Research
Palliative care development in the Asia-Pacific region: an international survey from the Asia Pacific Hospice Palliative Care Network (APHN) Takashi Yamaguchi,1,2 Meiko Kuriya,3 Tatsuya Morita,4 Meera Agar,5 Youn Seon Choi,6 Cynthia Goh,7 K B Lingegowda,8 Richard Lim,9 Rico K Y Liu,10 Roderick MacLeod,11 Rhodora Ocampo,12 Shao-Yi Cheng,13 Temsak Phungrassami,14 Yen-Phi Nguyen,15 Satoru Tsuneto16
For numbered affiliations see end of article. Correspondence to Dr Takashi Yamaguchi, Department of General Internal Medicine, Teine Keijinkai Hospital, 12-1-40, Maeda 1jyo, Sapporo, Hokkaido 006-8111, Japan; [email protected] Received 30 August 2013 Revised 2 May 2014 Accepted 17 June 2014 Published Online First 10 July 2014
To cite: Yamaguchi T, Kuriya M, Morita T, et al. BMJ Supportive & Palliative Care 2017;7:23–31.
ABSTRACT Background Although palliative care is an important public healthcare issue worldwide, the current situation in the Asia-Pacific region has not been systematically evaluated. Objectives This survey aimed to clarify the current status of palliative care in the Asia-Pacific region. Methods Questionnaires were sent to a representative physician of each member country/region of the Asia Pacific Hospice Palliative Care Network (APHN). The questionnaire examined palliative care service provision, information regarding physician certification in palliative care, the availability of essential drugs for palliative care listed by the International Association for Hospice and Palliative Care (IAHPC) and the regulation of opioid-prescribing practice. Results Of the 14 member countries/regions of the APHN, 12 (86%) responded. Some form of specialist palliative care services had developed in all the responding countries/regions. Eight member countries/regions had physician certifications for palliative care. Most essential drugs for palliative care listed by the IAHPC were available, whereas hydromorphone, oxycodone and transmucosal fentanyl were unavailable in most countries/regions. Six member countries/ regions required permission to prescribe and receive opioids. Conclusions The development of palliative care is in different stages across the surveyed countries/regions in the Asia-Pacific region. Data from this survey can be used as baseline data for monitoring the development of palliative care in this region.
Yamaguchi T, et al. BMJ Supportive & Palliative Care 2017;7:23–31. doi:10.1136/bmjspcare-2013-000588
INTRODUCTION Palliative care is defined as an approach to improve the quality of life (QOL) of patients facing a life-threatening illness and their families by relieving their symptoms and reducing suffering.1 Since the development of the modern hospice and palliative care movement in the UK in the 1960s, palliative care has become recognised as one of the most important fields of healthcare.2 Many empirical studies have revealed that the provision of palliative care improves the QOL of patients and their families, alleviates the symptom burden and decreases healthrelated costs.3–6 Recently, the European Association of Palliative Care (EAPC) published the EAPC Atlas of Palliative Care in Europe 2013.7 This report provides a comprehensive analysis of the development and accessibility of palliative care in 46 European countries. Accessibility to palliative care services has markedly improved in Europe in recent decades.8–11 However, the development and activities of palliative care appear patchy at the international level.12 13 In the Asia-Pacific region, the demand for palliative care is high.14–17 Many patients are diagnosed in the advanced stages of disease, and are likely to suffer physically and psychologically because of the limited resources for early diagnosis and treatment.18 19 To provide optimum care for this group of patients, palliative care is very important, but unfortunately the provision of palliative care appears
23
Research inadequate in many parts of this region.19 The Asia Pacific Hospice Palliative Care Network (APHN) was established in 2001.20 Over the past decade, the APHN has not only promoted a network of individuals and national organisations that are actively involved in palliative care in the Asia-Pacific region, but has also facilitated palliative care development in this region.21 There have been several preliminary or domestic reports about palliative care development from Asian countries, such as Thailand, Malaysia, Vietnam and India.22–25 However, there are no systematic benchmark data on the overall development of palliative care in the Asia-Pacific region. As the initial step to explore effective strategies for the expansion of palliative care services in the Asia-Pacific region, a comprehensive review of the current situation of palliative care in each country/region is of value. The aims of this survey were to clarify the number of palliative care services and to obtain information regarding physician certification in palliative care, the availability of essential drugs for palliative care listed by the International Association for Hospice and Palliative Care (IAHPC) and the regulation of opioidprescribing practices in the Asia-Pacific region. PARTICIPANTS AND METHODS This study was a questionnaire survey via email. Data were collected from questionnaires distributed to all member countries/regions of the APHN. The APHN council requested all representatives of the member countries/regions to respond to the questionnaire. The APHN consists of 14 founding member countries/ regions: Australia, Hong Kong, India, Indonesia, Japan, Malaysia, Myanmar, New Zealand, the Philippines, Singapore, South Korea, Taiwan, Thailand and Vietnam.20 Survey procedures
To obtain data regarding the status of palliative care in each country/region, we asked the APHN council to nominate one representative to report accurate data on their country/region. All nominated representatives of the 14 countries/regions agreed to participate. The nominated representatives were the directors of the national organisations of palliative care, or experienced physicians holding a leadership position in palliative care in each country/region. We distributed the questionnaires to the representatives in December 2011. We requested that each representative complete the questionnaire and seek advice from relevant authorities and organisations in their country/region when there was a lack of specific information. Reminders were sent out at the end of February and March 2012. These procedures were managed by one author (MK). All completed questionnaires were received until the end of April 2012. All data were reviewed by the 24
members of the task group of this survey (TY, MK, TM and ST) between May and July 2012. The data were summarised, tabulated, graphically presented and redistributed to all representatives to check for accuracy in November 2012. After amendment, the data were finalised in December 2012. The main form of communication between the investigators and representatives was through email with attached documents. Measurement
On the basis of a literature review,8–11 we developed a questionnaire that included questions about the following issues: specialist palliative care service provision, information regarding physician certification for palliative care, availability of essential drugs for palliative care listed by the IAHPC and regulation of opioid-prescribing practices. Specialist palliative care service provision
On the basis of the previous studies, we defined each type of specialist palliative care service as follows26 27: Palliative care unit, highly developed units for providing specific inpatient palliative care, located in oncology or general hospitals; Inpatient hospice, specific inpatient facilities where terminally ill patients are admitted when treatment in a hospital is unnecessary but care at home or in a nursing home is impossible; Hospital palliative care team, a consultation team providing specialist palliative care advice and support to other clinical staff, patients, families and caregivers in a hospital environment (the teams usually include well-trained nurses and physicians); Palliative outpatient clinic, outpatient services providing specialist palliative care for patients living at home who are able to visit the clinic; Home palliative care service, multidisciplinary teams providing specialist palliative care for patients and their caregivers at home; Palliative day care centre, care centre for palliative care for patients that provides daytime psychosocial support, nursing treatments and diverse types of care such as personal care, medication administration and oral hygiene (usually in operation 3–5 days a week). In the survey, we also enquired about the number of specialist palliative care services and the number of beds available for such services. Information regarding physician certification in palliative care
We asked for information regarding the presence or absence of certification procedures for palliative care specialist physicians. If certification existed, we requested a brief description of the training programme and the current number of certified physicians. Availability of essential drugs for palliative care listed by the IAHPC
We asked about the availability of the essential drugs for palliative care listed by the IAHPC, using three possible responses: ‘available’, ‘partially available’ or
Yamaguchi T, et al. BMJ Supportive & Palliative Care 2017;7:23–31. doi:10.1136/bmjspcare-2013-000588
Research ‘unavailable’.28 If certain drugs were available with some limitation due to cost, insurance coverage or other similar reasons, they were categorised as ‘partially available’. In addition, we asked about the cost to the consumer for 17 types of opioids commonly used in palliative care. Regulation of opioid prescriptions
We enquired about regulatory requirements for physicians prescribing oral morphine.10 In addition, we asked about the restriction of oral morphinedispensing privileges at pharmacies and the maximum number of days that medication could be dispensed on one oral morphine prescription. Ethics
This study was a surveillance study, which did not include patient information; therefore, approval from an institutional review board was unnecessary. RESULTS Of the 14 member countries/regions, 12 (86%) returned the questionnaires. The responding member countries/regions were Australia, Hong Kong, India, Japan, Malaysia, New Zealand, the Philippines, Singapore, South Korea, Taiwan, Thailand and Vietnam. Indonesia and Myanmar did not respond. Estimates of specialist palliative care services
Table 1 shows the estimated number of specialist palliative care services in the surveyed countries/regions. Palliative care units or inpatient hospices have developed in all surveyed countries/regions, being particularly prevalent in Oceania (Australia and New Zealand) and East Asia (Hong Kong, Japan, South Korea and Taiwan). The hospital palliative care team model has developed in most of the surveyed countries/regions and most notably in Japan. Models for home palliative care services and palliative outpatient clinics have also developed in all the surveyed countries/regions, and the number of home palliative care services available was notably high in India. The model of day palliative care centres has developed in seven of the surveyed countries/regions, and this type of service was pervasive in New Zealand and Hong Kong. Paediatric palliative care services were generally underdeveloped. In New Zealand, Hong Kong, Japan, Taiwan and Singapore, the ratio of beds for specialist palliative care per one million inhabitants ranged from approximately 13 to 59. In contrast, the ratio was less than 10 beds per one million inhabitants in Malaysia, the Philippines and Vietnam. In New Zealand, Hong Kong, Japan, Taiwan, Malaysia and Singapore, there are two or more specialist palliative care services per one million inhabitants.
In Australia, it was reported that specialist palliative care services were provided as a regional palliative care network, which consisted of inpatient services (inpatient hospices and/or palliative care units), home services and other services such as outpatient clinics and day care centres. Despite having well-developed clinical services, there is no central repository of each type of service available in Australia. In addition, several services also provide a variety of service types making it difficult to separate activity in Australia. The total number of specialist palliative care services in Australia was 107. Certification for physicians in palliative care
There was official certification for specialist palliative care physicians in 8 of the 12 responding member countries/regions (table 2). Palliative medicine is regarded as a subspecialty in six member countries/ regions (Australia, New Zealand, Hong Kong, Malaysia, Singapore and Taiwan). In Japan and India, palliative medicine had a full-specialty status. The training programmes for certification generally required 2–4 years of clinical training. In Australia, New Zealand, Japan, Taiwan and Singapore, written and oral examinations were required in addition to clinical training. Taiwan had the largest number of certified palliative care physicians. Availability of essential drugs for palliative care listed by the IAHPC
Figure 1 shows the availability of essential drugs for palliative care listed by the IAHPC. Although 24 of 37 drugs were available or at least partially available in all the surveyed countries/regions, some drugs (ie, transmucosal fentanyl, methadone, injectable oxycodone and levomepromazine) were not available in over half of the member countries/regions. The cost of opioids to consumers is summarised in figure 2. Although the cost allocation of opioids for patients with cancer was reported to be over 50% in the Philippines, Vietnam and India, the cost was
Palliative care development in the Asia-Pacific region: an international survey from the Asia Pacific Hospice Palliative Care Network (APHN) Takashi Yamaguchi,1,2 Meiko Kuriya,3 Tatsuya Morita,4 Meera Agar,5 Youn Seon Choi,6 Cynthia Goh,7 K B Lingegowda,8 Richard Lim,9 Rico K Y Liu,10 Roderick MacLeod,11 Rhodora Ocampo,12 Shao-Yi Cheng,13 Temsak Phungrassami,14 Yen-Phi Nguyen,15 Satoru Tsuneto16
For numbered affiliations see end of article. Correspondence to Dr Takashi Yamaguchi, Department of General Internal Medicine, Teine Keijinkai Hospital, 12-1-40, Maeda 1jyo, Sapporo, Hokkaido 006-8111, Japan; [email protected] Received 30 August 2013 Revised 2 May 2014 Accepted 17 June 2014 Published Online First 10 July 2014
To cite: Yamaguchi T, Kuriya M, Morita T, et al. BMJ Supportive & Palliative Care 2017;7:23–31.
ABSTRACT Background Although palliative care is an important public healthcare issue worldwide, the current situation in the Asia-Pacific region has not been systematically evaluated. Objectives This survey aimed to clarify the current status of palliative care in the Asia-Pacific region. Methods Questionnaires were sent to a representative physician of each member country/region of the Asia Pacific Hospice Palliative Care Network (APHN). The questionnaire examined palliative care service provision, information regarding physician certification in palliative care, the availability of essential drugs for palliative care listed by the International Association for Hospice and Palliative Care (IAHPC) and the regulation of opioid-prescribing practice. Results Of the 14 member countries/regions of the APHN, 12 (86%) responded. Some form of specialist palliative care services had developed in all the responding countries/regions. Eight member countries/regions had physician certifications for palliative care. Most essential drugs for palliative care listed by the IAHPC were available, whereas hydromorphone, oxycodone and transmucosal fentanyl were unavailable in most countries/regions. Six member countries/ regions required permission to prescribe and receive opioids. Conclusions The development of palliative care is in different stages across the surveyed countries/regions in the Asia-Pacific region. Data from this survey can be used as baseline data for monitoring the development of palliative care in this region.
Yamaguchi T, et al. BMJ Supportive & Palliative Care 2017;7:23–31. doi:10.1136/bmjspcare-2013-000588
INTRODUCTION Palliative care is defined as an approach to improve the quality of life (QOL) of patients facing a life-threatening illness and their families by relieving their symptoms and reducing suffering.1 Since the development of the modern hospice and palliative care movement in the UK in the 1960s, palliative care has become recognised as one of the most important fields of healthcare.2 Many empirical studies have revealed that the provision of palliative care improves the QOL of patients and their families, alleviates the symptom burden and decreases healthrelated costs.3–6 Recently, the European Association of Palliative Care (EAPC) published the EAPC Atlas of Palliative Care in Europe 2013.7 This report provides a comprehensive analysis of the development and accessibility of palliative care in 46 European countries. Accessibility to palliative care services has markedly improved in Europe in recent decades.8–11 However, the development and activities of palliative care appear patchy at the international level.12 13 In the Asia-Pacific region, the demand for palliative care is high.14–17 Many patients are diagnosed in the advanced stages of disease, and are likely to suffer physically and psychologically because of the limited resources for early diagnosis and treatment.18 19 To provide optimum care for this group of patients, palliative care is very important, but unfortunately the provision of palliative care appears
23
Research inadequate in many parts of this region.19 The Asia Pacific Hospice Palliative Care Network (APHN) was established in 2001.20 Over the past decade, the APHN has not only promoted a network of individuals and national organisations that are actively involved in palliative care in the Asia-Pacific region, but has also facilitated palliative care development in this region.21 There have been several preliminary or domestic reports about palliative care development from Asian countries, such as Thailand, Malaysia, Vietnam and India.22–25 However, there are no systematic benchmark data on the overall development of palliative care in the Asia-Pacific region. As the initial step to explore effective strategies for the expansion of palliative care services in the Asia-Pacific region, a comprehensive review of the current situation of palliative care in each country/region is of value. The aims of this survey were to clarify the number of palliative care services and to obtain information regarding physician certification in palliative care, the availability of essential drugs for palliative care listed by the International Association for Hospice and Palliative Care (IAHPC) and the regulation of opioidprescribing practices in the Asia-Pacific region. PARTICIPANTS AND METHODS This study was a questionnaire survey via email. Data were collected from questionnaires distributed to all member countries/regions of the APHN. The APHN council requested all representatives of the member countries/regions to respond to the questionnaire. The APHN consists of 14 founding member countries/ regions: Australia, Hong Kong, India, Indonesia, Japan, Malaysia, Myanmar, New Zealand, the Philippines, Singapore, South Korea, Taiwan, Thailand and Vietnam.20 Survey procedures
To obtain data regarding the status of palliative care in each country/region, we asked the APHN council to nominate one representative to report accurate data on their country/region. All nominated representatives of the 14 countries/regions agreed to participate. The nominated representatives were the directors of the national organisations of palliative care, or experienced physicians holding a leadership position in palliative care in each country/region. We distributed the questionnaires to the representatives in December 2011. We requested that each representative complete the questionnaire and seek advice from relevant authorities and organisations in their country/region when there was a lack of specific information. Reminders were sent out at the end of February and March 2012. These procedures were managed by one author (MK). All completed questionnaires were received until the end of April 2012. All data were reviewed by the 24
members of the task group of this survey (TY, MK, TM and ST) between May and July 2012. The data were summarised, tabulated, graphically presented and redistributed to all representatives to check for accuracy in November 2012. After amendment, the data were finalised in December 2012. The main form of communication between the investigators and representatives was through email with attached documents. Measurement
On the basis of a literature review,8–11 we developed a questionnaire that included questions about the following issues: specialist palliative care service provision, information regarding physician certification for palliative care, availability of essential drugs for palliative care listed by the IAHPC and regulation of opioid-prescribing practices. Specialist palliative care service provision
On the basis of the previous studies, we defined each type of specialist palliative care service as follows26 27: Palliative care unit, highly developed units for providing specific inpatient palliative care, located in oncology or general hospitals; Inpatient hospice, specific inpatient facilities where terminally ill patients are admitted when treatment in a hospital is unnecessary but care at home or in a nursing home is impossible; Hospital palliative care team, a consultation team providing specialist palliative care advice and support to other clinical staff, patients, families and caregivers in a hospital environment (the teams usually include well-trained nurses and physicians); Palliative outpatient clinic, outpatient services providing specialist palliative care for patients living at home who are able to visit the clinic; Home palliative care service, multidisciplinary teams providing specialist palliative care for patients and their caregivers at home; Palliative day care centre, care centre for palliative care for patients that provides daytime psychosocial support, nursing treatments and diverse types of care such as personal care, medication administration and oral hygiene (usually in operation 3–5 days a week). In the survey, we also enquired about the number of specialist palliative care services and the number of beds available for such services. Information regarding physician certification in palliative care
We asked for information regarding the presence or absence of certification procedures for palliative care specialist physicians. If certification existed, we requested a brief description of the training programme and the current number of certified physicians. Availability of essential drugs for palliative care listed by the IAHPC
We asked about the availability of the essential drugs for palliative care listed by the IAHPC, using three possible responses: ‘available’, ‘partially available’ or
Yamaguchi T, et al. BMJ Supportive & Palliative Care 2017;7:23–31. doi:10.1136/bmjspcare-2013-000588
Research ‘unavailable’.28 If certain drugs were available with some limitation due to cost, insurance coverage or other similar reasons, they were categorised as ‘partially available’. In addition, we asked about the cost to the consumer for 17 types of opioids commonly used in palliative care. Regulation of opioid prescriptions
We enquired about regulatory requirements for physicians prescribing oral morphine.10 In addition, we asked about the restriction of oral morphinedispensing privileges at pharmacies and the maximum number of days that medication could be dispensed on one oral morphine prescription. Ethics
This study was a surveillance study, which did not include patient information; therefore, approval from an institutional review board was unnecessary. RESULTS Of the 14 member countries/regions, 12 (86%) returned the questionnaires. The responding member countries/regions were Australia, Hong Kong, India, Japan, Malaysia, New Zealand, the Philippines, Singapore, South Korea, Taiwan, Thailand and Vietnam. Indonesia and Myanmar did not respond. Estimates of specialist palliative care services
Table 1 shows the estimated number of specialist palliative care services in the surveyed countries/regions. Palliative care units or inpatient hospices have developed in all surveyed countries/regions, being particularly prevalent in Oceania (Australia and New Zealand) and East Asia (Hong Kong, Japan, South Korea and Taiwan). The hospital palliative care team model has developed in most of the surveyed countries/regions and most notably in Japan. Models for home palliative care services and palliative outpatient clinics have also developed in all the surveyed countries/regions, and the number of home palliative care services available was notably high in India. The model of day palliative care centres has developed in seven of the surveyed countries/regions, and this type of service was pervasive in New Zealand and Hong Kong. Paediatric palliative care services were generally underdeveloped. In New Zealand, Hong Kong, Japan, Taiwan and Singapore, the ratio of beds for specialist palliative care per one million inhabitants ranged from approximately 13 to 59. In contrast, the ratio was less than 10 beds per one million inhabitants in Malaysia, the Philippines and Vietnam. In New Zealand, Hong Kong, Japan, Taiwan, Malaysia and Singapore, there are two or more specialist palliative care services per one million inhabitants.
In Australia, it was reported that specialist palliative care services were provided as a regional palliative care network, which consisted of inpatient services (inpatient hospices and/or palliative care units), home services and other services such as outpatient clinics and day care centres. Despite having well-developed clinical services, there is no central repository of each type of service available in Australia. In addition, several services also provide a variety of service types making it difficult to separate activity in Australia. The total number of specialist palliative care services in Australia was 107. Certification for physicians in palliative care
There was official certification for specialist palliative care physicians in 8 of the 12 responding member countries/regions (table 2). Palliative medicine is regarded as a subspecialty in six member countries/ regions (Australia, New Zealand, Hong Kong, Malaysia, Singapore and Taiwan). In Japan and India, palliative medicine had a full-specialty status. The training programmes for certification generally required 2–4 years of clinical training. In Australia, New Zealand, Japan, Taiwan and Singapore, written and oral examinations were required in addition to clinical training. Taiwan had the largest number of certified palliative care physicians. Availability of essential drugs for palliative care listed by the IAHPC
Figure 1 shows the availability of essential drugs for palliative care listed by the IAHPC. Although 24 of 37 drugs were available or at least partially available in all the surveyed countries/regions, some drugs (ie, transmucosal fentanyl, methadone, injectable oxycodone and levomepromazine) were not available in over half of the member countries/regions. The cost of opioids to consumers is summarised in figure 2. Although the cost allocation of opioids for patients with cancer was reported to be over 50% in the Philippines, Vietnam and India, the cost was
