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Tuca A, Viladot M, Carrera G, Llavata L, Barrera C, Chicote M, Marco-Hernández J, Padrosa J, Zamora-Martínez C, Grafia I, Pascual A, Font C, Font E. Evolution of Complexity of Palliative Care Needs and Patient Profiles According to the PALCOM Scale (Part Two): Pooled Analysis of the Cohorts for the Development and Validation of the PALCOM Scale in Advanced Cancer Patients. Cancers (Basel) 2024; 16:1744. [PMID: 38730696 PMCID: PMC11083064 DOI: 10.3390/cancers16091744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/19/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION Identifying the complexity of palliative care needs is a key aspect of referral to specialized multidisciplinary early palliative care (EPC) teams. The PALCOM scale is an instrument consisting of five multidimensional assessment domains developed in 2018 and validated in 2023 to identify the level of complexity in patients with advanced cancer. (1) Objectives: The main objective of this study was to determine the degree of instability (likelihood of level change or death), health resource consumption and the survival of patients according to the level of palliative complexity assigned at the baseline visit during a 6-month follow-up. (2) Method: An observational, prospective, multicenter study was conducted using pooled data from the development and validation cohort of the PALCOM scale. The main outcome variables were as follows: (a) instability ratio (IR), defined as the probability of level change or death; (b) emergency department visits; (c) days of hospitalization; (d) hospital death; (e) survival. All the variables were analyzed monthly according to the level of complexity assigned at the baseline visit. (3) Results: A total of 607 patients with advanced cancer were enrolled. According to the PALCOM scale, 20% of patients were classified as low complexity, 50% as medium and 30% as high complexity. The overall IR was 45% in the low complexity group, 68% in the medium complexity group and 78% in the high complexity group (p < 0.001). No significant differences in mean monthly emergency department visits (0.2 visits/ patient/month) were observed between the different levels of complexity. The mean number of days spent in hospital per month was 1.5 in the low complexity group, 1.8 in the medium complexity group and 3.2 in the high complexity group (p < 0.001). The likelihood of in-hospital death was significantly higher in the high complexity group (29%) compared to the medium (16%) and low (8%) complexity groups (p < 0.001). Six-month survival was significantly lower in the high complexity group (24%) compared to the medium (37%) and low (57%) complexity groups (p < 0.001). CONCLUSION According to the PALCOM scale, more complex cases are associated with greater instability and use of hospital resources and lower survival. The data also confirm that the PALCOM scale is a consistent and useful tool for describing complexity profiles, targeting referrals to the EPC and managing the intensity of shared care.
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Affiliation(s)
- Albert Tuca
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
- Psychosocial Support Team, “La Caixa” Foundation (EAPS), Clinic Hospital of Barcelona, 08036 Barcelona, Spain
- Chair of Palliative Care, University of Barcelona, 08036 Barcelona, Spain
| | - Margarita Viladot
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
| | - Gemma Carrera
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
| | - Lucia Llavata
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
| | - Carmen Barrera
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
- Chair of Palliative Care, University of Barcelona, 08036 Barcelona, Spain
| | - Manoli Chicote
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
| | - Javier Marco-Hernández
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
| | - Joan Padrosa
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
| | - Carles Zamora-Martínez
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
| | - Ignacio Grafia
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
| | - Anais Pascual
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
- Psychosocial Support Team, “La Caixa” Foundation (EAPS), Clinic Hospital of Barcelona, 08036 Barcelona, Spain
| | - Carme Font
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
| | - Elena Font
- Unit of Supportive Care in Cancer, Medical Oncology Department, Hospital Clinic and Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (G.C.); (L.L.); (C.B.); (M.C.); (J.M.-H.); (J.P.); (C.Z.-M.); (I.G.); (A.P.); (C.F.); (E.F.)
- Psychosocial Support Team, “La Caixa” Foundation (EAPS), Clinic Hospital of Barcelona, 08036 Barcelona, Spain
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Mocha Campillo F, Comín Orce AM, Monreal Cepero ML, Trincado Cobos P, Gómez Mugarza P, Barriendos Sanz S, Pascual de la Fuente N, Ruffini Egea S, Martínez Trufero J. Analysis of the Complexity of Palliative Care for Cancer Patients. Am J Hosp Palliat Care 2024:10499091241247169. [PMID: 38659417 DOI: 10.1177/10499091241247169] [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: 04/26/2024] Open
Abstract
INTRODUCTION The Spanish National Health System has defined complexity as a set of factors of increased difficulty that require the intervention of a palliative care team. Palliative care aims to improve the quality of life of patients with chronic terminal illnesses. This study aims to describe the degree of complexity of cancer patients in palliative care, to determine which elements of complexity are most prevalent and to determine which other hospital clinical factors are associated with the level of complexity. METHODS This study is a descriptive, observational, and cross-sectional analysis that included patients diagnosed with advanced oncological pathology undergoing palliative treatment who were admitted to the Medical Oncology ward of the Miguel Servet University Hospital between March and April 2023. RESULT A total of 100 patients were selected for the study. According to the IDC-Pal, 68% of patients were classified as highly complex, 26% of patients were complex and only 6% of patients were classified as non-complex. The presence of pain (P < .001), nausea and vomiting (P = .027), depression (P = .033) and functional status (P = .011) were statistically independent predictors of high complexity. DISCUSSION This study has shown that a high proportion of hospitalized palliative care cancer patients have high complexity, suggesting a good matching of healthcare resources to patient complexity. Four factors related to complexity have been identified, namely pain, nausea and vomiting, depression and a bedridden functional state. The presence of any of the 4 factors could help healthcare professionals to identify patients for early specialized palliative care.
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Affiliation(s)
| | - Ana María Comín Orce
- Department of Medical Oncology, Miguel Servet University Hospital, Zaragoza, Spain
| | | | - Pablo Trincado Cobos
- Department of Medical Oncology, Miguel Servet University Hospital, Zaragoza, Spain
| | - Pablo Gómez Mugarza
- Department of Medical Oncology, Miguel Servet University Hospital, Zaragoza, Spain
| | | | | | - Sofia Ruffini Egea
- Department of Medical Oncology, Miguel Servet University Hospital, Zaragoza, Spain
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Ostan R, Varani S, Pannuti F, Pannuti R, Biasco G, Bruera E. End-of-life care for patients with cancer: Clinical, geographical, and sociocultural differences. Palliat Support Care 2024; 22:155-162. [PMID: 36779268 DOI: 10.1017/s1478951523000032] [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: 02/14/2023]
Abstract
OBJECTIVES Timely, effective and personalized identification of the multidimensional needs in patients with advanced cancer are major goals of appropriate palliative care (PC) delivery. However, there is considerable variation in structures, processes, and patient demographics that might influence the intensity of end-of-life care. This study aims to characterize patterns in clinical and demographic characteristics at the inception point and their association with the intensity of care during the last month of life in advanced cancer patients assisted at home. METHODS Cancer patients entered in home PC during 2020 in Italy were considered. The association between home PC services during the last month of life (primary outcome) and demographic data, performance status (Karnofsky Performance Score [KPS]), symptoms, and therapies at the entry was explored in this retrospective study. RESULTS Among 1,721 consecutive patients (919 in Centre-North and 802 in Centre-South Italy), patients from Centre-South were younger (p < 0.001), had worse KPS (p < 0.001), and shorter survival (p = 0.010). Patient age was inversely associated with the number of total/physician/nurses services during the last month of life (p < 0.001, p = 0.001, and p = 0.008, respectively). Patients with severe symptoms (asthenia, pain, and anxiety) at inception needed more PC services at the end of life (p = 0.026, p = 0.008, and p = 0.038, respectively). The distribution of workload differed according to the geographical area, with higher number of PC services provided by physicians (p < 0.001) in Centre-North and by nurses (p = 0.002) in Centre-South. SIGNIFICANCE OF RESULTS These findings highlight major disparity in access and nature of PC in a country with universal access to health services. Studies aimed at comparing PC models among different countries should pay attention to the local heterogeneity within each health-care system.
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Affiliation(s)
- Rita Ostan
- Training and Research Department, National Tumor Assistance (ANT), Bologna, Italy
| | - Silvia Varani
- Training and Research Department, National Tumor Assistance (ANT), Bologna, Italy
| | | | - Raffaella Pannuti
- Training and Research Department, National Tumor Assistance (ANT), Bologna, Italy
| | - Guido Biasco
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX, USA
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Viladot M, Gallardo-Martínez JL, Hernandez-Rodríguez F, Izcara-Cobo J, Majó-LLopart J, Peguera-Carré M, Russinyol-Fonte G, Saavedra-Cruz K, Barrera C, Chicote M, Barreto TD, Carrera G, Cimerman J, Font E, Grafia I, Llavata L, Marco-Hernandez J, Padrosa J, Pascual A, Quera D, Zamora-Martínez C, Bozzone AM, Font C, Tuca A. Validation Study of the PALCOM Scale of Complexity of Palliative Care Needs: A Cohort Study in Advanced Cancer Patients. Cancers (Basel) 2023; 15:4182. [PMID: 37627210 PMCID: PMC10453100 DOI: 10.3390/cancers15164182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/04/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND In a patient-centred model of care, referral to early palliative care (EPC) depends on both the prognosis and the complexity of care needs. The PALCOM scale is a 5-domain multidimensional assessment tool developed to identify the level of complexity of palliative care needs of cancer patients. The aim of this study was to validate the PALCOM scale. PATIENT AND METHODS We conducted a prospective cohort study of cancer patients to compare the PALCOM scale and expert empirical assessment (EA) of the complexity of palliative care needs. The EA had to categorise patients according to their complexity, considering that medium to high levels required priority attention from specialist EPC teams, while those with low levels could be managed by non-specialist teams. Systematically collected multidimensional variables were recorded in an electronic report form and stratified by level of complexity and rating system (PALCOM scale versus EA). The correlation rank (Kendall's tau test) and accuracy test (F1-score) between the two rating systems were analysed. ROC curve analysis was used to determine the predictive power of the PALCOM scale. RESULTS A total of 283 advanced cancer patients were included. There were no significant differences in the frequency of the levels of complexity between the EA and the PALCOM scale (low 22.3-23.7%; medium 57.2-59.0%; high 20.5-17.3%). The prevalence of high symptom burden, severe pain, functional impairment, socio-familial risk, existential/spiritual problems, 6-month mortality and in-hospital death was significantly higher (p < 0.001) at the high complexity levels in both scoring systems. Comparative analysis showed a high correlation rank and accuracy between the two scoring systems (Kendall's tau test 0.81, F1 score 0.84). The predictive ability of the PALCOM scale was confirmed by an area under the curve in the ROC analysis of 0.907 for high and 0.902 for low complexity. CONCLUSIONS In a patient-centred care model, the identification of complexity is a key point to appropriate referral and management of shared care with EPC teams. The PALCOM scale is a high precision tool for determining the level of complexity of palliative care needs.
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Affiliation(s)
- Margarita Viladot
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | - Jose-Luís Gallardo-Martínez
- Home Care Support Teams Program (PADES) Group Mutuam, 08025 Barcelona, Spain; (J.-L.G.-M.); (J.I.-C.); (M.P.-C.); (K.S.-C.)
| | | | - Jessica Izcara-Cobo
- Home Care Support Teams Program (PADES) Group Mutuam, 08025 Barcelona, Spain; (J.-L.G.-M.); (J.I.-C.); (M.P.-C.); (K.S.-C.)
| | | | - Marta Peguera-Carré
- Home Care Support Teams Program (PADES) Group Mutuam, 08025 Barcelona, Spain; (J.-L.G.-M.); (J.I.-C.); (M.P.-C.); (K.S.-C.)
| | - Giselle Russinyol-Fonte
- Mutuam Güell Social Health Care Hospital, 08024 Barcelona, Spain; (F.H.-R.); (G.R.-F.); (D.Q.)
| | - Katia Saavedra-Cruz
- Home Care Support Teams Program (PADES) Group Mutuam, 08025 Barcelona, Spain; (J.-L.G.-M.); (J.I.-C.); (M.P.-C.); (K.S.-C.)
| | - Carmen Barrera
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | - Manoli Chicote
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | - Tanny-Daniela Barreto
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | - Gemma Carrera
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | - Jackeline Cimerman
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | - Elena Font
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
- Psychosocial Support Team, “La Caixa” Foundation (EAPS), Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Ignacio Grafia
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | - Lucia Llavata
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | - Javier Marco-Hernandez
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | - Joan Padrosa
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | - Anais Pascual
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
- Psychosocial Support Team, “La Caixa” Foundation (EAPS), Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Dolors Quera
- Mutuam Güell Social Health Care Hospital, 08024 Barcelona, Spain; (F.H.-R.); (G.R.-F.); (D.Q.)
| | - Carles Zamora-Martínez
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | | | - Carme Font
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
| | - Albert Tuca
- Unit of Supportive and Palliative Care in Cancer, Medical Oncology Department, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (C.B.); (M.C.); (T.-D.B.); (G.C.); (J.C.); (E.F.); (I.G.); (L.L.); (J.M.-H.); (J.P.); (A.P.); (C.Z.-M.); (C.F.)
- Psychosocial Support Team, “La Caixa” Foundation (EAPS), Hospital Clínic de Barcelona, 08036 Barcelona, Spain
- Chair of Palliative Care, University of Barcelona, 08036 Barcelona, Spain
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Asher A, Shirazipour CH, Capaldi JM, Kim S, Diniz M, Jones B, Wertheimer J. A 6-Week Program to Strengthen Resiliency Among Women With Metastatic Cancer: A Randomized Clinical Trial. Oncologist 2023:7146116. [PMID: 37104871 PMCID: PMC10400157 DOI: 10.1093/oncolo/oyad091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/14/2023] [Indexed: 04/29/2023] Open
Abstract
PURPOSE The objective of this study was to evaluate the effect of an intervention (Growing Resilience And CouragE; GRACE) on spiritual well-being, quality of life, and general well-being in women with metastatic cancers reporting existential or spiritual distress. PATIENTS AND METHODS Prospective, randomized, wait-list control clinical trial. Women with metastatic cancer experiencing existential or spiritual concerns were randomized to GRACE or waitlist control. Survey data were collected at baseline, end of program, and 1-month follow-up. Participants included English-speaking women, 18 or older, with metastatic cancer, existential or spiritual concerns, and reasonable medical stability. Eighty-one women were assessed for eligibility; 10 were excluded (not meeting exclusion criteria, refusal to participate, and death). The primary outcome was spiritual well-being measured pre- and post-program. Secondary measures assessed quality of life, anxiety, depression, hopelessness, and loneliness. RESULTS Seventy-one women (aged 47-72) were enrolled (GRACE n = 37, waitlist control n = 34). GRACE participants demonstrated significant improvements in spiritual well-being compared to control at end of program (parameter estimate (PE), 16.67, 95% CI, 13.17, 20.16) and 1-month follow-up (PE, 10.31, 95% CI, 6.73, 13.89). Additionally, significant improvements were demonstrated in quality of life at the end of program (PE, 8.51, 95% CI, 4.26, 12.76) and 1-month follow-up (PE, 6.17, 95% CI, 1.75, 10.58). GRACE participants also demonstrated improved depression and hopelessness at follow-up, as well as improved anxiety. CONCLUSIONS Findings suggest the value of evidence-based psychoeducational and experiential interventions for improving the well-being and quality of life of women with advanced cancer. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02707510.
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Affiliation(s)
- Arash Asher
- Department of Medicine and Physical Medicine and Rehabilitation and Patient and Family Support Program at Cedars-Sinai Cancer, Los Angeles, CA, USA
| | - Celina H Shirazipour
- Division of Population Sciences, Cedars-Sinai Cancer, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jessica M Capaldi
- Division of Population Sciences, Cedars-Sinai Cancer, Los Angeles, CA, USA
| | - Sungjin Kim
- Biostatistics Research Center, Samuel Oschin Comprehensive Cancer Center and Departments of Medicine and Biomedical Sciences, Los Angeles, CA, USA
| | - Marcio Diniz
- Biostatistics Research Center, Samuel Oschin Comprehensive Cancer Center and Departments of Medicine and Biomedical Sciences, Los Angeles, CA, USA
| | - Bronwen Jones
- Department of Spiritual Care, Cedars-Sinai Cancer, Los Angeles, CA, USA
| | - Jeffrey Wertheimer
- Department of Physical Medicine and Rehabilitation at Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Müller S, Fink M, Hense J, Comino MRS, Schuler M, Teufel M, Tewes M. Palliative care outpatients in a German comprehensive cancer center-identifying indicators for early and late referral. BMC Palliat Care 2022; 21:221. [PMID: 36503625 PMCID: PMC9743520 DOI: 10.1186/s12904-022-01114-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Despite that early integration of palliative care is recommended in advanced cancer patients, referrals to outpatient specialised palliative care (SPC) frequently occur late. Well-defined referral criteria are still missing. We analysed indicators associated with early (ER) and late referral (LR) to SPC of an high volume outpatient unit of a comprehensive cancer center. METHODS Characteristics, laboratory parameters and symptom burden of 281 patients at first SPC referral were analysed. Timing of referral was categorized as early, intermediate and late (> 12, 3-12 and < 3 months before death). Ordinal logistic regression analysis was used to identify factors related to referral timing. Kruskal-Wallis test was used to determine symptom severity and laboratory parameter in each referral category. RESULTS LRs (50.7%) had worse scores of weakness, loss of appetite, drowsiness, assistance of daily living (all p < 0.001) and organisation of care (p < 0.01) in contrast to ERs. The mean symptom sum score was significantly higher in LRs than ERs (13.03 vs. 16.08; p < 0.01). Parameters indicative of poor prognosis, such as elevated LDH, CRP and neutrophil-to-lymphocyte ratio (NLR) (p < 0.01) as well as the presence of ascites (p < 0.05), were significantly higher (all p < 0.001) in LRs. In univariable analyses, psychological distress (p < 0.05) and female gender (p < 0.05) were independently associated with an ER. CONCLUSION A symptom sum score and parameters of poor prognosis like NLR or LDH might be useful to integrate into palliative care screening tools.
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Affiliation(s)
- S. Müller
- grid.410718.b0000 0001 0262 7331Department of Palliative Medicine, West German Cancer Center Essen, University Hospital Essen, 45147 Essen, Germany
| | - M. Fink
- grid.5718.b0000 0001 2187 5445Clinic of Psychosomatic Medicine and Psychotherapy, University of Duisburg-Essen, LVR-Klinikum Essen, 45147 Essen, Germany
| | - J. Hense
- grid.410718.b0000 0001 0262 7331Department of Medical Oncology, West German Cancer Center Essen, University Hospital Essen, 45147 Essen, Germany
| | - M. R. Salvador Comino
- grid.410718.b0000 0001 0262 7331Department of Palliative Medicine, West German Cancer Center Essen, University Hospital Essen, 45147 Essen, Germany
| | - M. Schuler
- grid.410718.b0000 0001 0262 7331Department of Medical Oncology, West German Cancer Center Essen, University Hospital Essen, 45147 Essen, Germany ,grid.410718.b0000 0001 0262 7331German Cancer Consortium (DKTK), Partner Site University Hospital Essen, 45147 Essen, Germany
| | - M. Teufel
- grid.5718.b0000 0001 2187 5445Clinic of Psychosomatic Medicine and Psychotherapy, University of Duisburg-Essen, LVR-Klinikum Essen, 45147 Essen, Germany
| | - M. Tewes
- grid.410718.b0000 0001 0262 7331Department of Palliative Medicine, West German Cancer Center Essen, University Hospital Essen, 45147 Essen, Germany
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Pigni A, Alfieri S, Caraceni AT, Zecca E, Fusetti V, Tallarita A, Brunelli C. Development of the palliative care referral system: proposal of a tool for the referral of cancer patients to specialized palliative care. BMC Palliat Care 2022; 21:209. [PMID: 36443700 PMCID: PMC9816370 DOI: 10.1186/s12904-022-01094-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 11/02/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Early palliative care (PC) has shown beneficial effects for advanced cancer patients. However, it is still debated what criteria to use to identify patients for PC referral. AIM To document the initial steps of the development of the Palliative Care Referral System (PCRS), a tool to be used by oncologists in clinical practice. METHODS A multiprofessional working group developed the PCRS based on the results of a scoping literature review on PC referral criteria. PCRS criteria were evaluated by experts via a nominal group technique (NGT). Descriptive statistics were used to summarize expert scores on relevance, appropriateness and perceived feasibility of the criteria proposed. Quotations of participants during the discussion were also reported. RESULTS Sixteen studies, including PC referral criteria/tools, emerged from the scoping review. Severe symptoms, poor performance status, comorbidities and prognosis were the most commonly used criteria. The PCRS included nine major criteria and nine assessment methods; a scoring procedure was also proposed. Answers to the questionnaire during the NGT showed that five criteria reached full agreement on all items, while four did not, and were then discussed within the group. Participants agreed on the relevance of all criteria and on the appropriateness of methods proposed to assess most of them, while issues were raised about potential feasibility of the overall assessment of the PCRS in clinical practice. CONCLUSION The PCRS has been developed as an help for oncologists to timely identify patients for specialized PC referral. Since feasibility emerged as the main concern, implementation strategies have to be tested in subsequent studies.
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Affiliation(s)
- Alessandra Pigni
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sara Alfieri
- grid.417893.00000 0001 0807 2568Clinical Psychology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Augusto Tommaso Caraceni
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy ,grid.4708.b0000 0004 1757 2822Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Ernesto Zecca
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Viviana Fusetti
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy ,grid.6530.00000 0001 2300 0941Università degli Studi di Roma “Tor Vergata”, Rome, Italy
| | - Antonino Tallarita
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Cinzia Brunelli
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Brunelli C, Zecca E, Pigni A, Bracchi P, Caputo M, Lo Dico S, Fusetti V, Tallarita A, Bergamini C, Brambilla M, Raimondi A, Niger M, Provenzano S, Sepe P, Alfieri S, Tinè G, De Braud F, Caraceni AT. Outpatient palliative care referral system (PCRS) for patients with advanced cancer: an impact evaluation protocol. BMJ Open 2022; 12:e059410. [PMID: 36307164 PMCID: PMC9621186 DOI: 10.1136/bmjopen-2021-059410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Early palliative care (PC) in the clinical pathway of advanced cancer patients improves symptom control, quality of life and has a positive impact on overall quality of care. At present, standardised criteria for appropriate referral for early PC in oncology care are lacking. The aim of this project is to develop a set of standardised referral criteria and procedures to implement appropriate early PC for advanced cancer patients (the palliative care referral system, PCRS) and test its impact on user perception of quality of care received, on patient quality of life and on the use of healthcare resources. SETTING Selected oncology clinics and PC outpatient clinic. METHODS AND ANALYSIS A scoping literature review and an expert consultation through a nominal group technique will be used to revise existing referral tools and to develop a new one, the PCRS. 25 patients will be enrolled in a pilot study to assess feasibility of the implementation of PCRS; 10 interviews with patients and healthcare professionals will be carried out to evaluate applicability.A pretest-post-test quasiexperimental study involving 150 patients before implementation of the PCRS and 150 patients after implementation will be carried out.Patient satisfaction with care received, quality of life and use of resources, and caregiver satisfaction with care will also be assessed to explore the impact of the intervention. ETHICS AND DISSEMINATION Ethical approval for the study has been granted by the Institutional Review board of the Fondazione IRCCS Istituto Nazionale Tumori; approval reference INT201/19.Results will be disseminated through open access publications and through scientific communication presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT04936568.
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Affiliation(s)
- Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Ernesto Zecca
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Alessandra Pigni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Paola Bracchi
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Mariangela Caputo
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Silvia Lo Dico
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Viviana Fusetti
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
- Università degli Studi di Roma Tor Vergata, Roma, Lazio, Italy
| | - Antonino Tallarita
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Cristiana Bergamini
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Marta Brambilla
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Alessandra Raimondi
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Monica Niger
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Salvatore Provenzano
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Pierangela Sepe
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Sara Alfieri
- Clinical Psychology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Gabriele Tinè
- Unit of Clinical Epidemiology and Trial Organisation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Filippo De Braud
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
- Università degli Studi di Milano, Milano, Italy
| | - Augusto Tommaso Caraceni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
- Università degli Studi di Milano, Milano, Italy
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Busquet-Duran X, Moreno-Gabriel E, Jiménez-Zafra EM, Tura-Poma M, Bosch-DelaRosa O, Moragas-Roca A, Martin-Moreno S, Martínez-Losada E, Crespo-Ramírez S, Lestón-Lado L, Salamero-Tura N, Llobera-Estrany J, Salvago-Leiracha A, López-García AI, Manresa-Domínguez JM, Morandi-Garde T, Persentili-Viure ES, Torán-Monserrat P. Gender and Observed Complexity in Palliative Home Care: A Prospective Multicentre Study Using the HexCom Model. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:12307. [PMID: 34886027 PMCID: PMC8656577 DOI: 10.3390/ijerph182312307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 11/26/2022]
Abstract
This study analyses gender differences in the complexity observed in palliative home care through a multicentre longitudinal observational study of patients with advanced disease treated by palliative home care teams in Catalonia (Spain). We used the HexCom model, which includes six dimensions and measures three levels of complexity: high (non-modifiable situation), medium (difficult) and low. Results: N = 1677 people, 44% women. In contrast with men, in women, cancer was less prevalent (64.4% vs. 73.9%) (p < 0.001), cognitive impairment was more prevalent (34.1% vs. 26.6%; p = 0.001) and professional caregivers were much more common (40.3% vs. 24.3%; p < 0.001). Women over 80 showed less complexity in the following subareas: symptom management (41.7% vs. 51,1%; p = 0.011), emotional distress (24.5% vs. 32.8%; p = 0.015), spiritual distress (16.4% vs. 26.4%; p = 0.001), socio-familial distress (62.7% vs. 70.1%; p = 0.036) and location of death (36.0% vs. 49.6%; p < 0.000). Men were more complex in the subareas of "practice" OR = 1.544 (1.25-1.90 p = 0.000) and "transcendence" OR = 1.52 (1.16-1.98 p = 0.002). Observed complexity is related to male gender in people over 80 years of age. Women over the age of 80 are remarkably different from their male counterparts, showing less complexity regarding care for their physical, psycho-emotional, spiritual and socio-familial needs.
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Affiliation(s)
- Xavier Busquet-Duran
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Eduard Moreno-Gabriel
- Research Support Unit Metropolitana Nord, Primary Care Research Institute Jordi Gol (IDIAPJGol), 08303 Mataró, Spain; (J.M.M.-D.); (P.T.-M.)
| | - Eva Maria Jiménez-Zafra
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Magda Tura-Poma
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Olga Bosch-DelaRosa
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Anna Moragas-Roca
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Susana Martin-Moreno
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Emilio Martínez-Losada
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Silvia Crespo-Ramírez
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Lola Lestón-Lado
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Núria Salamero-Tura
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Joana Llobera-Estrany
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Ariadna Salvago-Leiracha
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Ana Isabel López-García
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Josep María Manresa-Domínguez
- Research Support Unit Metropolitana Nord, Primary Care Research Institute Jordi Gol (IDIAPJGol), 08303 Mataró, Spain; (J.M.M.-D.); (P.T.-M.)
- Department of Nursing, Autonomous University of Barcelona, 08193 Barcelona, Spain
| | - Teresa Morandi-Garde
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Eda Sara Persentili-Viure
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Pere Torán-Monserrat
- Research Support Unit Metropolitana Nord, Primary Care Research Institute Jordi Gol (IDIAPJGol), 08303 Mataró, Spain; (J.M.M.-D.); (P.T.-M.)
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