Determining the cut-off value for the Minimal Documentation System (MIDOS2) screening tool to initiate specialized palliative care based on patient's subjective need for palliative support and symptom burden in inpatients with advanced cancer.

PURPOSE: The Minimal Documentation System (MIDOS2) is recommended as a systematic screening tool for assessing symptom burden and patient needs in advanced cancer patients. Given the absence of an optimal weighting of individual symptoms and a corresponding cut-off value, this study aims to determine a threshold based on inpatient's subjective need for palliative support. Additionally, we investigate the correlation between symptom burden and subjective need for palliative support collected through a patient-reported outcome measure (PROM) with survival duration of less or more than one year. METHODS: Inpatients diagnosed with advanced solid cancer completed an electronic PROM, which included the MIDOS2 questionnaire among other tools. Differences in symptom burden were analysed between patients expressing subjective need for palliative support and those with survival of less or more than one year using ANOVA, Mann-Whitney-U Test, logistic regression, Pearson and Spearman correlation tests. Cut-off analyses were performed using a ROC curve. Youden-Index, sensitivity, and specificity measures were used as well. RESULTS: Between April 2020 and March 2021, 265 inpatients were included in the study. Using a ROC curve, the MIDOS2 analysis resulted in an Area under the curve (AUC) of 0.732, a corresponding cut-off value of eight points, a sensitivity of 76.36% and a specificity of 62.98% in assessing the subjective need for palliative support. The MIDOS2, with double weighting of the significant symptoms, showed a cut-off value of 14 points, achieving a sensitivity of 78.18% and a specificity of 72.38%. A total of 55 patients (20.8%) expressed a need for support from the palliative care team. This need was independent of the oncological tumour entity and increased among patients with a survival of less than one year. These patients reported significantly poorer physical (p < 0.001) or mental (p < 0.001) condition. Additionally, they reported higher intensities of pain (p = 0.002), depressive symptoms (p < 0.001), weakness (p < 0.001), anxiety (p < 0.001), and tiredness (p < 0.001). CONCLUSION: Using the established MIDOS2 cut-off value with an adjusted double weighting in our study, a large proportion of inpatients may be accurately referred to SPC based on their subjective need for palliative support. Additionally, subjective reports of poor general, mental, and physical condition, as well as pain, depressive symptoms, weakness, anxiety, and tiredness, increase the subjective need for palliative support, particularly in patients with a survival prognosis of less than one year.

Electronic Patient-Reported Outcome Measures (ePROMs) Improve the Assessment of Underrated Physical and Psychological Symptom Burden among Oncological Inpatients.

For advanced cancer inpatients, the established standard for gathering information about symptom burden involves a daily assessment by nursing staff using validated assessments. In contrast, a systematic assessment of patient-reported outcome measures (PROMs) is required, but it is not yet systematically implemented. We hypothesized that current practice results in underrating the severity of patients' symptom burden. To explore this hypothesis, we have established systematic electronic PROMs (ePROMs) using validated instruments at a major German Comprehensive Cancer Center. In this retrospective, non-interventional study, lasting from September 2021 to February 2022, we analyzed collected data from 230 inpatients. Symptom burden obtained by nursing staff was compared to the data acquired by ePROMs. Differences were detected by performing descriptive analyses, Chi-Square tests, Fisher's exact, Phi-correlation, Wilcoxon tests, and Cohen's r. Our analyses pointed out that pain and anxiety especially were significantly underrated by nursing staff. Nursing staff ranked these symptoms as non-existent, whereas patients stated at least mild symptom burden (pain: meanNRS/epaAC = 0 (no); meanePROM = 1 (mild); p < 0.05; r = 0.46; anxiety: meanepaAC = 0 (no); meanePROM = 1 (mild); p < 0.05; r = 0.48). In conclusion, supplementing routine symptom assessment used daily by nursing staff with the systematic, e-health-enabled acquisition of PROMs may improve the quality of supportive and palliative care.

Instruments to evaluate complexity in end-of-life care.

PURPOSE OF REVIEW: The growing number of patients with terminal and chronic conditions and co-morbidities constitutes a challenge for any healthcare system, to provide effective and efficient patient-centred care at the end of life. Resources are limited, and complexity is rising within patients' situations and healthcare professionals interventions. This review presents the state of art of the role of complexity in specialist palliative care provision. RECENT FINDINGS: Although studies related to complexity in palliative care are still limited, interesting reviews on complexity frameworks in co-morbidity conditions and palliative care are growing more present in current literature. They identify multidimensional issues, resource utilisation, and the relationship between them as fundamental aspects of complexity constructs, helping to define and understand complexity, and to therefore design validated tools to support healthcare professionals identifying the most complex patients, such as Hui's criteria, PALCOM, INTERMED, and IDC-Pal which is presented in this review. SUMMARY: There is an urgent need to guarantee quality and equity of care for all the patients eligible for palliative care, from those who need a palliative care approach to those needing specialist intensive palliative care. Implementing complexity theory into practice is paramount. In this review, complexity science, complexity frameworks, as well as tools evaluating complexity in palliative care are described.

El valor del Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos para identificar la complejidad en pacientes tributarios de cuidados paliativos / The value of the Diagnostic Tool for Complexity in Palliative Care for the assessment of palliative patients

INTRODUCCIÓN: Actualmente no existe una definición unánime en cuidados paliativos (CP) del término complejidad. Su correcta y objetiva valoración ayudaría a clasificar al paciente, permitiendo a los profesionales saber si se requieren recursos avanzados o convencionales de CP. OBJETIVOS: Describir la complejidad de los pacientes tributarios de CP en Sevilla mediante el Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos examinando el servicio sanitario prestado. MATERIAL Y MÉTODOS: Estudio observacional descriptivo transversal, con reclutamiento prospectivo. La herramienta Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos se aplicó a 74 pacientes tributarios de CP. Los datos se analizaron con el programa estadístico SSPS versión 20 y se analizaron las variables con el test chi-cuadrado. RESULTADOS: Tanto el equipo de recursos convencionales como el avanzado de CP tratan a pacientes independientemente de su complejidad (p = 0,482). El elemento de complejidad más prevalente fue el cambio brusco del nivel de autonomía funcional (n=27), sin que exista correlación con el equipo implicado. El elemento más prevalente para activar el equipo avanzado de CP es la naturaleza oncológica de la enfermedad (n=39; p = 0,018). CONCLUSIONES: La distribución de la complejidad en los pacientes tratados por recursos convencionales y avanzados de CP en el área estudiada es homogénea. Ello puede ser un indicador de la falta de adecuación de los recursos sanitarios con respecto a la complejidad del paciente. La implementación del Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos podría solventar este problema ya que ayuda a especificar cuándo y por qué se deriva un paciente a CP, evitando el exceso o defecto de dicha derivaciones

INTRODUCTION: There is currently no unanimous definition of the term complexity in palliative care (PC). The correct and objective assessment would help to classify palliative patients to enable health care professionals in their determination whether advanced or conventional PC resources are required. AIM: To describe the palliative patients' complexity, by using the Diagnostic Tool for Complexity in Palliative Care, and to examine the health care service provided. MATERIAL AND METHODS: A descriptive, cross-sectional, observational study with prospective recruiting was conducted by applying the Diagnostic Tool for Complexity in Palliative Care to 74 patients requiring PC in Seville, Spain. Data were analyzed using the statistical program SPSS version 20 and variables were analyzed using the chi-squared test. RESULTS: Both conventional and advanced PC teams treat patients regardless their degree of complexity (p= 0.482). The most prevalent complexity element was sudden change in the level of functional autonomy (n= 27), but there was no correlation with the team involved. The most prevalent element to drive involvement of the advanced PC team was the oncological nature of the disease (n= 39, p= 0.018). CONCLUSIONS: The distribution of complexity in PC patients treated by both conventional and advanced PC teams in the study area is homogeneous. This may be an indicator of the lack of appropriate health care resources as regards the complexity of the patient. Implementing the Diagnostic Tool for Complexity in Palliative Care may solve this problem by specifying when and why a PC patient is referred, and thus avoiding the excess or absence of such referrals

Diferencias y similitudes en la Medicina de Familia de los sistemas sanitarios en Alemania y España / Differences and similarities of Primary Care in the German and Spanish Health Care Systems

Una atención primaria eficaz es el pilar básico de cualquier sistema sanitario. A la hora de ofrecer una atención primaria costo-efectiva y eficiente para la población, existen muchas diferencias entre distintos países. En este artículo revisamos la literatura científica y socio-política actual de forma estructurada. Los resultados se complementan con la experiencia de una médico residente española en su último año de formación en medicina familiar y comunitaria, que completó cuatro meses de rotación en el sistema de salud alemán. De esta forma, destacamos algunas de las características de ambos sistemas sanitarios incluyendo los gastos, la relación entre atención primaria y secundaria, la organización en el ámbito académico y la formación de los futuros médicos de atención primaria. Tanto en España como en Alemania la atención primaria desempeña un papel central, ha de superar carencias, y en algunos puntos ambos países pueden aprender el uno del otro (AU)

An efficient primary care is of particular importance for any countries’ health care system. Many differences exist on how distinctive countries try to obtain the goal of an efficient, cost-effective primary care for its population. In this article we conducted a selective literature review, which includes both scientific and socio-political publications. The findings are complemented with the experience of a Spanish physician from Seville in her last year of training in family medicine, who completed a four months long rotation in the German health care system. We highlighted different features by comparing both countries, including their health care expenditure, the relation between primary and secondary care, the organization in the academic field and the training of future primary care physicians. It is clear that primary care in both countries plays a central role, have to deal with shortcomings, and in some points one system can learn from the other (AU)

[Differences and similarities of primary care in the German and Spanish health care systems]. / Diferencias y similitudes en la Medicina de Familia de los sistemas sanitarios en Alemania y España.

An efficient primary care is of particular importance for any countries' health care system. Many differences exist on how distinctive countries try to obtain the goal of an efficient, cost-effective primary care for its population. In this article we conducted a selective literature review, which includes both scientific and socio-political publications. The findings are complemented with the experience of a Spanish physician from Seville in her last year of training in family medicine, who completed a four months long rotation in the German health care system. We highlighted different features by comparing both countries, including their health care expenditure, the relation between primary and secondary care, the organization in the academic field and the training of future primary care physicians. It is clear that primary care in both countries plays a central role, have to deal with shortcomings, and in some points one system can learn from the other.