Jose Espinosa

Identifying needs and improving palliative care of chronically ill patients: a community-oriented, population-based, public-health approach

Purpose of reviewWe describe conceptual innovations in palliative care epidemiology and the methods to identify patients in need of palliative care, in all settings.In middle–high-income countries, more than 75% of the population will die from chronic progressive diseases. Around 1.2–1.4% of such populations suffer from chronic advanced conditions, with limited life expectancy. Clinical status deteriorates progressively with frequent crises of needs, high social impact, and high use of costly healthcare resources. Recent findingsThe innovative concept of patients with advanced chronic diseases and limited life prognosis has been addressed recently, and several methods to identify them have been developed. SummaryThe challenges are to promote early and shared interventions, extended to all patients in need, in all settings of the social care and healthcare systems; to design and develop Palliative Care Programmes with a Public Health perspective. The first action is to identify, using the appropriate tools early in the clinical evolution of the disease, all patients in need of palliative care in all settings of care, especially in primary care services, nursing homes, and healthcare services responsible for care provision for these patients; to promote appropriate care in patients with advanced diseases with prognosis of poor survival.

Identifying patients with chronic conditions in need of palliative care in the general population: development of the NECPAL tool and preliminary prevalence rates in Catalonia.

Palliative care (PC) has focused on patients with cancer within specialist services. However, around 75% of the population in middle-income and high-income countries die of one or more chronic advanced diseases. Early identification of such patients in need of PC becomes crucial. In this feature article we describe the initial steps of the NECPAL (Necesidades Paliativas [Palliative Needs]) Programme. The focus is on development of the NECPAL tool to identify patients in need of PC; preliminary results of the NECPAL prevalence study, which assessed prevalence of advanced chronically ill patients within the population and all socio-health settings of Osona; and initial implementation of the NECPAL Programme in the region. As first measures of the Programme, we present the NECPAL tool. The main differences from the British reference tools on which NECPAL is based are highlighted. The preliminary results of the prevalence study show that 1.45% of the total population and 7.71% of the population aged over 65 are ‘surprise question’ positive, while 1.33% and 7.00%, respectively, are NECPAL positive, and surprise question positive with at least one additional positive parameter. More than 50% suffer from geriatric pluri-pathology conditions or dementia. The pilot phase of the Programme consists of developing sectorised policies to improve PC in three districts of Catalonia. The first steps to design and implement a Programme to improve PC for patients with chronic conditions with a public health and population-based approach are to identify these patients and to assess their prevalence in the healthcare system.

The Catalonia World Health Organization Demonstration Project for Palliative Care Implementation: Quantitative and Qualitative Results at 20 Years

Catalonia (Spain) has a total population of 7.3 million citizens for whom the National Health Service (NHS) provides health care that is free at the point of access. The prevalence of terminally ill patients is between 30,100 and 39,600. Twenty years ago, the World Health Organization (WHO), in collaboration with the Catalan Department of Health and the Catalan Institute of Oncology, began a demonstration project (WHO Demonstration Project) in palliative care (PC) with the aim of implementing specialist PC services, generating experience in this field, identifying areas for improvement, and introducing educative procedures (clinical and nonclinical). Over the past 20 years, 237 PC clinical services (72 home care support teams, 49 hospital support teams, 60 units with 742 dedicated beds, 50 outpatient clinics, and six psychosocial support teams) have been implemented. In the five years since the previous evaluation, 57 new clinical services (15 new hospital support teams, 36 outpatient clinics, and six psychosocial support teams among others) and four nonclinical services (education, research, WHO Collaborating Center, and planning) have been implemented. During the year 2010, a total of 46,200 processes were undertaken for the care of 23,100 patients, of whom 12,100 (52%) had cancer and 11,000 (48%) had other chronic advanced diseases. The overall yearly costs are around €52,568,000, with an overall savings of €69,300,000 (€2275 per patient, net savings to the NHS of €16,732,000). In the last five years, three qualitative evaluations and a benchmarking process have been performed to identify weak points and inequities in care provision among districts. Systematic assessments indicate high cost-effectiveness of care as well as high levels of satisfaction by patients and their relatives, thus reinforcing the principle that access to PC under the auspices of the NHS at the end of life is a basic human right.

The costs and savings of a regional public palliative care program: the Catalan experience at 18 years.

Conceived as a World Health Organization demonstration project for public health initiatives at the end of life, the palliative care program in Catalonia illustrates the impact that similar initiatives may have in terms of cost savings for a regional health system. In a publicly funded and freely accessible health system, decreasing the number of hospital admissions, shortening the lengths of hospital stay, diminishing the frequency of emergency room consultations, shifting the use of acute hospital beds to palliative care beds for treating advanced disease inpatients, and substantially improving the use of opioids in the community are major determinants of the palliative care programs success. These features add to the opportunity the discipline offers to improve the quality of health care at the end of life. In this article, the information gathered over an 18-year trajectory of the program is summarized. Key features of the existing financial models used while developing palliative care in Catalonia are described, and the mechanisms by which palliative care may have contributed to increase savings for the health care system in end-of-life care, from euro3,000,000 in 1995 to euro8,000,000 in 2005, are discussed.

Estudio sobre necesidades formativas en cuidados paliativos para atención primaria

Introduccion. La estrategia en cuidados paliativos del Sistema Nacional de Salud del ano 2007 determina establecer programas de formacion continuada especifica para los profesionales del sistema sanitario con el fin de que atiendan adecuadamente las necesidades de los pacientes en situacion de enfermedad avanzada o terminal, y de su familia. Se propone conocer las necesidades en formacion percibidas por los profesionales de atencion primaria en Cataluna relacionadas con cuidados paliativos y sugerir enfoques formativos que impacten en el cuidado de pacientes comunitarios en situacion de enfermedad avanzada. Pacientes y metodos. Se llevo a cabo un estudio observacional, descriptivo, transversal, con metodologia cualitativa y cuantitativa, que incluia: a) encuesta a directores de equipos de atencion primaria, determinando necesidades y prioridades formativas en cuidados paliativos y viabilidad de los planes formativos; y b) grupos focales con profesionales y docentes expertos en cuidados paliativos y profesionales de atencion primaria, identificando similitudes y diferencias en las necesidades de formacion percibidas en cuidados paliativos.