Abstract number: L-02 Abstract type: Poster
Economic Evaluation of the Palliative Care Home Support Packages (PEACH) Program
Chow J.1, Jobburn K.1, Agar M.2, Harlum J.3
1South Western Sydney Local Health District, Clinical Innovation &
Business Unit, Liverpool, Australia, 2South Western Sydney Local Health District, Palliative Care, Liverpool, Australia, 3South Western Sydney Local Health District, Palliative Care Department, Liverpool, Australia Background: Economic evidence in palliative care is important for mak- ing decisions regarding allocation of resources and support patient pref- erences for end-of-life (EOL) care. However, there is limited evidence on the cost-effectiveness of palliative and EOL care to inform healthcare funding decisions.
Aims: To evaluate the cost-effectiveness of providing Palliative Care Extended Packages at Home (PEACH) in addition to usual care to support clients in their wish to be cared for, and die at home.
Methods: A modelled cost-effectiveness analysis was conducted from a healthcare provider perspective to estimate the incremental costs, effects and cost effectiveness. De-identified prospective and retrospective data on the resource use, cost and consequences of the PEACH Packages Program (n=75) and usual care (n=95) were collected from three partici- pating local health districts (LHDs) data information systems.
Sensitivity analyses was done to explore the robustness of the cost- effectiveness results to changes in the model inputs and assumptions.
Propensity score matching was used to estimate the effects of adding PEACH to usual care adjusting for any differences in key clinical and soci- odemographic characteristics in a sensitivity analysis. Where appropri- ate, the mean incremental net monetary benefit (INB) was estimated at potential threshold values for a unit gain in effect.
Results: Mean costs per patient of providing PEACH (AUD$3,493) in addition to usual care were offset by lower mean inpatient care (AUD$6,392) and emergency department presentation costs (AUD$139).
On average, patients receiving PEACH spent an additional four days at home in the last week of life and more died at home (95% vs 49%).
Conclusion: PEACH is a cost-effective model of care when added to usual care for people in the last week of life as PEACH plus usual care is more effective and less costly than usual care alone.
Abstract number: L-09 Abstract type: Poster
Perceptions and Experiences of Early Palliative Care for Patients around the Time of Haematopoietic Stem Cell Transplant: A Qualitative Study Gemmell R.1, Halley A.1, Ethell M.2, Stevens A.-M.1, Perkins M.3, Allam A.3, Droney J.1
1Royal Marsden NHS Foundation Trust, Palliative Care Department, London, United Kingdom, 2Royal Marsden NHS Foundation Trust, Haematology Department, London, United Kingdom, 3Royal Marsden NHS Foundation Trust, Public and Patient Representative, London, United Kingdom
Background: Early palliative care is increasingly utilised in solid tumour oncology alongside active treatment to improve patients’ quality of life.
Haemato-oncology patients are often referred later to palliative care despite having significant symptom burden. The time around stem cell transplant (SCT) offers an opportunity to introduce early palliative care, including symptom control, shared decision-making and advance care plan- ning to patients not typically referred to palliative care at a critical point in their care. While studies suggest feasibility and benefits to patients, deter- mining patient views is vital to ensure acceptability to patients.
Aims: To determine patient views and experiences of palliative care around the time of SCT.
Methods: A qualitative study, using a focus group (N=4) co-facilitated by public and patient representatives and interviews (N=12) for patients pre- and post-SCT. Semi-structured interviews were in person, via tele- phone or via online videoconferencing. Recordings were transcribed and analysed using thematic analysis.
This study was funded by the Hospital Palliative Care Research Fund.
Results: Themes identified were: Perceived needs; Information and deci- sion-making; Importance of relationships; Perception of palliative care;
and The future.
Patients pre-SCT had limited direct experience of palliative care, but associated it with end of life care due to indirect experiences and soci- etal views. Once the role of early palliative care was introduced, patients were accepting of it and could see its potential benefits. Patients described many needs around the time of SCT, many of which could be addressed by palliative care.
Conclusions: Palliative care should be integrated with standard care around the time of SCT. Patients should receive open and honest infor- mation regarding the role of palliative care. This will allow improved co- working alongside the haematology team and improved quality of life for patients.
Abstract number: L-11 Abstract type: Poster
Adaptation of the Australian Palliative Care Phase Concept to the Ger- man Context: A Mixed-methods Approach Using Cognitive Interviews and Cross-sectional Data
Lehmann E.1, Hodiamont F.1, Landmesser M.2, Nauck F.2, Knobloch C.3, Ostgathe C.3, Grüne B.1, Bausewein C.1
1University Hospital, LMU Munich, Germany, Department of Palliative Medicine, München, Germany, 2University Medical Center Goettingen, Department of Palliative Medicine, Göttingen, Germany,
3Universitätsklinikum Erlangen, CCC Erlangen –EMN, Friedrich- Alexander-Universität Erlangen-Nürnberg (FAU), Department of Palliative Medicine, Erlangen, Germany
Background: Palliative care phases (stable, unstable, deteriorating, ter- minal and bereavement) are routinely used in Australia and the UK to describe the clinical situation of patients and their families and to evalu- ate the associated care plan. In Germany, the concept is not used con- sistently due to various translations.
Aims: Developing a German version of the palliative care phase defini- tions by adapting them culturally, and to examine the inter-rater reliabil- ity of the adjusted definitions.
Methods (design, data collection, analysis): Mixed-methods approach:
(I) Cognitive interview study using ‘think aloud’ and verbal prob- ing techniques; analysed using a systematic qualitative analysis approach.
(II) Multi-center cross-sectional study, two clinicians indepen- dently assigning the phase definitions. Purposely sampled interviewees in specialist palliative care inpatient units, advi- sory and community services (I) and three specialized palliative care units with doctors, nursing staff and allied health profes- sionals (II).
Results: 15 interviews were conducted. Identified difficulties were:
Some translated terms were:
1) not self-explanatory (e.g. ‘family/carer’, ‘care plan’) and 2) too limited to the medical dimension neglecting the holistic
approach of palliative care.
3) Problems of comprehension regarding the concept in general occurred, e.g. in differentiating between the unstable and deteriorating phase. Inter-rater reliability was moderate (kappa=0.44; 95% CI=0.39-0.52). The assignment of the phase deteriorating has caused the most difficulties.
Conclusion/Discussion: Overall, the adopted palliative care phases are suitable to use in the German specialist palliative care setting. However, the concept of the phases is not self-explanatory. To implement it nationwide for outcome measurement/benchmarking, it requires fur- ther education, on-the-job training and experience as well as the involvement of healthcare professionals.
Abstract number: L-14 Abstract type: Poster
The Impact of Accessible Cancer Care to Enable Support for Survivors (ACCESS) Service Model on Healthcare Utilization Patterns among Breast and Gynaecological Cancer Patients
Tan M.Q.Y.1, Ke Y.2, Lim S.Y.3, Yang G.M.J.1, Tan Y.Y.1, Si P.E.H.4, Xu Z.Z.1, Natesan N.1, Tay B.C.1, Neo P.S.H.1
1National Cancer Centre Singapore, Division of Supportive and Palliative Care, Singapore, Singapore, 2National University of Singapore, Department of Pharmacy, Singapore, Singapore, 3Duke-NUS Medical School Singapore, Singapore, Singapore, 4National Cancer Centre Singapore, Department of Pharmacy, Singapore, Singapore
Background: Accessible Cancer Care to Enable Support for Cancer Survivors (ACCESS) is a multidisciplinary survivorship care model, that aims to identify and address the varying needs of cancer patients in a large ambulatory oncology centre in Singapore. Patients within ACCESS are triaged using a routine distress screening tool, and those with high distress will be followed up by a supportive care team that provides interventions according to patients’ identified needs.
Aim: This study aims to investigate the impact of the ACCESS service model on patients’ healthcare utilization patterns.
Methods: This is a retrospective study comparing ACCESS service recipi- ents (N = 1292) to non-recipients (N = 1296) in the same calendar period from 16/9/19 to 16/2/20. All patients were diagnosed with breast
or gynaecological cancer. Data were extracted from electronic medical records. Key outcome measures were hospital admissions, length of hos- pital stay (LOS), visits to the emergency department (ED) and outpatient visits. Categorical and continuous variables were compared using chi- square and Mann-Whitney U tests respectively.
Results: As compared to non-recipients, a lower proportion of ACCESS service recipients had 1 or more hospital admissions (16.2% vs 20.3%, P=0.007), as well as ED visits (10.9% vs 13.4%, P=0.051). ACCESS service recipients also had shorter LOS per hospital admission (3 days vs 4 days, P=0.0016). A larger proportion of ACCESS service recipients attended outpatient cancer rehabilitation and allied health therapy appointments (2.2% vs 0.5%, P<0.001). Outpatient medical (P=0.291), surgical (P=0.377) and imaging (P=0.089) visits were similar in both groups.
Conclusion: The service model instituted appropriate referrals targeting symptoms early upstream. This prevents more severe manifestations in the form of acute healthcare utilization, benefitting both patients and the healthcare system.
Abstract number: L-15 Abstract type: Poster
Palliative Care Needs of Patients with Mesothelioma and their Family Carers: An Integrative Systematic Review
Harrison M.1, Gardiner C.1, Taylor B.1, Ejegi-Memeh S.1, Darlison L.2
1The University of Sheffield, Health Sciences School, Sheffield, United Kingdom, 2University Hospitals of Leicester, Leicester, United Kingdom Background: Patients with mesothelioma and their families have pallia- tive care needs throughout the relatively short trajectory of their illness, from diagnosis to the end of life.
Aim: To describe the palliative care needs of patients with mesothelioma and their families.
Design: Integrative systematic review with narrative synthesis (PROSPERO: CRD42020190115).
Data sources: MEDLINE, CINAHL, PsycINFO and the Cochrane Library were searched for articles published between 01 January 2000 and 10 May 2020. Articles were included if they presented empirical studies or comprehensive reviews including information about the palliative care needs of patients with mesothelioma and their family carers.
Results: The search yielded 508 articles, 14 were included in the analy- sis. A cross cutting theme of ‘uncertainty’ was identified encompassing five themes: (1) organisation and co-ordination of services, (2) commu- nication and information needs, (3) management of care needs and high symptom burden, (4) consideration of the impact of seeking compensa- tion, and (5) family caregiver needs. Our findings demonstrate that patients with mesothelioma want a co-ordinated, team-based approach to palliative care with a named point of contact. Whilst carers value and benefit from early referral to specialist palliative care, this does not nec- essarily reflect the outcomes and views of patients.
Conclusion: The evidence base around the palliative care needs of patients with mesothelioma and their carers needs to be strengthened. The results of this review support the need to develop a greater understanding about the role non-specialist palliative care clinicians’ play in providing generalist palliative care for people with mesothelioma and their carers.
Abstract number: L-17 Abstract type: Poster
A National Survey of the Role of Healthcare Assistants in Hospice Out- of-Hours Services
Fee A.1, Hasson F.1, McIlfatrick S.1, Payne S.2, Slater P.1, McConnell T.3, Finlay D.-A.4
1Ulster University, School of Nursing, Ulster University, Jordanstown, United Kingdom, 2Lancaster University, International Observatory on End of Life Care, Lancaster, United Kingdom, 3Marie Curie UK, Belfast, United Kingdom, 4C/O Ulster University, Belfast, United Kingdom
Background: The majority of out-of-hours (OOH) community-based hos- pice palliative care services include professionals and healthcare assis- tants in their teams, although models of provision and skill mix differ.
Increasingly, the unregistered healthcare assistant (HCA) is involved in the team, however little is known about their role or contribution to OOH palliative care.
Aim: To describe current UK hospice models of out-of-hours community palliative care, and involvement of HCAs within these models.
Method: An online survey, comprising open and closed items, was sent to managers of 150 UK adult hospices providing out-of-hours services.
Questions, adapted from COVPALL (Higginson et al. 2020), concerned service configuration, referral, and staffing. Descriptive analysis was undertaken with quantitative and qualitative data.
Results: 58/150 services (response rate 38%) provided data. Diversity of ser- vice models was recorded. The most common OOH service was telephone advice (n=72%), followed by care at home (60%), and Rapid Response (n=35%). Hospices delivering hospice at home service reported that this ser- vice was delivered predominantly by HCAs (n=58%); for rapid response, the service was provided mainly by nurses (n=32%), with HCAs (n=19%); and telephone advice was provided by nurses (n=58%), and HCAs (n=21%).
Qualitative data suggested that HCAs were a flexible and skilled workforce.
Conclusion / discussion: Findings suggest that hospices provide a range of services that involve HCAs within OOH community palliative care; and that HCAs have played a role in enabling hospices to adapt to increased demand for such services. Further research is required to explore the impact of HCAs within different OOH service models.
Abstract number: L-18 Abstract type: Poster
Do Clinicians’ Estimates of Prognosis Impact on Patient Care? A Retro- spective Evaluation of Referrals to a UK Hospice Inpatient Unit Tavabie S.1, Hargreaves A.2, Tookman A.2, Stone P.3
1Royal London Hospital, Barts Health NHS Trust, Palliative Medicine, London, United Kingdom, 2Marie Curie Hospice Hampstead, London, United Kingdom, 3Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
Aim: To evaluate the accuracy and impact of referring clinicians’ esti- mates of prognosis in patients referred to hospice inpatient care.
Methods: Retrospective review of twelve months’ referrals to an inpa- tient hospice unit. Routinely collected data were extracted including demographics, date and source of referral, estimated prognosis, date of admission and death (or date last known to be alive) and preferred place of death. To assess impact, data were collected on: delays to admission;
length of stay; place of death; and extent of discharge planning.
Results: 383 eligible patient notes with full datasets were identified.
Mean age of 72 years (range 24-101) and majority of referrals received from specialist palliative care teams (365/388: 95.3%).
Prognostic Accuracy: The median (range) survival of patients with a clini- cian estimated prognosis (CEP) of ‘days’ (n=141) was 7 (0-164) days; for CEP of ‘weeks’ (n=167) was 14 (1-538) days; and for CEP ‘months’ (n=75) was 32 (2-507) days. Kaplan-Meier survival curves showed a significant difference between CEP survival categories of months and weeks (p<0.0001); and between months and days (p< 0.0001); but not between days and weeks (p= 0.1).
Impact of CEP: The time between receipt of referral and admission increased with increasing length of CEP: CEP days (n=105) median 1 (0-14) days; CEP weeks (n= 154) median 2 (0-46) days; CEP months (n=69) median 3 (0-46) days. No significant difference was demonstrated in the number of discharge planning conversations between groups (0.9 conversations per patient). The proportion of patients achieving preferred place of death was found to be higher for those inaccurately given a CEP of days (19/35: 54%) compared to those inaccurately given a CEP of months (16/47: 34%).
Conclusions: CEP on referral forms affects the prioritisation given to referrals for admission by hospices. Inaccurate CEP on referral forms may influence achievement of preferred place of death.
Abstract number: L-19 Abstract type: Poster
A Survey of Palliative Care Involvement with People with MND/ALS in the UK
Oliver D.1, Baker I.2, Faull C.3, Stockdale C.4
1University of Kent, Tizard Centre, Canterbury, United Kingdom,
2University of Swansea, Ty Olwen Hospice, Swansea, United Kingdom,
3LOROS, Leicester, United Kingdom, 4Severn Hospice, Shrewsbury, United Kingdom
Introduction: The care of people with MND/ALS have often received care from palliative care services – at home and in hospice inpatient units. National guidelines have recommended early involvement and that specialist palliative care should be available as a regular member of the multidisciplinary team(MDT).
Aims: This survey was to ascertain the extent of the involvement of pal- liative care services in the UK with people with MND/ALS.
Methods: An on-line survey was used, and the details of which were distributed by the Association of Palliative Medicine, which represents doctors working in palliative care.
Results: 86 specialists responded – representing about 40% of specialist palliative care units in the UK. 97% saw MND/ALS patients.
The majority of services (79%) were involved when the patients had spe- cific needs and only a small number were involved only at the end of life or in the terminal stages. There was often collaboration with neurology services (86%), with 60% being part of the MDT. There were few barriers to referral with neurology services not making referrals reported by only 16% and patient or family reluctance to involvement was rare (20%).
Patients with non-invasive ventilation (59%) and tracheostomy ventila- tion (37%) were often seen. 34% were involved in the care of patients with NIV at home and 96% of services were involved in the discussions of withdrawal of treatment at the end of life.
Discussion: The majority of the respondents were involved in MND/ALS care, although the respondents may be those most involved in this care and may not be representative of the whole of the UK. For the respond- ents palliative care was often included within the MDT approach. The services were very commonly involved in the care of patients receiving ventilatory support, including advice and support in the difficult, com- plex and ethical issues of withdrawal of treatment at the end of life.
Abstract number: L-20 Abstract type: Poster
Insights and Awareness Gained by the Self-assesment Tool Palliative Care Aids Organisations to Improve their Palliative Care
van Drielen E.1, Brummelhuis I.1, Tummers R.-M.1, Fransen H.2, Schoonheim-Lunenborg H.3, Kessels M.4
1Stichting Fibula, Utrecht, Netherlands, 2Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands, 3Palliative Care Network Drenthe Steenwijkerland, Meppel, Netherlands, 4Palliative Care Network Noord-Limburg, Venlo, Netherlands
Background: The Dutch national framework for palliative care provides insights into the quality of palliative care (PC). Based on the frame- work, a self-assessment tool for healthcare organisations (HCO) has been developed. The tool reveals the state of an organisation concern- ing the organisation of PC and indicates which elements can be improved.
Aims: This study aims at describing the status of 50 organisations that have used the tool for the self-assessment of PC.
Methods: 50 HCO used the digital application of the self-assessment tool. Elements of this tool adress patient care, organisation of PC and collaboration with other organisations. All 50 organisations answered questions and used 10 patient records of the last non-unexpected death patients. Extracted data were analysed both quantitatively and qualita- tively by 2 independent researchers.
Results: The self-assessment tool showed that the identification of pal- liative patients remains difficult for HCO working in different settings.
The understanding of what encompasses PC and when it should be intro- duced varies widely. Some HCO stated that PC should start only in the last 72 hours of life whereas others replied that all clients in a nursing home were labelled as palliative. Furthermore, reporting in patient records varied widely, but significant differences were observed in spir- itual, social and psychological dimension of PC.
Conclusion: The self-assessment tool provides HCO insights into the quality of the PC they provide. The analysis of the output shows that internal discussion about PC leads to awareness and insights in its per- formance, with respect to the topics that need improvement. Areas of improvement encompass the identification of palliative patients and their needs on social, psychological and spiritual issues as well as report- ing on the specific care for these patients.
Abstract number: L-21 Abstract type: Poster
Associations between Goals of Care Designation Orders and Health Resource Utilization: A Prospective Cohort Study of Older, Seriously Ill Adults in Acute Care
Simon J.1, Earp M.2, Douglas M.3, Biondo P.2, Davison S.4, Brisebois A.3, Sia W.3, King S.2, Esau L.5, Wasylenko E.1, Fassbender K.3
1University of Calgary, Oncology, Calgary, Canada, 2University of Calgary, Calgary, Canada, 3University of Alberta, Edmonton, Canada,
4University of Alberta, Nephrology, Edmonton, Canada, 5Alberta Health Services, Lethbridge, Canada
Background: Medical order frameworks communicate patients’ goals beyond resuscitation, e.g. Goals of Care Designation (GCD) orders describe care focus, interventions and locations through 3 categories (Resuscitative, Medical and Comfort Care) and 7 subcategories. Health resource utilization consequences of GCD are unknown.
Aims: To correlate GCD and resource use during an index hospital admis- sion and evaluate associations between discharge GCD and 30-day readmissions.
Methods: A prospective cohort of 475 acutely hospitalized, seriously ill, older adults were studied (Audit of Communication, Care Planning, and Documentation (ACCEPT) study, 8 hospitals, Alberta, Canada, 2017).
Data collected:
(A) patient questionnaire, 2-5 days into admission (demographics and frailty),
(B) patients’ medical charts audited at enrolment and 3 months (GCD before admission, at enrolment and discharge, discharge location/death), and
(C) administrative hospital records for 6 months from enrolment (Length of Stay (LOS), Intensive Care Unit hours, Resource Intensity Weighting (RIW), Flagged Interventions (FI)).
Results: Enrolment GCD was associated with all demographic and index admission characteristics, except sex and FI. Patients with Comfort- focused GCD had higher frailty index, more co-morbidities, longer LOS, higher RIW, more FI (almost all related to symptom management), and more palliative care referrals (p<0.001). The last recorded GCD was highly associated with death and discharge location (p<0.001).
Readmission within 30-days occurred for 17% (n=76/436) of discharges.
Trends but no significant association was seen between discharge GCD and 30-day readmissions (Medical focused GCD 22%, Resuscitative 15%, Comfort 6%, no GCD 6% readmitted) however discharge location was associated with 30-day readmission.
Conclusion: GCDs appeared appropriately applied and were associated with health resource use during hospitalization and discharge location but not statistically with 30-day readmissions.
Abstract number: L-22 Abstract type: Poster
Predictors of Home Death for Palliative Care Patients Receiving a Nurse-led End of Life (PEACH) Program
Agar M.1,2,3, Xuan W.3, Jobburn K.2, Chow J.S.F.2,4,5, Lee J.6, Barclay G.7, Oloffs A.8, Maurya N.2, PEACH research and evaluation group
1University of Technology Sydney, IMPACCT Centre, Ultimo Sydney, Australia, 2South West Sydney Local Health District, Sydney, Australia,
3Ingham Institute of Applied Medical Research, Sydney, Australia,
4University of Tasmania, Tasmania, Australia, 5University of Sydney, Sydney, Australia, 6Sydney Local Health District, Sydney, Australia,
7Illawarra Shoalhaven Local Health District, Warrawong, Australia,
8Nepean Blue Mountains Local Health District, Penrith, Australia Background: Many people at the end of life prefer to be cared for and, often, die at home. Home palliative care services increase the odds of dying at home, but there is room to improve services to meet prefer- ences. Little is known of factors which influence location of death in peo- ple receiving tailored models of care aimed to improve match between preference and actual place of death. The PEACH model of care is a rapid response nurse-led package of care mobilised for palliative care patients who have an expressed preference to die at home.
Aims: To explore association of referral characteristics with separation status at completion of a PEACH package episode of care.
Methods: Prospective cohort study of consecutive PEACH package recip- ients (Dec 2013 - Jan 2017). Eligibility for PEACH required deteriorating/
terminal phase of illness, poor performance status and preference to die at home. Variables included age, gender, carer status, location at refer- ral, primary diagnosis, language spoken and geographic location. The outcome of interest was mode of separation (status of patient at PEACH package episode of care end (discharge, transfer to inpatient care or death)). Descriptive analyses and logistic regression were performed to explore key predictors.
Results: 1,754 clients received PEACH package over study period (Mean age 70 yrs, 55% male). Mode of separation was home death (75.7% n=1327), hospital/palliative care unit admission (13.5% n=237)
& 10.8% (n=190) alive and discharged from PEACH program. Of partici- pants with clear preference to die at home at referral (n=1571) 79%
met their wish. Cancer diagnosis (OR 1.97, p=0.003), preferred home death (OR 6.07, p<.0001), & carer relationship (Child/grandchild) (OR 0.57, p=0.0003) were significantly associated with mode of separation (home death).
Conclusion: Opportunities to tailor home care based on referral charac- teristics to meet patient preference to die at home, at individual, system and policy levels exist.
Abstract number: L-23 Abstract type: Poster
Out-of-Hours Care for Patients Nearing the End of Life in the Commu- nity and their Families. Systematic Review of Key Processes, Compo- nents and Outcomes
Firth A.M1, Lin C.P.1, Goodrich J.1, Brown D.1, Harding R.1, Tutt L.1, Murtagh F.EM2, Evans C.J1
1King’s College London, Cicely Saunders Institute, London, United Kingdom, 2University of Hull, Wolfson Palliative Care Research Centre, Hull, United Kingdom
Background: Patients with advanced conditions in the community have complex and fluctuating needs. Yet, little is known about how best to deliver out-of-hours care. This study aims to identify the processes, com- ponents and outcomes for ‘out-of-hours’ community-based care for patients in the last year of life and their families.
Methods: Systematic review using a two-stage search strategy