The Catalonia WHO Demonstration Project on Palliative Care implementation: results at 20 years

Institut Català d’OncologiaICO DiR. The ‘Qualy’ End of Life Care Observatory - WHO Collaborating Centre for Public Health Palliative Care Programmes

The Catalonia WHO Demonstration Project

on Palliative Care implementation:

results at 20 yearsX Gómez-Batiste MD, PhD

The ‘Qualy’ End of Life Care Observatory WHO Collaborating Centre for Public Health Palliative Care

Programmes

Institut Català d’Oncologia

10th March 2011

.


Background 80’s

• Eric Wilkes (Sheffield)• Vittorio Ventafridda (Milano)• Jan Stjernsward (WHO)• Kathy Foley (OSI, NY)

Palliative Care as a Public Health topic


Catalonia / Barcelona


Catalonia 2009• 7.500.000 inhabitants (4.5 in

Metropolitan Barcelona)• > 65 years: 17%• 60.000 people with dementia• 130.000 elderly with

pluripatology and dependency• Mortality rate: 9 / 1.000• Life expectancy: 79 m / 82 f


Catalonia 2009

• Autonomous Government, Parliament, and Regional DoH

• HCS: Free of charge, universal, accesible

• Acute beds: 18.000• Socio-Health (geriatric, chronic,

dementia, RHB and palliative care): 7.000 beds

• Nursing homes: 50.000 beds• Primary care: Health care centers


Catalonia: Mortality / prevalence

Mortality • Global : 60.000• Cancer : 16.000• Noncancer chronic: 24.000• Total chronic conditions: 40.000Prevalence terminal patients:• Cancer: 4.000 (mean survl 3 months)

• Other conditions: 18.000 (mean sl 9 months)

• Total: 22.000Estimation based in McNamara, 2006


Quantitative analisys: JPSM, 2007

Institut Català d’OncologiaCare Resources 2009 (Total: 236)

PADES: 74

HSTs: 49

PCUs: 60Outps: 50

Other: 10


Resources CP Cat 2009DIRECT

PC ServicesAcute: 32Non Acute: 27

Total: 59

OutpatientsCExt EIAIA: 22CExt convenc: 28

Total: 50

Hospital Support Teams

38 Total: 38

Home Support Teams

74 Total: 74

Psicosocial Support Teams

5 Total: 5

Other 5 5

TOTAL 231

INDIRECT

PlanningResearchKnowledgeTraining

Dpment of Health -PDSSCatalan Institute of Oncology – Training & Research Dpments The ‘Qualy’ Observatory/WHOCC

5

TOTAL SPECIFIC RESOURCES PC

236


Specialist services Additional processes / year Other relevant outputs

CARE SERVICES

Home Care Support Teams

721 / 110,000 citizensProcesses: 13,000

% Cancer / non-cancer: 49 / 51

Mean age: 76 Death at home: 68% Duration of intervention:

80 days

PCUs in Socio-Health Centers

PCUs: 28Beds: 383Processes:

6,300

Total PCUs: 60Total beds: 742

(110 beds / million)Processes: 10,450

Mean age: 74 Length of stay: 20.3 days Mortality: 72.9%

PCUs in Nursing Homes

PCUs: 27Beds: 319Processes:

3,150

Mean age: 82 Length of stay: 35 days Mortality: 85%

PCUs in Acute Bed Hospitals

PCUs: 5Processes:

1,000

Cancer 80% Mean age: 61 Length of stay: 11d Mortality: 55%

Hospital Support Teams

49 Processes: 10,700

Cancer / non-cancer: 60 / 40

Mean Age: 73 Length of stay: 10 days

Psychosocial Support Teams

6 Processes: 1,500 Cancer 80%

Outpatient Clinics 50 Processes: 9,000 Cancer / non-cancer: 60 /

40

TOTAL CARE SERVICES: 237 TOTAL CARE PROCESSES: 46,200 (2 / patient)

Other Services (4)

- Team at the Department of Health- Education and Training Unit (ICO)- The ‘Qualy’ EoL Observatory / WHOCC (ICO)- Clinical Research Team (ICO)

• Specialist Services: 241• Full time Doctors: 240 (32.8 / million)• Total Patients: 23,100; Cancer: 12,100 (52%); Non-cancer: 11,000 (48%)• Coverage: Cancer: 73.3%; Non-cancer: 31% -58%; Geographic area cover: 100%


Catalonia 2010• Coverage (geographic): 100%• Coverage cancer: 73%• Coverage non cancer: 40-56% (*)• Proportion cancer/noncancer : 50%• Nº Dispositives: 236• Beds/milion: 101.6• Full time doctors: 220 (30 / milion)

(*) McNamara, 2006


Training

• 423 health-care professionals (60% doctors and 40% nurses) have been taught PC to Master’s degree level at the University of Barcelona.

• All nursing schools, 50% of medical and social work schools now include modules of PC.

• Most family doctors (General Practitioners) have a PC stage of 1 or 2 month’s duration inserted in their specialist training.


Training Primary care

Coverage of PC training in primary care professionals: 70.5%

• Advanced/Master’s degree 3.4% • Intermediate 15.2%• Basic level 51.9%


Populational impact 1990-2005

- More than 250.000 patients attended- More than 900.000 persons (14% of

population) in direct contact with palliative care services


Cost/efficiencyType of service Calculation Subtotal / type Estimated

savings; Euros

HCST 229,000 x 72 services

16,488,000 (31%)

TOTAL SAVINGS: 3,000 / patient x 23,100 = 69,300,000

HST 279,000 x 49 services

13,671,000 (26%)

PCU 96 x 209,000 stays

20,064,000 (38%)

OUTPAT 155 x 9,000 processes

1,395,000 (3%)

PST 190,000 x 5 services

950,000 (2%)

TOTAL TOTAL COSTS: 52,568,000 / year

NET SAVINGS: 16,732,000 / year


Evaluations of the Catalonia WHO Demonstration Project: Methods

- External evaluation of indicators (Suñol et al, 2008)

- SWOT nominal group of health-care professionals (Gomez-Batiste et al, 2007)

- Focal group of relatives (Brugulat et al, 2008) - Benchmark process (2008) (Gomez-Batiste et al,

2010)- Efficiency (Serra-Prat et al 2002 & Gomez-

Batiste et al 2006)- Effectiveness (Gomez-Batiste et al, J Pain

Symptom Manage 2010)- Satisfaction of patients and their relatives

(Survey CatSalut, 2008)





0

10

20

30

40

50

60

70

80

DOL CRIS AST ANS INS

DIA 1DIA 7

Efectpal (111 teams): Results Symptoms day 1 day 7

(p < 0.001) R Roca, PhD 2007

Effectiveness: Efectpal


Efficiency of PCSs

• Multicenter longitudinal study on the use of resources by cancer patients attended by PCSs• Comparison with previous use without PCSs• 171 teams / 395 patients



0

10

20

30

40

50

60

70

80

INGRÉS ESTMITJ URGENC DOMI COST

19922002

COMPARISON 1992-2002: USE/COST OF RESOURCESINGR: % malalts / ESTMITJ: dies / URGENC: %malalts COST: euros x 100 (XGB et al, 2006)



Dimensions of PCPHPs

• Coverage • Access / equity / availability /

continuity• Quality of services • Sectorised coordination • Opioids• Professionals• Education and Training• Evaluation• Research• Financing• Other…….


Qualitative analisys: results

Strong Points• Region of 7.3 milion habs• High coverage cancer,

relative noncancer, and geographical

• High coverage home care cancer and non cancer

• Professional’s committment• Public Health Planning• Insertion in the HCS,

diversity, models • Effectiveness• Efficiency• Satisfaction

Weak Points• Low coverage noncancer,

inequity variability, sectors and services (specific and conventional)

• Difficulties in access and continuing care (weekends)

• Late intervention • Evaluation, emotional

support, bereavement, • Professionals: low income,

support, and academic recognition

• Financing model and complexity

• Research and evidence


Proposals


GeneralIndicators

(20)

Hospitalization ServicesDay Care & Support Teams

OUTPATIENTS

(5)

HOME SUPPORT TEAMS

(6)

HOSPITAL SUPPORT TEAMS

(7)

DAY CARE

(6)

MEDIUM-STAY

(6)

LONG-STAY

(7)

PALLIATIVE (5)

Indicators per device

Indicators per Care line

INDICATORS MODEL

PAL

PAL

PAL

PAL

PAL

PAL


Models in Demographic settings



Organic Law 6/2006 of the 19th July, on the Reform of the Statute of Autonomy of Catalonia

ARTICLE 20. THE RIGHT TO UNDERGO THE PROCESS OF DEATH WITH DIGNITY

1. Each individual has the right to receive appropriate treatment of pain and complete palliative attention and to undergo the process of death with dignity.

2. Each individual has the right to express his or her will in advance in order to record instructions regarding any medical treatment or intervention that he or she may undergo. These instructions must be respected especially by medical staff, in accordance with the terms established by the law, if the individual is not able to express his or her wishes personally.

The Parliament of Catalonia


Institut Català d’OncologiaICO DiR. The ‘Qualy’ End of Life Care Observatory - WHO Collaborating Centre for Public Health Palliative Care Programmes

.

The ‘Qualy’ End of Life Care Observatory WHO Collaborating Centre for Public Health Palliative Care

[email protected]

+34 93 260 77 36

ICO l’HospitaletHospital Duran i ReynalsGran Via de l’Hospitalet, 199-20308908 l’Hospitalet de Llobregat


Documents

The Catalonia WHO Demonstration Project on Palliative Care implementation: results at 20 years