Timothy To

Predictors of chronic breathlessness: a large population study

BackgroundBreathlessness causes significant burden in our community but the underlying socio-demographic and lifestyle factors that may influence it are not well quantified. This study aims to define these predictors of chronic breathlessness at a population level.MethodsData were collected from adult South Australians in 2007 and 2008 (n = 5331) as part of a face-to-face, cross-sectional, whole-of-population, multi-stage, systematic area sampling population health survey. The main outcome variable was breathlessness in logistic regression models. Lifestyle factors examined included smoking history, smoke-free housing, level of physical activity and body mass index (obesity).ResultsThe participation rate was 64.1%, and 11.1% of individuals (15.0% if aged ≥50 years) chronically had breathlessness that limited exertion. Significant bivariate associations with chronic breathlessness for the whole population and only those ≥50 included: increasing age; female gender; being separated/divorced/widowed; social disadvantage; smoking status; those without a smoke-free home; low levels of physical activity; and obesity. In multi-variate analyses adjusted for age, marital status (p < 0.001), physical activity (p < 0.001), obesity (p < 0.001), gender (p < 0.05) and social disadvantage (p < 0.05) remained significant factors. Smoking history was not a significant contributor to the model.ConclusionsThere is potential benefit in addressing reversible lifestyle causes of breathlessness including high body mass index (obesity) and low levels of physical activity in order to decrease the prevalence of chronic breathlessness. Clinical intervention studies for chronic breathlessness should consider stratification by body mass index.

A point prevalence survey of hospital inpatients to define the proportion with palliation as the primary goal of care and the need for specialist palliative care

The direct burden of people whose goal of care is a palliative approach has not been estimated in the acute care setting. Using a single time point, cross‐sectional survey of all inpatient beds, an estimate was generated across a network of three South Australian public hospitals. One in three inpatients had a palliative approach as the goal of care and of these, only one in five had been referred to specialist palliative care services. Those referred were significantly more likely to have cancer and be younger men. Active recognition and documentation that a palliative approach frames the goals of care for this person needs to be incorporated more systematically into clinical practice in the acute care setting. At the same time, triggers for needs‐based referral for specialist assessment should be implemented. Specialist palliative care services must also provide direct care for a wider range of patients than just those with cancer.

An international initiative to create a collaborative for pharmacovigilance in hospice and palliative care clinical practice

BACKGROUND Medication registration currently requires evidence of safety and efficacy from adequately powered phase 3 studies. Pharmacovigilance (phase 4 studies, postmarketing data, adverse drug reaction reporting) provide data on more widespread and longer term use. Historically, voluntary reporting systems for pharmacovigilance have had low reporting rates, relying on ad hoc reporting and retrospective chart reviews, or prospective registries have often been limited to specific drugs or clinical conditions. Furthermore, these data are often irrelevant in hospice and palliative care due to the timeliness of which such data become available and the unique characteristics of our population and prescribing: compounding comorbidities, progressive organ failure, accumulation of symptom-specific medications, tendency to attribute toxicity to disease progression, use of old, off-patent medications, and incorporation of evolving evidence. There is a need for prospective, systematic pharmacovigilance in hospice and palliative care. METHOD Here we describe an international, Web-based, 128-bit secure initiative to collect pharmacovigilance data documenting net clinical benefit and safety of common medications. The intention is for a diverse and large group of clinical units to record data prospectively on a small deidentified consecutive cohort of patients started on the medication of interest. A new medication would be studied every 3 months. Three key time points (different for each medication) will be assessed for each patient, collecting easily codefiable data at baseline, a point at which clinical benefit should be experienced, and a point at which short- to medium-term toxicities may occur. Toxicities can additionally be recorded at any time they occur. Data collection will take a maximum of 10 minutes per patient. CONCLUSION The intention is to create an efficient, relevant system to improve hospice and palliative care with maximally generalizable results.

Adverse Events in Hospice and Palliative Care: A Pilot Study to Determine Feasibility of Collection and Baseline Rates

BACKGROUND Continuous quality improvement is fundamental in all health care, including hospice and palliative care. Identifying and systematically reducing symptomatic adverse events is limited in hospice and palliative care because these events are mostly attributed to disease progression. OBJECTIVES The aim of this study was to assess the feasibility of symptomatic adverse events in hospice and palliative care and assessing their incidence. METHODS A retrospective, consecutive cohort of notes from a specialist palliative care inpatient service was surveyed by a clinical nurse consultant for symptomatic adverse events: falls, confusion, decreased consciousness, hypo- and hyperglycaemia, urinary retention, and hypotension. Demographic and clinical factors were explored for people at higher risk. RESULTS Data were available on the most recent admissions of 65 people, generating >900 inpatient days. Fifty people (78%) had events precipitating admission, of whom 31 (62%) had at least one further event during admission. Eleven of 15 people who were admitted without an event experienced at least one during their admissions. Only 4 did not have an adverse event. During their stay, there were 0.13 (standard deviation [SD] = 0.19) events per patient per day. No drug-drug or drug-host events were noted. No clinical or demographic factors predicted groups at higher risk. CONCLUSIONS This pilot highlights the feasibility of collecting, and ubiquity of, symptomatic adverse events, and forms a baseline against which future interventions to decrease the frequency or intensity can be measured. Given the frailty of hospice and palliative patients, any adverse event is likely to accelerate irreversibly their systemic decline.

The Role of Ondansetron in the Management of Cholestatic or Uremic Pruritus—A Systematic Review

CONTEXT Pruritus associated with hepatic or renal failure can be a troublesome symptom, refractory to treatment and associated with significant physical and emotional distress and a reduction in quality of life for patients already burdened with chronic disease. Serotonin has been implicated as a possible pathological mediator, and, therefore, 5HT(3) antagonists have been suggested as a possible therapeutic intervention. OBJECTIVES This review of the literature systematically explores the role of ondansetron in the management of cholestatic or uremic pruritus. METHODS Electronic databases were systematically searched for randomized controlled trials examining the role of ondansetron in cholestatic or uremic pruritus between 1966 and 2008. RESULTS Five randomized controlled trials were included in this systematic review: three for cholestatic pruritus and two for uremic pruritus. All trials examined ondansetron vs. placebo, with differing treatment protocols. Overall, three studies showed no benefit to ondansetron over placebo; however, two studies in cholestatic pruritus showed small reductions in pruritus with questionable clinical significance. CONCLUSION Ondansetron was demonstrated to have negligible effect on cholestatic or uremic pruritus on the basis of a limited number of studies.

Prescribing at Times of Clinical Transition in Chronic Or Progressive Diseases

SUMMARY The goals of all clinical care are based on optimizing a person’s comfort and function in physical, emotional, existential, sexual and social domains. Chronic, progressive illnesses generate specific challenges as systemic deterioration shifts the benefit–toxicity balance for the treatment of some long-term comorbid diseases. At every clinical encounter, and especially at times of transition in clinical care (admission to hospital, discharge to the community, a new diagnosis), the opportunity to review the management of comorbid conditions must be taken. This is especially important when a life-limiting illness is first recognized. Careful rationalization of the treatment of chronic comorbid conditions in a systematic way as a person experiences systemic deterioration requires a framework for considering short- and long-term sequelae of both treating and not treating a given condition. The preventative intent of therapy (primary, secondary, tertiary) must be known to make this clinical decision. The numbers needed to treat to avoid one adverse outcome will tend to increase as a person experiences systemic decline and, conversely, the numbers needed to harm will decrease. In addition to reviewing individual medications, consideration must be given to the total burden of prescribing for cumulative effects (e.g., risk of drug–drug interactions, anticholinergic load). Judicious dose reduction or substitution of a more appropriate agent, given the global decline, with continued careful review will allow medications to be titrated to minimize harm at the end of life. [International Journal of Gerontology 2009; 3(1): 1–8]

Anti-cholinergic load, health care utilization, and survival in people with advanced cancer: a pilot study.

INTRODUCTION Anti-cholinergic medications have been associated with increased risks of cognitive impairment, premature mortality and increased risk of hospitalisation. Anti-cholinergic load associated with medication increases as death approaches in those with advanced cancer, yet little is known about associated adverse outcomes in this setting. METHODS A substudy of 112 participants in a randomised control trial who had cancer and an Australia modified Karnofsky Performance Scale (AKPS) score (AKPS) of 60 or above, explored survival and health service utilisation; with anti-cholinergic load calculated using the Clinician Rated Anti-cholinergic Scale (modified version) longitudinally to death. A standardised starting point for prospectively calculating survival was an AKPS of 60 or above. RESULTS Baseline entry to the sub-study was a mean 62 +/- 81 days (median 37, range 1-588) days before death (survival), with mean of 4.8 (median 3, SD 4.18, range 1 - 24) study assessments in this time period. Participants spent 22% of time as an inpatient. There was no significant association between anti-cholinergic score and time spent as an inpatient (adjusted for survival time) (p = 0.94); or survival time. DISCUSSION No association between anti-cholinergic load and survival or time spent as an inpatient was seen. Future studies need to include cognitively impaired populations where the risks of symptomatic deterioration may be more substantial.

Implementation of a pilot telehealth programme in community palliative care: A qualitative study of clinicians’ perspectives

Background: Telehealth technologies are an emerging resource opening up the possibility of greater support if they have utility for patients, carers and clinicians. They may also help to meet health systems’ imperatives for improved service delivery within current budgets. Clinicians’ experiences and attitudes play a key role in the implementation of any innovation in service delivery. Aim: To explore clinicians’ perspectives on and experiences of the utilisation of a pilot telehealth model and its integration into a specialist community palliative care programme. Design: Focus groups and interviews generated data that were analysed through the lens of a realistic evaluation theoretical framework. Setting/participants: The study was conducted in a metropolitan specialist palliative care service in South Australia. Participants (n = 10) were clinicians involved in the delivery of community specialist palliative care and the piloting of a telehealth programme. Results: Service providers consider telehealth resources as a means to augment current service provision in a complementary way rather than as a replacement for face-to-face assessments. Introducing this technology, however, challenged the team to critically explore aspects of current service provision. The introduction of technologies also has the potential to alter the dynamic of relationships between patients and families and community palliative care clinicians. Conclusion: Implementation of a pilot telehealth programme in a specialist palliative community team needs to involve clinical staff in service redesign from the outset. Reliable IT infrastructure and technical support is critical for telehealth models to be effective and will aid uptake.

Multidisciplinary care needs in an Australian tertiary teaching hospital

BACKGROUND The ageing of the Australian population is placing increasing demand on the nations healthcare system. This study set out to describe the level of need for multidisciplinary care in an Australian tertiary hospital setting. METHODS A cross-sectional audit by case note review of all patients on acute medical and surgical wards in an Australian tertiary hospital. The primary outcome was an identified need for multidisciplinary assessment and intervention. RESULTS A total of 60% of the 295 inpatients audited required multidisciplinary care. Of those who were admitted to geriatric and rehabilitation units, 84% required multidisciplinary care. Patients in acute medical and surgical units also had substantial multidisciplinary care needs. Age was a significant influence with 79% of those aged 86 and above having multidisciplinary care needs, whilst only 38% of those aged 55 or less required multidisciplinary care. Difficulties with mobility, need for assistance with self-care, and continence problems were associated with higher requirement for multidisciplinary care. CONCLUSIONS In the hospital population, significant multidisciplinary care needs exist. These needs are not limited to inpatients that are elderly or admitted to geriatric or rehabilitation units. This has implications for planning, funding, provision of health care resources, and training of medical and allied health staff.

Is geriatric assessment being incorporated into general oncology

A growing group of clinicians believe in the value of geriatric assessment (GA) in theevaluationof theolder adultswith cancer. Most commonly, GA is a conglomeration of assessment tools which are aggregated to give the treating clinician an indication of the fitness of the patient. Less frequently, a GA is performed by a geriatrician. The incorporation of GA into routine practice, however, has occurred in relatively few centers internationally. Even amongst centers with GA in oncology, the impact on decision making or clinical outcomes is yet to be defined. In a recent article published in this journal, Decoster et al. describe a large and important study examining the influence of GA on the treatment decisions of medical oncologists in a heterogeneous group of older patients with cancer. The GA results were available to the clinicians, who were then asked: whether they reviewed the GA prior to making their treatment decision, if they had modified the treatment compared to standard therapy, and whether the GA influenced this treatment decision. Using predefined geriatric risk criteria, almost three quarters of patients were defined as ‘at risk’. The influence of clinical assessment on treatment modification corresponded poorly to those identified as ‘at risk’: 34% of ‘fit’ patients did not receive standard treatment, whilst 55% of those ‘at risk’ were given standard treatment. Furthermore, despite all patients having a GA, this assessment was only consulted in 56% of patients, andof these patients, theGAonly influenced treatment decisions in 6%. These results are not surprising— in a similar study, Kenis et al. found that only 61% of the GA were reviewed prior to making treatment decisions, and of these patients, the GA influenced treatment decisions in only 25%. This was despite theGA yielding additional information over clinical assessment in 62% of the cases. McCleary et al. developed a computerized version of a self-reportedGAwhichwas found beneficial by 75% of clinicians, however almost all clinicians felt that the GA would not influence current or future treatment plans. GA also did not change oncological management in a pilot study by Aparicio et al. In contrast, GA by a geriatrician followed by an oncogeriatric multidisciplinary discussion altered cancer management in 21–39%, with a higher rate of alterations (49%) when older patients with complexity were targeted.