Integration of oncology and palliative care : a Lancet Oncology Commission

Full integration of oncology and palliative care relies on the specific knowledge and skills of two modes of care: the tumour-directed approach, the main focus of which is on treating the disease; and the host-directed approach, which focuses on the patient with the disease. This Commission addresses how to combine these two paradigms to achieve the best outcome of patient care. Randomised clinical trials on integration of oncology and palliative care point to health gains: improved survival and symptom control, less anxiety and depression, reduced use of futile chemotherapy at the end of life, improved family satisfaction and quality of life, and improved use of health-care resources. Early delivery of patient-directed care by specialist palliative care teams alongside tumour-directed treatment promotes patient-centred care. Systematic assessment and use of patient-reported outcomes and active patient involvement in the decisions about cancer care result in better symptom control, improved physical and mental health, and better use of health-care resources. The absence of international agreements on the content and standards of the organisation, education, and research of palliative care in oncology are major barriers to successful integration. Other barriers include the common misconception that palliative care is end-of-life care only, stigmatisation of death and dying, and insufficient infrastructure and funding. The absence of established priorities might also hinder integration more widely. This Commission proposes the use of standardised care pathways and multidisciplinary teams to promote integration of oncology and palliative care, and calls for changes at the system level to coordinate the activities of professionals, and for the development and implementation of new and improved education programmes, with the overall goal of improving patient care. Integration raises new research questions, all of which contribute to improved clinical care. When and how should palliative care be delivered? What is the optimal model for integrated care? What is the biological and clinical effect of living with advanced cancer for years after diagnosis? Successful integration must challenge the dualistic perspective of either the tumour or the host, and instead focus on a merged approach that places the patient's perspective at the centre. To succeed, integration must be anchored by management and policy makers at all levels of health care, followed by adequate resource allocation, a willingness to prioritise goals and needs, and sustained enthusiasm to help generate support for better integration. This integrated model must be reflected in international and national cancer plans, and be followed by developments of new care models, education and research programmes, all of which should be adapted to the specific cultural contexts within which they are situated. Patient-centred care should be an integrated part of oncology care independent of patient prognosis and treatment intention. To achieve this goal it must be based on changes in professional cultures and priorities in health care

Are family physician visits and continuity of care associated with acute care use at end-of-life? A population-based cohort study of homecare cancer patients

Background: Previous end-of-life cancer research has shown an association between increased family physician continuity of care and reduced use of acute care services; however, it did not focus on a homecare population or control for homecare nursing. Aim: Among end-of-life homecare cancer patients, to investigate the association of family physician continuity with location of death and hospital and emergency department visits in the last 2 weeks of life while controlling for nursing hours. Design: Retrospective population-based cohort study. Setting/participants: Cancer patients with ≥1 family physician visit in 2006 from Ontario, Canada. Family physician continuity of care was assessed using two measures: Modified Usual Provider of Care score and visits/week. Its association with location of death and hospital and emergency department visits in the last 2 weeks of life was examined using logistic regression. Results: Of 9467 patients identified, the Modified Usual Provider of Care score demonstrated a dose–response relationship with increasing continuity associated with decreased odds of hospital death and visiting the hospital and emergency department in the last 2 weeks of life. More family physician visits/week were associated with lower odds of an emergency department visit in the last 2 weeks of life and hospital death, except for patients with greater than 4 visits/week, where they had increased odds of hospitalizations and hospital deaths. Conclusions: These results demonstrate an association between increased family physician continuity of care and decreased odds of several acute care outcomes in late life, controlling for homecare nursing and other covariates. </jats:sec

Evaluation of a multisite educational intervention to improve mobilization of older patients in hospital: protocol for mobilization of vulnerable elders in Ontario (MOVE ON)

Abstract Background Functional decline is a common adverse outcome of hospitalization in older people. Often, this decline is not related to the illness that precipitated admission, but to the process of care delivered in hospital. The association between immobility and adverse consequences is well established, yet older inpatients spend significant amounts of time supine in bed. We aim to implement and evaluate the impact of an evidence-based strategy to promote early mobilization and prevent functional decline in older patients admitted to university-affiliated acute care hospitals in Ontario, Canada. We will implement a multi-component educational intervention to support a change in practice to enhance mobilization of older patients. Methods/design Implementation of our early mobilization strategy is guided by the Knowledge to Action Cycle. Through focus groups with frontline staff, we will identify barriers and facilitators to early mobilization. We will tailor the intervention at each site to the identified barriers and facilitators, focusing on the following key messages: to complete a mobility assessment and care plan within 24 hours of the decision to admit patients aged 65 years and older; to achieve mobilization at least 3 times per day; and, to ensure that mobilization is scaled and progressive. The primary outcome, number of patients observed out of bed, will be documented three times per day (in the morning, at lunch and in the afternoon), two days each week. This data collection will occur over 3 phases: pre-implementation (10 weeks), implementation (8 weeks), and post-implementation (20 weeks). Discussion This is the first large, multisite study to evaluate the impact of a multi-component knowledge translation strategy on rates of mobilization of older patients in hospital. Our implementation is framed by the Knowledge to Action Cycle, and the intervention is being adapted to the local context. These unique features render our intervention approach more generalizable to multiple practice settings. Contextualization of the intervention has also facilitated engagement of participants from multiple hospitals. Upon completion of this study, we will better understand the barriers and facilitators to implementing an early mobilization strategy across a spectrum of hospitals, as well as the impact of a mobilization strategy

Mapping barriers and intervention activities to behaviour change theory for Mobilization of Vulnerable Elders in Ontario (MOVE ON), a multi-site implementation intervention in acute care hospitals

Abstract Background As evidence-informed implementation interventions spread, they need to be tailored to address the unique needs of each setting, and this process should be well documented to facilitate replication. To facilitate the spread of the Mobilization of Vulnerable Elders in Ontario (MOVE ON) intervention, the aim of the current study is to develop a mapping guide that links identified barriers and intervention activities to behaviour change theory. Methods Focus groups were conducted with front line health-care professionals to identify perceived barriers to implementation of an early mobilization intervention targeted to hospitalized older adults. Participating units then used or adapted intervention activities from an existing menu or developed new activities to facilitate early mobilization. A thematic analysis was performed on the focus group data, emphasizing concepts related to barriers to behaviour change. A behaviour change theory, the ‘capability, opportunity, motivation-behaviour (COM-B) system’, was used as a taxonomy to map the identified barriers to their root causes. We also mapped the behaviour constructs and intervention activities to overcome these. Results A total of 46 focus groups were conducted across 26 hospital inpatient units in Ontario, Canada, with 261 participants. The barriers were conceptualized at three levels: health-care provider (HCP), patient, and unit. Commonly mentioned barriers were time constraints and workload (HCP), patient clinical acuity and their perceived ‘sick role’ (patient), and lack of proper equipment and human resources (unit level). Thirty intervention activities to facilitate early mobilization of older adults were implemented across hospitals; examples of unit-developed intervention activities include the ‘mobility clock’ communication tool and the use of staff champions. A mapping guide was created with barriers and intervention activities matched though the lens of the COM-B system. Conclusions We used a systematic approach to develop a guide, which maps barriers, intervention activities, and behaviour change constructs in order to tailor an implementation intervention to the local context. This approach allows implementers to identify potential strategies to overcome local-level barriers and to document adaptations