World Universities Network Presentation

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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

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Introduction

• Overview of program of research
• Introduction to this presentation
• Background Study One

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Exploratory research

• To explore the nature of nurse-patient 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

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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

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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) 352-359

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Study Two
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Chemotherapy outpatients unplanned presentations
to hospital A retrospective study

• Funding Merck Sharp Dohme

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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

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Background

• NSW (2006)
• 600 outpatient chemotherapy chairs
• 125,000 outpatient chemotherapy visits annually
• Research demonstrates side effects of
  chemotherapy can be distressing and debilitating

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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)

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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

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Between October 2006 - September 2007 316
people 469 unplanned presentations
No Chemotherapy six months prior to unplanned
presentation(s) Visits 106 (22.6) People 83
(26.3)
Chemotherapy six months prior to unplanned
presentation(s) Visits 363 (77.4) People
233 (73.7)
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363 Presentations 233 People chemotherapy within
6 months
No Chemotherapy in last 4 weeks prior to
visit 110 visits (23.4) 45 people (14.2)
Chemotherapy in last 4 weeks prior to
visit 253 visits (53.9) 188 people (59.5)
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Chemotherapy within last 4 weeks prior to
visit 253 Visits 188 people
Other Non cancer related Radiotherapy side
effects Lack of information 41 visits (16.3)
Side effects of chemotherapy 133 visits
(52.5)
Effects of the disease 79 visits (31.2)
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• 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 Id rather do without
  it and not overload the resources.
• But I just feel that I need it sometimes cause
  Im really very shaky and there is nothing that
  we can do at home, that we can think ofI 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)
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• I am a small person and he was barely able to
  walk. It was hard to put him in the car ... Its
  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 doesnt 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)
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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

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Study Three

• Closing the circle of care
• Evaluating a shared care clinical pathway
  intervention for chemotherapy outpatients

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• 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

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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.

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Study Design

• Multi-centre RCT of chemotherapy outpatients
  undergoing chemotherapy cycles 1, 2 3
• Standard Treatment versus Clinical Pathway
• Target Recruitment 300 patients

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Intervention

• Structured Community Nurse Assessment and follow
  up post chemotherapy
• Clinical Pathway Guided Care
• Feedback to Cancer Centre

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Community Nurse Education

• Two Day Education Program
• Trends in cancer
• Chemotherapy
• Symptom assessment
• Supportive Care
• Clinical Assessment
• Study protocol
• Patient education

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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 patients specialist cancer centre and GP

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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

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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.

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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.

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• Facilitating patient and carer education
• Coordinating the interface between community and
  cancer centre settings