Palliative and supportive interventions to improve patient-reported outcomes in rural residents with cancer
Palliative care and supportive oncology are designed to increase the quality of life and other important patient-reported outcomes for people with advanced cancer. People living in rural areas have limited access to these supportive services and the impact of palliative care and supportive oncology on this population is not well studied. The objective of this systematic review is to identify publications that evaluated effects of palliative care and supportive oncology interventions on various PROs in people with advanced cancer in rural areas. Systematic search was conducted in Psych INFO, CINHAL, PubMed and Scopus. The databases were searched up to December 2016. Eight studies were included in this systematic review. The studies identified consisted primarily of small sample sizes, single-group designs, and were not powered to detect impact on PROs. However, these studies did provide preliminary evidence that palliative care and supportive oncology interventions may have a positive effect on physical and emotional symptoms as well as overall QoL in this population. In addition, these interventions were positively viewed by participants and have the potential to positively impact financial outcomes for the individuals and the society. Funding This work was supported by a Junior Faculty Career Development Award from the National Palliative Care Research Center.
Accepted for publication April 28, 2017
Correspondence
Stephanie Gilbertson-White, PhD, APRN;
stephanie-gilbertsonwhite@uiowa.edu
Disclosures The authors report no disclosures/conflicts of interest
Citation JCSO 2017;15(5):e248-e255
©2017 Frontline Medical Communications
doi https://doi.org/10.12788/jcso.0348
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Financial impact. Two articles described the financial impact of cancer care costs on the patient and society.14,22 In a study by Watanabe and colleagues in Canada,14 the amount of savings after the intervention in terms of travel expenses was C$192.71 for each visit because patients had previously had to travel from their rural communities to urban tertiary hospitals to receive palliative care. For some patients in that study, the amount of saving for expenses was as high as C$500 a visit. In addition, some individuals were not able to travel and would not have received anything if the intervention had not been available remotely.14 In a study by Smith and colleagues in the United States, there was a 62% decrease in the cost to society for each patient, from US$10,233 to US$3,862.22 The factors contributing to that reduction included increasing outpatient services, engaging nurses and primary care providers instead of specialists, and the lower costs of living in rural areas. In addition, the rural hospitals saw an increase in revenue and profits because of higher admission rates ($500,00 for each hospital annually).22
Discussion
The articles identified in this review provide some evidence of the potential impact that palliative and supportive oncology interventions could have on PROs for rural residents with advanced cancer. Noteworthy results were seen for impact on reducing physical and emotional symptoms, increasing overall QoL and well-being, increasing satisfaction and access to palliative care, and reducing the overall cost of palliative care for individuals and society.14-18,20-22
Although statistical significance was not observed for most of the symptom assessment, trends toward improved symptom reports were observed. A likely explanation for this finding, is the small sample size or inadequate design to evaluate symptoms as an outcome measure. Three studies were pilot or feasibility projects15,20,21 that were not powered to detect the impact of the intervention on symptoms. In contrast, QoL stands out as an outcome that was positively affected by palliative care interventions. Further research is needed to determine if there are important mediating and moderating factors that contribute to improve QoL that are specific to rural residents. Significant outcomes were also reported for participant satisfaction with the interventions, the increase in access to services, and the decrease in costs.
,Although there were not enough studies to determine the efficacy of these interventions, these results suggest that palliative and supportive interventions can have an impact on important patient-reported outcomes, such as symptoms and quality of life, and on health care system outcomes, such as cost. Evidence supporting the extent of the effectiveness of palliative care on various PROs in rural people is limited. None of the studies in this review evaluated the different aspects of palliative care specifically in rural residents.
It is interesting to note that all but one of the interventions used a telehealth approach to deliver the intervention. Telehealth interventions seem to be feasible, acceptable to people in rural areas, and show preliminary evidence that they can have an impact on PROs.
Limitations of this review include only inclusion of publications in English. In addition, some studies in this review include populations that were not exclusively rural residents, which makes it difficult for generalization.
Conclusion
Palliative and supportive interventions may improve various PROs in people with advanced cancer living in rural areas. Technologies that support remote access to people in rural areas, such as teleconferencing and videoconferencing, seem particularly promising delivery modalities with their potential to increase access to palliative and supportive interventions in underserved communities. Large-scale studies that are powered to test the impact of palliative care and support oncology interventions on PROs and other aspects of quality care among rural residents with advanced cancer are needed.
The authors thank Jennifer DeBerg, Health Science Librarian at the University of Iowa for her assistance in developing the literature search strategies.
