Support Care Cancer DOI 10.1007/s00520-015-2630-z
ORIGINAL ARTICLE
How well is palliative care integrated into cancer care? A MASCC, ESMO, and EAPC Project Mellar P. Davis & Florian Strasser & Nathan Cherny
Received: 24 September 2014 / Accepted: 22 January 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Introduction The benefits of integration of palliative care into oncology have become evidence-based. How palliative care is perceived and structured in various settings and countries would be of interest. Method We used a previously published questionnaire to survey multiple institutions with members in MASCC and ESMO. The survey was made available on the MASCC website for approximately 6 months and repeated requests were made to complete the survey. Comparisons were made between NCI/ESMO designated cancer centers, nondesignated cancer centers, and urban hospitals. Results One hundred eighty-three different institutions completed this survey, 28 % of ESMO designated centers. Most institutions had palliative care programs and most programs consisted of an inpatient consult service and outpatient clinics. A minority had inpatient palliative care beds and institution supported hospice services. Barriers to palliative care were largely financial. Integration of palliative care into oncology was highly desirable but only a minority of respondents felt that their institution would financially support expanded services and additional palliative care personnel. Designated cen-
M. P. Davis (*) Palliative Medicine and Supportive Oncology Services, Division of Solid Tumor, Taussig Cancer Institute, The Cleveland Clinic, Cleveland Clinic Lerner School of Medicine Case Western Reserve University, Cleveland, OH, USA e-mail: [email protected] F. Strasser Oncological Palliative Medicine, Clinic for Oncology and Hematology, Department Internal Medicine & Centre for Palliative Care, Cantonal Hospital, St. Gallen, Switzerland N. Cherny Cancer Pain and Palliative Medicine Service, Department Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
ters were more likely to have expanded palliative care services. Discussion Our findings are very similar to those previously published. Multiple studies have demonstrated that though palliative care integration into oncology is highly beneficial as measured by patient related outcomes, there is a great concern about reimbursement for services and budget constraints which prevent expansion of services. Conclusion Palliative care integration into cancer care is largely through consulting services for inpatients and outpatient clinics. Financial concerns limit integration and expansion of palliative care services. Designated cancer centers have more extensive palliative care services relative to nondesignated cancer centers and urban hospitals. Keywords Palliative . Oncology . Service . Integration Introduction Optimal cancer care requires multidisciplinary teams. Multidisciplinary teams “are alliances of all medical and health care professionals related to a specific tumor whose approach to cancer care is guided by a willingness to agree on evidence-based clinical decisions and to coordinate the delivery of care at all stages of the process” [1]. Palliative care at its heart is a multidisciplinary or interdisciplinary team which centers on quality of life of patients with life limiting illnesses and their family. Cancer care is undergoing a paradigm shift from a disease management to a patient-centered approach which requires professionals to focus on psychosocial concerns, quality of life, symptoms, patient rights and empowerment, comorbidities, and more recently survivorship [1]. Recent evidence suggests that early involvement of palliative care for those with advanced incurable cancer has multiple subjective and objective benefits [2,3]. Utilization of palliative care and integration
Support Care Cancer
into cancer care is considered a basic quality indicator of national palliative care development [4]. Integration of palliative services into cancer care may also involve expansion of services if seen as valuable. The purpose of this study was to survey cancer programs through the oncology leadership to find out how palliative care is integrated into cancer care in individual institutes; to determine perceptions of palliative care merits and the potential for increasing resources in the development of palliative care services.
Methods Research design This study used a primary analysis from a cross-sectional survey conducted through the Multinational Association of Supportive Care in Cancer (MASCC) website using Survey Monkey (www.surveymonkey.com). This project was reviewed by the Cleveland Clinic Institutional Review Board and was granted exemption. The main method of this survey was a questionnaire which was modified from the original questionnaire by Dr Hui and colleagues [5]. Sample The data was generated from members of MASCC, the European Society of Medical Oncology (ESMO) and the European Association of Palliative Care (EAPC) who completed the survey on the website. Members were informed of the survey and invited to complete the survey by entering the MASCC website. Repeated invitations were made until no further surveys were received. Questionnaire The questionnaire was slightly modified to fit the purposes of the study to include ESMO members (Fig. 1). Permission was obtained from the authors to use the questionnaire. The questionnaire asked type of cancer center, palliative care access, type of palliative care practitioners in their particular institution, availability and type of palliative care services, barriers to palliative care integration, effectiveness of palliative services, the perception of need of palliative care services in particular cancer care, palliative care research, potential for palliative care growth in terms of personnel, palliative care acute care beds and funding. Questions were scored on a 0–10 scale; arbitrary scores of 0–3 indicated a negative response, 4–7 a neutral response, and 8–10 a positive response. Wilcoxon signed rank test was done for comparisons. A p value of < 0.05 was considered significant. Chi-square test was used for questions with categorical
responses, Cochran-Armitage test for trend for questions involving a 0–11 scale, unless otherwise noted and the KruskalWallis test for other comparisons.
Results Table 1 lists survey responses. The survey was sent November 15, 2011 to 676 MASCC members and made available on the MASCC website for non-MASCC members. The survey was removed from the website April 20, 2012. We had 183 respondents; of which, 34 of 120 (28 %) ESMO designated centers responded. Nineteen respondents (10 %) were from the National Cancer Institute (NCI) designated centers. Sixty-five (36 %) were from other cancer centers, 45 (25 %) from urban hospitals, 7 (4 %) were from rural hospitals and 11 (6 %) were from hospice centers. The potential for multiple respondents from one cancer center was considered to be quite low. In the analysis, rural hospitals and hospice centers were excluded because of small numbers. Overall, most institutions (83 %) had palliative care available sometime during the past 10 years, most (93 %) palliative services were under the leadership of a physician, most (91 %) had at least one palliative care physician on staff; most (84 %) had dedicated inpatient beds for cancer care. The most commonly offered palliative care service was a consultative/mobile team (72 %) and an outpatient palliative/ supportive care clinic (64 %). A little over half of respondents (52 %) indicated that both types of services were available at their institution. In contrast, only 39 % of respondents indicated that dedicated palliative care acute care inpatient beds were available and only 21 % indicated that there were institutionoperated hospice services available. The most commonly noted barrier to palliative care access and development was a limited budget (55 %), followed by a lack of adequately trained palliative care physicians and nurses (40 %), and poor reimbursement for services (32 %). Only 5 % identified a lack of evidence that palliative care improves patient outcomes as a barrier; only 4 % indicated that palliative care had a potentially negative impact on the hospitals national ranking. Respondents indicated that the effectiveness and quality of their palliative care program improved at least a little bit over the last 5 years (median of 1 level change in effectiveness and median of 2 level changes in quality, p
ORIGINAL ARTICLE
How well is palliative care integrated into cancer care? A MASCC, ESMO, and EAPC Project Mellar P. Davis & Florian Strasser & Nathan Cherny
Received: 24 September 2014 / Accepted: 22 January 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Introduction The benefits of integration of palliative care into oncology have become evidence-based. How palliative care is perceived and structured in various settings and countries would be of interest. Method We used a previously published questionnaire to survey multiple institutions with members in MASCC and ESMO. The survey was made available on the MASCC website for approximately 6 months and repeated requests were made to complete the survey. Comparisons were made between NCI/ESMO designated cancer centers, nondesignated cancer centers, and urban hospitals. Results One hundred eighty-three different institutions completed this survey, 28 % of ESMO designated centers. Most institutions had palliative care programs and most programs consisted of an inpatient consult service and outpatient clinics. A minority had inpatient palliative care beds and institution supported hospice services. Barriers to palliative care were largely financial. Integration of palliative care into oncology was highly desirable but only a minority of respondents felt that their institution would financially support expanded services and additional palliative care personnel. Designated cen-
M. P. Davis (*) Palliative Medicine and Supportive Oncology Services, Division of Solid Tumor, Taussig Cancer Institute, The Cleveland Clinic, Cleveland Clinic Lerner School of Medicine Case Western Reserve University, Cleveland, OH, USA e-mail: [email protected] F. Strasser Oncological Palliative Medicine, Clinic for Oncology and Hematology, Department Internal Medicine & Centre for Palliative Care, Cantonal Hospital, St. Gallen, Switzerland N. Cherny Cancer Pain and Palliative Medicine Service, Department Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
ters were more likely to have expanded palliative care services. Discussion Our findings are very similar to those previously published. Multiple studies have demonstrated that though palliative care integration into oncology is highly beneficial as measured by patient related outcomes, there is a great concern about reimbursement for services and budget constraints which prevent expansion of services. Conclusion Palliative care integration into cancer care is largely through consulting services for inpatients and outpatient clinics. Financial concerns limit integration and expansion of palliative care services. Designated cancer centers have more extensive palliative care services relative to nondesignated cancer centers and urban hospitals. Keywords Palliative . Oncology . Service . Integration Introduction Optimal cancer care requires multidisciplinary teams. Multidisciplinary teams “are alliances of all medical and health care professionals related to a specific tumor whose approach to cancer care is guided by a willingness to agree on evidence-based clinical decisions and to coordinate the delivery of care at all stages of the process” [1]. Palliative care at its heart is a multidisciplinary or interdisciplinary team which centers on quality of life of patients with life limiting illnesses and their family. Cancer care is undergoing a paradigm shift from a disease management to a patient-centered approach which requires professionals to focus on psychosocial concerns, quality of life, symptoms, patient rights and empowerment, comorbidities, and more recently survivorship [1]. Recent evidence suggests that early involvement of palliative care for those with advanced incurable cancer has multiple subjective and objective benefits [2,3]. Utilization of palliative care and integration
Support Care Cancer
into cancer care is considered a basic quality indicator of national palliative care development [4]. Integration of palliative services into cancer care may also involve expansion of services if seen as valuable. The purpose of this study was to survey cancer programs through the oncology leadership to find out how palliative care is integrated into cancer care in individual institutes; to determine perceptions of palliative care merits and the potential for increasing resources in the development of palliative care services.
Methods Research design This study used a primary analysis from a cross-sectional survey conducted through the Multinational Association of Supportive Care in Cancer (MASCC) website using Survey Monkey (www.surveymonkey.com). This project was reviewed by the Cleveland Clinic Institutional Review Board and was granted exemption. The main method of this survey was a questionnaire which was modified from the original questionnaire by Dr Hui and colleagues [5]. Sample The data was generated from members of MASCC, the European Society of Medical Oncology (ESMO) and the European Association of Palliative Care (EAPC) who completed the survey on the website. Members were informed of the survey and invited to complete the survey by entering the MASCC website. Repeated invitations were made until no further surveys were received. Questionnaire The questionnaire was slightly modified to fit the purposes of the study to include ESMO members (Fig. 1). Permission was obtained from the authors to use the questionnaire. The questionnaire asked type of cancer center, palliative care access, type of palliative care practitioners in their particular institution, availability and type of palliative care services, barriers to palliative care integration, effectiveness of palliative services, the perception of need of palliative care services in particular cancer care, palliative care research, potential for palliative care growth in terms of personnel, palliative care acute care beds and funding. Questions were scored on a 0–10 scale; arbitrary scores of 0–3 indicated a negative response, 4–7 a neutral response, and 8–10 a positive response. Wilcoxon signed rank test was done for comparisons. A p value of < 0.05 was considered significant. Chi-square test was used for questions with categorical
responses, Cochran-Armitage test for trend for questions involving a 0–11 scale, unless otherwise noted and the KruskalWallis test for other comparisons.
Results Table 1 lists survey responses. The survey was sent November 15, 2011 to 676 MASCC members and made available on the MASCC website for non-MASCC members. The survey was removed from the website April 20, 2012. We had 183 respondents; of which, 34 of 120 (28 %) ESMO designated centers responded. Nineteen respondents (10 %) were from the National Cancer Institute (NCI) designated centers. Sixty-five (36 %) were from other cancer centers, 45 (25 %) from urban hospitals, 7 (4 %) were from rural hospitals and 11 (6 %) were from hospice centers. The potential for multiple respondents from one cancer center was considered to be quite low. In the analysis, rural hospitals and hospice centers were excluded because of small numbers. Overall, most institutions (83 %) had palliative care available sometime during the past 10 years, most (93 %) palliative services were under the leadership of a physician, most (91 %) had at least one palliative care physician on staff; most (84 %) had dedicated inpatient beds for cancer care. The most commonly offered palliative care service was a consultative/mobile team (72 %) and an outpatient palliative/ supportive care clinic (64 %). A little over half of respondents (52 %) indicated that both types of services were available at their institution. In contrast, only 39 % of respondents indicated that dedicated palliative care acute care inpatient beds were available and only 21 % indicated that there were institutionoperated hospice services available. The most commonly noted barrier to palliative care access and development was a limited budget (55 %), followed by a lack of adequately trained palliative care physicians and nurses (40 %), and poor reimbursement for services (32 %). Only 5 % identified a lack of evidence that palliative care improves patient outcomes as a barrier; only 4 % indicated that palliative care had a potentially negative impact on the hospitals national ranking. Respondents indicated that the effectiveness and quality of their palliative care program improved at least a little bit over the last 5 years (median of 1 level change in effectiveness and median of 2 level changes in quality, p
