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Palliative Care implementation in Catalonia 1990-2003: a WHO demonstration project

Palliative Care implementation in Catalonia 1990-2003: a WHO demonstration project. Catalonia. 6.200.000 habitants, > 65: 17% Regional autonomous public NHS Hospitals: 16.000 beds, Mid term: 5.000, Residential: 40.000 Acute bed / Primary care / Sociohealth system /Residential

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Palliative Care implementation in Catalonia 1990-2003: a WHO demonstration project

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  1. Palliative Care implementation in Catalonia 1990-2003:a WHO demonstration project

  2. Catalonia • 6.200.000 habitants, > 65: 17% • Regional autonomous public NHS • Hospitals: 16.000 beds, Mid term: 5.000, Residential: 40.000 • Acute bed / Primary care / Sociohealth system /Residential • Cancer mortality: 13.000 • Dementia prevalence: 90.000

  3. PCPC: Background • British experience on Hospices: model of care and internal organisation • The Public Health approach: Wilkes’s Report (1985) + Jan Stjernsward (WHO) • Smart Minister of Health!

  4. PCPC: principles • Measures in all places • Sectorized • Insertion in preexisting services • Gradual implementation • Public Planning • Public Financement

  5. PCPC: aims • Coverage: for all in everywhere • Equity and accesibility • Quality: effectiveness, efficiency, satisfaction • Reference WHO

  6. PCPC: elements • Evaluation of needs • Implementation of specific services • Measures in general services • Training • Legislation and standards • Availability opioids • Financing and payment system • Evaluation of results

  7. Initial estimation of needs • Cancer: Incidence: 18.000 Mortality: 12.000 Prevalence: 40.000 Prev. pain: 17.000 • Aids (mortality): 600 • Dementia (prevalence): 60.000

  8. PCPC: global results 2001 • Nº total resources: 133 • Interventions/year: 17.455 • Coverage cancer: 67.1% • Coverage, geographical: 95% • Coverage, populational (PADES): 88.7% • Total beds: 523 • Beds /milion hab: 84.3% • Full time doctors: 118

  9. Placement of services Hospitals Centres sociosanitaris Centres Residencials Comunitat Hospices

  10. Specific resources: placement Mitja estada polivalent Unitats Equips de suport Hospitals de dia

  11. Units • Nº total: 50 • Beds: 523 (10.5/UCP) • Length stay: 22.8 days • Mortality: 69.7% • Discharges home: 23.0%

  12. Units 2001: placementXGB, 2003 Hosp Univ: 6 Hosp Gen: 4 ICO: 1 CSS: 38 MEP: 11

  13. Home Care Support Teams (PADES) • Nº total: 60 at 2003 • Nº new patients/year: 250 • Cancer, geriatrics, chronic • Prevalents: 30-40 • Time intervention: 6 setmanes • Place of death: 61% home, 19% CSS, 12% HA • Nº total professionals (2003): 318

  14. Complex metropolitan systems (300-500.000 hab): levels, coordination

  15. CP: levels of complexity Complete teams Units Reference: complexity+ training+ research Basic Support Teams General Measures in Conventional Services

  16. Comprehensive district system(12 sectors of 100-150.000 hab): integrated Unit at the CSS, Support teams to Hospital, Home, and residences

  17. Comprehensive system in small districts(5 of 20-50.000 hab) Basic team acting in all settings, conventional beds in acute or subacute settings

  18. MORCANC (1992) Patients: 388 Population Follow-up: 4 w Length stay: (25.5 per 6 weeks) Hospital stays: 7.114 URSPAL (2002) Patients: 395 Attended by pcs Follow-up: 6 setm. Length stay: 19 days/ 6 setmanes Hospital stays: 4.085 (69.9% at pcs) Comparison 1992-2002 XGB et al, 1999 / XGB et al, 2002

  19. 1992 2001 1992 Vs URSPAL 2001: Place of Death (%)

  20. Comparison 1992-2002: Use/cost of Resources (XGB et al, 2002)

  21. Cost of stay (euros/day) in 2001 Source: Servei Hospitals, SCS,2002

  22. Hospital Costs: 1992 vs 2001(Cost / process-patient / 6 weeks) • 1992: 4.987 euros • 2001: 1.701 euros • Diference: 3.286 euros / patient

  23. Effectiveness? • Basal Pain in a survey of 57 teams, including 396 patients, to study irruptive pain: Mean: 2.9 Median: 2.0

  24. Efectiveness: % Pain 5 X EVA 3,6 3 2,8 n416 238 150 Outpatient’s clinic ICO Porta et al, 2002

  25. Morphine Comsumption (kg / milion habitants / year)

  26. Catalan Decret i ordre 1991 • Recomendaciones de la SECPAL, Ministerio de Sanidad (1993) • Estàndards de cures pal.liatives, SCS, SCBCP (1993) • Decreto/orden 1993 (Opioides) Ministerio • Plan Nacional de Cuidados Paliativos (2001) • Guía de criterios de calidad en cuidados paliativos: SECPAL, Ministerio Sanidad (2002) • Indicadores de calidad en cuidados paliativos: SECPAL, Ministerio de Sanidad LEGISLATION/STANDARDS 1990-2003

  27. PCPC: EVOLUTIVE TENDENCIES 1990-2000 • Consolidation of teams, diversity, and coverage • Complexity of patients and intervention • Cooperation, early intervention, shared care • Extension of training • Initial phase of research (observational) • Social satisfaction

  28. Public Health approach • Coverage, equity, access (cancer) • Influence and coverage in geriatric care • Community oriented • Diversity of services and models • Highly experienced teams • Model of care implemented • Coverage of training • Effectiveness, efficiency, satisfaction • Initial phase of research (multicentric) • Social, media, and values impact PCPC: STRONG POINTS

  29. PCPC: AREAS FOR IMPROVEMENT • Late intervention • Some places and pathologies not yet implemented • Low implementation of some complex interventions, psichosocial aspects, and complementary • Variability in access and continuing care • Risk of burnout for small teams • Variability of measures in general services • Training not yet academically recognised • Low generation of evidence • Low financement for UCPs in sociohealth centers

  30. Dilemas and Questions • Initial measures? • Placement of resources? • Number of resources? • Coverage? • Mixed or specific for diseases? • Evaluation? • Hierarchy and dependence? Use your knowledge and common sense

  31. PCPC: CONCLUSIONS and RECOMENDATIONS Very hard work, But Very nice results!

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