Using Process Indicators to Monitor Documentation of Patient-Centred Variables in an Integrated Oncology and Palliative Care Pathway-Results from a Cluster Randomized Trial

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02170168.

Analysis and mapping the research landscape on patient-centred care in the context of chronic disease management

RATIONALE

Patient-centred care has emerged as a transformative approach in managing chronic diseases, aiming to actively involve patients in their healthcare decisions.

AIMS AND OBJECTIVES

This study was conducted to analyse and map the research landscape on patient-centred care in the context of chronic disease management.

METHODS

This study used Scopus to retrieve the relevant articles. The analysis focused on the growth pattern, highly cited articles, randomised clinical trials, patients and providers perspectives, facilitators and barriers, frequent author keywords, emerging topics, and prolific countries and journals in the field.

RESULTS

In total, 926 research articles met the inclusion criteria. There was a notable increase in the number of publications over time. Cancer had the highest number of articles (n = 379, 40.9%), followed by diabetes mellitus, and mental health and psychiatric conditions. Studies on patient-centred care in diabetic patients received the highest number of citations. The results identified 52 randomised controlled trials that covered four major themes: patient-centred care for diabetes management, shared decision-making in mental health and primary care, shared decision-making in cancer care, and economic evaluation and cost-effectiveness. The study identified 51 studies that examined the impact of tools such as computer-based systems, decision aids, smartphone apps, and online tools to improve patient-centred outcomes. A map of author keywords showed that renal dialysis, HIV, and atrial fibrillation were the most recent topics in the field. Researchers from the United States contributed to more than half of the retrieved publications. The top active journals included "Patient Education and Counselling" and "Health Expectations".

CONCLUSION

This study provides valuable insights into the research landscape of patient-centred care within the context of chronic diseases. The current study provided a comprehensive overview of the research landscape on patient-centred care, which can empower patients by raising their awareness about clinical experiences and outcomes.

PALLiative care in ONcology (PALLiON): A cluster-randomised trial investigating the effect of palliative care on the use of anticancer treatment at the end of life

BACKGROUND

Effects on anticancer therapy following the integration of palliative care and oncology are rarely investigated. Thus, its potential effect is unknown.

AIM

To investigate the effects of the complex intervention PALLiON versus usual care on end-of-life anticancer therapy.

DESIGN

Cluster-randomised controlled trial (RCT), registered at ClinicalTrials.gov (No. NCT03088202). The complex intervention consisted of a physician education program enhancing theoretical, clinical and communication skills, a patient-centred care pathway and patient symptom reporting prior to all consultations. Primary outcome was overall use, start and cessation of anticancer therapy in the last 3 months before death. Secondary outcomes were patient-reported outcomes. Mixed effects logistic regression models and Cox proportional hazard were used.

SETTING

A total of 12 Norwegian hospitals (03/2017-02/2021).

PARTICIPANTS

Patients ⩾18 years, advanced stage solid tumour, starting last line of anticancer therapy, estimated life expectancy ⩽12 months.

RESULTS

A total of 616 (93%) patients were included (intervention: 309/control:307); 63% males, median age 69, 77% had gastrointestinal cancers. Median survival time from inclusion was 8 (IQR 3-14) and 7 months (IQR 3-12), and days between anticancer therapy start and death were 204 (90-378) and 168 (69-351) (intervention/control). Overall, 78 patients (13%) received anticancer therapy in the last month (intervention: 33 [11%]/control: 45 [15%]). No differences were found in patient-reported outcomes.

CONCLUSION

We found no significant differences in the probability of receiving end-of-life anticancer therapy. The intervention did not have the desired effect. It was probably too general and too focussed on communication skills to exert a substantial influence on conventional clinical practice.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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