UK telehealth initiatives in palliative care: a review

National digital strategies and innovative eHealth policies concerning older adults' dignity: a document analysis in three Scandinavian countries

BACKGROUND

Scandinavian countries are internationally recognised for leading the way in older adult care and in digitally transforming healthcare. Dignity has become a central value in care for older adults in all three Scandinavian countries. Investigating documents about digitalisation in these countries can offer insights into how the dignity of older adults is impacted by digitally transforming healthcare. This study aims to provide knowledge about digital strategies and eHealth policies concerning older adults' dignity in three Scandinavian countries: Norway, Sweden and Denmark.

METHODS

National-level documents by the Norwegian Directorate of eHealth, the Norwegian Directorate of Health, the Swedish Ministry of Health and Social Affairs and the Danish Ministry of Health concerning older adults were used as data sources. In addition, a systematic search of databases, informed by the Joanna Briggs Institute framework for systematic reviews of text and opinion papers, was undertaken to find relevant papers. All extracts concerning national digital strategies or innovative eHealth policies were deductively coded. Thereafter, extracts concerning older adults were inductively coded using a thematic analytic approach.

RESULTS

A total of 26 sources satisfied the inclusion criteria, 14 governmental papers and 12 other papers. The three countries' national digital strategies focused on access to digital technologies and continuous learning for digital skills. The included papers describing national eHealth policies underlined the importance of placing the patient at the centre of healthcare and how digital systems can increase feelings of safety. Both types of documents concerned access to data, digital device security and the human dimension of care.

CONCLUSION

The findings present evidence on Scandinavian countries' national digital strategies and innovative eHealth policies concerning older adults' dignity. The documents describe a lack of digital competence among older adults, resulting disengagement may put their well-being and human dignity at risk. Findings also underline the importance of security and at the same time the human dimension of care: Use of new digital systems must be meaningfully integrated into digital strategies and eHealth policies. All three Scandinavian countries strategies and policies underline the importance of equal access to healthcare services, as thus they promote a stance of dignified care.

The role of telehealth on quality of life of palliative care patients during the COVID-19 pandemic: an integrative review

Telehealth looks to be a viable tool to meet patients’ expectations and requirements during home treatment; however, there are obstacles to overcome. Palliative care has been described as ‘high touch’ rather than ‘high tech’, which may restrict healthcare workers’ enthusiasm in integrating technological advances into the development and refinement of interventions. As a result, the goal of this integrative review was to map and evaluate existing research on the use of telemedicine and telehealth in palliative care patients during the COVID-19 outbreak. This review was guided using the PRISMA Model and CASP guidelines. A total of 17 articles on the use of telehealth in palliative care satisfied the inclusion and exclusion criteria of the review. This integrative review provided more evidence for the function and application of telehealth in palliative care. It demonstrated the resiliency of individuals in swiftly adjusting to a new system or application and the adaptability of healthcare systems and providers in establishing an alternate means of providing treatment to patients during a crisis.

Virtual care in end of life and palliative care: A rapid evidence check

The purpose of this rapid evidence check was to identify virtual care modalities that are safe and effective in the delivery of end of life and palliative care. Thirty-three peer reviewed articles which were either review articles or interventional/evaluative studies presenting comparative data were identified through PubMed, Google, and Google Scholar searches. Extracted data was synthesized narratively and outcomes were categorised separately for patients, healthcare providers, caregivers and health system. Included studies reported on a wide range of virtual care modalities, including video consultation, mobile apps, videos, websites, telephone support, email and alert messages. Generally, studies reported similar or favourable quality of life outcomes to face-to-face palliative care, especially when virtual care was used as a supplement rather than a substitute for face-to-face care. Positive attitudes for perceived usefulness and helpfulness were reported by patients, caregivers and healthcare providers. Challenges identified related to technology limitations, trust, ethical concerns, administrative burden and evidence gaps. Overall, most studies found virtual care modalities to be safe and effective in end of life and palliative care with no detrimental adverse outcomes, when used as a supplement to face-to-face care.

Telehealth and digital developments in society that persons 75 years and older in European countries have been part of: a scoping review

BACKGROUND

Demographic changes are leading to an ageing population in Europe. People are becoming more dependent on digital technologies and health ministries invest increasingly in digitalisation. Societal digital demands impact older people and learning to use new telehealth systems and digital devices are seen as a means of securing their needs.

METHODS

The present study undertakes a scoping review in order to map relevant evidence about telehealth and digital developments in society involving citizens aged 75 and over in European countries. It focuses on their experiences and the main barriers to, and facilitators of, societal digital demands. A framework proposed by Arksey and O`Malley was used to guide the scoping review process. The studies included in the review covered telehealth, digital technology and digital devices, and the context covered participants` own home or surroundings. A comprehensive search on PubMed/MEDLINE, CINAHL, Scopus, Embase and Open Grey was undertaken.

RESULTS

Out of 727 identified citations, 13 sources which met the inclusion criteria (9 original study articles, 2 theses, 1 letter about a product and 1 project report). Few of the studies identified have investigated European citizens 75 years and older separately. The studies included varied in their design, location and focus. Older people have experienced both telehealth and digital devices making life easier and the opposite. The outstanding facilitator found was that technology should be easy to use, and difficulty in remembering the instructions was seen as an important barrier. Interestingly, both social support and lack of social support were found as facilitators of using new devices.

CONCLUSIONS

Telehealth may give a sense of security but learning to use a new device often takes extra effort. Older people were more open to new devices if the possible advantages of the new technology outweighed the effort that would be involved in adopting a new strategy. As technology develops rapidly, and life expectancy in Europe is anticipated to rise continually, there is a need for new and additional research among older European citizens. Future research should cover the technical solutions most relevant to older people today, social support and participants` access to the devices.

Virtual models of care for people with palliative care needs living in their own home: A systematic meta-review and narrative synthesis

BACKGROUND

Access to palliative care in the community enables people to live in their preferred place of care, which is often home. Community palliative care services struggle to provide timely 24-h services to patients and family. This has resulted in calls for 'accessible and flexible' models of care that are 'responsive' to peoples' changing palliative care needs. Digital health technologies provide opportunities to meet these requirements 24-h a day.

AIM

To identify digital health technologies that have been evaluated for supporting timely assessment and management of people living at home with palliative care needs and/or their carer(s), and the evidence-base for each.

DESIGN

A systematic review of systematic reviews ('meta-review'). Systematic reviews evaluating evidence for virtual models of palliative or end-of-life care using one or more digital health technologies were included. Systematic reviews were evaluated using the Risk of Bias Tool for Systematic Reviews. A narrative approach was used to synthesise results.

DATA SOURCES

Medline, Embase, Web of Science, CINAHL and Cochrane Database of systematic reviews were searched for English-language reviews published between 2015 and 2020.

RESULTS

The search yielded 2266 articles, of which 12 systematic reviews met criteria. Sixteen reviews were included in total, after four reviews were found via handsearching. Other than scheduled telehealth, video-conferencing, or after-hours telephone support, little evidence was found for digital health technologies used to deliver virtual models of palliative care.

CONCLUSIONS

There are opportunities to test new models of virtual care, beyond telehealth and/or video conferencing, such as 24-h command centres, and rapid response teams.

SYSTEMATIC REVIEW REGISTRATION NUMBER

Prospero CRD42020200266.

Patients' Experiences of Telehealth in Palliative Home Care: Scoping Review

Background

Telehealth is increasingly being used in home care and could be one measure to support the needs of home-based patients receiving palliative care. However, no previous scoping review has mapped existing studies on the use of telehealth for patients in palliative home care.

Objective

The aim of this study was to map and assess published studies on the use of telehealth for patients in palliative home care.

Methods

A scoping review was conducted using the methodological framework of Arksey and O’Malley. Reporting was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. A systematic and comprehensive search of Medical Literature Analysis and Retrieval System Online, EMBASE, PsycINFO, and Cumulative Index to Nursing and Allied Health was performed for studies published between January 2000 and October 2018. Two authors independently assessed eligibility and extracted data.

Results

The review included 22 papers from 19 studies. Four thematic groupings were identified among the included papers: easy and effortless use of telehealth regardless of the current health condition, visual features that enhance communication and care via telehealth, symptom management and self-management promotion by telehealth, and perceptions of improved palliative care at home.

Conclusions

The use of telehealth in palliative home care seems to be feasible, improving access to health care professionals at home and enhancing feelings of security and safety. The visual features of telehealth seem to allow a genuine relationship with health care professionals. However, there are contradicting results on whether the use of telehealth improves burdensome symptoms and quality of life. Future research should investigate the experiences of using telehealth among patients with life-limiting illness other than cancer and patients aged 85 years or older. More research is needed to increase the body of knowledge regarding the effectiveness of telehealth on symptoms and quality of life.

Using telehealth to support end of life care in the community: a feasibility study

Background

Telehealth is being used increasingly in providing care to patients in the community setting. Telehealth enhanced service delivery could offer new ways of managing load and care prioritisation for palliative care patients living in the community. The study assesses the feasibility of a telehealth-based model of service provision for community based palliative care patients, carers and clinicians.

Methods

This study was a prospective cohort study of a telehealth-based intervention for community based patients of a specialist palliative care service living in Southern Adelaide, South Australia. Participants were 43 community living patients enrolled in the Southern Adelaide Palliative Service. To be eligible patients needed to be over 18 years and have an Australian modified Karnofksy Performance Score > 40. Exclusion criteria included a demonstrated inability to manage the hardware or technology (unless living with a carer who could manage the technology) or non-English speaking without a suitable carer/proxy. Participants received video-based conferences between service staff and the patient/carer; virtual case conferences with the patient/carer, service staff and patient’s general practitioner (GP); self-report assessment tools for patient and carer; and remote activity monitoring (ACTRN12613000733774).

Results

The average age of patients was 71.6 years (range: 49 to 91 years). All 43 patients managed to enter data using the telehealth system. Self-reported data entered by patients and carers did identify changes in performance status leading to changes in care. Over 4000 alerts were generated. Staff reported that videocalls were similar (22.3%) or better/much better (65.2%) than phone calls and similar (63.1%) or better/much better (27.1%) than face-to-face. Issues with the volume of alerts generated, technical support required and the impact of service change were identified.

Conclusions

The trial showed that patients and carers could manage the technology and provide data that would otherwise not have been available to the palliative care service.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12613000733774 registered on 02/07/2013.

Tele-monitoring of ventilator-dependent patients: a European Respiratory Society Statement

The estimated prevalence of ventilator-dependent individuals in Europe is 6.6 per 100 000 people. The increasing number and costs of these complex patients make present health organisations largely insufficient to face their needs. As a consequence, their burden lays mostly over families. The need to reduce healthcare costs and to increase safety has prompted the development of tele-monitoring for home ventilatory assistance.

A European Respiratory Society Task Force produced a literature research based statement on commonly accepted clinical criteria for indications, follow-up, equipment, facilities, legal and economic issues of tele-monitoring of these patients.

Many remote health monitoring systems are available, ensuring safety, feasibility, effectiveness, sustainability and flexibility to face different patients' needs. The legal problems associated with tele-monitoring are still controversial. National and European Union (EU) governments should develop guidelines and ethical, legal, regulatory, technical, administrative standards for remote medicine. The economic advantages, if any, of this new approach must be compared to a “gold standard” of home care that is very variable among different European countries and within each European country.

Much more research is needed before considering tele-monitoring a real improvement in the management of these patients.

Using technology to improve access to specialist care in amyotrophic lateral sclerosis: A systematic review

Our objective was to review the evidence for using technology to improve access to specialist care for patients with amyotrophic lateral sclerosis (ALS) and their carers. Medline, Google Scholar and the Cochrane library were searched for articles describing technology that enabled clinical care of patients with ALS or their carers where the patient/carer and clinician were not in the same location. Two applications were identified: telemedicine to facilitate video conferencing as an alternative to outpatient consultations and telehealth monitoring for patients with respiratory failure. One randomized controlled trial using telehealth in patients with respiratory failure including 22 patients with ALS was identified. While rates of hospitalization were reduced, overall mortality was unchanged and there were too few patients with ALS in the study to detect significant benefit. In conclusion, there is limited evidence to support the use of telemedicine or telehealth in the care of patients with ALS. Future research needs to develop an understanding of the key beneficial aspects of the traditional specialist ALS service and how these factors could be delivered using technology. Successful evaluation and implementation of technologies to facilitate access to specialist care will only be possible if all the relevant impacts of an intervention are understood and measured.

Palliative care professional education via video conference builds confidence to deliver palliative care in rural and remote locations

BACKGROUND

People living in rural and remote locations are disadvantaged in accessing palliative care. This can be attributed to several factors including the role diversity and the low numbers of patients with specific conditions, as well as the difficulties rural health practitioners have in accessing opportunities for professional education. A program of multidisciplinary palliative care video conferences was presented to health practitioners across part of northern Australia in an effort to address this problem.

METHOD

The educational content of the video conferences was developed from participant responses to an educational needs assessment. Following cycles of four consecutive video conferences, 101 participants completed evaluative on-line surveys. The quantitative data were analysed using frequencies and analysis of variance tests with post-hoc analyses where appropriate, and an accessibility and remoteness index was used to classify their practice location.

RESULTS

All participants found the content useful regardless of their remoteness from the tertiary centre, their years of experience caring for palliative care patients or the number of patients cared for each year. However, change in confidence to provide palliative care as a result of attending the video conferences was significant across all disciplines, regardless of location. Doctors, medical students and allied health professionals indicated the greatest change in confidence.

CONCLUSIONS

The provision of professional education about palliative care issues via multidisciplinary video conferencing increased confidence among rural health practitioners, by meeting their identified need for topic and context specific education. This technology also enhanced the networking opportunities between practitioners, providing an avenue of ongoing professional support necessary for maintaining the health workforce in rural and remote areas. However, more attention should be directed to the diverse educational needs of allied health professionals.

Elements of effective palliative care models: a rapid review

BACKGROUND

Population ageing, changes to the profiles of life-limiting illnesses and evolving societal attitudes prompt a critical evaluation of models of palliative care. We set out to identify evidence-based models of palliative care to inform policy reform in Australia.

METHOD

A rapid review of electronic databases and the grey literature was undertaken over an eight week period in April-June 2012. We included policy documents and comparative studies from countries within the Organisation for Economic Co-operation and Development (OECD) published in English since 2001. Meta-analysis was planned where >1 study met criteria; otherwise, synthesis was narrative using methods described by Popay et al. (2006).

RESULTS

Of 1,959 peer-reviewed articles, 23 reported systematic reviews, 9 additional RCTs and 34 non-randomised comparative studies. Variation in the content of models, contexts in which these were implemented and lack of detailed reporting meant that elements of models constituted a more meaningful unit of analysis than models themselves. Case management was the element most consistently reported in models for which comparative studies provided evidence for effectiveness. Essential attributes of population-based palliative care models identified by policy and addressed by more than one element were communication and coordination between providers (including primary care), skill enhancement, and capacity to respond rapidly to individuals' changing needs and preferences over time.

CONCLUSION

Models of palliative care should integrate specialist expertise with primary and community care services and enable transitions across settings, including residential aged care. The increasing complexity of care needs, services, interventions and contextual drivers warrants future research aimed at elucidating the interactions between different components and the roles played by patient, provider and health system factors. The findings of this review are limited by its rapid methodology and focus on model elements relevant to Australia's health system.

Community-based palliative care: the natural evolution for palliative care delivery in the U.S

Palliative care in the U.S. has evolved from a system primarily reliant on community-based hospices to a combined model that includes inpatient services at most large hospitals. However, these two dominant approaches leave most patients needing palliative care-those at home (including nursing homes) but not yet ready for hospice-unable to access the positive impacts of the palliative care approach. We propose a community-based palliative care (CPC) model that spans the array of inpatient and outpatient settings in which palliative care is provided and links seamlessly to inpatient care; likewise, it would span the full trajectory of advanced illness rather than focusing on the period just before death. Examples of CPC programs are developing organically across the U.S. As our understanding of CPC expands, standardization is needed to ensure replicability, consistency, and the ability to relate intervention models to outcomes. A growing body of literature examining outpatient palliative care supports the role of CPC in improving outcomes, including reduction in symptom burden, improved quality of life, increased survival, better satisfaction with care, and reduced health care resource utilization. Furthermore the examination of how to operationalize CPC is needed before widespread implementation can be realized. This article describes the key characteristics of CPC, highlighting its role in longitudinal care across patient transitions. Distinguishing features include consistent care across the disease trajectory independent of diagnosis and prognosis; inclusion of inpatient, outpatient, long-term care, and at-home care delivery; collaboration with other medical disciplines, nursing, and allied health; and full integration into the health care system (rather than parallel delivery).