Downloaded from http://spcare.bmj.com/ on July 7, 2015 - Published by group.bmj.com
Research
Effectiveness of a multidisciplinary consultation team for cancer pain and palliative care in a large university hospital in the Netherlands Joost L M Jongen,1 Anke Overbeck,1 Dirk L Stronks,2 Lia van Zuylen,3 Monique Booms,3 Frank J Huygen,2 Carin C D van der Rijt3 ▶ Additional data (supplementary figures) are published online only. To view these files please visit the journal online (http://spcare.bmj.com) 1Department
of Neurology, Erasmus MC, Rotterdam, The Netherlands 2Department of Pain Medicine, Erasmus MC, Rotterdam, The Netherlands 3Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands Correspondence to Joost L Jongen, Department of Neurology, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands; [email protected] Received 8 July 2011 Accepted 17 September 2011 Published Online First 9 October 2011
ABSTRACT Background Multidisciplinary palliative care teams (PCTs) are increasingly employed for cancer patients. However, relatively few studies have prospectively assessed the clinical effectiveness of inpatient PCTs. Our aim was to evaluate the effectiveness of a multidisciplinary PCT for hospitalised cancer patients in a large university hospital in the Netherlands. Methods Clinical data and duration of hospitalisation were prospectively collected between January 2007 and December 2008. A group of cancer pain patients from 2006 served as a historical control. Results The number of consultations increased from 130 in 2006 to 235 in 2008. The reason for consultation changed from pain in 98% of consultations in 2006 to a diversity of palliative symptoms in 2008. In 2008 a significant decrease in mean pain intensity, including a 70% reduction in severe pain, occurred within 24 h following consultation, although the authors did not demonstrate that the effectiveness of the PCT in 2007 and 2008 surpassed that of routine oncological care including pain control in 2006. Similarly, the median severity for 7 out of 10 items from the Edmonton Symptom Assessment System (ESAS) decreased significantly within 72 h following consultation. The median number of days in hospital for patients for whom the PCT was consulted decreased from 14 days in 2006 to 10 days in 2008. Conclusions The authors conclude that a multidisciplinary PCT for clinical cancer patients may have a positive effect on pain, on ESAS symptoms and on duration of hospitalisation. INTRODUCTION WHO defi nes palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness”. Palliative care is mainly provided in a primary care setting or hospice and mostly concerns cancer patients. However, as cancer treatment options are increasing and cancer care becomes more and more complicated, there is an growing need for hospital-based palliative care. Hospital-based oncological palliative care may be provided in specialised palliative care units (PCUs). Multidisciplinary palliative care teams (PCTs), mostly working on a consultation basis, may offer alternative or additional care to that provided in PCUs. PCTs may work on an inpatient or outpatient basis. Originating in the 1980s, PCTs are now increasingly employed in countries such as Canada,1 Italy, 2 the UK, 3 Australia,4 the USA, 5 Japan6 and the Netherlands.7
322
While cost savings with both outpatient 8 and hospital-based PCTs9 have been demonstrated and some prospective studies10–12 have demonstrated improvements in symptoms, quality of life and mood in outpatient cancer patients, relatively few studies have prospectively assessed the clinical efficacy of inpatient PCTs using validated and clinically relevant outcome measures.13–16 In 2007 a multidisciplinary PCT, consisting of palliative care nurses, a medical oncologist, a neurologist and a team of anaesthesiologists, was set up in Erasmus MC. The team does not have beds at their disposal, but can be consulted for palliative care for cancer patients. Our aim was to deliver rapid symptom control and accelerated transfer to an out-of-hospital setting. From the outset, we set out to evaluate clinical effectiveness by recording all relevant clinical data, including duration of admission, on a structured data sheet, as part of routine medical practice. We used a group of cancer pain patients from 2006 as a historical control to evaluate whether the effectiveness of our multidisciplinary team surpassed that of routine oncological care including pain control.
METHODS Patients and interventions Our 769 bed general university hospital did not have a palliative care facility until 2007, although symptomatic cancer pain relief was provided by palliative care nurses and consulting anaesthesiologists, the latter as a 24/7 service. This service, which may be considered a predecessor of the multidisciplinary PCT, included prescription advice concerning oral and transdermal analgesics, the delivery and setup of intravenous and epidural/intraspinal pumps, and the application of nerve blocks, if necessary. Since 2007, cancer patients in the general university hospital are provided with comprehensive palliative care by a multidisciplinary PCT consisting of palliative care nurses, a medical oncologist, a neurologist and a team of anaesthesiologists that is available 24/7. The PCT focuses on symptom management, psychosocial support and medical decision making at the end of life. Regarding symptom management, symptomatic as well as disease modifying interventions are considered, depending on the type and underlying causes of the symptoms, the patient’s condition and life expectancy. To ensure rapid symptom relief, the PCT directly prescribes medication on all departments,
BMJ Supportive & Palliative Care 2011;1:322–328. doi:10.1136/bmjspcare-2011-000087
Downloaded from http://spcare.bmj.com/ on July 7, 2015 - Published by group.bmj.com
Research with the exception of the Department of Medical Oncology, where doctors are more familiar with prescribing opioids. To support adherence to the pharmaceutical interventions, the palliative care nurse explains the use of sustained release and immediate release opioids to patients and, if necessary, educates and instructs the nursing staff on the analgesic regimen and observations needed to monitor effects and toxicity. The palliative care nurse also evaluates the psychosocial and home situation of the patient, to accelerate transfer to an out-of-hospital setting and by detecting the need for additional physical and mental care at an early stage. In case of a need for specialised psychosocial help, a social worker, clinical psychologist or spiritual adviser may be consulted by the palliative care nurse. With respect to the role of the PCT in medical decision-making, the team closely collaborates with the treating physicians. For example, the team is actively involved in decisions concerning continuation of or abstention from anticancer treatment and, as mentioned above, in clinical decisions concerning symptom control by treating the underlying disease. Finally, the team is involved in end-of-life care, including palliative sedation.17–19
Study design We studied 565 admissions of advanced cancer patients, whose symptoms were collected on a structured data collection sheet at fi xed time points, as part of routine medical practice. These admissions represented 486 patients, since some patients were admitted more than once. Patients’ performance status was scored using the Eastern Cooperative Oncology Group (ECOG)/WHO score. 20 Patients included from 1 January 2007 to 31 December 2008 formed the actual study population, while patients included from 1 January 2006 to 31 December 2006 served as a historical control. We studied differences in outcome before and after the intervention for the three different year groups, as well as differences between the patients who were exposed to comprehensive palliative care (2007 and 2008) versus the historical control (2006).
Clinical analyses From the last quarter of 2006 onwards, present pain intensity was rated using a 0–10 numerical rating scale (NRS) at the start of the consultation, at 48 h thereafter and at discharge. Additionally, in 2008 pain intensity was recorded at 24 h after the start of consultation. When these time points occurred during weekends, pain intensities were collected on Fridays or Mondays, depending on which day was closest. Missing data occurred when patients were not on the ward at the time of the visit or when patients were discharged without prior notification to the team. In 2008 we started using the Edmonton Symptom Assessment System (ESAS) to rate 11 symptoms other than pain at start, at 72 h and at discharge. The ESAS form was fi lled in by the patient themselves, although a relative/friend or the palliative care nurse was allowed to assist if the patient was unable to complete the form due to physical limitations, not cognitive impairment. 21 Missing data occurred when patients were not on the ward at the time of the visit, when patients were discharged without prior notification to the team, when patients did not understand the Dutch language or when patients were too ill to fi ll out the ESAS form. The mean±SD pain intensity of all patients was calculated after it had been verified that values were normally distributed. A repeated measures analysis of variance (ANOVA) was applied to study the variance of mean intensities during consultation (T=0 h, T=48 h and T=discharge) and over the years BMJ Supportive & Palliative Care 2011;1:322–328. doi:10.1136/bmjspcare-2011-000087
(2006, 2007 and 2008). Additionally, pain intensity was classified as mild pain (NRS 0–4), moderate pain (NRS 5–7) and severe pain (NRS 8–10). 22 χ2 Tests were used to compare the proportions of patients with mild, moderate and severe pain at the various time points, for each year. The median (range) was calculated for symptoms other than pain. Friedman’s test was applied to compare ESAS symptom severity at the various time points during and following consultation. We also recorded treatment-related parameters, including equianalgesic opioid dosages and the use of subcutaneous pumps and epidural and spinal catheters at discharge. Equianalgesic dosages were expressed as 10 mg parenteral morphine/24 h. Conversion factors were according to the Dutch consensus guideline ‘Cancer Pain’23 (see supplementary online figure). We used sustained release and continuous intravenous medication for calculating the equianalgesic dosage. Although we did not collect information on all rescue medication for individual patients, the maximum daily dosage of oral and intravenous rescue medication as a rule consisted of 100% of the sustained release or continuous intravenous opioid dosage. When patients were using more than 50% of the rescue doses, sustained release or continuous intravenous opioid dosage was increased. Thus, the equianalgesic dosage that we calculate represents 67–100% of the actual equianalgesic dosage Table 1 Baseline characteristics Consultations Total number of consultations Symptoms Pain Dyspnoea Ascites Terminal discomfort Nausea Psychosocial factors Constipation Other Clinical characteristics Mean±SD age (years) Sex Male Female Primary cancer site Lung Gynaecological Urological Larynx/mouth Gastrointestinal tumours Breast Bone marrow Unknown origin Other Metastasised Mean WHO performance status ≤2 3 4 Median Anticancer treatment No more anticancer treatment Chemotherapy Radiotherapy Surgery Chemotherapy and surgery Chemotherapy and radiotherapy Baseline median (range) equianalgesic dose of opioids (mg intravenous morphine/24 h)
2006
2007
2008
N=130
N=200
N=235
127 (97.7%) 1 (0.8%) 1 (0.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.8%)
185 (92.5%) 4 (2.0%) 0 (0.0%) 5 (2.5%) 2 (1.0%) 0 (0.0%) 0 (0.0%) 4 (2.0%)
184 (78.3%) 6 (2.6%) 1 (0.4%) 12 (5.1%) 2 (0.9%) 20 (8.5%) 1 (0.4%) 9 (3.8%)
58.9±12.9
58.6±14.6
59.7±13.9
71 (54.6%) 59 (45.4%)
121 (60.5%) 79 (39.5%)
131 (55.7%) 104 (44.3%)
3 (2.3%) 6 (4.6%) 30 (23.1%) 18 (13.8%) 46 (35.3%) 7 (5.4%) 6 (4.6%) 3 (2.3%) 11 (8.5%) 78 (61.4%) N=125 48 (38.4%) 43 (34.4%) 34 (27.2%) 2.82 N=125 99 (79.2%) 11 (8.8%) 4 (3.2%) 7 (5.6%) 2 (1.6%) 2 (1.6%) 20 (0–520)
18 (9%) 19 (9.5%) 36 (18%) 24 (12%) 70 (35%) 4 (2%) 11 (5.5%) 6 (3%) 12 (6%) 156 (78%) N=191 81 (42.4%) 63 (33.0%) 47 (24.6%) 2.71 N=190 139 (73.2%) 18 (9.5%) 16 (8.4%) 12 (6.3%) 3 (1.6%) 2 (1.1%) 25 (0–1121)
13 (5.5%) 26 (11.1%) 34 (14.5%) 25 (10.6%) 100 (42.6%) 3 (1.3%) 9 (3.8%) 7 (3.0%) 18 (7.7%) 164 (69.8%) N=209 63 (30.1%) 87 (41.6%) 59 (28.2%) 2.97 N=208 173 (83.2%) 19 (9.1%) 5 (2.4%) 7 (3.4%) 2 (1.0%) 2 (1.0%) 20 (0–840)
323
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Research
Figure 1 Changes in pain severity. The lines represent the mean±upper limit of the SD pain intensity. The bars represent the frequencies of patients with light (NRS 0–4), moderate (NRS 5–7) and severe (NRS 8–10) pain at T=0 h, at T=48 h and at discharge. NRS, numerical rating scale. that the patients used, including rescue medication. Friedman’s test was applied to compare equianalgesic dosages of opioids at baseline and at discharge in 2006, 2007 and 2008.
Impact on duration of hospitalisation To estimate how the multidisciplinary PCT affected duration of hospital stay, we determined the median number of days (since the data were heavily skewed) that patients were hospitalised in the current study. Friedman’s test was applied to compare the numbers of days of hospitalisation in 2006, 2007 and 2008. We also collected the number of days patients had been admitted before the PCT was consulted. The duration of hospitalisation for the patients visited by the PCT was compared with the mean duration of hospitalisation of all patients admitted to departments with a fair share of cancer patients. The mean number of hospitalised days/department was calculated from the total number of hospitalised patients and the total number of hospitalised days from these departments, using fi nancial databases. A one-way ANOVA was applied to study the variance in the number of days of hospitalisation over the years. All statistical analyses were performed using the statistical packages GraphPad Prism v5b (www.graphpad.com) and SPSS v15 (www-01.ibm.com/software/analytics/spss).
RESULTS Baseline characteristics The total number of consultations and the diversity of presenting symptoms for which the team was consulted in 2006, 2007 and 2008, are presented in table 1. The number of consultations increased from 130 in 2006 to 235 in 2008. The diversity of presenting symptoms increased from 3% primarily non-pain consultations in 2006 to 22% primarily non-pain consultations in 2008. Prevalent symptoms other than pain included nausea, dyspnoea, ascites, psychosocial factors and terminal agitation. Patients with terminal agitation refractory to medical treatment were usually treated with palliative sedation, according to the Dutch national guideline on palliative sedation.17 Within the group of primarily pain consultations, 18%, 7% and 9% of patients also had one or more non-pain symptoms in 2006, 2007 and 2008, respectively. 324
Table 1 also summarises the clinical characteristics of the patients for whom the PCT was consulted. The gastrointestinal tract was by far the most prevalent cancer site for which the team was consulted, followed by urological and head and neck cancers. Mean ECOG/WHO performance status was almost 3, meaning that patients in general were capable of only limited self-care and/or confi ned to bed or a chair for more than 50% of their waking hours. A large majority of the patients did not receive anticancer treatment at the time of admission. Overall, 13%, 16% and 18% of patients died during hospital admission in 2006, 2007 and 2008, respectively.
Changes in pain intensity Figure 1 depicts the course of the mean±SD pain intensity in the last quarter of 2006 and the whole of 2007 and 2008. Some 38% of values (not patients) were missing. The effect of missing values on mean pain intensity was analysed by comparing the mean pain intensity from groups of patients in whom at least one value at one time point was missing with the mean pain intensity from patients with no missing values. It was thus determined that missing data did not affect mean pain intensity (Mann-Whitney U test and Kruskal–Wallis p≥0.05 for all comparisons; non-parametric tests were selected because groups of missing data sets were not always normally distributed). Pain intensity decreased from 6.6±2.5 (mean±SD) at start of the consultation, to 4.0±2.5 at 48 h and to 2.6±1.8 at discharge (all years analysed together). The decrease in pain intensity was highly significant from T=0 h to T=discharge (p0.5; repeated measures ANOVA, source year). Figure 1 also depicts the percentages of patients with mild, moderate and severe pain. This included a 70% reduction in the proportion of patients with severe pain within 24 h following the start of consultation in 2008 (not shown). Again, the proportions of patients with mild, moderate and severe pain were significantly different at the start of consultation, at 48 h and at discharge, in 2006, 2007 and 2008 (p
Research
Effectiveness of a multidisciplinary consultation team for cancer pain and palliative care in a large university hospital in the Netherlands Joost L M Jongen,1 Anke Overbeck,1 Dirk L Stronks,2 Lia van Zuylen,3 Monique Booms,3 Frank J Huygen,2 Carin C D van der Rijt3 ▶ Additional data (supplementary figures) are published online only. To view these files please visit the journal online (http://spcare.bmj.com) 1Department
of Neurology, Erasmus MC, Rotterdam, The Netherlands 2Department of Pain Medicine, Erasmus MC, Rotterdam, The Netherlands 3Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands Correspondence to Joost L Jongen, Department of Neurology, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands; [email protected] Received 8 July 2011 Accepted 17 September 2011 Published Online First 9 October 2011
ABSTRACT Background Multidisciplinary palliative care teams (PCTs) are increasingly employed for cancer patients. However, relatively few studies have prospectively assessed the clinical effectiveness of inpatient PCTs. Our aim was to evaluate the effectiveness of a multidisciplinary PCT for hospitalised cancer patients in a large university hospital in the Netherlands. Methods Clinical data and duration of hospitalisation were prospectively collected between January 2007 and December 2008. A group of cancer pain patients from 2006 served as a historical control. Results The number of consultations increased from 130 in 2006 to 235 in 2008. The reason for consultation changed from pain in 98% of consultations in 2006 to a diversity of palliative symptoms in 2008. In 2008 a significant decrease in mean pain intensity, including a 70% reduction in severe pain, occurred within 24 h following consultation, although the authors did not demonstrate that the effectiveness of the PCT in 2007 and 2008 surpassed that of routine oncological care including pain control in 2006. Similarly, the median severity for 7 out of 10 items from the Edmonton Symptom Assessment System (ESAS) decreased significantly within 72 h following consultation. The median number of days in hospital for patients for whom the PCT was consulted decreased from 14 days in 2006 to 10 days in 2008. Conclusions The authors conclude that a multidisciplinary PCT for clinical cancer patients may have a positive effect on pain, on ESAS symptoms and on duration of hospitalisation. INTRODUCTION WHO defi nes palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness”. Palliative care is mainly provided in a primary care setting or hospice and mostly concerns cancer patients. However, as cancer treatment options are increasing and cancer care becomes more and more complicated, there is an growing need for hospital-based palliative care. Hospital-based oncological palliative care may be provided in specialised palliative care units (PCUs). Multidisciplinary palliative care teams (PCTs), mostly working on a consultation basis, may offer alternative or additional care to that provided in PCUs. PCTs may work on an inpatient or outpatient basis. Originating in the 1980s, PCTs are now increasingly employed in countries such as Canada,1 Italy, 2 the UK, 3 Australia,4 the USA, 5 Japan6 and the Netherlands.7
322
While cost savings with both outpatient 8 and hospital-based PCTs9 have been demonstrated and some prospective studies10–12 have demonstrated improvements in symptoms, quality of life and mood in outpatient cancer patients, relatively few studies have prospectively assessed the clinical efficacy of inpatient PCTs using validated and clinically relevant outcome measures.13–16 In 2007 a multidisciplinary PCT, consisting of palliative care nurses, a medical oncologist, a neurologist and a team of anaesthesiologists, was set up in Erasmus MC. The team does not have beds at their disposal, but can be consulted for palliative care for cancer patients. Our aim was to deliver rapid symptom control and accelerated transfer to an out-of-hospital setting. From the outset, we set out to evaluate clinical effectiveness by recording all relevant clinical data, including duration of admission, on a structured data sheet, as part of routine medical practice. We used a group of cancer pain patients from 2006 as a historical control to evaluate whether the effectiveness of our multidisciplinary team surpassed that of routine oncological care including pain control.
METHODS Patients and interventions Our 769 bed general university hospital did not have a palliative care facility until 2007, although symptomatic cancer pain relief was provided by palliative care nurses and consulting anaesthesiologists, the latter as a 24/7 service. This service, which may be considered a predecessor of the multidisciplinary PCT, included prescription advice concerning oral and transdermal analgesics, the delivery and setup of intravenous and epidural/intraspinal pumps, and the application of nerve blocks, if necessary. Since 2007, cancer patients in the general university hospital are provided with comprehensive palliative care by a multidisciplinary PCT consisting of palliative care nurses, a medical oncologist, a neurologist and a team of anaesthesiologists that is available 24/7. The PCT focuses on symptom management, psychosocial support and medical decision making at the end of life. Regarding symptom management, symptomatic as well as disease modifying interventions are considered, depending on the type and underlying causes of the symptoms, the patient’s condition and life expectancy. To ensure rapid symptom relief, the PCT directly prescribes medication on all departments,
BMJ Supportive & Palliative Care 2011;1:322–328. doi:10.1136/bmjspcare-2011-000087
Downloaded from http://spcare.bmj.com/ on July 7, 2015 - Published by group.bmj.com
Research with the exception of the Department of Medical Oncology, where doctors are more familiar with prescribing opioids. To support adherence to the pharmaceutical interventions, the palliative care nurse explains the use of sustained release and immediate release opioids to patients and, if necessary, educates and instructs the nursing staff on the analgesic regimen and observations needed to monitor effects and toxicity. The palliative care nurse also evaluates the psychosocial and home situation of the patient, to accelerate transfer to an out-of-hospital setting and by detecting the need for additional physical and mental care at an early stage. In case of a need for specialised psychosocial help, a social worker, clinical psychologist or spiritual adviser may be consulted by the palliative care nurse. With respect to the role of the PCT in medical decision-making, the team closely collaborates with the treating physicians. For example, the team is actively involved in decisions concerning continuation of or abstention from anticancer treatment and, as mentioned above, in clinical decisions concerning symptom control by treating the underlying disease. Finally, the team is involved in end-of-life care, including palliative sedation.17–19
Study design We studied 565 admissions of advanced cancer patients, whose symptoms were collected on a structured data collection sheet at fi xed time points, as part of routine medical practice. These admissions represented 486 patients, since some patients were admitted more than once. Patients’ performance status was scored using the Eastern Cooperative Oncology Group (ECOG)/WHO score. 20 Patients included from 1 January 2007 to 31 December 2008 formed the actual study population, while patients included from 1 January 2006 to 31 December 2006 served as a historical control. We studied differences in outcome before and after the intervention for the three different year groups, as well as differences between the patients who were exposed to comprehensive palliative care (2007 and 2008) versus the historical control (2006).
Clinical analyses From the last quarter of 2006 onwards, present pain intensity was rated using a 0–10 numerical rating scale (NRS) at the start of the consultation, at 48 h thereafter and at discharge. Additionally, in 2008 pain intensity was recorded at 24 h after the start of consultation. When these time points occurred during weekends, pain intensities were collected on Fridays or Mondays, depending on which day was closest. Missing data occurred when patients were not on the ward at the time of the visit or when patients were discharged without prior notification to the team. In 2008 we started using the Edmonton Symptom Assessment System (ESAS) to rate 11 symptoms other than pain at start, at 72 h and at discharge. The ESAS form was fi lled in by the patient themselves, although a relative/friend or the palliative care nurse was allowed to assist if the patient was unable to complete the form due to physical limitations, not cognitive impairment. 21 Missing data occurred when patients were not on the ward at the time of the visit, when patients were discharged without prior notification to the team, when patients did not understand the Dutch language or when patients were too ill to fi ll out the ESAS form. The mean±SD pain intensity of all patients was calculated after it had been verified that values were normally distributed. A repeated measures analysis of variance (ANOVA) was applied to study the variance of mean intensities during consultation (T=0 h, T=48 h and T=discharge) and over the years BMJ Supportive & Palliative Care 2011;1:322–328. doi:10.1136/bmjspcare-2011-000087
(2006, 2007 and 2008). Additionally, pain intensity was classified as mild pain (NRS 0–4), moderate pain (NRS 5–7) and severe pain (NRS 8–10). 22 χ2 Tests were used to compare the proportions of patients with mild, moderate and severe pain at the various time points, for each year. The median (range) was calculated for symptoms other than pain. Friedman’s test was applied to compare ESAS symptom severity at the various time points during and following consultation. We also recorded treatment-related parameters, including equianalgesic opioid dosages and the use of subcutaneous pumps and epidural and spinal catheters at discharge. Equianalgesic dosages were expressed as 10 mg parenteral morphine/24 h. Conversion factors were according to the Dutch consensus guideline ‘Cancer Pain’23 (see supplementary online figure). We used sustained release and continuous intravenous medication for calculating the equianalgesic dosage. Although we did not collect information on all rescue medication for individual patients, the maximum daily dosage of oral and intravenous rescue medication as a rule consisted of 100% of the sustained release or continuous intravenous opioid dosage. When patients were using more than 50% of the rescue doses, sustained release or continuous intravenous opioid dosage was increased. Thus, the equianalgesic dosage that we calculate represents 67–100% of the actual equianalgesic dosage Table 1 Baseline characteristics Consultations Total number of consultations Symptoms Pain Dyspnoea Ascites Terminal discomfort Nausea Psychosocial factors Constipation Other Clinical characteristics Mean±SD age (years) Sex Male Female Primary cancer site Lung Gynaecological Urological Larynx/mouth Gastrointestinal tumours Breast Bone marrow Unknown origin Other Metastasised Mean WHO performance status ≤2 3 4 Median Anticancer treatment No more anticancer treatment Chemotherapy Radiotherapy Surgery Chemotherapy and surgery Chemotherapy and radiotherapy Baseline median (range) equianalgesic dose of opioids (mg intravenous morphine/24 h)
2006
2007
2008
N=130
N=200
N=235
127 (97.7%) 1 (0.8%) 1 (0.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.8%)
185 (92.5%) 4 (2.0%) 0 (0.0%) 5 (2.5%) 2 (1.0%) 0 (0.0%) 0 (0.0%) 4 (2.0%)
184 (78.3%) 6 (2.6%) 1 (0.4%) 12 (5.1%) 2 (0.9%) 20 (8.5%) 1 (0.4%) 9 (3.8%)
58.9±12.9
58.6±14.6
59.7±13.9
71 (54.6%) 59 (45.4%)
121 (60.5%) 79 (39.5%)
131 (55.7%) 104 (44.3%)
3 (2.3%) 6 (4.6%) 30 (23.1%) 18 (13.8%) 46 (35.3%) 7 (5.4%) 6 (4.6%) 3 (2.3%) 11 (8.5%) 78 (61.4%) N=125 48 (38.4%) 43 (34.4%) 34 (27.2%) 2.82 N=125 99 (79.2%) 11 (8.8%) 4 (3.2%) 7 (5.6%) 2 (1.6%) 2 (1.6%) 20 (0–520)
18 (9%) 19 (9.5%) 36 (18%) 24 (12%) 70 (35%) 4 (2%) 11 (5.5%) 6 (3%) 12 (6%) 156 (78%) N=191 81 (42.4%) 63 (33.0%) 47 (24.6%) 2.71 N=190 139 (73.2%) 18 (9.5%) 16 (8.4%) 12 (6.3%) 3 (1.6%) 2 (1.1%) 25 (0–1121)
13 (5.5%) 26 (11.1%) 34 (14.5%) 25 (10.6%) 100 (42.6%) 3 (1.3%) 9 (3.8%) 7 (3.0%) 18 (7.7%) 164 (69.8%) N=209 63 (30.1%) 87 (41.6%) 59 (28.2%) 2.97 N=208 173 (83.2%) 19 (9.1%) 5 (2.4%) 7 (3.4%) 2 (1.0%) 2 (1.0%) 20 (0–840)
323
Downloaded from http://spcare.bmj.com/ on July 7, 2015 - Published by group.bmj.com
Research
Figure 1 Changes in pain severity. The lines represent the mean±upper limit of the SD pain intensity. The bars represent the frequencies of patients with light (NRS 0–4), moderate (NRS 5–7) and severe (NRS 8–10) pain at T=0 h, at T=48 h and at discharge. NRS, numerical rating scale. that the patients used, including rescue medication. Friedman’s test was applied to compare equianalgesic dosages of opioids at baseline and at discharge in 2006, 2007 and 2008.
Impact on duration of hospitalisation To estimate how the multidisciplinary PCT affected duration of hospital stay, we determined the median number of days (since the data were heavily skewed) that patients were hospitalised in the current study. Friedman’s test was applied to compare the numbers of days of hospitalisation in 2006, 2007 and 2008. We also collected the number of days patients had been admitted before the PCT was consulted. The duration of hospitalisation for the patients visited by the PCT was compared with the mean duration of hospitalisation of all patients admitted to departments with a fair share of cancer patients. The mean number of hospitalised days/department was calculated from the total number of hospitalised patients and the total number of hospitalised days from these departments, using fi nancial databases. A one-way ANOVA was applied to study the variance in the number of days of hospitalisation over the years. All statistical analyses were performed using the statistical packages GraphPad Prism v5b (www.graphpad.com) and SPSS v15 (www-01.ibm.com/software/analytics/spss).
RESULTS Baseline characteristics The total number of consultations and the diversity of presenting symptoms for which the team was consulted in 2006, 2007 and 2008, are presented in table 1. The number of consultations increased from 130 in 2006 to 235 in 2008. The diversity of presenting symptoms increased from 3% primarily non-pain consultations in 2006 to 22% primarily non-pain consultations in 2008. Prevalent symptoms other than pain included nausea, dyspnoea, ascites, psychosocial factors and terminal agitation. Patients with terminal agitation refractory to medical treatment were usually treated with palliative sedation, according to the Dutch national guideline on palliative sedation.17 Within the group of primarily pain consultations, 18%, 7% and 9% of patients also had one or more non-pain symptoms in 2006, 2007 and 2008, respectively. 324
Table 1 also summarises the clinical characteristics of the patients for whom the PCT was consulted. The gastrointestinal tract was by far the most prevalent cancer site for which the team was consulted, followed by urological and head and neck cancers. Mean ECOG/WHO performance status was almost 3, meaning that patients in general were capable of only limited self-care and/or confi ned to bed or a chair for more than 50% of their waking hours. A large majority of the patients did not receive anticancer treatment at the time of admission. Overall, 13%, 16% and 18% of patients died during hospital admission in 2006, 2007 and 2008, respectively.
Changes in pain intensity Figure 1 depicts the course of the mean±SD pain intensity in the last quarter of 2006 and the whole of 2007 and 2008. Some 38% of values (not patients) were missing. The effect of missing values on mean pain intensity was analysed by comparing the mean pain intensity from groups of patients in whom at least one value at one time point was missing with the mean pain intensity from patients with no missing values. It was thus determined that missing data did not affect mean pain intensity (Mann-Whitney U test and Kruskal–Wallis p≥0.05 for all comparisons; non-parametric tests were selected because groups of missing data sets were not always normally distributed). Pain intensity decreased from 6.6±2.5 (mean±SD) at start of the consultation, to 4.0±2.5 at 48 h and to 2.6±1.8 at discharge (all years analysed together). The decrease in pain intensity was highly significant from T=0 h to T=discharge (p0.5; repeated measures ANOVA, source year). Figure 1 also depicts the percentages of patients with mild, moderate and severe pain. This included a 70% reduction in the proportion of patients with severe pain within 24 h following the start of consultation in 2008 (not shown). Again, the proportions of patients with mild, moderate and severe pain were significantly different at the start of consultation, at 48 h and at discharge, in 2006, 2007 and 2008 (p
