life-limiting illness: a systematic review. BMJ Support Palliat Care 2016; 7:113-121. [DOI: 10.1136/bmjspcare-2015-000941] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 10/09/2015] [Accepted: 11/25/2015] [Indexed: 12/20/2022]
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Knowledge, attitudes and beliefs of patients and carers regarding medication adherence: a review of qualitative literature. Eur J Clin Pharmacol 2014; 70:1423-31. [PMID: 25277162 DOI: 10.1007/s00228-014-1761-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 09/21/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this review is to cohere evidence on the knowledge, attitudes and beliefs of patients and carers regarding medication adherence. Medication adherence refers to "the extent to which the patient's action matches the agreed recommendations". Medication adherence is vital in preventing, managing and curing illnesses and, hence, is linked with positive health outcomes. METHODS A search was conducted using the following databases: CINAHL, Embase, PubMed and Web of Knowledge from inception to November 2013. Titles and abstracts were screened for inclusion in the review according to pre-defined inclusion and exclusion criteria. Studies were assessed for quality, and data were extracted into a data extraction form. Results were analysed thematically. RESULTS The final results included 34 articles. Eight analytical themes were identified: (i) beliefs and experiences of medicines, (ii) family support and culture, (iii) role of and relationship with health-care practitioners, (iv) factors related to the disease, (v) self-regulation, (vi) communication, (vii) cost and (viii) access. The theme, "beliefs and experiences of medicines", was present in 33 studies, with many discussing the influence that side effects have on medication adherence. CONCLUSIONS There are a number of variables that impact upon the knowledge, attitudes and beliefs of patients and carers regarding medication adherence. This review presents an overview of the analytical themes which offers the opportunity to examine interventions and their relative efficacies to increase medication adherence.
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Hutt E, Fink RM, Nelson-Marten P, Jones J, Kutner JS. Measuring pain perceptions and medication taking behavior at the end of life: a pilot study. Am J Hosp Palliat Care 2013; 31:726-9. [PMID: 24065272 DOI: 10.1177/1049909113504484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Understanding why some patients with terminal illness are reluctant to take sufficient medication to control pain is critical to effective pain management. OBJECTIVE As a first step toward exploring the pain medication-taking behavior of palliative care patients, this pilot study tested a survey regarding pain medication adherence, medication beliefs, and quality of life (QoL). DESIGN Convenience sample; survey. SETTING/SUBJECTS Six patients receiving inpatient Palliative Care consultations at an academic medical center answered questions about their outpatient pain medication-taking behavior. MEASUREMENTS Medication Adherence Report Scale (MARS), Beliefs about Medications Questionnaire (BMQ), Brief Pain Inventory (BPI), closed-response items from a pain medication adherence study in terminally ill patients, the McGill Quality of Life Questionnaire (McGill), and demographic items. RESULTS The battery of questionnaires took approximately 53 minutes; five of six participants were able to complete all items. Respondents reported moderate to severe pain (mean 4.3/10 for pain on average; 7/10 for worst pain in past 24 hours), and excellent medication adherence. When asked how much relief was provided by pain therapies, respondents reported a mean 73% (range 50-100%) relief. They expressed little concern about addiction, but more concern about medication-induced nausea and constipation. Overall QoL was good (mean 6.8/10, range 5-10, higher score better), with notably high scores in existential and support domains. CONCLUSIONS Inpatients receiving palliative care consultation were able to complete interviewer-administered questionnaires regarding their pain perceptions, medications, and QoL. Further studies using these instruments are feasible and could inform shared decision making about pain management.
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Affiliation(s)
- Evelyn Hutt
- Physician and Director, Colorado REAP in Care Coordination Eastern Colorado Health Care System/Denver VAMC
| | - Regina M Fink
- Research Nurse Scientist, University of Colorado Hospital Associate Professor, University of Colorado College of Nursing, Anschutz Medical Campus
| | - Paula Nelson-Marten
- Associate Professor, University of Colorado College of Nursing, Anschutz Medical Campus
| | - Jacqueline Jones
- Associate Professor, University of Colorado College of Nursing, Anschutz Medical Campus
| | - Jean S Kutner
- Gordon Meiklejohn Endowed Professor of Medicine Division Head, Division of General Internal Medicine University of Colorado School of Medicine
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Reeve E, Wiese MD, Hendrix I, Roberts MS, Shakib S. People's attitudes, beliefs, and experiences regarding polypharmacy and willingness to Deprescribe. J Am Geriatr Soc 2013; 61:1508-14. [PMID: 24028356 DOI: 10.1111/jgs.12418] [Citation(s) in RCA: 164] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To capture people's attitudes, beliefs, and experiences regarding the number of medications they are taking and their feelings about stopping medications. DESIGN Administration of a validated questionnaire. SETTING Multidisciplinary ambulatory consulting service at the Royal Adelaide Hospital. PARTICIPANTS Participants were individuals aged 18 and older (median 71.5) taking at least one regular prescription medication; 100 participants completed all items of the questionnaire, 65 of whom were aged 65 and older. MEASUREMENTS Participants were administered the 15-item Patients' Attitudes Towards Deprescribing (PATD) questionnaire. RESULTS Participants were taking an average of 10 different prescription and nonprescription (including complementary), regular and as-needed medications. More than 60% felt that they were taking a "large number" of medications, and 92% stated that they would be willing to stop one or more of their current medications if possible. Number of regular medications, age, and number of medical conditions were not found to be correlated with willingness to stop a medication. The findings were similar in older and younger participants. CONCLUSION This study has shown that a cohort of mostly older adults were largely accepting of a trial of cessation of medication(s) that their prescriber deemed to be no longer required. Because few factors were associated with willingness to cease medications, all patients should be individually evaluated for deprescribing.
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Affiliation(s)
- Emily Reeve
- Sansom Institute, University of South Australia, Adelaide, SA, Australia; Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
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Luckett T, Davidson PM, Green A, Boyle F, Stubbs J, Lovell M. Assessment and management of adult cancer pain: a systematic review and synthesis of recent qualitative studies aimed at developing insights for managing barriers and optimizing facilitators within a comprehensive framework of patient care. J Pain Symptom Manage 2013; 46:229-53. [PMID: 23159681 DOI: 10.1016/j.jpainsymman.2012.07.021] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 07/23/2012] [Accepted: 07/28/2012] [Indexed: 11/26/2022]
Abstract
CONTEXT Cancer pain is a common, burdensome problem, which is not well managed despite evidence-based guidelines. OBJECTIVES To develop insights for managing barriers and optimizing facilitators to adult cancer pain assessment and management within a comprehensive framework of patient care. METHODS We undertook a systematic review and synthesis of qualitative studies. Medline, PsycINFO, Embase, AMED, CINAHL, and Sociological Abstracts were searched from May 20 to 26, 2011. To be included, the articles had to be published in a peer-reviewed journal since 2000; written in English; and report original qualitative studies on the perspectives of patients, their significant others, or health care providers. Article quality was rated using the checklist of Kitto et al. Thematic synthesis followed a three-stage approach using Evidence for Policy and Practice Information and Co-ordinating Centre-Reviewer 4 software: 1) free line-by-line coding of "Results," 2) organization into "descriptive" themes, and 3) development of "analytical" themes informative to our objective. At Stage 3, a conceptual framework was selected from the peer-reviewed literature according to prima facie "fit" for descriptive themes. RESULTS Of 659 articles screened, 70 met the criteria, reporting 65 studies with 48 patient, 19 caregiver, and 21 health care provider samples. Authors rarely reported reflexivity or negative cases. Mead and Bower's model of patient-centered care accommodated 85% of the descriptive themes; 12% more related to the caregiver and service/system factors. Three themes could not be accommodated. CONCLUSION Findings highlight the need to integrate patient/family education within improved communication, individualize care, use more nonpharmacological strategies, empower patients/families to self-manage pain, and reorganize multidisciplinary roles around patient-centered care and outcomes. These conclusions require validation via consensus and intervention trials.
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Affiliation(s)
- Tim Luckett
- Improving Palliative Care through Clinical Trials, New South Wales Palliative Care Clinical Trials Collaborative, Sydney, NSW 2007, Australia.
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Cortis LJ, McKinnon RA, Anderson C. Palliative care is everyone's business, including pharmacists. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2013; 77:21. [PMID: 23520403 PMCID: PMC3602845 DOI: 10.5688/ajpe77221] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Laura J Cortis
- Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, Australia.
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