Transcript presentation - Worldwide Universities Network

World Universities Network
Presentation
Dr Heather McKenzie
Professor Kate White
Dr Lillian Hayes
Mr Keith Cox
Associate Professor Maureen Boughton
Ms Judith Fethney
Ms Jo Dunn
1
Introduction
• Overview of program of research
• Introduction to this presentation
• Background: Study One
Exploratory research
• To explore the nature of nursepatient encounters and relationships
in the context of community care of
cancer patients
• Research focus was on particular
nurse-patient encounters & involved
interviews with nurses and patients
and observation of each encounter
Research findings
• Sense of security for patients and their
families about the ‘immediate situation’
• A pivotal role for community nurses
• Education of patients and their families
about managing self care
• Potential for reduction in unplanned
presentations to hospital for cancer
patients
Publications
• McKenzie H, Hayes S, Forsyth S & , Boughton
M (2008) Explaining the Complexities and Value
of Nursing Practice and Knowledge. In Crouch M
& Morley I (Eds) Illumination Through Critical
Prisms, Rodopi, Amsterdam
• McKenzie H, Boughton M, Hayes L, Forsyth S,
McVey P, Davies M, Underwood E (2007) A
sense of security for cancer patients at home:
the role of community nurses, Journal of Health
and Social Care in the Community, 15(4): 352359
Study Two
Chemotherapy
outpatients’
unplanned
presentations to
hospital:
A retrospective study
Funding: Merck Sharp & Dohme
Aims
• To identify and analyse the nature and
magnitude of chemotherapy outpatients
unplanned presentations (and admissions) to
the emergency department or cancer centre at
a large metropolitan hospital
• To explore the antecedents to these visits
Background
NSW (2006):
• 600 outpatient
chemotherapy chairs
• 125,000 outpatient
chemotherapy visits
annually
• Research demonstrates
side effects of
chemotherapy can be
distressing and
debilitating
What is Known?
• Chemotherapy-related
serious adverse effects may
be more common than
reported in clinical trials
• Cancer patients receiving
chemotherapy are more
likely than those who are not
to visit the emergency room
or be hospitalised
• Chemotherapy patients incur
significant costs
(Hassett et al 2006)
Methodology
• Retrospective study
– October 1, 2006 - September 30, 2007
– Data bases, medical records from ED & Sydney Cancer
Centre
– All patients on chemotherapy within 6 months of their
unplanned presentation to RPAH
– Variables: cancer diagnosis, reason for presentation,
chemotherapy regimen, position in the treatment
trajectory, whether or not they were admitted & if so for
how long, and a range of demographics.
• Interviews (2008)
– To explore antecedents to the unplanned presentations to
hospital
Between October 2006 - September 2007:
316 people
469 unplanned presentations
Chemotherapy
six months prior to
unplanned presentation(s)
No Chemotherapy
six months prior to
unplanned presentation(s)
Visits = 363 (77.4%)
People = 233 (73.7%)
Visits = 106 (22.6%)
People = 83 (26.3%)
Age group
90
80
70
35.6%
Mean age: 58.9 years
Stdev: 13.6 years
Range 18 - 89
Frequency
60
21.0%
50
18.9%
40
10.7%
30
20
10
6.0
1.3
3.4
3.0%
0
< 19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 - 89
Individuals on chemotherapy in last 6
months who made an unplanned
presentation: Principal diagnosis
60
Frequency
50
21.0% 19.7%
40
30
20
10
0
8.2%
6.9%
5.6%
4.7%
4.7% 3.4%
Admissions
Length of stay
Total bed days
over the study
period
Cost
(estimated bed day
$886)
317 of 363 visits (87.3%)
resulted in a hospital
admission
Median = 5 days
Range 1 – 70 days
2,622
$2,323,092
363 Presentations
233 People
chemotherapy within 6 months
Chemotherapy
in last 4 weeks
prior to visit
No Chemotherapy
in last 4 weeks
prior to visit
253 visits (53.9%)
188 people (59.5%)
110 visits (23.4%)
45 people (14.2%)
Chemotherapy within last
4 weeks prior to visit
253 Visits
188 people
Side effects of
chemotherapy
Effects of the
disease
Other
Non cancer related
Radiotherapy side effects
Lack of information
133 visits (52.5%)
79 visits (31.2%)
41 visits (16.3%)
Visits made within 4 weeks of
chemotherapy (n=253): day in cycle
80
33.3%
70
29.6%
60
Frequency
50
20.7%
40
16.4%
30
20
10
0
1- 7
8 - 14
Day in cycle
15 - 21
22 - 28
Conditions of people on chemotherapy in last four weeks:
differences between those presenting for chemotherapyrelated and disease-related reasons
Presentations for
chemotherapyrelated reasons
70
60
50
Presentations for
disease-related
reasons
40
30
20
10
Shortness
of breath
Anaemia
Pain
Dehydration
Nausea
and/or
vomiting
Fever and/or
febrile
neutropenia
0
“My GP has seen me and she says, 'you're
pretty awful again today, if you need support
then go back to your chemo people’… I’d
rather do without it … and not overload the
resources.
But I just feel that I need it sometimes cause I’m
really very shaky and there is nothing that we
can do at home, that we can think of…I have
absolutely no coping skills...I felt awful coming
up but at the same time I felt I needed support
in my struggle. And how do I get that at
home?”
Woman (60 yrs) describes why she chose to come to the Cancer Centre
(September 2008)
“I am a small person and he was barely able to walk.
It was hard to put him in the car ... It’s a lot for his
body because he is so weak. He is not able to walk
properly and he is not feeling well.
And that is why he doesn’t want to come here. You
wait and wait and you get to the point where it is
more and more.
There should be a way to avoid this situation. It
should be easier.”
Wife, and main carer, of man (59 years) with Gastric Carcinoma.
Unplanned visit to cancer centre 3 days after treatment (October 2008)
21
Conclusion
• Chemotherapy
outpatients have
significant unmet needs
• Increasing trend towards
outpatient care
• Improved integration of
tertiary and community
care is needed to
address the burden of
chemotherapy side
effects
22
Study Three
Closing the circle of care:
Evaluating a shared care clinical
pathway intervention for
chemotherapy outpatients
• RCT of community/hospital shared care
clinical pathway intervention for patients
receiving outpatient chemotherapy.
• H1 There is a statistically significant
reduction in the number of unplanned
presentations to hospital between the
control and intervention groups
Aim
• Determine if the intervention reduces the
number of unplanned presentations to
hospital for chemotherapy outpatients;
and
• Improve physical and psychosocial
health outcomes.
• To explore the cost-effectiveness of the
intervention, focusing on the potential
reduction in hospital costs and improved
quality of life.
Study Design
• Multi-centre RCT of chemotherapy
outpatients undergoing chemotherapy
cycles 1, 2 & 3
• Standard Treatment versus Clinical
Pathway
• Target Recruitment : 300 patients
Intervention
• Structured Community Nurse
Assessment and follow up post
chemotherapy
• Clinical Pathway Guided Care
• Feedback to Cancer Centre
Community Nurse Education
• Two Day Education Program:
– Trends in cancer
– Chemotherapy
– Symptom assessment
– Supportive Care
– Clinical Assessment
– Study protocol
– Patient education
Standard Care
1. Pre-treatment baseline
assessment
2. Cycle 1: Day 2 Phone
Call
3. Cycle 2: Day 2 Phone
Call
4. Cycle 3: Day 2 phone call
Clinical Pathway
1. Pre-treatment baseline
assessment
2. Cycle 1: Day 2 and Day 5
home visits CN
3. Cycle 2: Day 2 and Day 5
home visits CN
4. Cycle 3: Day 2 and Day 5
home visits CN
Intervention: The CN Visit
• The standardised visits will focus on:
– Assessment of the patient (physical and
psychosocial and knowledge)
– Referral , provide care and advice as needed
– Electronic documentation Chemotherapy
Symptom Assessment Scale (C-SAS)
Brown et al 2001
• C-SAS transferred (via palm pilot
technology) to the patient’s specialist
cancer centre and GP
Data Collection 4 time points
• Baseline: demographic & treatment information
• SF36 and time point 4
All time points:
• Unplanned presentations to hospital
• Patient participant quality of life measures;
• Hospital Anxiety and Depression Scale (HADS),
• Functional Assessment of Cancer Therapy –
General (FACT-G)
• Cancer Behaviour Inventory – Long version
(CBI-L).
• Individual and focus group interviews with HCT
Standard Care
1. Pre-treatment baseline
assessment
2. End of Cycle 1
3. End of cycle 2
4. End of cycle 4
Clinical Pathway
1. Pre-treatment baseline
assessment
2. End of Cycle 1
3. End of cycle 2
4. End of cycle 4
Outcomes
• Primary: A reduction in the proportion of
chemotherapy outpatients on cycles 1, 2 & 3
making an unplanned presentation to hospital.
• Secondary: Chemotherapy outpatients in the
intervention group will have statistically
significantly improved scores QoL measures
compared with the control group.
Data Analysis
Quantitative Data:
• Poisson regression analysis
• Repeated Measures Analysis of Variance
Economic Analysis:
• Data linkage
• Cost weights for DRG
• Clinical outcomes: test for differences into index
of overall health-related quality of life using
algorithms to convert response of the SF-36.
• Facilitating patient and carer education
• Coordinating the interface between
community and cancer centre settings