Impact of a Multidisciplinary Supportive Care Model Using Distress Screening at an Asian Ambulatory Cancer Center: A Cluster Randomized Controlled Trial.

PURPOSE: The Accessible Cancer Care to Enable Support for Cancer Survivors (ACCESS) program adopts a multidisciplinary supportive care model with routine distress screening to triage newly diagnosed cancer survivors for additional support on the basis of distress levels. This study aimed to evaluate the clinical impact of ACCESS over 1 year. METHODS: We performed cluster random assignment at the oncologist level in a 1:1 ratio to receive ACCESS or usual care. Participants 21 years and older, newly diagnosed with breast or gynecologic cancer, and receiving care at National Cancer Centre Singapore were included. Outcomes assessed every 3 months for 1 year included quality of life (QoL) (primary), functioning, physical and psychological symptom burden, and activity levels. Data were analyzed using mixed-effects models. RESULTS: Participants from 16 clusters (control = 90, intervention = 83) were analyzed. The ACCESS program did not significantly improve QoL (primary outcome). However, compared with usual care recipients, ACCESS recipients reported higher physical functioning (P = .017), role functioning (P = .001), and activity levels (P < .001) at 9 months and lower psychological distress (P = .025) at 12 months. ACCESS recipients screened with high distress had poorer QoL, lower role and social functioning, and higher physical symptom distress at 3 months but had comparable scores with ACCESS recipients without high distress after 12 months. CONCLUSION: Compared with usual care, participation in the ACCESS program did not yield QoL improvement but showed earlier functioning recovery related to activities of daily living and reduced psychological distress. Routine distress screening is a promising mechanism to identify survivors with poorer health for more intensive supportive care.

Implementing an Inclusive, Multidisciplinary Supportive Care Model to Provide Integrated Care to Breast and Gynaecological Cancer Survivors: A Case Study at an Asian Ambulatory Cancer Centre.

Introduction: Supportive care models considering inclusivity and community services to improve integrated care for cancer survivors are limited. In this case study, we described the implementation of a multidisciplinary care model employing routine distress screening and embedded integrated care pathways to integrate care across disciplines and care sectors, while remaining inclusive of the multi-ethnic and multilingual population in Singapore. We reported implementation outcomes after 18 months of implementation. Description: We reviewed the model's process indicators from September 2019 to February 2021 at the largest public ambulatory cancer centre. Outcomes assessed included penetration, fidelity to screening protocol, and feasibility in three aspects - inclusiveness of different ethnic and language groups, responsiveness to survivors reporting high distress, and types of community service referrals. Discussion/conclusion: We elucidated opportunities to promote access to community services and inclusivity. Integration of community services from tertiary settings should be systematic through mutually beneficial educational and outreach initiatives, complemented by their inclusion in integrated care pathways to encourage systematic referrals and care coordination. A hybrid approach to service delivery is crucial in ensuring inclusivity while providing flexibility towards external changes such as the COVID-19 pandemic. Future work should explore using telehealth to bolster inclusiveness and advance community care integration.

Factors associated with distress and the impact of distress on acute health-care service utilization among patients diagnosed with breast and gynecological cancers.

OBJECTIVES: Patients with cancer often have unmet needs (e.g., physical, psychosocial, and emotional) during their cancer journey, putting them at risk for distress. This study aimed to identify factors associated with distress and to investigate the association between distress and acute health-care services utilization in a cohort of breast and gynecological cancer patients across different survivorship stages. METHODS: This was a retrospective cohort study of patients who visited National Cancer Centre Singapore between September 2019 and July 2020. Distress was evaluated using the self-reported Distress Thermometer and Problem List, with a distress thermometer score ≥4 signifying high distress. Data were extracted from electronic medical records. Multivariable logistic regression was used to identify demographic or clinical variables associated with distress and estimate the odds of emergency department (ED) visits and hospitalizations within 30 days of distress screening, adjusted for covariates. RESULTS: Of the 1386 patients included in the analysis, 510 (36.8%) reported high distress on their first distress screening. Variables associated with high distress included younger age, presence of psychiatric diagnosis, poorer Eastern Cooperative Oncology Group performance status, and shorter duration from cancer diagnosis to distress screening. Patients with high distress were associated with higher odds of ED visits (adjusted odds ratio [OR] = 2.25, 95% confidence interval [CI]: 1.14-4.43) and hospitalizations (adjusted OR = 2.11, 95% CI: 1.27-3.50) within 30 days of distress screening. SIGNIFICANCE OF RESULTS: Self-reported high distress was associated with higher odds of increased acute health-care services utilization (ED visits and hospitalizations) in patients with breast and gynecological cancer. Identifying the subgroups at risk of high distress could trigger early interventions that reduce unplanned health-care services utilization and possibly health-care costs.

Experience and Views of Oncology and Palliative Care Professionals on a Corounding Model of Care for Inpatients With Advanced Cancer.

BACKGROUND: Palliative care is associated with better outcomes in advanced cancer, but there is limited research comparing different models of palliative care delivery alongside oncology care. For inpatients with cancer, palliative care is mostly delivered through a consult service, primarily relying on oncologist-initiated referrals to a separate specialist palliative care team. In our hospital setting, we piloted a palliative care and oncology corounding model of care. AIM: To explore the views and experience of oncology and palliative care professionals on the corounding model compared to an inpatient consult service. DESIGN: A qualitative study nested within a pre-post study of the corounding model of care, with semistructured interviews using thematic analysis. SETTING/PARTICIPANTS: Eleven doctors and nurses involved in the pilot corounding model were interviewed. RESULTS: Two main themes emerged: (1) the efficiency of care delivery and (2) quality of patient care. The theme on the efficiency of care delivery was related to access to palliative care input, team communications, and parallel workflow. The quality of patient care was described in terms of holistic approach to cancer care and rapport building with patients and their families. Most participants acknowledged positive aspects of the corounding model, yet some minor concerns were reported, such as disagreements between oncology and palliative care professionals. CONCLUSIONS: This study provides insights into the benefits and drawbacks of a corounding model of care for inpatients. The views of health-care professionals can be incorporated into the development of integrated oncology and palliative care models to improve care for patients with advanced cancer.

Effect of a spiritual care training program for staff on patient outcomes.

OBJECTIVE: Physicians and nurses do not assess spirituality routinely, even though spiritual care is a vital part of palliative care for patients with an advanced serious illness. The aim of our study was to determine whether a training program for healthcare professionals on spirituality and the taking of a spiritual history would result in improved patient quality of life (QoL) and spiritual well-being. METHOD: This was a cluster-controlled trial of a spiritual care training program for palliative care doctors and nurses. Three of seven clinical teams (clusters) received the intervention, while the other four served as controls. Included patients were newly referred to the palliative care service, had an estimated survival of more than one month, and were aware of their diagnosis and prognosis. The primary outcome measure was the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) patient-reported questionnaire, which patients completed at two timepoints. Total FACIT-Sp score includes the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire, which measures overall quality of life, as well as a spiritual well-being score. RESULTS: Some 144 patients completed the FACIT-Sp at both timepoints-74 in the control group and 70 in the intervention group. The change in overall quality of life, measured by change in FACT-G scores, was 3.89 points (95% confidence interval [CI 95%] = -0.42 to 8.19, p = 0.076) higher in the intervention group than in the control group. The difference between the intervention and control groups in terms of change in spiritual well-being was 0.32 (CI 95% = -2.23 to 2.88, p = 0.804). SIGNIFICANCE OF RESULTS: A brief spiritual care training program can possibly help bring about enhanced improvement of global patient QoL, but the effect on patients' spiritual well-being was not as evident in our participants. Further study with larger sample sizes is needed to allow for more definite conclusions to be drawn.

Caregiving and Its Resulting Effects-The Care Study to Evaluate the Effects of Caregiving on Caregivers of Patients with Advanced Cancer in Singapore.

Informal caregivers (IC) are key to enabling home deaths, where preferred, at the end-of-life. Significant morbidity from advanced cancer can make caregiving burdensome. However, knowledge about the nature of the caregiving burden for caregivers in Singapore is limited. Hence, the key objective in this study was to examine the impact of the caregiving burden on quality of life (QOL), mental health and work capacity among local ICs. Eligible English-speaking ICs of hospitalized advanced cancer patients were recruited through non-random sampling. The Zarit Burden Interview (ZBI), Caregiver Quality of Life Index-Cancer (CQOLC), Center for Epidemiologic Studies Depression Scale-Revised (CESD-R), and Work Productivity and Activity Impairment Questionnaire (WPAI) were interviewer-administered to eligible ICs. Altogether, 16 ICs were surveyed. The mean age of ICs was 43.8 years. Most were children of patients (43.8%), and eight ICs had high burden (ZBI > 17). Those with ZBI > 17 had lower QOL, higher depression scores as well as greater work and activity impairment. In conclusion, high caregiver burden has adverse effects on QOL, mental health and work productivity. Non-physical elements of caregiving (particularly financial and decision-making) and increased number of care roles undertaken by a single IC contribute to high burden. Future interventions for caregiving burden in Singapore should also address the financial and decision-making aspects of caregiving. Outsourcing selected aspects of the caregiving role to community services may reduce the number of caregiving aspects undertaken by a single IC and caregiver burden.

Facilitating terminal discharge: fulfilling the hospitalised patient's wish for home death in the final hours.

BACKGROUND: Terminal discharge (TD) is the rapid discharge of a hospitalised patient when death is imminent. Its time-limited nature makes it challenging, particularly for ward nurses. AIM: To report the development of a structured TD framework, and determine if the framework can expedite TD processes and improve nurses' experience in conducting TDs. METHODS: A 3-phase audit was carried out in a Singapore hospital. The baseline and post intervention audits evaluated the time taken for TD, incidence of prescription errors, continuity of care, and timeliness of equipment arrangement. Nurse satisfaction was assessed through a written survey. Interventions encompassed the implementation of workflow changes and a TD guide. RESULTS: The mean time taken to complete TDs was shorter in the post-compared to pre-intervention phase (2.9±1.4 vs. 4.6±2.3 hours respectively, p<0.01). Approximately 89% of nurses who used the TD guide were satisfied that it made TDs easier. CONCLUSION: A structured TD framework is effective in expediting TDs and improving nurse satisfaction.

A Quantitative Framework Classifying the Palliative Care Workforce into Specialist and Generalist Components.

BACKGROUND: Early referral to palliative care (PC) services has been shown to improve quality of life in advanced cancer. However, limitations in trained PC workforce raise issues with the sustainability of delivering PC with early PC referral. Classifying PC into generalist and specialist components could be one approach to sustainable PC delivery models but a quantitative guide for this classification is presently lacking in the literature. OBJECTIVE: To undertake a retrospective examination of clinical data obtained from a PC benchmarking project to develop a quantitative framework guiding classification of PC services into specialist and generalist components. DESIGN: A descriptive retrospective study of data from 2726 hospitalized inpatients under the care of a tertiary consultative PC service over a 2-year period was conducted. Daily categorical symptom, overall psychological and social distress scores at the start and end of 3392 palliative care episodes as well as the number of visits made by the PC team to patients were extracted for analysis. RESULTS: More than 50% of patients had symptom, overall psychological or social distress scores of nil or mild severity at episode start and end. Approximately 20% of all 2726 patients accounted for approximately half of all visits made by the team regardless of the reasons for review. This patient percentage minority had more PC episodes starting with moderate or severe pain. These findings suggest a Pareto-like distribution in the occurrence of moderate/severe PC problems and the intensity of PC input. CONCLUSIONS: Large-scale clinical data supports the use of a Pareto-based quantitative framework for a workforce comprising of mainly generalist PC staff supported by smaller numbers of PC specialists.

'Rapid discharge': issues for hospital-based nurses in discharging cancer patients home to die.

AIMS AND OBJECTIVES: To explore issues for hospital-based nurses in arranging rapid home discharge for imminently dying cancer patients in a Singapore acute hospital. BACKGROUND: Dying at home is an important measure of a 'good death'. For hospitalised terminally ill patients, achieving home death can be of paramount importance to them and their family. Nurses experience many challenges in discharging imminently dying cancer patients home, due to time limitations and complex needs of patients and their families. DESIGN: Qualitative interpretive description. METHOD: Using purposive sampling, 14 registered nurses from an oncology ward in a Singapore hospital were recruited to participate in individual, semi-structured interviews. RESULTS: Nursing issues in facilitating rapid discharge fell into three categories: time, discharge processes and family preparation. Decisions to die at home appeared solely family/patient driven, and were made when death appeared imminent. Discharge then became time-critical, as nurses needed to complete multiple tasks within short timeframes. Stress was further exacerbated by nurses' inexperience and the infrequent occurrence of rapid discharge, as well as absence of standardised discharge framework for guidance. Together, the lack of time and discharge processes to enable smooth hospital-to-home transition potentially affected nurses' capacity to adequately prepare families, and may contribute to caregiver anxiety. CONCLUSION: Rapid discharge processes are needed as sudden patient/family decisions to die at home will continue. Earlier involvement of palliative care and implementation of a discharge pathway can potentially help nurses address their multiple responsibilities to ensure a successful transition from hospital to home. RELEVANCE TO CLINICAL PRACTICE: Recognition of nursing issues and challenges during rapid discharge has implications for clinical improvements in supporting nurses during this challenging situation. Results of this study can be used to inform the conceptualisation of clinical interventions to facilitate urgent discharges of imminently dying patients.