Abstract
Dear Editor:
The real-world effectiveness of pharmacological and nonpharmacological interventions in hospice/palliative care is often difficult to quantify. The Improving Palliative, Aged, and Chronic Care through Clinical Research and Translation (IMPACCT) Rapid Program adds to the evidence base by prospectively examining the net effects (benefits and harms) of treatments widely used in hospice/palliative care. The program is made up of a series of studies that collect data from a large number of participating sites internationally, on a consecutive cohort of patients where the clinician has already made the decision to use that intervention. 1
Rigorous quality improvement programs, such as IMPACCT Rapid, are cost- and time-effective. Carefully selected prospectively collected observational data can add genuinely to the knowledge base to inform and refine clinical practice. 2 Defining the net effect of interventions requires data from the population that we serve, directly reflecting everyday hospice/palliative care practice.
The IMPACCT Rapid Program commenced systematically collecting data prospectively in 2011. Each series requests that clinicians collect data on the next three (or more) consecutive patients being administered the therapy of interest for the index indication. Data are collected at three time points: baseline, time to expected benefit, and time to immediate- and short-term harms. Nine series have been completed and published in peer-reviewed journals, including the first nonpharmacological series—the world's largest consecutive cohort study of packed cell transfusions in hospice/palliative care. 3
By April 2020, 10 countries had contributed data on >1200 patients, with 19 series in progress, including the first nursing series, the first series in pediatric palliative care and a series looking at symptom burden trajectories in COVID-19. There have been three derivative articles, including one of the only comparisons of gabapentin and pregabalin using identical measures and time points.
This survey sought to determine whether in hospice/palliative care, the program
is improving the evidence base for clinical care;
is improving the understanding of burdens and harms of therapies used; and
can be improved and inform future planning?
Methods
A cross-sectional survey was carried out in January 2020 of site investigators who had contributed or are contributing data to at least one case series. Quantitative and qualitative data were collected.
Results
Of the 61 site investigators approached, 32 (52%) completed the online survey. The respondents had participated in 2–15 of the series.
Responding to “Participating …has made me more alert to the possible benefits and harms of …interventions commonly used in palliative and supportive care,” 25 (78%) respondents agreed. Responding to “(This) has enabled me to collect information on the benefits of medicines and interventions commonly used in palliative and supportive care,” 27 (84%) respondents agreed. Responding to “(This) has enabled me to collect information on the harms of medicines and interventions commonly used in palliative and supportive care,” 27 (84%) respondents agreed. Responding to “(This) adds to the body of evidence in palliative and supportive care medicine,” 28 (87%) respondents agreed. To the statement “(Participating) has improved my reflective clinical practice,” 21 (66%) agreed.
Comments included:
“Fabulous way of involving clinical sites in research who are interested but may otherwise not have the capacity or expertise.”
“This has been, and is a great exercise to corral practice and give our experiential practice some clear grounding in a global context.”
“We as a team feel this is important research totally relevant to our field.”
Discussion
These results support previous data of collateral benefits from participating actively in quality improvement projects such as IMPACCT Rapid. 4 The process of reflecting on patient outcomes and clinical practice is crucial in optimizing care.
Carefully defining treatment and evaluating the effects with a small number of standardized measures at baseline and at two further time points is low cost and low intensity for each site, but when aggregated across multiple sites, generates high-quality information. Quantifying benefits and harms of interventions in the population we serve is fundamental to quality improvement cycles. The high levels of symptom burden at baseline in each of the studies to date reflects (1) current symptom control and (2) the difficulty of attributing effects of interventions without excellent baseline measures.
The strength of this survey was that it was anonymous. In response to the survey, certificates of participation for sites to acknowledge contribution to IMPACCT Rapid Program have been reimplemented, given the commitment of staff to contribute to this program. Development of more streamlined case report forms so that information required is clearer and easier for staff to enter online continues.
Positive responses from participating clinicians who voluntarily provide data without additional resources speaks to the value that respondents put in being part of this international community of practice. Building momentum to evaluate further nonpharmacological and pharmacological treatments can continue to inform care. It also speaks to feasibility of building research capacity for clinicians who carry busy clinical loads. Emerging evidence suggests that engagement of clinicians and clinical teams in research and rigorous evaluation of clinic practice is associated with better patient outcomes. 5