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Effectiveness of a multidisciplinary consultation team for cancer pain and palliative care in a large university hospital in the Netherlands
  1. Joost L M Jongen1,
  2. Anke Overbeck1,
  3. Dirk L Stronks2,
  4. Lia van Zuylen3,
  5. Monique Booms3,
  6. Frank J Huygen2 and
  7. Carin C D van der Rijt3
  1. 1Department of Neurology, Erasmus MC, Rotterdam, The Netherlands
  2. 2Department of Pain Medicine, Erasmus MC, Rotterdam, The Netherlands
  3. 3Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands
  1. Correspondence to Joost L Jongen, Department of Neurology, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands; j.jongen{at}erasmusmc.nl

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.

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Introduction

WHO defines 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

While cost savings with both outpatient8 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, 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 fixed 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 filled 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 fill 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 (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 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 financial 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.

Table 1

Baseline characteristics

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 confined 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).

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.

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 (p<0.01; repeated measures ANOVA, source time point), although this decrease was not significantly different between years (p>0.5; 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<0.01; χ2 tests).

Changes in severity of non-pain symptoms

Figure 2 depicts the median (range) ESAS symptom severity in 2008, at the start of consultation, at 72 h and at discharge. The ESAS scale is constructed so that a decrease in symptom severity always means an improvement.24 Thus, an appetite severity of 10 means worst appetite, while a nausea severity of 10 means worst nausea. Between 60% and 72% of the values (not patients) were missing for the various ESAS symptoms. Using Friedman's test to investigate the change in individual ESAS symptoms during consultation, a significant (p<0.05) improvement was found in seven out of 11 ESAS symptoms, while the remaining four symptoms, that is, depression, drowsiness, shortness of breath and constipation, did not change significantly.

Figure 2

Changes in severity of ESAS symptoms in 2008. The whiskers represent the median (range) symptom severity of various ESAS symptoms at T=0 h, at T=72 h and at discharge and bars represent IQRs. Symptom severity decreased significantly for seven symptoms following consultation, while for four symptoms the change was not significant. Only symptoms with a significant change are presented here. *p<0.05; **p<0.01. ESAS, Edmonton Symptom Assessment System.

Medical treatment

Table 2 summarises the medical treatment of pain following PCT consultation. Although median equianalgesic dosages of opioids at discharge were significantly higher than at baseline (p<0.01; χ2 test), no significant changes in equianalgesic dosages between 2006, 2007 and 2008, at baseline (p=0.7; Friedman's test) or at discharge (p=0.9), were observed. The percentage of patients who needed opioid rotation (ie, another drug or another route of administration) did not show a trend towards decrease or increase over the years. The number of patients using parenteral opioids at discharge (ie, subcutaneous pumps and epidural and spinal catheters) decreased slightly over the years. The type of adjuvant medication seemed to shift from antidepressants to anticonvulsants from 2006 to 2008. Other medical treatments did not change dramatically from 2006 to 2008.

Table 2

Therapeutic interventions after PCT consultation

Impact on duration of hospitalisation

The number of days in hospital of patients for whom the PCT was consulted is shown in figure 3. The total number of days these patients were hospitalised decreased from a median (range) of 14 (1–61) days in 2006 to 9 (1–48) days in 2007 and 10 (1–63) days in 2008. This decrease was highly significant (p=0.001, Friedman's test). The percentage of patients who were referred to a hospice, nursing home or other hospital was 16%, 13% and 14% in 2006, 2007 and 2008, respectively. The median (range) number of days patients were hospitalised before PCT consultation was 2 (0–49) days in 2006, 1 (0–76) days in 2007 and 1 (0–74) days in 2008. These differences were not statistically significant (p=0.6, Friedman's test).

Figure 3

Number of days in hospital. The bars represent the frequencies of the total number of days that patients seen by the palliative care team were hospitalised. The vertical lines represent the median number of days.

To investigate whether there was a general trend towards shorter total duration of hospitalisation in the years 2006–2008, we used data from the financial databases of eight departments with a fair share of cancer patients. The mean number of hospitalised days for all patients in these departments did not decrease significantly from 2006 to 2008 (p=0.8; one-way ANOVA).

Discussion

In this study we first show that the number of consultations and the diversity of symptoms for which the PCT was consulted greatly increased from when the team was set up in 2007. From this we conclude that there is a strong demand for multidisciplinary palliative care in our general hospital. Apparently, this demand previously went unnoticed, since patients' demographic and clinical data did not change during the study period. The percentage of pain consultations was relatively high, which can be explained by the fact that our PCT evolved from a cancer pain service. Secondly, clinically relevant outcome measures for advanced cancer patients (ie, pain NRS in 2006, 2007 and 2008 and symptoms measured by ESAS in 2008) showed a rapid and significant improvement during hospitalisation. However, although we used a historical cohort and an ANOVA for pain intensity, we did not demonstrate that the effectiveness of the PCT improved over the years or surpassed that of routine oncological care including pain control. We did not observe an increase in opioid equianalgesic dose at baseline or at discharge over the years. Finally, since the median duration of hospitalisation decreased from 14 days in 2006 to 10 days in 2008, we conclude that the interventions of our multidisciplinary PCT may contribute to a shorter duration of hospitalisation.

Although palliative care has existed for more than 20 years, surprisingly little systematic research has been carried out in the non-PCU clinical setting involving different medical specialties and using clinically relevant and validated clinical outcome measures. We are aware of only two such studies, one a randomised controlled trial comparing the efficacy of a full PCT service with that of telephone consultations14 and one study prospectively evaluating the efficacy of a PCU versus a non-PCU PCT.15 Both studies measured the effect of a PCT on the intensity of pain and other symptoms, but only at 1 week following consultation, while we demonstrated a significant reduction in pain intensity within 24 h following consultation in 2008. The paucity of studies may be partially explained by the inherent variability of the patient population, making it an unattractive target for medical research. Since our study was initiated as a project whose continuation depended on demonstrating effectiveness, we set out to evaluate clinical effectiveness using well-defined and clinically relevant parameters for advanced cancer patients from the start.

As a first parameter to evaluate clinical effectiveness, we chose pain intensity measured by present pain NRS at three time points (four time points in 2008). Pain NRS is a generally accepted measure which can be easily and reliably monitored in almost all cancer patients, even the very ill.25 The 38% of missing values at some time point were due to logistical reasons, for example, patients not being present on the ward at the time of the visit, patients being prematurely discharged without notification to the team, etc. If one of the various time points for collecting pain intensity data was during a weekend, we chose pain intensity on the closest Friday or Monday to prevent even more missing data. Thus, missing data were randomly distributed and did not seem to affect overall mean pain scores in our missing data analysis. We also categorised pain into three groups: mild pain (NRS 0–4) requiring no or minimal change in analgesic medication, moderate pain (NRS 5–7) requiring an increase or change in mediation and severe pain (NRS 8–10) requiring immediate pain relief, the latter usually involving the use of parenteral opioids. Although there is some debate about the cut point between moderate and severe pain (ie, NRS 7 or 8),22 26 this classification is widely used and clinically very useful because of its treatment implications.

Secondly, we used ESAS to assess non-pain symptoms starting in 2008, because the team was increasingly consulted for non-pain symptoms and because it appeared that within the group of primarily pain consultations a number of patients also had one or more other symptoms. ESAS is a validated and well-established scale specifically designed for a palliative care population.21 24 We noticed that a substantial percentage of our patients had difficulties filling out the ESAS, some for physical reasons such as confusion or fatigue, but also because of language problems (ie, non-native Dutch speakers). This resulted in a high percentage of missing data, which prevents firm conclusions. On the other hand, the percentages of missing pain intensity and ESAS data in our study are very similar those in other studies using inpatient subjects.14 27 In line with a swift improvement in pain, most ESAS data also showed a rapid and statistically significant improvement in the majority of symptoms during admission, suggesting that this may be related to the actions of the PCT, more specifically the medical oncologist and palliative care nurse.

In contrast to previous papers,1 28 we did not observe an increase in opioid equianalgesic dose at baseline or at discharge over the years. This may well be explained by the fact that our PCT evolved from a cancer pain service, which was already very effective in controlling cancer pain in 2006.

Finally, we showed that the decreased number of hospitalised days in our patients was not caused by a general trend towards shorter hospitalisations in our hospital from 2006 to 2008. Besides, the percentage of patients who were referred to a hospice, nursing home or hospital was relatively small and stable over the years and is therefore not expected to affect median duration of hospitalisation. Although this study used a historical control instead of a randomised controlled design, we hypothesise that the shorter admissions in our patients were actually due to the rapid interventions of the team. Apart from contributing to patients' satisfaction, a reduction in hospitalisation of 4 days may also generate significant savings, although we did not perform a thorough cost-effectiveness analysis as carried out by Morrison et al.9

Our report is one of only a few systematic analyses using validated and clinically relevant outcome measures to evaluate the effectiveness of an inpatient multidisciplinary PCT for cancer patients, although missing data and a failure to demonstrate superior pain control during the actual study period over the historical control prevents firm conclusions. We demonstrated a strong demand for multidisciplinary palliative care in our university hospital. Although others14 15 have previously demonstrated symptom control by a PCT, the 70% decrease in severe pain within 24 h of consultation that we describe here is especially significant. In addition, we demonstrate a decrease in the duration of hospitalisation for the first time. We conclude that a multidisciplinary PCT for cancer patients may have a positive effect on pain, on ESAS symptoms and on duration of hospitalisation.

The number of consultation almost doubled from 2006 to 2008 and, although pain remains the most prevalent primary symptom, an increase in the diversity of symptoms over the years is readily apparent. Patients' demographic and clinical data are similar in 2006, 2007 and 2008.

  • Received 8 July 2011.
  • Accepted 17 September 2011.

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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