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Youn N, Sorensen J, Howland C, Gilbertson-White S. Social Determinants of Health and Cancer Pain in the US: Scoping Review. Clin Nurs Res 2024; 33:416-428. [PMID: 38375791 DOI: 10.1177/10547738241232018] [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: 02/21/2024]
Abstract
Social determinants of health (SDOH) are structural factors that yield health inequities. Within the context of cancer, these inequities include screening rates and survival rates, as well as higher symptom burden during and after treatment. While pain is one of the most frequently reported symptoms, the relationship between SDOHs and cancer pain is not well understood. The purpose of this study is to describe and synthesize the published research that has evaluated the relationships between SDOH and cancer pain. A systematic search of PubMed, CINAHL, and Embase was conducted to identify studies in which cancer pain and SDOH were described. In all, 20 studies met the inclusion criteria. In total, 14 studies reported a primary aim related to SDOH and cancer pain. Demographic variables including education or income were used most frequently. Six specific measurements were utilized to measure SDOH, such as the acculturation scale, the composite measure of zip codes for poverty level and blight prevalence, or the segregation index. Among the five domains of SDOH based on Healthy People 2030, social and community was the most studied, followed by economic stability, and education access and quality. The neighborhood and built environment domain was the least studied. Despite increasing attention to SDOH, the majority of published studies use single-dimension variables derived from demographic data to evaluate the relationships between SDOH and cancer pain. Future research is needed to explore the intersectionality of SDOH domains and their impact on cancer pain. Additionally, intervention studies should be conducted to address existing disparities and to reduce the incidence and impact of cancer pain.
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Affiliation(s)
- Nayung Youn
- Univeristy of Iowa, College of Nursing, IA, USA
| | - Jamie Sorensen
- Department of Epidemiology, University of Iowa College of Public Health, IA, USA
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Goodrich J, Watson C, Gaczkowska I, Harding R, Evans C, Firth A, Murtagh FE. Understanding patient and family utilisation of community-based palliative care services out-of-hours: Additional analysis of systematic review evidence using narrative synthesis. PLoS One 2024; 19:e0296405. [PMID: 38381768 PMCID: PMC10880966 DOI: 10.1371/journal.pone.0296405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 12/12/2023] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Community-based out-of-hours services are an integral component of end-of-life care. However, there is little understanding of how patients and families utilise these services. This additional analysis of a systematic review aims to understand and identify patterns of out-of-hours service use and produce recommendations for future service design. METHOD Data on service use was extracted and secondary analysis undertaken, from a systematic review of models of community out-of-hours services. Narrative synthesis was completed, addressing four specific aspects of service use: 1.Times when patients/families/healthcare professionals need to contact out-of-hours services; 2. Who contacts out-of-hours services; 3. Whether a telephone call, centre visit or home visit is provided; 4. Who responds to out-of-hours calls. RESULTS Community-based out-of-hours palliative care services were most often accessed between 5pm and midnight, especially on weekdays (with reports of 69% of all calls being made out-of-hours). Family members and carers were the most frequent callers to of the services (making between 60% and 80% of all calls). The type of contact (telephone, centre visit or home visit) varied based on what was offered and on patient need. Over half of services were led by a single discipline (nurse). CONCLUSIONS Out-of-hours services are highly used up to midnight, and particularly by patients' family and carers. Recommendations to commissioners and service providers are to: • Increase provision of out-of-hours services between 5pm and midnight to reflect the increased use at these times. • Ensure that family and carers are provided with clear contact details for out-of-hours support. • Ensure patient records can be easily accessed by health professionals responding to calls, making the triage process easier. • Listen to patients, family and carers in the design of out-of-hours services, including telephone services. • Collect data systematically on out-of-hours-service use and on outcomes for patients who use the service.
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Affiliation(s)
- Joanna Goodrich
- Cicely Saunders Institute of Palliative Care and Rehabilitation, King’s College London, London, United Kingdom
| | - Caleb Watson
- King’s College London Medical School, London, United Kingdom
| | - Inez Gaczkowska
- Cicely Saunders Institute of Palliative Care and Rehabilitation, King’s College London, London, United Kingdom
| | - Richard Harding
- King’s College London Medical School, London, United Kingdom
| | - Catherine Evans
- Cicely Saunders Institute of Palliative Care and Rehabilitation, King’s College London, London, United Kingdom
- Sussex Community NHS Foundation Trust, Brighton, United Kingdom
| | - Alice Firth
- Cicely Saunders Institute of Palliative Care and Rehabilitation, King’s College London, London, United Kingdom
| | - Fliss E.M. Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
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3
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Diernberger K, Clausen E, Murray G, Wee B, Kaasa S, Hall P, Fallon M. Cancer pain assessment and management: does an institutional approach individualise and reduce cost of care? BMJ Support Palliat Care 2024; 13:e1258-e1264. [PMID: 37236649 PMCID: PMC10850828 DOI: 10.1136/spcare-2022-003547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 01/13/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To understand individual prescribing and associated costs in patients managed with the Edinburgh Pain Assessment and management Tool (EPAT). METHODS The EPAT study was a two-arm parallel group cluster randomised (1:1) trial, including 19 UK cancer centres. Study outcome assessments, including pain levels, analgesia and non-pharmacological and anaesthetic interventions, collected at baseline, 3-5 days and, if applicable, 7-10 days after admission. Costs calculated for inpatient length of stay (LoS), medications and complex pain interventions. Analysis accounted for the clustered nature of the trial design. In this post-hoc analysis, healthcare utilisation and costs are presented descriptively. PARTICIPANTS 10 centres randomised to EPAT (487 patients) and 9 (449 patients) to usual care (UC). MAIN OUTCOME MEASURES Pharmacological and non-pharmacological management, complex pain interventions, length of hospital stay and costs related to these outcomes. RESULTS The mean per patient hospital cost was £3866 with EPAT and £4194 with UC, reflecting a mean LoS of 2.9 days and 3.1 days, respectively. Costs were lower for non-opioids, Non-steroidal anti-inflammatories (NSAIDs) and opioids but slightly higher for adjuvants with EPAT than with UC. The mean per-patient opioid costs were £17.90 (EPAT) and £25.80 (UC). Mean per patient costs of all medication were £36 (EPAT) and £40 (UC).Complex pain intervention costs were £117 with EPAT per patient and £90 with UC. Overall mean cost per patient was £4018.3 (95% CI 3698.9 to 4337.8) with EPAT and £4323.8 (95% CI 4060.0 to 4587.7) with UC. CONCLUSIONS EPAT facilitated personalised medicine and may result in less opioids, more specific treatments, improved pain outcomes and cost savings.
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Affiliation(s)
| | - Eleanor Clausen
- The International Spine Centre, Adelaide, South Australia, Australia
| | - Gordon Murray
- Public Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Bee Wee
- University of Oxford, Oxford, UK
| | - Stein Kaasa
- University of Oslo Faculty of Medicine, Oslo, Norway
| | - Peter Hall
- University of Edinburgh Western General Hospital, Edinburgh, UK
| | - Marie Fallon
- Department of Palliative Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
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Robinson OC, Pini S, Flemming K, Campling N, Fallon M, Richards SH, Mayland CR, Boland E, Swinson D, Hurlow A, Hartup S, Mulvey MR. Exploration of pain assessment and management processes in oncology outpatient services with healthcare professionals: a qualitative study. BMJ Open 2023; 13:e078619. [PMID: 38151273 PMCID: PMC10753735 DOI: 10.1136/bmjopen-2023-078619] [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] [Received: 08/07/2023] [Accepted: 10/17/2023] [Indexed: 12/29/2023] Open
Abstract
OBJECTIVES This study explored cancer pain management practices and clinical care pathways used by healthcare professionals (HCPs) to understand the barriers and facilitators for standardised pain management in oncology outpatient services (OS). DESIGN Data were collected using semistructured interviews that were audio-recorded and transcribed. The data were analysed using thematic analysis. SETTING Three NHS trusts with oncology OS in Northern England. PARTICIPANTS Twenty HCPs with varied roles (eg, oncologist and nurse) and experiences (eg, registrar and consultant) from different cancer site clinics (eg, breast and lung). Data were analysed using thematic analysis. RESULTS HCPs discussed cancer pain management practices during consultation and supporting continuity of care beyond consultation. Key findings included : (1) HCPs' level of clinical experience influenced pain assessments; (2) remote consulting impeded experienced HCPs to do detailed pain assessments; (3) diffusion of HCP responsibility to manage cancer pain; (4) nurses facilitated pain management support with patients and (5) continuity of care for pain management was constrained by the integration of multidisciplinary teams. CONCLUSIONS These data demonstrate HCP cancer pain management practices varied and were unstructured. Recommendations are made for a standardised cancer pain management intervention: (1) detailed evaluation of pain with a tailored self-management strategy; (2) implementation of a structured pain assessment that supports remote consultations, (3) pain assessment tool that can support both experienced and less experienced clinicians. These findings will inform the development of a cancer pain management tool to integrate within routine oncology OS.
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Affiliation(s)
| | - Simon Pini
- Psychological and Social Medicine, University of Leeds, Leeds, UK
| | | | - Natasha Campling
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Marie Fallon
- MRC Institute of Genetics & Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Catriona R Mayland
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
- Divison of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Elaine Boland
- Palliative Medicine, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Daniel Swinson
- St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Adam Hurlow
- Palliative Care Team, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sue Hartup
- St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew R Mulvey
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Alshehri AM, Almogbel YS, Alonazi RE, Alshehri WM, Alkhelaifi HA, Almutairi SA, Alenazi OS, Alali AZ. Pharmacists' Knowledge and Intention to Provide Palliative Care Services in Saudi Arabia: Using the Theory of Planned Behaviour. Healthcare (Basel) 2023; 11:2173. [PMID: 37570413 PMCID: PMC10418381 DOI: 10.3390/healthcare11152173] [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: 04/20/2023] [Revised: 06/17/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Providing palliative care to patients with life-threatening illnesses requires multidisciplinary efforts from different healthcare providers. Identifying the attitude, knowledge, and intentions of pharmacists to provide this service in Saudi Arabia is essential. Therefore, this study aimed to identify the palliative care knowledge, intentions, attitudes, subjective norms, and perceived behavioural control of pharmacists and what factors predict their intentions. Cross-sectional questionnaires based on the theory of planned behaviour were distributed to pharmacists in hospitals and community pharmacies. They included items that measured palliative care knowledge, attitudes, intentions, subjective norms, and the perceived behavioural control of pharmacists and identified other sociodemographic and pharmacy-practice-related items. In total, 131 pharmacists completed the questionnaires, showing an average score on palliative knowledge (8.82 ± 1.96; range: 1-14), strong intentions (5.84 ± 1.41; range: 1-7), positive attitudes (6.10 ± 1.47; range: 1-7), positive subjective norms (5.31 ± 1.32; range: 1-7), and positive perceived behavioural control (5.04 ± 1.21; range: 1-7). Having completed a pharmacy residency program, working longer hours per week, having a more positive attitude, and perceived stronger subjective norms were significantly associated with a strong intention to provide palliative care services. Therefore, enabling and motivating pharmacists to complete pharmacy residency programs and improve their attitudes could increase their intentions to provide these services.
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Affiliation(s)
- Ahmed M. Alshehri
- Clinical Pharmacy Department, College of Pharmacy, Prince Sattam bin Abdulaziz University, Al-Kharj 16273, Saudi Arabia; (S.A.A.); (O.S.A.); (A.Z.A.)
| | - Yasser S. Almogbel
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraidah 51452, Saudi Arabia;
| | - Rana E. Alonazi
- Pharmacology Department, College of Pharmacy, Prince Sattam bin Abdulaziz University, Al-Kharj 16273, Saudi Arabia;
| | - Waleed M. Alshehri
- Clinical Pharmacy Department, King Fahad Medical City, Riyadh 11525, Saudi Arabia;
| | - Hind A. Alkhelaifi
- Contracts Management Department, National Unified Procurement Company (NUPCO), Riyadh 12251, Saudi Arabia;
| | - Salman A. Almutairi
- Clinical Pharmacy Department, College of Pharmacy, Prince Sattam bin Abdulaziz University, Al-Kharj 16273, Saudi Arabia; (S.A.A.); (O.S.A.); (A.Z.A.)
| | - Omar S. Alenazi
- Clinical Pharmacy Department, College of Pharmacy, Prince Sattam bin Abdulaziz University, Al-Kharj 16273, Saudi Arabia; (S.A.A.); (O.S.A.); (A.Z.A.)
| | - Ali Z. Alali
- Clinical Pharmacy Department, College of Pharmacy, Prince Sattam bin Abdulaziz University, Al-Kharj 16273, Saudi Arabia; (S.A.A.); (O.S.A.); (A.Z.A.)
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Firth AM, Lin CP, Yi DH, Goodrich J, Gaczkowska I, Waite F, Harding R, Murtagh FE, Evans CJ. How is community based 'out-of-hours' care provided to patients with advanced illness near the end of life: A systematic review of care provision. Palliat Med 2023; 37:310-328. [PMID: 36924146 PMCID: PMC10126468 DOI: 10.1177/02692163231154760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Deaths in the community are increasing. However, community palliative care out-of-hours is variable. We lack detailed understanding of how care is provided out-of-hours and the associated outcomes. AIM To review systematically the components, outcomes and economic evaluation of community-based 'out-of-hours' care for patients near the end of life and their families. DESIGN Mixed method systematic narrative review. Narrative synthesis, development and application of a typology to categorise out-of-hours provision. Qualitative data were synthesised thematically and integrated at the level of interpretation and reporting. DATA SOURCES Systematic review searching; MEDLINE, EMBASE, PsycINFO, CINAHL from January 1990 to 1st August 2022. RESULTS About 64 publications from 54 studies were synthesised (from 9259 retrieved). Two main themes were identified: (1) importance of being known to a service and (2) high-quality coordination of care. A typology of out-of-hours service provision was constructed using three overarching dimensions (service times, focus of team delivering the care and type of care delivered) resulting in 15 categories of care. Only nine papers were randomised control trials or controlled cohorts reporting outcomes. Evidence on effectiveness was apparent for providing 24/7 specialist palliative care with both hands-on clinical care and advisory care. Only nine publications reported economic evaluation. CONCLUSIONS The typological framework allows models of out-of-hours care to be systematically defined and compared. We highlight the models of out-of-hours care which are linked with improvement of patient outcomes. There is a need for effectiveness and cost effectiveness studies which define and categorise out-of-hours care to allow thorough evaluation of services.
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Affiliation(s)
- Alice M Firth
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Cheng-Pei Lin
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.,Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei
| | - Deok Hee Yi
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Joanna Goodrich
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Inez Gaczkowska
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Frances Waite
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Richard Harding
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Fliss Em Murtagh
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.,University of Hull, Wolfson Palliative Care Research Centre, Hull, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
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Low C, Namasivayam P, Barnett T. Co-designing Community Out-of-hours Palliative Care Services: A systematic literature search and review. Palliat Med 2023; 37:40-60. [PMID: 36349547 PMCID: PMC9843546 DOI: 10.1177/02692163221132089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND In order to provide responsive, individualised and personalised care, there is now greater engagement with patients, families and carers in designing health services. Out-of-hours care is an essential component of community palliative care. However, little is known about how patients, families and carers have been involved in the planning and design of these services. AIM To systematically search and review the research literature that reports on how out-of-hours palliative care services are provided in the community and to identify the extent to which the principles of co-design have been used to inform the planning and design of these services. DESIGN Systematic literature search and review. DATA SOURCES A systematic search for published research papers from seven databases was conducted in MEDLINE, PsycINFO, Embase, Emcare, PubMed, CINAHL and Web of Science, from January 2010 and December 2021. Reference list searches of included papers were undertaken to source additional relevant literature. A manifest content analysis was used to analyse the data. RESULTS A total of 77 papers were included. The majority of out-of-hours services in the community were provided by primary care services. The review found little evidence that patients, families or carers were involved in the planning or development of out-of-hours services. CONCLUSION Incorporating patients, families and carers priorities and preferences in the planning and designing of out-of-hours palliative care service is needed for service providers to deliver care that is more patient-centred. Adopting the principles of co-design may improve how out-of-hours care scan be delivered.
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Affiliation(s)
- Christine Low
- Centre for Rural Health, School of Health Sciences, University of Tasmania, Launceston, TAS, Australia
| | | | - Tony Barnett
- Centre for Rural Health, School of Health Sciences, University of Tasmania, Launceston, TAS, Australia
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Austin PD, Siddall PJ, Lovell MR. Feasibility and acceptability of virtual reality for cancer pain in people receiving palliative care: a randomised cross-over study. Support Care Cancer 2022; 30:3995-4005. [PMID: 35064330 PMCID: PMC8782583 DOI: 10.1007/s00520-022-06824-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/10/2022] [Indexed: 10/26/2022]
Abstract
CONTEXT Pain management in palliative care remains inadequate; the development of innovative therapeutic options is needed. OBJECTIVES To determine the feasibility and preliminary effectiveness for larger randomised controlled trials of 3D head-mounted (HMD) virtual reality (VR) for managing cancer pain (CP) in adults. METHODS Thirteen people receiving palliative care participated in a single-session randomised cross-over trial, after which they completed a qualitative semi-structured interview. We also compared the effects of 3D HMD VR and 2D screen applications on CP intensity and levels of perceived presence. Feasibility was assessed with recruitment, completion rates and time required to recruit target sample. RESULTS Although recruitment was slow, completion rate was high (93%). Participants reported that the intervention was acceptable and caused few side effects. Although participants reported significantly reduced CP intensity after 3D HMD VR (1.9 ± 1.8, P = .003) and 2D screen applications (1.5 ± 1.6, P = .007), no significant differences were found between interventions (-.38 ± 1.2, 95% CI: -1.1-.29, P = .23). Participants reported significantly higher levels of presence with the 3D HMD VR compared to 2D screen (60.7 ± SD 12.4 versus 34.3 ± SD 17.1, mean 95% CI: 16.4-40.7, P = .001). Increased presence was associated with significantly lower pain intensity (mean 95% CI: -.04--0.01, P = 0.02). CONCLUSIONS Our preliminary findings support growing evidence that both 3D and 2D virtual applications provide pain relief for people receiving palliative care. Given the relative lack of cybersickness and increasing access to portable VR, we suggest that larger clinical studies are warranted.
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Affiliation(s)
- Philip D Austin
- Department of Palliative Care, HammondCare, Greenwich Hospital, Sydney, New South Wales, Australia.
| | - Philip J Siddall
- Department of Pain Management, HammondCare, Greenwich Hospital, Sydney, New South Wales, Australia.,Sydney Medical School-Northern, University of Sydney, Sydney, New South Wales, Australia
| | - Melanie R Lovell
- Department of Palliative Care, HammondCare, Greenwich Hospital, Sydney, New South Wales, Australia.,Sydney Medical School-Northern, University of Sydney, Sydney, New South Wales, Australia
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Out-of-hours services and end-of-life hospital admissions: a complex intervention systematic review and narrative synthesis. Br J Gen Pract 2021; 71:e780-e787. [PMID: 34489250 PMCID: PMC8436777 DOI: 10.3399/bjgp.2021.0194] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/11/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Out-of-hours (OOH) hospital admissions for patients receiving end-of-life care are a common cause of concern for patients, families, clinicians, and policymakers. It is unclear what issues, or combinations of issues, lead OOH clinicians to initiate hospital care for these patients. AIM To investigate the circumstances, processes, and mechanisms of UK OOH services-initiated end-of-life care hospital admissions. DESIGN AND SETTING Systematic literature review and narrative synthesis. METHOD Eight electronic databases were searched from inception to December 2019 supplemented by hand-searching of the British Journal of General Practice. Key search terms included: 'out-of-hours services', 'hospital admissions', and 'end-of-life care'. Two reviewers independently screened and selected articles, and undertook quality appraisal using Gough's Weight of Evidence framework. Data was analysed using narrative synthesis and reported following PRISMA Complex Intervention guidance. RESULTS Searches identified 20 727 unique citations, 25 of which met the inclusion criteria. Few studies had a primary focus on the review questions. Admissions were instigated primarily to address clinical needs, caregiver and/or patient distress, and discontinuity or unavailability of care provision, and they were arranged by a range of OOH providers. Reported frequencies of patients receiving end-of-life care being admitted to hospital varied greatly; most evidence related to cancer patients. CONCLUSION Although OOH end-of-life care can often be readily resolved by hospital admissions, it comes with multiple challenges that seem to be widespread and systemic. Further research is therefore necessary to understand the complexities of OOH services-initiated end-of-life care hospital admissions and how the challenges underpinning such admissions might best be addressed.
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10
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Booth S. Hypnosis in a specialist palliative care setting - enhancing personalized care for difficult symptoms and situations. Palliat Care Soc Pract 2020; 14:2632352420953436. [PMID: 33111060 PMCID: PMC7556168 DOI: 10.1177/2632352420953436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 07/31/2020] [Indexed: 11/15/2022] Open
Abstract
This is a personal account of using hypnosis as an adjunct to specialist palliative care (SPC) treatment approaches. After a brief systematic review of the literature, one clinician's experience is outlined illustrated by short, anonymized case histories. It argues that the approach is underused in SPC. The barriers currently restricting its routine adoption in SPC are discussed including (1) a lack of SPC clinical trials, (2) a misunderstanding of hypnosis leading to stigma, and (3) its absence from clinicians' training pathways. While the evidence base for the effectiveness of hypnosis in 'supportive care', for example, managing chemotherapy-induced vomiting, is appreciable, there is a gap in SPC. There is little data to guide the use of hypnosis in the intractable symptoms of the dying, for example, breathlessness or the distress associated with missed or late diagnosis. There are many people now 'living with and beyond cancer' with chronic symptomatic illness, 'treatable but not curable'. Patients often live with symptoms over a long period, which are only partially responsive to pharmacological and other therapies. Hypnosis may help improve symptom control and quality of life. SPC trials are needed so that this useful tool for self-management of difficult symptoms can be more widely adopted.
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Affiliation(s)
- Sara Booth
- Hon Consultant Palliative Care Service, Cambridge University Hospitals NHS Foundation Trust (CUHNHSFT), Cambridge, UK; Hon Sen Lecturer, Cicely Saunders Institute, King's College London, London CB2 0QQ, UK
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11
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Adam R, Bond CM, Burton CD, de Bruin M, Murchie P. Can-Pain-a digital intervention to optimise cancer pain control in the community: development and feasibility testing. Support Care Cancer 2020; 29:759-769. [PMID: 32468132 PMCID: PMC7767903 DOI: 10.1007/s00520-020-05510-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/05/2020] [Indexed: 11/29/2022]
Abstract
Purpose To develop a novel digital intervention to optimise cancer pain control in the community. This paper describes intervention development, content/rationale and initial feasibility testing. Methods Determinants of suboptimal cancer pain management were characterised through two systematic reviews; patient, caregiver and healthcare professional (HCP) interviews (n = 39); and two HCP focus groups (n = 12). Intervention mapping was used to translate results into theory-based content, creating the app “Can-Pain”. Patients with/without a linked caregiver, their general practitioners and community palliative care nurses were recruited to feasibility test Can-Pain over 4 weeks. Results Patients on strong opioids described challenges balancing pain levels with opioid intake, side effects and activities and communicating about pain management problems with HCPs. Can-Pain addresses these challenges through educational resources, contemporaneous short-acting opioid tracking and weekly patient-reported outcome monitoring. Novel aspects of Can-Pain include the use of contemporaneous breakthrough analgesic reports as a surrogate measure of pain control and measuring the level at which pain becomes bothersome to the individual. Patients were unwell due to advanced cancer, making recruitment to feasibility testing difficult. Two patients and one caregiver used Can-Pain for 4 weeks, sharing weekly reports with four HCPs. Can-Pain highlighted unrecognised problems, promoted shared understanding about symptoms between patients and HCPs and supported shared decision-making. Conclusions Preliminary testing suggests that Can-Pain is feasible and could promote patient-centred pain management. We will conduct further small-scale evaluations to inform a future randomised, stepped-wedge trial. Trial registration Qualitative research: ClinicalTrials.gov, reference NCT02341846 Feasibility study: NIHR CPMS database ID 34172 Electronic supplementary material The online version of this article (10.1007/s00520-020-05510-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rosalind Adam
- Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Room 1:020, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | - Christine M Bond
- Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
| | - Christopher D Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, England, UK
| | - Marijn de Bruin
- Health Psychology, Radboud University Medical Centre, Radboud Institute of Health Sciences, IQ Healthcare, Nijmegen, Netherlands
| | - Peter Murchie
- Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
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Chapman EJ, Edwards Z, Boland JW, Maddocks M, Fettes L, Malia C, Mulvey MR, Bennett MI. Practice review: Evidence-based and effective management of pain in patients with advanced cancer. Palliat Med 2020; 34:444-453. [PMID: 31980005 DOI: 10.1177/0269216319896955] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pain of a moderate or severe intensity affects over half of patients with advanced cancer and remains undertreated in at least one-third of these patients. AIM The aim of this study was to provide a pragmatic overview of the evidence supporting the use of interventions in pain management in advanced cancer and to identify where encouraging preliminary results are demonstrated but further research is required. DESIGN A scoping review approach was used to examine the evidence supporting the use of guideline-recommended interventions in pain management practice. DATA SOURCES National or international guidelines were selected if they described pain management in adult cancer patients and were written within the last 5 years in English. The Cochrane Database of Systematic Reviews (January 2014 to January 2019) was searched for 'cancer' AND 'pain' in the title, abstract or keywords. A MEDLINE search was also made. RESULTS A strong opioid remains the drug of choice for treating moderate or severe pain. Bisphosphonates and radiotherapy are also effective for cancer-related bone pain. Optimal management requires a tailored approach, support for self-management and review of treatment outcomes. There is likely a role for non-pharmacological approaches. Paracetamol should not be used in patients taking a strong opioid to treat pain. Cannabis-based medicines are not recommended. Weak opioids, ketamine and lidocaine are indicated in specific situations only. CONCLUSION Interventions commonly recommended by guidelines are not always supported by a robust evidence base. Research is required to evaluate the efficacy of non-steroidal anti-inflammatory drugs, anti-convulsants, anti-depressants, corticosteroids, some invasive anaesthetic techniques, complementary therapies and transcutaneous electrical nerve stimulation.
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Affiliation(s)
- Emma J Chapman
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, Leeds, UK
| | - Zoe Edwards
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, Leeds, UK
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Lucy Fettes
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | | | - Matthew R Mulvey
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, Leeds, UK
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, Leeds, UK
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Foster H, Moffat KR, Burns N, Gannon M, Macdonald S, O'Donnell CA. What do we know about demand, use and outcomes in primary care out-of-hours services? A systematic scoping review of international literature. BMJ Open 2020; 10:e033481. [PMID: 31959608 PMCID: PMC7045150 DOI: 10.1136/bmjopen-2019-033481] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To synthesise international evidence for demand, use and outcomes of primary care out-of-hours health services (OOHS). DESIGN Systematic scoping review. DATA SOURCES CINAHL; Medline; PsyARTICLES; PsycINFO; SocINDEX; and Embase from 1995 to 2019. STUDY SELECTION English language studies in UK or similar international settings, focused on services in or directly impacting primary care. RESULTS 105 studies included: 54% from mainland Europe/Republic of Ireland; 37% from UK. Most focused on general practitioner-led out-of-hours cooperatives. Evidence for increasing patient demand over time was weak due to data heterogeneity, infrequent reporting of population denominators and little adjustment for population sociodemographics. There was consistent evidence of higher OOHS use in the evening compared with overnight, at weekends and by certain groups (children aged <5, adults aged >65, women, those from socioeconomically deprived areas, with chronic diseases or mental health problems). Contact with OOHS was driven by problems perceived as urgent by patients. Respiratory, musculoskeletal, skin and abdominal symptoms were the most common reasons for contact in adults; fever and gastrointestinal symptoms were the most common in the under-5s. Frequent users of daytime services were also frequent OOHS users; difficulty accessing daytime services was also associated with OOHS use. There is some evidence to suggest that OOHS colocated in emergency departments (ED) can reduce demand in EDs. CONCLUSIONS Policy changes have impacted on OOHS over the past two decades. While there are generalisable lessons, a lack of comparable data makes it difficult to judge how demand has changed over time. Agreement on collection of OOHS data would allow robust comparisons within and across countries and across new models of care. Future developments in OOHS should also pay more attention to the relationship with daytime primary care and other services. PROSPERO REGISTRATION NUMBER CRD42015029741.
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Affiliation(s)
- Hamish Foster
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Keith R Moffat
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Nicola Burns
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Maria Gannon
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Sara Macdonald
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
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ADISA R, ANIFOWOSE AT. Pharmacists' knowledge, attitude and involvement in palliative care in selected tertiary hospitals in southwestern Nigeria. BMC Palliat Care 2019; 18:107. [PMID: 31783834 PMCID: PMC6884848 DOI: 10.1186/s12904-019-0492-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/20/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The growing number of people living with life-limiting illness is a global health concern. This study therefore aimed to explore the involvement of pharmacists in selected tertiary hospitals in Nigeria in palliative care (PC). It also sought to evaluate their knowledge and attitude to PC as well as factors that hinder pharmacists' participation in PC. METHOD Questionnaire-guided survey among pharmacists working in three-tertiary hospitals in southwestern Nigeria. The self-administered questionnaire comprised 18-item general knowledge questions related to PC, attitude statements with 5-point Likert-scale options and question-items that clarify extent of involvement in PC and barriers to participation. Overall score by pharmacists in the knowledge and attitude domains developed for the purpose of this study was assigned into binary categories of "adequate" and "inadequate" knowledge (score > 75% versus≤75%), as well as "positive" and "negative" attitude (ranked score > 75% versus≤75%), respectively. Descriptive statistics, Mann-Whitney-U and Kruskal-Wallis tests were used for analysis at p < 0.05. RESULTS All the 110 pharmacists enrolled responded to the questionnaire, given a response rate of 100%. Overall, our study showed that 23(21.1%) had adequate general knowledge in PC, while 14(12.8%) demonstrated positive attitude, with 45(41.3%) who enjoyed working in PC. Counselling on therapy adherence (100;90.9%) was the most frequently engaged activity by pharmacists; attending clinical meetings to advise health team members (45;40.9%) and giving educational sessions (47;42.7%) were largely cited as occasionally performed duties, while patient home visit was mostly cited (60;54.5%) as a duty not done at all. Pharmacists' unawareness of their need in PC (86;79.6%) was a major factor hindering participation, while pharmacists with PC training significantly felt more relaxed around people receiving PC compared to those without training (p = 0.003). CONCLUSION Hospital pharmacists in selected tertiary care institutions demonstrate inadequate knowledge, as well as negative attitude towards PC. Also, extent of involvement in core PC service is generally low, with pharmacists' unawareness of their need in PC constituting a major barrier. Thus, a need for inclusion of PC concept into pharmacy education curriculum, while mandatory professional development programme for pharmacists should also incorporate aspects detailing fundamental principles of PC, in order to bridge the knowledge and practice gaps.
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Affiliation(s)
- Rasaq ADISA
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadan, Nigeria
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Factors affecting use of unscheduled care for people with advanced cancer: a retrospective cohort study in Scotland. Br J Gen Pract 2019; 69:e860-e868. [PMID: 31740459 PMCID: PMC6863679 DOI: 10.3399/bjgp19x706637] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/31/2019] [Indexed: 12/12/2022] Open
Abstract
Background People with advanced cancer frequently attend unscheduled care, but little is known about the factors influencing presentations. Most research focuses on accident and emergency (A&E) and does not consider GP out-of-hours (GPOOH). Aim To describe the frequency and patterns of unscheduled care use by people with cancer in their last year of life and to examine the associations of demographic and clinical factors with unscheduled care attendance. Design and setting Retrospective cohort study of all 2443 people who died from cancer in Tayside, Scotland, during 2012–2015. Clinical population datasets were linked to routinely collected clinical data using the Community Health Index (CHI) number. Method Anonymised CHI-linked data were analysed in SafeHaven, with descriptive analysis, using binary logistic regression for adjusted associations. Results Of the people who died from cancer, 77.9% (n = 1904) attended unscheduled care in the year before death. Among unscheduled care users, most only attended GPOOH (n = 1070, 56.2%), with the rest attending A&E only (n = 204, 10.7%), or both (n = 630, 33.1%). Many attendances occurred in the last week (n =1360, 19.7%), last 4 weeks (n = 2541, 36.7%), and last 12 weeks (n = 4174, 60.3%) of life. Age, sex, deprivation, and cancer type were not significantly associated with unscheduled care attendance. People living in rural areas were less likely to attend unscheduled care: adjusted odds ratio (aOR) 0.64 (95% confidence interval = 0.50 to 0.82). Pain was the commonest coded clinical reason for presenting (GPOOH: n = 482, 10.5%; A&E: n = 336, 28.8%). Of people dying from cancer, n = 514, 21.0%, were frequent users (≥5 attendances/year), and accounted for over half (n = 3986, 57.7%) of unscheduled care attendances. Conclusion Unscheduled care attendance by people with advanced cancer was substantially higher than previously reported, increased dramatically towards the end of life, was largely independent of demographic factors and cancer type, and was commonly for pain and palliative care.
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Interventionen zur Förderung des Selbstmanagements bei Tumorschmerz. Schmerz 2019; 33:255-260. [DOI: 10.1007/s00482-019-0372-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Brettell R, Fisher R, Hunt H, Garland S, Lasserson D, Hayward G. Out-of-hours primary care end of life prescribing: a data linkage study. BMJ Support Palliat Care 2019; 10:e45. [PMID: 31072824 DOI: 10.1136/bmjspcare-2019-001784] [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: 01/30/2019] [Revised: 03/27/2019] [Accepted: 04/23/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Out-of-hours (OOH) primary care services are contacted in the last 4 weeks of life by nearly 30% of all patients who die, but OOH palliative prescribing remains poorly understood. Our understanding of prescribing demand has previously been limited by difficulties identifying palliative patients seen OOH. This study examines the volume and type of prescriptions issued by OOH services at the end of life. METHODS A retrospective cohort study was performed by linking a database of Oxfordshire OOH service contacts over a year with national mortality data, identifying patients who died within 30 days of OOH contact. Demographic, service and prescribing data were analysed. RESULTS A prescription is issued at 14.2% of contacts in the 30 days prior to death, compared with 29.9% of other contacts. The most common prescriptions were antibiotics (22.2%) and strong opioids (19%). 41.8% of prescriptions are for subcutaneously administered medication. Patients who were prescribed a syringe driver medication made twice as many OOH contacts in the 30 days prior to death compared with those who were not. CONCLUSION Absolute and relative prescribing rates are low in the 30 days prior to death. Further research is required to understand what occurs at these non-prescribing end of life contacts to inform how OOH provision can best meet the needs of dying patients. Overall, relatively few patients are prescribed strong opioids or syringe drivers. When a syringe driver medication is prescribed this may help identify patients likely to be in need of further support from the service.
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Affiliation(s)
- Rachel Brettell
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rebecca Fisher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,Quality Team, The Health Foundation, London, UK
| | - Helen Hunt
- Oxford Healthcare Improvement, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Sophie Garland
- Oxford Healthcare Improvement, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Hong AS, Sadeghi N, Harvey V, Lee SC, Halm EA. Characteristics of Emergency Department Visits and Select Predictors of Hospitalization for Adults With Newly Diagnosed Cancer in a Safety-Net Health System. J Oncol Pract 2019; 15:e490-e500. [PMID: 30964735 DOI: 10.1200/jop.18.00614] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE There is little description of emergency department (ED) visits and subsequent hospitalizations among a safety-net cancer population. We characterized patterns of ED visits and explored nonclinical predictors of subsequent hospitalization, including time of ED arrival. PATIENTS AND METHODS This was a retrospective cohort study of patients with cancer (excluding leukemia and nonmelanoma skin cancer) between 2012 and 2016 at a large county urban safety-net health system. We identified ED visits occurring within 180 days after a cancer diagnosis, along with subsequent hospitalizations (observation stay or inpatient admission). We used mixed-effects multivariable logistic regression to model hospitalization at ED disposition, accounting for variability across patients and emergency physicians. RESULTS The 9,050 adults with cancer were 77.2% nonwhite and 55.0% female. Nearly one-quarter (24.7%) of patients had advanced-stage cancer at diagnosis, and 9.7% died within 180 days of diagnosis. These patients accrued 11,282 ED visits within 180 days of diagnosis. Most patients had at least one ED visit (57.7%); half (49.9%) occurred during business hours (Monday through Friday, 8:00 am to 4:59 pm), and half (50.4%) resulted in hospitalization. More than half (57.5%) of ED visits were for complaints that included: pain/headache, nausea/vomiting/dehydration, fever, swelling, shortness of breath/cough, and medication refill. Patients were most often discharged home when they arrived between 8:00 am and 11:59 am (adjusted odds ratio for hospitalization, 0.69; 95% CI, 0.56 to 0.84). CONCLUSION ED visits are common among safety-net patients with newly diagnosed cancer, and hospitalizations may be influenced by nonclinical factors. The majority of ED visits made by adults with newly diagnosed cancer in a safety-net health system could potentially be routed to an alternate site of care, such as a cancer urgent care clinic.
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Affiliation(s)
- Arthur S Hong
- 1 University of Texas Southwestern Medical Center, Dallas, TX
| | - Navid Sadeghi
- 1 University of Texas Southwestern Medical Center, Dallas, TX.,2 Parkland Health & Hospital System, Dallas, TX
| | | | - Simon Craddock Lee
- 1 University of Texas Southwestern Medical Center, Dallas, TX.,3 Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| | - Ethan A Halm
- 1 University of Texas Southwestern Medical Center, Dallas, TX.,3 Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
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Abstract
OBJECTIVES Uncontrolled pain in advanced cancer is a common problem and has significant impact on individuals' quality of life and use of healthcare resources. Interventions to help manage pain at the end of life are available, but there is limited economic evidence to support their wider implementation. We conducted a case study economic evaluation of two pain self-management interventions (PainCheck and Tackling Cancer Pain Toolkit [TCPT]) compared with usual care. METHODS We generated a decision-analytic model to facilitate the evaluation. This modelled the survival of individuals at the end of life as they moved through pain severity categories. Intervention effectiveness was based on published meta-analyses results. The evaluation was conducted from the perspective of the U.K. health service provider and reported cost per quality-adjusted life-year (QALY). RESULTS PainCheck and TCPT were cheaper (respective incremental costs -GBP148 [-EUR168.53] and -GBP474 [-EUR539.74]) and more effective (respective incremental QALYs of 0.010 and 0.013) than usual care. There was a 65 percent and 99.5 percent chance of cost-effectiveness for PainCheck and TCPT, respectively. Results were relatively robust to sensitivity analyses. The most important driver of cost-effectiveness was level of pain reduction (intervention effectiveness). Although cost savings were modest per patient, these were considerable when accounting for the number of potential intervention beneficiaries. CONCLUSIONS Educational and monitoring/feedback interventions have the potential to be cost-effective. Economic evaluations based on estimates of effectiveness from published meta-analyses and using a decision modeling approach can support commissioning decisions and implementation of pain management strategies.
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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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Meads DM, O’Dwyer JL, Hulme CT, Chintakayala P, Vinall-Collier K, Bennett MI. Patient Preferences for Pain Management in Advanced Cancer: Results from a Discrete Choice Experiment. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2017; 10:643-651. [DOI: 10.1007/s40271-017-0236-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Utilising out-of-hours primary care for assistance with cancer pain: a semi-structured interview study of patient and caregiver experiences. Br J Gen Pract 2016; 65:e754-60. [PMID: 26500323 DOI: 10.3399/bjgp15x687397] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Pain is the most frequent complication of cancer and an important reason for out-of-hours (OOH) primary care contacts by patients with established cancer. Existing quantitative data give little insight into the reason for these contacts. Exploring such encounters of care could highlight ways to improve anticipatory cancer care and communication between daytime and OOH primary care services. AIM To explore the experiences, views, and opinions of patients and their caregivers who have used OOH primary care for help with managing cancer pain. DESIGN AND SETTING A semi-structured interview study with patients and caregivers who have utilised an OOH primary care service in Grampian, Scotland, because of pain related to cancer. METHOD Semi-structured interviews with 11 patients and four caregivers (n = 15), transcribed verbatim and analysed using framework analysis and, to a lesser extent, inductive thematic analysis. RESULTS Six key themes emerged: making sense of pain and predicting its likely course; beliefs about analgesics; priority daytime access; the importance of continuity of care and communication between all involved; barriers and facilitators to seeking help in the OOH period; and satisfaction/dissatisfaction with OOH care. Three prominent sub-themes were: patient knowledge; the influence of a caregiver on decision-making; and the benefits of having a palliative care summary. CONCLUSION Effective daytime and anticipatory care can positively influence OOH care. Interventions that aid patients in understanding cancer pain, communicating about pain, utilising analgesics effectively, and seeking appropriate and timely help may improve cancer pain management.
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Thoresen CK, Sandvik H, Hunskaar S. Cancer patients' use of primary care out-of-hours services: a cross-sectional study in Norway. Scand J Prim Health Care 2016; 34:232-9. [PMID: 27406005 PMCID: PMC5036012 DOI: 10.1080/02813432.2016.1207140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To investigate how cancer patients in Norway use primary care out-of-hours (OOH) services and describe different contact types and procedures. DESIGN A retrospective cross-sectional registry study using a billing registry data source. SETTING Norwegian primary care OOH services in 2014. SUBJECTS All patients' contacts in OOH services in 2014. Cancer patients were identified by ICPC-2 diagnosis. MAIN OUTCOME MEASURES Frequency of cancer patients' contacts with OOH services, contact types, diagnoses, procedures, and socio-demographic characteristics. RESULTS In total, 5752 cancer patients had 20,220 contacts (1% of all) in OOH services. Half of the contacts were cancer related. Cancer in the digestive (22.9%) and respiratory (18.0%) systems were most frequent; and infection/fever (21.8%) and pain (13.6%) most frequent additional diagnoses. A total of 4170 patients had at least one cancer-related direct contact; of these, 64.5% had only one contact during the year. Cancer patients had more home visits and more physicians' contact with municipal nursing services than other patients, but fewer consultations (p < 0.001). Patients in the least central municipalities had significantly more contacts than more central municipalities (p < 0.001). CONCLUSION There was no indication of overuse of OOH services by cancer patients in Norway, which could indicate good quality of cancer care in general. KEY POINTS Many are concerned about unnecessary use of emergency medical services for non-urgent conditions. • There was no indication of overuse of out-of-hours services by cancer patients in Norway. • Cancer patients had relatively more home visits, physician's contact with the municipal nursing service, and weekend contacts than other patients. • Cancer patients in the least central municipalities had relatively more contacts with out-of-hours services than those in more central municipalities.
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Affiliation(s)
- Camilla Kjellstadli Thoresen
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway
- CONTACT Camilla Kjellstadli Thoresen Department of Global Public Health and Primary Care, University of Bergen, Centre for Elderly and Nursing Home Medicine, Kalfarveien 31, PO Box 7804, N-5018 Bergen, Norway
| | - Hogne Sandvik
- National Centre for Emergency Primary Health Care, Uni Research Health, Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, Uni Research Health, Bergen, Norway
- Department of Global Public Health and Primary Care, Research Group for General Practice, University of Bergen, Bergen, Norway
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Out-of-hours primary care use at the end of life: a descriptive study. Br J Gen Pract 2016; 66:e654-60. [PMID: 27381487 DOI: 10.3399/bjgp16x686137] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/22/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Out-of-hours (OOH) primary care services are integral to the care of patients at end of life. Little is known about the OOH service usage of patients with palliative care needs. AIM To describe patterns of usage of patients presenting to an OOH service and coded as 'palliative'. DESIGN AND SETTING A descriptive study of data from the Oxfordshire OOH service. METHOD A database of all patient contacts with the Oxfordshire OOH service from a 4-year period (June 2010-August 2014) was used to extract demographic and service usage data for all contacts to which clinicians had applied a 'palliative' code. Observed differences in demographic features between palliative and non-palliative contacts were tested using logistic regression. RESULTS Out of a total of 496 931 contacts, there were 6045 contacts coded palliative; those 'palliative' contacts provided care to 3760 patients. Patients contacting the OOH service with palliative care needs did so predominantly during weekend daytime periods, and over a third had more than one contact. Patients were predictably older than the average population, but contacts coded as 'palliative' were relatively less deprived than contacts to the OOH service for all causes, even after adjusting for age and sex. CONCLUSION The current 'one-size-fits-most' model of OOH primary care may not allow for the specific needs of patients at the end of life. Wider analysis of palliative patient flow through urgent care services is needed to identify whether healthcare access at the end of life is inequitable, as well as the capacity requirements of a community-based service that can provide high-quality end-of-life care.
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Arris SM, Fitzsimmons DA, Mawson S. Moving towards an enhanced community palliative support service (EnComPaSS): protocol for a mixed method study. BMC Palliat Care 2015; 14:17. [PMID: 25924815 PMCID: PMC4422119 DOI: 10.1186/s12904-015-0012-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The challenge of an ageing population and consequential increase of long term conditions means that the number of people requiring palliative care services is set to increase. One UK hospice is introducing new information and communication technologies to support the redesign of their community services; improve experiences of existing patients; and allow efficient and effective provision of their service to more people. Community Palliative Care Nurses employed by the hospice will be equipped with a mobile platform to improve communication, enable accurate and efficient collection of clinical data at the bedside, and provide access to clinical records at the point of care through an online digital nursing dashboard. It is believed that this will ensure safer clinical interventions, enable delegated specialist care deployment, support the clinical audit of patient care and improve patient safety and patient/carer experience. Despite current attempts to evaluate the implementation of such technology into end of life care pathways, there is still limited evidence supporting the notion that this can be sustained within services and implemented to scale. This study presents an opportunity to carry out a longitudinal evaluation of the implementation of innovative technology to provide evidence for designing more efficient and effective community palliative care services. METHODS A mixed methods approach will be used to understand a wide range of organisational, economic, and patient-level factors. The first stage of the project will involve the development of an organisational model incorporating proposed changes resulting from the introduction of new novel mobile technologies. This model will guide stage two, which will consist of gathering and analysing primary evidence. Data will be collected using interviews, focus groups, observation, routinely collected data and documents. DISCUSSION The implementation of this new approach to community-based palliative care delivery will require significant changes to established working patterns. This new service delivery model is being developed by the Hospice in collaboration with a team of international academic, industry, and clinical commissioning service improvement specialists. The findings from this initial evaluation will provide valuable baseline evidence regarding the delivery of palliative and end-of-life care services.
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Affiliation(s)
- Steven M Arris
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, South Yorkshire, S1 4DA, UK.
| | - Deborah A Fitzsimmons
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, South Yorkshire, S1 4DA, UK. .,School of Health Studies, Western University, London, ON, N6A 3B4, Canada.
| | - Susan Mawson
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, South Yorkshire, S1 4DA, UK.
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Magee C, Koffman J. Out-of-hours palliative care: what are the educational needs and preferences of general practitioners? BMJ Support Palliat Care 2015; 6:362-8. [DOI: 10.1136/bmjspcare-2014-000764] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 02/17/2015] [Indexed: 11/04/2022]
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Pittman NM, Hopman WM, Mates M. Emergency Room Visits and Hospital Admission Rates After Curative Chemotherapy for Breast Cancer. J Oncol Pract 2015; 11:120-5. [DOI: 10.1200/jop.2014.000257] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The authors conclude that over half of all patients receiving curative chemotherapy for breast cancer visited the emergency room at least once, and 13% required hospital admissions.
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Affiliation(s)
- Natalia M. Pittman
- Cancer Centre of Southeastern Ontario at Kingston General Hospital; Queen's University; and Kingston General Hospital Clinical Research Centre, Kingston, Ontario, Canada
| | - Wilma M. Hopman
- Cancer Centre of Southeastern Ontario at Kingston General Hospital; Queen's University; and Kingston General Hospital Clinical Research Centre, Kingston, Ontario, Canada
| | - Mihaela Mates
- Cancer Centre of Southeastern Ontario at Kingston General Hospital; Queen's University; and Kingston General Hospital Clinical Research Centre, Kingston, Ontario, Canada
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Adam R, Bond C, Murchie P. Educational interventions for cancer pain. A systematic review of systematic reviews with nested narrative review of randomized controlled trials. PATIENT EDUCATION AND COUNSELING 2015; 98:269-282. [PMID: 25483575 DOI: 10.1016/j.pec.2014.11.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 10/08/2014] [Accepted: 11/08/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Educational interventions are one approach to improving cancer pain management. This review aims to determine whether educational interventions can improve cancer pain management and to characterize components of cancer pain educational interventions. METHODS Medline, EMBASE, CINAHL, and Cochrane databases were searched. Systematic reviews that assessed educational interventions to improve cancer pain management were included. Randomized controlled trials (RCTs) were identified from each review. A narrative approach was taken to summarizing the nature and components of interventions. RESULTS Eight systematic reviews and 34 randomized controlled trials (RCTs) were reviewed. Interventions targeting patients can achieve small to moderate reductions in pain intensity. Interventions targeting professionals can improve their knowledge but most trials have not assessed for resultant patient benefits. All interventions included at least one of seven core components: improving knowledge about the nature of cancer pain; aiding communication about cancer pain; enhancing pain assessment; improving analgesic prescribing; tackling barriers to analgesic non-adherence; teaching non-pharmacological pain management strategies; and promoting re-assessment. CONCLUSIONS Cancer pain educational interventions can improve pain outcomes. They are complex heterogeneous interventions which often contain a combination of active components. PRACTICE IMPLICATIONS Suggestions are made to aid the development of future interventions.
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Affiliation(s)
- Rosalind Adam
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK.
| | - Christine Bond
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
| | - Peter Murchie
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
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van der Eerden M, Csikos A, Busa C, Hughes S, Radbruch L, Menten J, Hasselaar J, Groot M. Experiences of patients, family and professional caregivers with Integrated Palliative Care in Europe: protocol for an international, multicenter, prospective, mixed method study. BMC Palliat Care 2014; 13:52. [PMID: 25473377 PMCID: PMC4254197 DOI: 10.1186/1472-684x-13-52] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 11/04/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The number of people living with advanced cancer and chronic disease has increased worldwide. Many of these patients could benefit from palliative care, focusing on optimising the quality of life of patients and their families facing problems resulting from life-threatening diseases. However, fragmentation and discontinuity of palliative care services often result in suboptimal palliative care. In order to overcome these problems, models using an integrated care approach are increasingly advocated in palliative care services. Although several models and definitions of Integrated Palliative Care (IPC) have been developed, the effects of integrated care are still under-investigated. Knowledge of the key components that constitute successful palliative care integration is still lacking. This mixed methods study will examine the experiences of patients, family caregivers and professional caregivers in order to provide insight into the mechanisms that constitute successful palliative care integration. METHODS/DESIGN Prospective multiple embedded case study. Three to five integrated palliative care initiatives will be selected in Belgium, Germany, Hungary, The Netherlands and the United Kingdom. Data collection will involve Social Network Analysis (SNA), a patient diary, semi-structured interviews, and questionnaires: Palliative care Outcome Scale (POS), Canhelp Lite, Caregiver Reaction Assessment (CRA). Patients and family caregivers will be followed in 4 consecutive contact moments over 3 months. The diary will be kept weekly by patients. One focus group per initiative will be conducted with professional caregivers. Interviews and focus groups will be tape recorded, transcribed and qualitatively analysed using NVivo 10. SPSS Statistics 20 will be used for statistical analysis. DISCUSSION This study will provide valuable knowledge about barriers, opportunities and good practices in palliative care integration in the selected initiatives across countries. This knowledge can be used in the benchmark of integrated palliative care initiatives across Europe. It will add to the scientific evidence for IPC services internationally and will contribute to improvements in the quality of care and the quality of living and dying of severely ill patients and their relatives in Europe.
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Affiliation(s)
- Marlieke van der Eerden
- Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Agnes Csikos
- Department of Family Medicine, University of Pecs Medical School (UP), Pécs, Hungary
| | - Csilla Busa
- Department of Family Medicine, University of Pecs Medical School (UP), Pécs, Hungary
| | - Sean Hughes
- Division of Health Research, International Observatory on End of Life Care, Lancaster university, Lancaster, UK
| | - Lukas Radbruch
- Klinik für Palliativmedizin, Universitätsklinikum Bonn, Bonn, Germany
| | - Johan Menten
- Radiation Oncology Department, University Hospital Leuven, Leuven, Belgium
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke Groot
- Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Flarup L, Moth G, Christensen MB, Vestergaard M, Olesen F, Vedsted P. Daytime use of general practice and use of the out-of-hours primary care service for patients with chronic disease: a cohort study. BMC FAMILY PRACTICE 2014; 15:156. [PMID: 25238694 PMCID: PMC4262984 DOI: 10.1186/1471-2296-15-156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/15/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND The importance of proactive chronic care has become increasingly evident. Yet, it is unknown whether the use of general practice (GP) during daytime may affect the use of Out-of-Hours (OOH) Primary Care Service for people with chronic disease. We aimed to analyse the association between use of daytime general practice (GP) and use of OOH services for heart disease, lung disease, diabetes, psychiatric disease, or cancer. In particular, we intended to study the association between OOH contacts due to chronic disease exacerbation and recent use of daytime GP. METHODS Data comprised a random sample of contacts to the OOH services ('LV-KOS2011'). Included patients were categorised into the following chronic diseases: heart disease, lung disease, diabetes, psychiatric disease, or cancer. Information on face-to-face contacts to daytime GP was obtained from the Danish National Health Insurance Service Registry and information about exacerbation or new episodes from the LVKOS2011 survey. Associations between number of regular daytime consultations and annual follow-up consultations during one, three, six, and 12 months prior to index contacts, and outcomes of interest were estimated by using logistic regression. RESULTS In total, 11,897 patients aged ≥ 18 years were included. Of these, 2,665 patients (22.4%) were identified with one of the five selected chronic diseases; 673 patients (5.7%) had two or more. A higher odds ratio (OR) for exacerbation as reason for encounter (RFE) at the index contact was observed among patients with psychiatric disease (OR = 2.15) and cancer (OR = 2.17) than among other patients for ≥2 daytime recent contacts. When receiving an annual follow-up, exacerbation OR at index contact lowered for patients with lung disease (OR = 0.68), psychiatric disease (OR = 0.42), or ≥2 diseases (OR = 0.61). CONCLUSION Recent and frequent use of daytime GP for patients with the selected chronic diseases was associated with contacts to the OOH services due to exacerbation. These findings indicate that the most severely chronically ill patients tend to make more use of general practice. The provision of an annual follow-up daytime GP consultation may indicate a lower risk of contacting OOH due to exacerbation.
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Affiliation(s)
- Lone Flarup
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
| | - Grete Moth
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
| | - Morten Bondo Christensen
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
| | - Mogens Vestergaard
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
- />Department of Public Health, Section for General Medical Practice, Aarhus University, Aarhus, Denmark
| | - Frede Olesen
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
| | - Peter Vedsted
- />Department of Public Health, Research Unit for General Practice, Aarhus University, DK-Bartholins Allé 8000 Aarhus C, Aarhus, Denmark
- />Department of Public Health, Danish Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Aarhus, Denmark
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