Clinician estimates of prognosis: accuracy and impact-a retrospective inpatient hospice study

Objective: To evaluate the accuracy and impact of clinicians’ estimates of prognosis (CEP) in patients referred for hospice inpatient care. Methods: Retrospective review of 12 months’ referrals to a London hospice unit. Data extracted included date of referral, admission and death and CEP. Results: N=383. Mean age 72 years (range 24–101). CEP accuracy: Median survival where CEP was ‘days’ (n=141) was 7 days (0–164); CEP ‘weeks’ (n=167) was 14 days (1–538); CEP ‘months’ (n=75) was 32 days (2–507). Kaplan-Meier survival curves showed significant difference between CEP of ‘months’ and ‘weeks’ (p<0.0001); ‘months’ and ‘days’ (p<0.0001); but not ‘days’ and ‘weeks’ (p=0.1). CEP impact: admission waiting time increased with increasing CEP: CEP ‘days’ (n=105) median 1 day (0–14); CEP ‘weeks’ (n=154) median 2 days (0–46); CEP ‘months’ (n=69) median 3 days (0–46). No significant difference was demonstrated in the number of discharge planning conversations between groups (0.9/patient). Conclusions: CEP was accurate in over half of the cases but did not adequately discriminate between those with prognoses of days or weeks. CEP may affect the prioritisation given to patients by hospices. Inaccurate CEP on referral forms may influence other aspects of care; however, further research is needed

A short report examining the introduction of routine use of patient reported outcome measures in a mixed oncology population

Aims: People living with treatable but not curable cancer often experience a range of symptoms related to their cancer and its treatment. During the COVID-19 pandemic, face-to-face consultations were reduced and so remote monitoring of these needs was necessary. University Hospitals Sussex implemented the routine use of electronic remote patient-reported outcome measures (PROMs) in a mixed oncology population, focusing on those with treatable but not curable cancers. Materials and methods: Over a 9-month period, patients were invited to register with My Clinical Outcomes (MCO) – a secure online platform for the collection of electronic PROMs. They were prompted by e-mail to complete assessments (EORTC QLQ-C30, EQ-5D-3L and EQ-5D VAS) routinely every 2 weeks. The team monitored patient scores and changes in these prompted clinical interventions. Results: In total, 324 patients completed at least one assessment. The median number of assessments completed by each patient was eight. The most represented tumour groups were secondary breast (28%), prostate (25%) and other (32%). Median scores for the assessments did not deteriorate in a clinically or numerically significant way for patients living with non-curable conditions for the majority of patients monitored. Conclusion: Routine collection of electronic remote PROMs is an effective and useful strategy to provide real-time clinical feedback to teams. With integration into existing systems, online platforms (such as MCO) could provide efficient and patient-centred information for those providing care for people with cancer

A systematic review of using virtual reality technology in palliative care

Background: Virtual Reality (VR) has the potential to ease patient symptomatology but its efficacy is not known. Aim: A systematic review on the feasibility and effectiveness of VR intervention in a palliative care setting. Methods: Medline, Embase, AMED, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science were searched from inception up to March 2021. Studies that reported on the use of VR in an adult (over 18 years) palliative population were included. The ROB-2 (for RCTs) and ROBINS tools (for non-RCTs) were used to assess risk of bias. The GRADE tool assessed the quality of the evidence. The standardised mean differences were calculated from the pre- and post- data of the Edmonton Symptom Assessment System-revised (ESAS-r). A DerSimonian-Laird random effects model meta-analysis was conducted. Registered: PROSPERO (CRD42021240395, 03/03/2021) Results: 8 studies were included, 3 were included in the meta-analysis. All studies had at least some concern for risk of bias. 225 patients used the VR technology. Patient diagnoses included cancer (3/8; 37.5%), multiple (3/8; 37.5%), advanced heart disease (1/8; 12.5%), and dementia (1/8; 12.5%). 44% (97/219) were male; the mean age ranged from 47 to 85 (years). Recruitment was feasible and retention rates ranged between 55% and 100%. Overall, participants reported a positive experience with using VR and were happy to repeat the experience. Discomfort and technical issues were recorded in 4/7 studies (57%). The meta-analysis showed limited evidence for VR across the domains of the ESAS-r. The quality of the evidence was rated as low to very low. Conclusions: VR in palliative care is feasible and has varying acceptability. Limited sample sizes and low-quality studies mean that the efficacy of VR is difficult to draw definitive conclusions on. Existing studies provide valuable insights and guidance into how to set up VR in clinical practice settings and the challenges to expect

7 Virtual reality in palliative care: a systematic review and meta-analysis

Introduction Virtual Reality (VR) has the potential to alleviate common mental and physical health symptoms at the end-of-life. There is limited data on the efficacy of VR in palliative care. Aims To review the feasibility and effectiveness of VR intervention within a palliative care setting. Method Medline, Embase, AMED, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science were searched from inception up to March 2021. Studies that reported on the use of VR in an adult (over 18 years) palliative population were included. The ROB-2 (for RCTs) and ROBINS tools (for non-RCTs) were used to assess risk of bias. The GRADE tool assessed the quality of the evidence. Data regarding feasibility, acceptability, and changes of psychological and physical symptoms of palliative care patients were extracted. Standardised mean differences (Hedges’ g) were calculated from the pre- post data reported on patient outcomes. A DerSimonian-Laird random effects model meta-analysis was conducted. PROSPERO (CRD42021240395, 03/03/2021) Results 524 studies were identified; 8 studies were included, 5 were included in the meta-analysis. All studies had at least some concern for risk of bias. 44% (97/219) of patients were male; the mean age ranged from 47 to 85 (years). Recruitment was feasible and retention rates ranged between 55% and 100%. Discomfort and technical issues were recorded in 4/7 studies (57%) but overall, participants reported a positive experience. The meta-analysis showed VR statistically significantly improved pain (p=0.0363), tiredness (p=0.0030), drowsiness (p=0.0051), shortness of breath (p=0.0284), depression (p=0.0091), and psychological well-being (p=0.0201). The quality of the evidence was graded as low to very low. Conclusion VR in palliative care is feasible and acceptable. Larger trials with a control arm are needed. Impact VR could be an adjuvant non-pharmacological therapy for symptoms such as anxiety, pain, or depression. Higher quality studies are needed to inform clinical recommendations

Delivery Models and Health Economics of Supportive Care Services in England: A Multicentre Analysis

AIMS: Improvements in cancer treatment have led to more people living with and beyond cancer. These patients have symptom and support needs unmet by current services. The development of enhanced supportive care (ESC) services may meet the longitudinal care needs of these patients, including at the end of life. This study aimed to determine the impact and health economic benefits of ESC for patients living with treatable but not curable cancer. MATERIALS AND METHODS: A prospective observational evaluation was undertaken over 12 months across eight cancer centres in England. ESC service design and costs were recorded. Data relating to patients' symptom burden were collected using the Integrated Palliative Care Outcome Scale (IPOS). For patients in the last year of life, secondary care use was compared against an NHS England published benchmark. RESULTS: In total, 4594 patients were seen by ESC services, of whom 1061 died during follow-up. Mean IPOS scores improved across all tumour groups. In total, £1,676,044 was spent delivering ESC across the eight centres. Reductions in secondary care usage for the 1061 patients who died saved a total of £8,490,581. CONCLUSIONS: People living with cancer suffer with complex and unmet needs. ESC services appear to be effective at supporting these vulnerable people and significantly reduce the costs of their care.Published version, accepted version (12 month embargo)The article is available via Open Access. Click on the 'Additional link' above to access the full-text

Delivery Models and Health Economics of Supportive Care Services in England: A Multicentre Analysis

Aims: Improvements in cancer treatment have led to more people living with and beyond cancer. These patients have symptom and support needs unmet by current services. The development of enhanced supportive care (ESC) services may meet the longitudinal care needs of these patients, including at the end of life. This study aimed to determine the impact and health economic benefits of ESC for patients living with treatable but not curable cancer. Materials and methods: A prospective observational evaluation was undertaken over 12 months across eight cancer centres in England. ESC service design and costs were recorded. Data relating to patients' symptom burden were collected using the Integrated Palliative Care Outcome Scale (IPOS). For patients in the last year of life, secondary care use was compared against an NHS England published benchmark. Results: In total, 4594 patients were seen by ESC services, of whom 1061 died during follow-up. Mean IPOS scores improved across all tumour groups. In total, £1,676,044 was spent delivering ESC across the eight centres. Reductions in secondary care usage for the 1061 patients who died saved a total of £8,490,581. Conclusions: People living with cancer suffer with complex and unmet needs. ESC services appear to be effective at supporting these vulnerable people and significantly reduce the costs of their care

Progress is impossible without change: understanding the evolving nomenclature of steatotic liver disease and its effect on hepatology practice

\ua9 2024The American, European, and Latin American liver societies have proposed a change in the nomenclature we use to describe alcohol-related liver disease and non-alcoholic fatty liver disease. Additionally, a term encompassing both is now advocated: steatotic liver disease, which includes metabolic dysfunction associated steatotic liver disease (MASLD) and MASLD with greater alcohol consumption (MetALD). These classifications offer increased relevance for clinicians, researchers, and patients alike. In this Viewpoint, we discuss the basis for this nomenclature shift and how it was developed. We also explore the challenges that will be faced in the adoption of such change. The proposed change seeks to banish stigma associated with phrasing such as alcoholic and fatty. However stigma, particularly related to the term fatty, is culturally nuanced, and reflects different entities depending on location. If such a change is internationally accepted, there will be wide-reaching effects on practitioners in primary care and metabolic medicine, and on patients. We discuss those effects and the opportunities the nomenclature change could offer, particularly for patients with alcohol and metabolic risk factors who represent a group previously ignored by clinical trials

Implementation of an intervention bundle leads to quality improvement in ulcerative colitis endoscopy reporting

BACKGROUND: Accurate and detailed endoscopy reporting in ulcerative colitis (UC) is critical for clinical decision‐making. High‐quality reporting involves inclusion of several criteria, previously identified by an independent group of experts (Building Research in IBD Globally (BRIDGe) group). Few studies have evaluated UC reporting quality. Our aim was to evaluate the impact of an intervention bundle designed to standardise and improve UC endoscopy reporting. METHODS: This intervention bundle included: integration of a template into reporting software; endoscopist training; instructional posters in endoscopy rooms; cohorting patients onto specific lists. Reporting quality was judged against 10 criteria recommended by BRIDGe. In phase one, UC endoscopy reports were retrospectively evaluated at a centre with prior implementation of the intervention bundle and compared to six centres without. In phase two, the intervention bundle was prospectively implemented and evaluated at a single centre. RESULTS: In phase one, the intervention was associated with greater inclusion of BRIDGe reporting criteria from median 5 (IQR 5‐7) to 7 (5‐8), P < 0.0001. This was replicated in phase two, with improved reporting after the intervention from 5 (4‐6) to 6 (5‐8), P < 0.0001. Reporting of endoscopic indices was more frequent in the centre with prior intervention (77.7% (202/260) vs 44.4% (400/900), OR 4.35 95%CI 3.16‐6.00, P < 0.0001). In phase two, implementation of the bundle increased the use of endoscopic indices pre‐intervention vs post‐intervention (57.7% (131/190) vs 69.6% (117/168), OR 1.68 95%CI 1.1‐2.56, P = 0.02). CONCLUSION: This is the first study to demonstrate that an intervention bundle can achieve greater standardisation and improve UC endoscopy reporting