Palliative and Supportive Services Collected Works

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Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea.
(BMJ Publishing Group - http://bjo.bmjjournals.com/, 2003-09) Abernethy, Amy Pickar; Currow, David Christopher; Frith, David; Fazekas, Belinda Susan; McHugh, Annie; Bui, Chuong
Grief and loss: the needs of the whole population
(2004) Currow, David Christopher
The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice [ISRCTN81117481]
(2005) Woods, David A; Abernethy, Amy Pickar; Shelby-James, Tania Maree; Fazekas, Belinda Susan; Currow, David Christopher
Background : The Karnofsky Performance Status (KPS) is a gold standard scale. The Thorne-modified KPS (TKPS) focuses on community-based care and has been shown to be more relevant to palliative care settings than the original KPS. The Australia-modified KPS (AKPS) blends KPS and TKPS to accommodate any setting of care. Methods : Performance status was measured using all three scales for palliative care patients enrolled in a randomized controlled trial in South Australia. Care occurred in a range of settings. Survival was defined from enrollment to death. Results : Ratings were collected at 1600 timepoints for 306 participants. The median score on all scales was 60. KPS and AKPS agreed in 87% of ratings; 79% of disagreements occurred within 1 level on the 11-level scales. KPS and TKPS agreed in 76% of ratings; 85% of disagreements occurred within one level. AKPS and TKPS agreed in 85% of ratings; 87% of disagreements were within one level. Strongest agreement occurred at the highest levels (70–90), with greatest disagreement at lower levels (≤40). Kappa coefficients for agreement were KPS-TKPS 0.71, KPS-AKPS 0.84, and AKPS-TKPS 0.82 (all p < 0.001). Spearman correlations with survival were KPS 0.26, TKPS 0.27 and AKPS 0.26 (all p < 0.001). AKPS was most predictive of survival at the lower range of the scale. All had longitudinal test-retest validity. Face validity was greatest for the AKPS. Conclusion : The AKPS is a useful modification of the KPS that is more appropriate for clinical settings that include multiple venues of care such as palliative care.
Caresearch: finding and evaluating Australia's missing palliative care literature
(2005) Tieman, Jennifer; Abernethy, Amy Pickar; Fazekas, Belinda Susan; Currow, David Christopher
Implementation science: a role for parallel dual processing models of reasoning?
(2006) Sladek, Ruth; Phillips, Paddy Andrew; Bond, Malcolm James
Palliative management of refractory dyspnea in COPD
(2006) Currow, David Christopher; Abernethy, Amy Pickar; Uronis, H E
Challenges experienced by informal caregivers in cancer
(2006) Girgis, Afaf; Johnson, Claire; Aoun, Samar M; Currow, David Christopher
What are the essential medications in palliative care? - A survey of Australian palliative care doctors
(2006) Good, Phillip D; Cavenagh, John D; Currow, David Christopher; Woods, David A; Tuffin, Penelope H; Ravenscroft, Peter J
Until the chemist opens - palliation from the doctor's bag
(2006) Seidel, Rebecca; Sanderson, Christine Ruth; Mitchell, Geoffrey K; Currow, David Christopher
Knowledge, knowledge management and knowledge networks
(Australian Library and Information Association, 2006-10) Tieman, Jennifer
Integration, Coordination and Multidisciplinary Care: What can These Approaches Offer to Australian Primary Health Care?
(2007) Tieman, Jennifer; Mitchell, Geoffrey K; Shelby-James, Tania Maree; Currow, David Christopher; Fazekas, Belinda Susan; O'Doherty, Lorna Jane; Hegarty, Margaret Mary; Erikssen, Lars; Brown, Robyn; Reid-Orr, Desley Anne
Promoting patient centred palliative care through case conferencing
(2007) Williams, Helena; Shelby-James, Tania Maree; Currow, David Christopher; Phillips, Paddy Andrew; Abernethy, Amy Pickar
Handheld computers for data entry: high tech has its problems too
(BioMed Central - http://www.biomedcentral.com, 2007-02-20) Shelby-James, Tania Maree; Abernethy, Amy Pickar; McAlindon, Andrew; Currow, David Christopher
Background The use of handheld computers in medicine has increased in the last decade, they are now used in a variety of clinical settings. There is an underlying assumption that electronic data capture is more accurate that paper-based data methods have been rarely tested. This report documents a study to compare the accuracy of hand held computer data capture versus more traditional paper-based methods. Methods Clinical nurses involved in a randomised controlled trial collected patient information on a hand held computer in parallel with a paper-based data form. Both sets of data were entered into an access database and the hand held computer data compared to the paper-based data for discrepancies. Results Error rates from the handheld computers were 67.5 error per 1000 fields, compared to the accepted error rate of 10 per 10,000 field for paper-based double data entry. Error rates were highest in field containing a default value. Conclusion While popular with staff, unacceptable high error rates occurred with hand held computers. Training and ongoing monitoring are needed if hand held computers are to be used for clinical data collection.
Improving search filter development: a study of palliative care literature
(BioMed Central - http://www.biomedcentral.com, 2007-06-28) Sladek, Ruth; Tieman, Jennifer; Currow, David Christopher
Background It is difficult to systematically search for literature relevant to palliative care in general medical journals. A previously developed search filter for use on OVID Medline validated using a gold standard set of references identified through hand searching, achieved an unacceptably low sensitivity (45.4%). Retrieving relevant literature is integral to support evidence based practice, and understanding the nature of the incorrectly excluded citations (false negatives) using the filter may lead to improvement in the filter's performance. Methods The objectives were to describe the nature of subjects reflected in the false negative citations and to empirically improve the sensitivity of the search filter. A thematic analysis of MeSH terms by three independent reviewers was used to describe the subject coverage of the missed records. Using a frequency analysis of MeSH terms, those headings which could individually contribute at least 2.5% to sensitivity (occurring 19 or more times) were added to the search filter. All previously run searches were rerun at the same time as the revised filter, and results compared. Results Thematic analysis of MeSH terms identified thirteen themes reflected in the missing records, none of them intrinsically palliative. The addition of six MeSH terms to the existing search filter (physician-patient relations, prognosis, quality of life, survival rate, treatment outcome and attitude to health) led to an increase in sensitivity from 46.3% to 64.7%, offset by a decrease in precision from 72.6% to 21.9%. Conclusion The filter's sensitivity was successfully increased using frequency analysis of MeSH terms, offset by a decrease in precision. A thematic analysis of MeSH terms for the false negative citations confirmed the absence of any intrinsically palliative theme or term, suggesting that future improvements to search filters for palliative care literature will first depend on better identifying how clinicians and researchers conceptualise palliative care. It is suggested that a constellation of parameters: stage of disease (advanced or active), prospect of cure (little or none), and treatment goals (primarily quality of life) may ultimately inform search strategies. This may be similarly true for chronic diseases, which share the inherent passage of time which marks them apart from acute, and therefore more readily identifiable, episodes of care.
Promoting patient centred palliative care through case conferencing
(Royal Australian College of General Practitioners, 2007-11) Shelby-James, Tania Maree; Currow, David Christopher; Phillips, Paddy Andrew; Williams, Helena; Abernethy, Amy Pickar
BACKGROUND What are the characteristics of case conferences between general practitioners and specialised palliative care services (SPCS)? METHODS Study participants were adults (N=461) with pain in the preceding 3 months who were referred to a SPCS and their GPs (N=230). Patients were randomised to case conferences or routine care by SPCS. RESULTS One hundred and sixty-seven conferences were held; 46 patients withdrew and 142 died before the conference could be conducted. Medicare payment was requested for 72 (43%) conferences. Median time from randomisation to case conference was 52 days (SD: 55), and from case conference to death/end of study was 79 days (SD: 166). Twenty-five percent of conferences had over three health professionals participant; patients and/or their caregivers participated in 91%. Average conference duration was 39 minutes (SD: 13). Mean conference length did not increase when more health professionals were present (3 vs. >3, 39 [SD: 14] vs. 42 [SD 11] minutes, p=0.274), nor when patients/caregivers were present (present vs. absent, 39 [SD: 13] vs. 44 [SD: 14] minutes, p=0.159). DISCUSSION Case conferencing involving SPCS, the GP, other health professionals and the patient can be an efficient part of routine care.
Caregivers for people with end-stage lung disease: characteristics and unmet needs in the whole population
(2008) Currow, David Christopher; Burns, Catherine Mary; Ward, Alicia M; Clark, Katherine; Abernethy, Amy Pickar
Bereavement help-seeking following an 'expected' death: a cross-sectional randomised face-to-face population survey
(2008) Plummer, John Lewis; Currow, David Christopher; Allen, Katrina; Aoun, Samar M; Hegarty, Margaret Mary; Abernethy, Amy Pickar
Background : This study examines the prevalence and nature of bereavement help-seeking among the population who experienced an "expected" death in the five years before their survey response. Such whole population data are not limited by identification through previous access to specific services nor practitioners. Methods : In a randomised, cross-sectional, state-wide population-based survey, 6034 people over two years completed face-to-face interviews in South Australia by trained interviewers using piloted questions (74.2% participation rate). Respondent demographics, type of grief help sought, and circumstantial characteristics were collected. Uni- and multi-variate logistic regression models were created. Results : One in three people (1965/6034) had experienced an 'expected' death of someone close to them in the last five years. Thirteen per cent sought help for their grief from one or more: friend/family members (10.7%); grief counselors (2.2%); spiritual advisers (1.9%); nurses/doctors (1.5%). Twenty five respondents (1.3%) had not sought, but would have valued help with their grief. In multi-variate regression modeling, those who sought professional help (3.4% of the bereaved) had provided more intense care (OR 5.39; CI 1.94 to14.98; p < 0.001), identified that they were less able to 'move on' with their lives (OR 7.08; CI 2.49 to 20.13; p = 0.001) and were more likely not to be in full- or part-time work (OR 3.75; CI 2.31 – 11.82; p = 0.024; Nagelkerke's R2 = 0.33). Conclusion : These data provide a whole-of-population baseline of bereavement help-seeking. The uniquely identified group who wished they had sought help is one where potentially significant health gains could be made as we seek to understand better any improved health outcomes as a result of involving bereavement services.
Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems
(2008) Abbott, David H; Grambow, Steven C; Zafar, S Yousuf; Abernethy, Amy Pickar; Marcello, Jennifer E; Herndon II, James E; Rowe, Krista L; Kolimaga, Jane T; Zullig, Leah L; Patwardhan, Meenal; Provenzale, Dawn T
Background : Stage at diagnosis plays a significant role in colorectal cancer (CRC) survival. Understanding which factors contribute to a more advanced stage at diagnosis is vital to improving overall survival. Comorbidity, race, and age are known to impact receipt of cancer therapy and survival, but the relationship of these factors to stage at diagnosis of CRC is less clear. The objective of this study is to investigate how comorbidity, race and age influence stage of CRC diagnosis. Methods : Two distinct healthcare populations in the United States (US) were retrospectively studied. Using the Cancer Care Outcomes Research and Surveillance Consortium database, we identified CRC patients treated at 15 Veterans Administration (VA) hospitals from 2003–2007. We assessed metastatic CRC patients treated from 2003–2006 at 10 non-VA, fee-for-service (FFS) practices. Stage at diagnosis was dichotomized (non-metastatic, metastatic). Race was dichotomized (white, non-white). Charlson comorbidity index and age at diagnosis were calculated. Associations between stage, comorbidity, race, and age were determined by logistic regression. Results : 342 VA and 340 FFS patients were included. Populations differed by the proportion of patients with metastatic CRC at diagnosis (VA 27% and FFS 77%) reflecting differences in eligibility criteria for inclusion. VA patients were mean (standard deviation; SD) age 67 (11), Charlson index 2.0 (1.0), and were 63% white. FFS patients were mean age 61 (13), Charlson index 1.6 (1.0), and were 73% white. In the VA cohort, higher comorbidity was associated with earlier stage at diagnosis after adjusting for age and race (odds ratio (OR) 0.76, 95% confidence interval (CI) 0.58–1.00; p = 0.045); no such significant relationship was identified in the FFS cohort (OR 1.09, 95% CI 0.82–1.44; p = 0.57). In both cohorts, no association was found between stage at diagnosis and either age or race. Conclusion : Higher comorbidity may lead to earlier stage of CRC diagnosis. Multiple factors, perhaps including increased interactions with the healthcare system due to comorbidity, might contribute to this finding. Such increased interactions are seen among patients within a healthcare system like the VA system in the US versus sporadic interactions which may be seen with FFS healthcare.
Thinking styles and doctors' knowledge and behaviours relating to acute coronary syndromes guidelines
(BioMed Central - http://www.biomedcentral.com, 2008-04-25) Sladek, Ruth; Bond, Malcolm James; Huynh, Luan; Chew, Derek Peng; Phillips, Paddy Andrew
Background How humans think and make decisions is important in understanding behaviour. Hence an understanding of cognitive processes among physicians may inform our understanding of behaviour in relation to evidence implementation strategies. A personality theory, Cognitive-Experiential Self Theory (CEST) proposes a relationship between different ways of thinking and behaviour, and articulates pathways for behaviour change. However prior to the empirical testing of interventions based on CEST, it is first necessary to demonstrate its suitability among a sample of healthcare workers. Objectives To investigate the relationship between thinking styles and the knowledge and clinical practices of doctors directly involved in the management of acute coronary syndromes. Methods Self-reported doctors' thinking styles (N = 74) were correlated with results from a survey investigating knowledge, attitudes, and clinical practice, and evaluated against recently published acute coronary syndrome clinical guidelines. Results Guideline-discordant practice was associated with an experiential style of thinking. Conversely, guideline-concordant practice was associated with a higher preference for a rational style of reasoning. Conclusion Findings support that while guidelines might be necessary to communicate evidence, other strategies may be necessary to target discordant behaviours. Further research designed to examine the relationships found in the current study is required.
Measurement properties of the Inventory of Cognitive Bias in Medicine (ICBM)
(BioMed Central - http://www.biomedcentral.com, 2008-05-28) Sladek, Ruth; Phillips, Paddy Andrew; Bond, Malcolm James
Background Understanding how doctors think may inform both undergraduate and postgraduate medical education. Developing such an understanding requires valid and reliable measurement tools. We examined the measurement properties of the Inventory of Cognitive Bias in Medicine (ICBM), designed to tap this domain with specific reference to medicine, but with previously questionable measurement properties. Methods First year postgraduate entry medical students at Flinders University, and trainees (postgraduate doctors in any specialty) and consultants (N = 348) based at two teaching hospitals in Adelaide, Australia, completed the ICBM and a questionnaire measuring thinking styles (Rational Experiential Inventory). Results Questions with the lowest item-total correlation were deleted from the original 22 item ICBM, although the resultant 17 item scale only marginally improved internal consistency (Cronbach's α = 0.61 compared with 0.57). A factor analysis identified two scales, both achieving only α = 0.58. Construct validity was assessed by correlating Rational Experiential Inventory scores with the ICBM, with some positive correlations noted for students only, suggesting that those who are naïve to the knowledge base required to "successfully" respond to the ICBM may profit by a thinking style in tune with logical reasoning. Conclusion The ICBM failed to demonstrate adequate content validity, internal consistency and construct validity. It is unlikely that improvements can be achieved without considered attention to both the audience for which it is designed and its item content. The latter may need to involve both removal of some items deemed to measure multiple biases and the addition of new items in the attempt to survey the range of biases that may compromise medical decision making.

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