General Practice and Primary Care - Research Publications
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ItemCommunication about early palliative care: A qualitative study of oncology providers' perspectives of navigating the artful introduction to the palliative care team(FRONTIERS MEDIA SA, 2022-12-09)BACKGROUND: Despite robust evidence for the integration of early palliative care for patients with advanced cancer, many patients still access this approach to care late. Communication about the introduction of Early Palliative Care is an important skill of healthcare providers working in this setting. In the context of limited community understanding about palliative care, patients and their families may express fear or negative reactions to its early introduction. Health professionals may lack the confidence or skill to describe the role and benefits of early palliative care. AIM: This study sought to explore clinicians' perspectives on communication about referral to early palliative care, specifically identifying facilitators in undertaking this communication task. METHODS: An exploratory qualitative study set within a tertiary oncology service in Victoria, Australia. Semi-structured interviews were conducted with purposively sampled oncology clinicians exploring their perspectives on communication about referral to early palliative care. A reflexive thematic analysis was undertaken by two researchers, including both latent and semantic coding relevant to the research question. Reporting of the research was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. RESULTS: Twelve oncology clinicians (58% female, with 67% > 15 years clinical experience) from medical oncology, surgical oncology, and haematology participated. The artful navigation of communication about early palliative care was characterised by the need for a 'spiel' involving the adoption of a series of strategies or 'tactics' when introducing this service. These themes included: 1) Using carefully selected and rehearsed language; 2) Framing in terms of symptom control; 3) Framing as additive to patient care; 4) Selling the service benefits of early palliative care; 5) Framing acceptance of referral as an altruistic act; and 6) Adopting a phased approach to delivering information about palliative care. IMPLICATIONS: This study highlights the wide ranging and innovative communication strategies and skills required by health professionals to facilitate referral to early palliative care for cancer patients and their families. Future focus on upskilling clinicians around communication of this topic will be important to ensure successful implementation of models of early palliative care in routine cancer care.
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ItemThe feasibility of triggers for the integration of Standardised, Early Palliative (STEP) Care in advanced cancer: A phase II trial(FRONTIERS MEDIA SA, 2022-09-15)BACKGROUND: While multiple clinical trials have demonstrated benefits of early palliative care for people with cancer, access to these services is frequently very late if at all. Establishing evidence-based, disease-specific 'triggers' or times for the routine integration of early palliative care may address this evidence-practice gap. AIM: To test the feasibility of using defined triggers for the integration of standardised, early palliative (STEP) care across three advanced cancers. METHOD: Phase II, multi-site, open-label, parallel-arm, randomised trial of usual best practice cancer care +/- STEP Care conducted in four metropolitan tertiary cancer services in Melbourne, Australia in patients with advanced breast, prostate and brain cancer. The primary outcome was the feasibility of using triggers for times of integration of STEP Care, defined as enrolment of at least 30 patients per cancer in 24 months. Triggers were based on hospital admission with metastatic disease (for breast and prostate cancer), or development of disease recurrence (for brain tumour cohort). A mixed method study design was employed to understand issues of feasibility and acceptability underpinning trigger points. RESULTS: The triggers underpinning times for the integration of STEP care were shown to be feasible for brain but not breast or prostate cancers, with enrolment of 49, 6 and 10 patients across the three disease groups respectively. The varied feasibility across these cancer groups suggested some important characteristics of triggers which may aid their utility in future work. CONCLUSIONS: Achieving the implementation of early palliative care as a standardized component of quality care for all oncology patients will require further attention to defining triggers. Triggers which are 1) linked to objective points within the illness course (not dependent on recognition by individual clinicians), 2) Identifiable and visible (heralded through established service-level activities) and 3) Not reliant upon additional screening measures may enhance their feasibility.
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ItemNo Preview AvailableTelehealth in outpatient delivery of palliative care: a prospective survey evaluation by patients and clinicians(WILEY, 2022-07)BACKGROUND: In Australia during the COVID-19 pandemic new funding models were introduced to support telehealth consultations, resulting in their widescale adoption in palliative care service delivery. Clarity around the clinical circumstances and patient populations that might be most appropriate for telehealth models was required. AIMS: To evaluate patient and physician satisfaction, acceptability and utility of outpatient palliative care provision through telehealth. METHODS: This is a multi-site prospective, cross-sectional, observational study conducted during a time of significant public health restrictions. A survey was used to collect matched patient- and physician-reported perceptions of palliative care telehealth consultations across three metropolitan hospitals in Victoria, Australia. RESULTS: There were 127 matched patient-physician data of telehealth consultations and a further 812 physician-only assessments. Telehealth was generally acceptable and satisfactory, with patients providing greater positive scores than clinicians. Telehealth incorporating both audio and video were more acceptable and satisfactory, particularly with the presence of a carer, and during routine reviews. Physicians were less satisfied using telehealth when there was increasing symptom complexity across all domains (pain, psychological, and other symptoms). CONCLUSIONS: Telehealth has high utility in palliative care practice. A future hybrid model of care comprising both face-to-face and telehealth consultations seems favoured by patients and physicians but must be accompanied by targeted support for specific patient groups to ensure equitable healthcare access. Further evaluation of telehealth during a time of fewer public health emergency measures and lower community anxiety is required to fully understand its ongoing role.
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ItemPerceptions of telehealth in real-world oncological care: An exploration of matched patient- and clinician-reported acceptability data from an Australian cancer centre(WILEY, 2022-09)BACKGROUND: Prior to 2020, the use of telehealth in cancer care was limited, but COVID-19 necessitated its rapid and widespread adoption into routine care delivery. This study aimed to evaluate perceptions of telehealth through a dyadic exploration of matched cancer patient- and clinician-reported acceptability data and to explore factors that may predict greater suitability for telehealth. METHODS: A prospective, cross-sectional, exploratory survey study assessed (matched) patient- and clinician-reported perceptions of telehealth consultations occurring at a metropolitan, tertiary-based cancer centre in Victoria, Australia. RESULTS: One-hundred and fifty-five matched patient- and clinician-reported data were included. High rates of acceptability with telehealth were reported by patients (93%) and clinicians (91%), who mostly shared concordant views (86%). Factors significantly associated with increased acceptability for telehealth, included, for clinicians, greater familiarity with the patient (OR 8.20, 95% CI: 1.50-45.06, p = 0.02), and younger patient age (OR 1.06, 95% CI: 0.99-1.13, p = 0.05), and for patients was earlier stage disease (≤stage III) (OR 5.29, 95% CI: 1.08-25.82, p = 0.04). Lower acceptability for telehealth according to clinicians was associated with poorer patient performance status (OR 0.04, 95% CI 1.00-1.08, p = 0.04) and for patients with the need for an interpreter (0R 0.06, 95% CI: 0.008-0.51, p = 0.009). CONCLUSION: While overall telehealth is acceptable in cancer care, our findings raise important implications for future service development, notably that it may be less optimal for patients with higher complexity of need-including those with more advanced disease, poorer performance status, those less well known to treating clinicians and those identified to have additional language barriers.
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ItemNo Preview AvailableCOVID-19 end-of-life care: symptoms and supportive therapy use in an Australian hospital(WILEY, 2021-09)BACKGROUND: Descriptions of symptoms and medication use at end of life in COVID-19 are limited to small cross-sectional studies, with no Australian longitudinal data. AIMS: To describe end-of-life symptoms and care needs of people dying of COVID-19. METHODS: This retrospective cohort study included consecutive admitted patients who died at a Victorian tertiary referral hospital from 1 January to 30 September directly due to COVID-19. Clinical characteristics, symptoms and use of supportive therapies, including medications and non-pharmacological interventions in the last 3 days of life were extracted. RESULTS: The cohort comprised 58 patients (median age 87 years, interquartile range (IQR) 81-90) predominantly admitted from home (n = 30), who died after a median of 11 days (IQR 6-28) in the acute medical (n = 31) or aged care (n = 27) wards of the hospital. The median Charlson Comorbidity Score was 7 (IQR 5-8). Breathlessness (n = 42), agitation (n = 36) and pain (n = 33) were the most frequent clinician-reported symptoms in the final 3 days of life, with most requiring opioids (n = 52), midazolam (n = 40), with dose escalation commonly being required. While oxygen therapy was commonly used (n = 47), few (n = 13) required an anti-secretory agent. CONCLUSIONS: This study presents one of the first and largest Australian report of the end of life and symptom experience of people dying of COVID-19. This information should help clinicians to anticipate palliative care needs of these patients, for example, recognising that higher starting doses of opioids and sedatives may help reduce prevalence and severity of breathlessness and agitation near death.
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ItemNo Preview AvailableChallenges in data linkage - experiences from an upper gastrointestinal cancer data linkage study(OXFORD UNIV PRESS, 2021-09)Abstract Background Linked, population-level data is valuable for mapping patterns of care and evaluating health service utilisation, particularly in difficult-to-reach populations. Upper gastrointestinal (UGI) cancers have a dismal prognosis, creating difficulties engaging patients in research. The utility of a linked dataset in this population is of high value. Methods Key objectives included identifying the operational and feasibility issues associated with linking Australian state-based administrative and registry data for understanding health service utilisation in UGI cancers. Datasets pertained to hospital admissions, radiotherapy, community health, primary care, palliative care, Medicare and Pharmaceutical Benefits Schedule’s and UGI cancers. Results From a logistical perspective, data access request approval processes varied, with some requiring consent to be sought from individual services contributing data. The availability of unique person-level identifying information varied widely. Additionally, the time period of data capture differed between and within datasets, limiting the quality of the linked data. Significant costs were associated with linking with primary care and Medicare and Pharmaceutical Benefits Schedule’s. Federal dataset linkage required at least a one-year waiting period. Conclusions Whilst in theory data linkage is a powerful mechanism for obtaining population-level data, in reality, there are many logistical and financial barriers to linking multiple datasets. Consequently, critical data, which has the potential to inform policy and improve patient outcomes, cannot be procured. Key messages Logistical and financial challenges are associated with linking administrative and registry datasets for research, limiting the potential of data linkage.