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

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

• 6.200.000 habitants, gt 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

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PCPC Background

• British experience on Hospices model of care and
  internal organisation
• The Public Health approach Wilkess Report
  (1985) Jan Stjernsward (WHO)
• Smart Minister of Health!

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PCPC principles

• Measures in all places
• Sectorized
• Insertion in preexisting services
• Gradual implementation
• Public Planning
• Public Financement

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PCPC aims

• Coverage for all in everywhere
• Equity and accesibility
• Quality effectiveness, efficiency, satisfaction
• Reference WHO

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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

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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

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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

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Placement of services
Hospitals
Centres sociosanitaris
Centres Residencials
Comunitat
Hospices
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Specific resources placement
Mitja estada polivalent
Unitats Equips de suport Hospitals de dia
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Units

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

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Units 2001 placement
XGB, 2003
Hosp Univ 6
Hosp Gen 4
ICO 1
CSS 38
MEP 11
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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
• 
  

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Complex metropolitan systems (300-500.000 hab)
levels, coordination
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CP levels of complexity
Complete teams Units
Reference complexity training research
Basic Support Teams
General Measures in Conventional Services
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Comprehensive district system(12 sectors of
100-150.000 hab) integrated
Unit at the CSS, Support teams to Hospital, Home,
and residences
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Comprehensive system in small districts(5 of
20-50.000 hab)
Basic team acting in all settings, conventional
beds in acute or subacute settings
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Comparison 1992-2002

• 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)

XGB et al, 1999 / XGB et al, 2002
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1992
2001
1992 Vs URSPAL 2001 Place of Death ()
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Comparison 1992-2002 Use/cost of Resources

(XGB et al, 2002)
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Cost of stay (euros/day) in 2001

Source Servei Hospitals, SCS,2002
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Hospital Costs 1992 vs 2001(Cost /
process-patient / 6 weeks)

• 1992 4.987 euros
• 2001 1.701 euros
• Diference 3.286 euros / patient

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Effectiveness?

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

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Efectiveness Pain ?5
X EVA 3,6 3
2,8
n 416 238 150
Outpatients clinic ICO Porta et al, 2002
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Morphine Comsumption (kg / milion habitants /
year)
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LEGISLATION/STANDARDS 1990-2003
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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

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PCPC STRONG POINTS


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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

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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

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PCPC CONCLUSIONS and RECOMENDATIONS

• Very hard work,
• But
• Very nice results!