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      Telemonitoring via Self-Report and Video Review in Community Palliative Care: A Case Report

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          Abstract

          Continuous monitoring and management of a person’s symptoms and performance status are critical for the delivery of effective palliative care. This monitoring occurs routinely in inpatient settings; however, such close evaluation in the community has remained elusive. Patient self-reporting using telehealth offers opportunities to identify symptom escalation and functional decline in real time, and facilitate timely proactive management. We report the case of a 57-year-old man with advanced non-small cell lung cancer who participated in a telehealth trial run by a community palliative care service. This gentleman was able to complete self-reporting of function and symptoms via iPad although at times he was reticent to do so. Self-reporting was perceived as a means to communicate his clinical needs without being a bother to the community palliative care team. He also participated in a videoconference with clinical staff from the community palliative care service and his General Practitioner. Videoconferencing with the nurse and GP was highly valued as an effective way to communicate and also because it eliminated the need for travel. This case report provides important information about the feasibility and acceptability of palliative care telehealth as a way to better manage clinical care in a community setting.

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          Most cited references17

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          The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice [ISRCTN81117481]

          Background The Karnofsky Performance Status (KPS) is a gold standard scale. The Thorne-modified KPS (TKPS) focuses on community-based care and has been shown to be more relevant to palliative care settings than the original KPS. The Australia-modified KPS (AKPS) blends KPS and TKPS to accommodate any setting of care. Methods Performance status was measured using all three scales for palliative care patients enrolled in a randomized controlled trial in South Australia. Care occurred in a range of settings. Survival was defined from enrollment to death. Results Ratings were collected at 1600 timepoints for 306 participants. The median score on all scales was 60. KPS and AKPS agreed in 87% of ratings; 79% of disagreements occurred within 1 level on the 11-level scales. KPS and TKPS agreed in 76% of ratings; 85% of disagreements occurred within one level. AKPS and TKPS agreed in 85% of ratings; 87% of disagreements were within one level. Strongest agreement occurred at the highest levels (70–90), with greatest disagreement at lower levels (≤40). Kappa coefficients for agreement were KPS-TKPS 0.71, KPS-AKPS 0.84, and AKPS-TKPS 0.82 (all p < 0.001). Spearman correlations with survival were KPS 0.26, TKPS 0.27 and AKPS 0.26 (all p < 0.001). AKPS was most predictive of survival at the lower range of the scale. All had longitudinal test-retest validity. Face validity was greatest for the AKPS. Conclusion The AKPS is a useful modification of the KPS that is more appropriate for clinical settings that include multiple venues of care such as palliative care.
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            Delivery strategies to optimize resource utilization and performance status for patients with advanced life-limiting illness: results from the "palliative care trial" [ISRCTN 81117481].

            Evidence-based approaches are needed to improve the delivery of specialized palliative care. The aim of this trial was to improve on current models of service provision. This 2×2×2 factorial cluster randomized controlled trial was conducted at an Australian community-based palliative care service, allowing three simultaneous comparative effectiveness studies. Participating patients were newly referred adults, experiencing pain, and who were expected to live >48 hours. Patients enrolled with their general practitioners (GPs) and were randomized three times: 1) individualized interdisciplinary case conference including their GP vs. control, 2) educational outreach visiting for GPs about pain management vs. control, and 3) structured educational visiting for patients/caregivers about pain management vs. control. The control condition was current palliative care. Outcomes included Australia-modified Karnofsky Performance Status (AKPS) and pain from 60 days after randomization and hospitalizations. There were 461 participants: mean age 71 years, 50% male, 91% with cancer, median survival 179 days, and median baseline AKPS 60. Only 47% of individuals randomized to the case conferencing intervention received it; based on a priori-defined analyses, 32% of participants were included in final analyses. Case conferencing reduced hospitalizations by 26% (least squares means hospitalizations per patient: case conference 1.26 [SE 0.10] vs. control 1.70 [SE 0.13], P=0.0069) and better maintained performance status (AKPS case conferences 57.3 [SE 1.5] vs. control 51.7 [SE 2.3], P=0.0368). Among patients with declining function (AKPS <70), case conferencing and patient/caregiver education better maintained performance status (AKPS case conferences 55.0 [SE 2.1] vs. control 46.5 [SE 2.9], P=0.0143; patient/caregiver education 54.7 [SE 2.8] vs. control 46.8 [SE 2.1], P=0.0206). Pain was unchanged. GP education did not change outcomes. A single case conference added to current specialized community-based palliative care reduced hospitalizations and better maintained performance status. Comparatively, patient/caregiver education was less effective; GP education was not effective. Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
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              Perceptions of the use of a remote monitoring system in patients receiving palliative care at home.

              In remote communities, where frequent face-to-face contact with health professionals may be difficult, the ongoing review and management of symptoms--a fundamental part of good palliative care--can be difficult to achieve. Telecare and other developments in information technology are increasingly being sought as a means of addressing shifting population demographics and rising demands on stretched health services, and may help in providing a system which allows patients to report their symptoms as they are happening. This may be one way of enhancing symptom management and improving quality of care at the end of life. A study testing the feasibility of using mobile phone-based technology (Advanced Symptom Management System in Palliative Care (ASyMSp)) to monitor and manage symptoms reported by patients being cared for at home in the advanced stages of their illness was carried out in two rural communities in the north of Scotland. The results of this study show that the system was usable and acceptable to patients and the health professionals who cared for them.
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                Author and article information

                Contributors
                Role: Academic Editor
                Role: Academic Editor
                Journal
                Healthcare (Basel)
                Healthcare (Basel)
                healthcare
                Healthcare
                MDPI
                2227-9032
                31 August 2017
                September 2017
                : 5
                : 3
                : 51
                Affiliations
                [1 ]Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Bedford Park, Adelaide 5001, Australia; Kate.Swetenham@ 123456sa.gov.au (K.S.); Timothy.To@ 123456sa.gov.au (T.H.M.T.); David.Currow@ 123456sa.gov.au (D.C.C.); Jennifer.Tieman@ 123456flinders.edu.au (J.J.T.)
                [2 ]Southern Adelaide Palliative Services, Daw Park, Adelaide 5041, Australia
                Author notes
                [* ]Correspondence: Deidre.Morgan@ 123456flinders.edu.au ; Tel.: +61-8-7221-8220
                Author information
                https://orcid.org/0000-0001-8725-9477
                https://orcid.org/0000-0002-2611-1900
                Article
                healthcare-05-00051
                10.3390/healthcare5030051
                5618179
                28858221
                fcf1a2a7-af11-43cf-a699-a600c871f613
                © 2017 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 11 July 2017
                : 24 August 2017
                Categories
                Case Report

                telemonitoring,palliative care,video-conference,community,cancer

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