Building an action plan to tackle palliative care inequality through multi-stakeholder platforms.

Background: To achieve universal care and overcome existing barriers, the most effective strategy is to devise an action plan that incorporates palliative care into primary health care (PHC), as recommended by the World Health Organization's (WHO) Astana Declaration. In Colombia, a country with an upper-middle-income status, about 128,000 individuals experience severe health-related suffering (SHS) that necessitates palliative care. Although the country's healthcare system has made steady strides in the integration and development of palliative care, there is still no national plan in place for palliative care. Objective: Build up Colombia's palliative care plan through stakeholder consensus. Method: Based on the participatory action research method and the multi-stakeholder platforms model, this study convened 142 stakeholders from different levels of the health system (patient representatives, journalists, health professionals, government entities, insurance companies, universities, and drug regulatory authorities). Results: The national plan aims to achieve its objectives through a series of strategic actions. These include integrating and diversifying palliative care services, improving access to opioids, increasing palliative care education, promoting community-based palliative care programs, securing funding, and implementing a regulatory framework for palliative care by public policymakers. Conclusions: The national palliative care is an alliance that aims to reduce palliative care inequity in Colombia by 2026 by empowering stakeholders nationwide to collaborate around specific goals and objectives.

Rural Palliative Care Telemedicine for Advanced Cancer Patients: A Systematic Review.

Context: Telemedicine offers the opportunity to provide remote palliative care for patients to control symptoms and improve quality of life, even for patients with advanced diseases. Objectives: Establish a telemedicine model of rural palliative care for advanced cancer patients with difficulties in accessing standard care. Methods: This review comports with the minimum standards described in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and uses the palliative care literature review iterative method (PALETTE) proposed by Zwakman et al in 2018. Results: Three hundred, ninety-two articles were identified in PubMed and EMBASE databases and alternative search engines such as Google Scholar and OpenGrey. A telemedicine delivery model was developed for patients with limited access to standard care, which consists of identifying the candidate population, establishing the most convenient telemedicine modality, agreeing with patients and caregivers on palliative care needs, and evaluating the interventions effectiveness. Conclusion: Telemedicine is a revolutionary tool to provide palliative care to advanced cancer patients whose clinical condition or location prevent them from accessing conventional care.

Subcutaneous Administration of Medications and Fluids by Nonprofessional Caregivers at Home.

Background: Patients requiring home-based palliative care have advanced complex illnesses with functional limitations and decline. This retrospective study reviewed caregiver administration of subcutaneous (SQ) medications and fluids when symptom control could not be achieved using the oral route. Methods: Medical records from September 1, 2017 to February 28, 2018 were reviewed for 272 consecutive patients who received SQ administration of medications or fluids at a home-based palliative care program. We analyzed the clinical characteristics of patients and caregivers, medications administered, and catheter outcomes. Results: Patients' median age was 74 years, and 163 (60%) were women. The most common cancer diagnoses were stomach 26 (12%), lung 22 (10%), and colorectal 20 (9%). Dementia 24 (44%), cerebrovascular disease 9 (16%), and congestive heart failure 7 (13%) were the most frequent nonmalignant diseases. Poor symptom control 162 (60%) and impaired oral intake 107 (39%) were the most common indications for an SQ route of administration. Nonprofessional caregivers trained by a nurse administered medications to 218 patients (80%). During interventions, the patients received a mean of 4 medications (±2 standard deviation). A total of 903 catheters were inserted, 15/732 (2%) catheters handled by nonprofessional caregivers caused a local infection, compared with 3/171 (1.8%) of catheters handled by nurses. Hydromorphone was the most common opioid used (57%), followed by morphine (35%). The median length of stay in the program was 24 days (interquartile range: 11-60). Conclusions: SQ administration of medications and fluids by nonprofessional caregivers trained by health care professionals is feasible and promising, but additional testing is needed.

Cancer and Non-cancer Fatigue Treated With Bupropion: A Systematic Review.

CONTEXT: Fatigue is a predominant and distressing symptom in cancer and non-cancer conditions for which there is a paucity of recommendations for pharmacological interventions. Bupropion is a novel treatment whose efficacy and safety in the treatment of fatigue are unknown. OBJECTIVES: This study aimed to systematically assess the evidence on the efficacy and safety of bupropion in the treatment of fatigue in people with cancer and non-cancer conditions. METHODS: PubMed, EMBASE, and Ovid Medline databases were searched up to July 26, 2022. Studies were included if they reported bupropion as an intervention for cancer and non-cancer-related fatigue and used an objective scale to assess symptom outcomes. Experimental and quasi-experimental studies in adult patients published in English were included. RESULTS: This review reports on seven studies (three randomized studies, three non-randomized studies, and one case series) that enrolled a total of 584 patients. Bupropion was tested in five studies for treating cancer-related fatigue and in two studies for treating fatigue in non-cancer conditions. The reviewed studies were heterogeneous in relation to the scales used to assess fatigue. Six out of seven studies reported that bupropion significantly reduced the fatigue burden without causing major adverse effects. These positive results must be taken with caution caused by the small sample sizes and low quality of the studies reviewed. CONCLUSION: Bupropion may prove to be an effective and safe intervention for fatigue in cancer and non-cancer conditions. A high-quality randomized trial is warranted to test current preliminary results.

Barriers to Access to Palliative Care in Colombia: A Social Mapping Approach Involving Stakeholder Participation.

This study aimed to identify barriers to access to palliative care through a social mapping approach. In Colombia, the barriers to access to palliative care denote an enormous geographic disparity of resources and health needs, making it necessary to conduct community-based participatory research using an approach such as social mapping. A qualitative research design was used. Stakeholders from health insurance companies, regulatory authorities, regional health secretariats, health care professionals, patient and caregiver organizations, scientific societies, and medical journalists from 7 Colombian regions participated. It involved 3 stages. Stage 1: Semi-structured, audio-recorded interviews were conducted with 36 stakeholders and were subsequently transcribed and analyzed. Stage 2: An electronic survey was conducted to obtain feedback on the first outline of the map and the categories that emerged from stage 1. Stage 3: The nominal group technique was used to analyze and validate the barriers to access to palliative care included in the final map. The COREQ checklist was used. Twenty-seven barriers to access to palliative care related to limited availability of medications, stakeholders' poor knowledge of regulations, limited formal education in palliative care, few patients' support networks, patient care fragmentation, few specialized programs of palliative care, and mistaken beliefs about palliative care were identified. Stakeholders' diverse perspectives and opinions were crucial to understanding the development of palliative care in Colombia and its challenges. Better knowledge about palliative care can open opportunities to overcome the barriers identified in this study, directly impacting access to palliative care.

Availability and accessibility of opioids for pain and palliative care in Colombia: a survey study / Disponibilidad y accesibilidad de los opioides para manejo del dolor y cuidado paliativo en Colombia: estudio tipo encuesta

Abstract Introduction: Access to essential medicines, including opioids, is a component of the right to health. Objective: To identify barriers to opioid availability and accessibility for pain and palliative care. Methods: Online survey with Colombian prescribers. Availability barriers were analyzed for each facility (distribution and/or dispensing). Accessibility barriers were analyzed by type. Descriptive analyses were conducted using relative frequencies. Significance within categories and regions was measured using Fisher's exact test. Results: Out of 1,208 prescribers invited, 806 (66.7%) completed the survey. Availability: 76.43% reported barriers. The most cited barrier was "Pharmacies authorized by health insurance companies", where opioids are frequently unavailable. Accessibility: 74.6% reported barriers. Most frequently cited was "Difficulty securing payment authorization for medication from health insurance companies". Significant differences were observed in terms of regions and "Cost" (p=0.02). Lack of coordination among procuring and distributing agencies affects availability. Limited awareness and bureaucratic procedures affect accessibility. Conclusions: There are barriers to opioid availability and access in Colombia, related to the existing structure for guaranteeing equitable supply. From the perspective of healthcare providers, problems related to pharmacy availability, prescription and cost of medicines hinder pain treatment.

Resumen Introducción: El acceso a medicamentos esenciales, incluidos los opioides, es un componente del derecho a la salud. Objetivo: Identificar las barreras de disponibilidad y acceso a los opioides para dolor y cuidados paliativos. Métodos: Encuesta virtual a prescriptores colombianos. Las barreras de disponibilidad se analizaron para cada centro (distribución y/o dispensación) y las barreras de acceso se analizaron por tipo. Los análisis descriptivos se realizaron utilizando frecuencias relativas. La significancia dentro de categorías y regiones se midió utilizando la prueba exacta de Fischer. Resultados: De los 1208 prescriptores invitados, 806 (66.7%) respondieron la encuesta. Disponibilidad: el 76,43% reportó barreras. La barrera más citada fue la relacionada con las "farmacias autorizadas por las aseguradoras de salud", donde los opioides con frecuencia no están disponibles. Acceso: el 74,6% reportó barreras. Se citó con mayor frecuencia la "Dificultad para obtener la autorización de pago de medicamentos por parte de las aseguradoras". Se observaron diferencias significativas entre regiones y "costos" (p=0,02). La falta de coordinación entre las entidades de adquisición y distribución afecta la disponibilidad. La limitada conciencia y los procedimientos burocráticos afectan la accesibilidad. Conclusiones: Existen barreras de disponibilidad y acceso a los opioides en Colombia, las cuales están relacionadas con la estructura disponible para garantizar un suministro equitativo. Desde el punto de vista de los prescriptores, los problemas relacionados con la disponibilidad de las farmacias, la prescripción y el costo de los medicamentos, obstaculizan el tratamiento adecuado del dolor.

The Development of Palliative Care in Colombia: An Analysis of Geographical Inequalities Through the Application of International Indicators.

CONTEXT: The national evaluation of an individual country is a tool used to improve the universal provision of palliative care. The evaluation of a country's internal situation, by means of an analysis of the development of palliative care by region, may also be an instrument for improvement. OBJECTIVES: The aim of this study was to understand the regional development of palliative care in Colombia, through the application of international indicators. METHODS: Regional development was analyzed for Colombia, with a country-specific adaptation of the evaluation method used in the latest edition of the Palliative Care World Map (Clark D, 2020), the need for palliative care per death with serious health-related suffering (Knaul FN, 2019), and the coverage of specialized services, following European standards (Centeno, 2016). A total of 33 of the country's regions were classified. RESULTS: Some 41% of the people who die in Colombia need palliative care. The average figure for specialized services is 0.5/100,000 inhabitants, with a maximum coverage of 51%. In Colombia, there are 12 regions with a generalized level of provision; six regions with isolated provision, nine regions developing their capacity, four with no known activity, and two at an advanced level of palliative care integration. The regions with the highest level of palliative care development coincide with higher demand and coverage of specialized services. CONCLUSION: Regional palliative care development is unequal and unbalanced. Applying international indicators to levels of regional development allows for the identification of geographical inequalities and highlights low palliative care development, especially in the rural areas of the country.

Opioids for the management of dyspnea in patients with heart failure: a systematic review of the literature / Opioides para el manejo de la disnea en pacientes con insuficiencia cardiaca: Revisión sistemática de la literatura

Abstract Introduction: Heart failure is a chronic, progressive, prevalent disease, with a high impact on health systems and on the quality of life of patients and families. Dyspnea is a common symptom and management with opioids has been proposed. Objective: To conduct a systematic review of the literature pertaining to the use of opioids for the management of dyspnea in patients with stable chronic heart failure, functional class New York Heart Association (NYHA) II, III, or IV. Materials and methods: A systematic review was conducted in the MEDLINE, Embase, Cochrane, OVID, LILACS, and PROSPERO databases of articles published in 5 languages between January 1, 1995 and July 31, 2018. Studies describing the administration of any type of opioid for the management of dyspnea in patients with stable chronic heart failure NYHA II, III, or IV were included. Results: Four clinical trials were obtained for the final analysis with a total number of 70 patients, describing opioid administration for the management of dyspnea in patients with stable chronic heart failure, NYHA II, III, or IV. Conclusion: In adult patients with compensated chronic heart failure under optimum treatment, there is low-quality evidence that shows benefit with the use of opioids for the management of dyspnea. For a stronger recommendation, controlled, randomized studies with a larger number of subjects are required.

Resumen Introducción: La insuficiencia cardiaca es una enfermedad crónica, progresiva, prevalente, con un alto impacto en los sistemas de salud y en la calidad de vida de los pacientes y sus familias, la disnea es un síntoma común y se ha planteado el uso de opioides para su control. Objetivo: Revisión sistemática de la literatura sobre el uso de opioides en el manejo de la disnea en pacientes con insuficiencia cardiaca crónica estable con clase funcional NYHA II, III o IV. Materiales y métodos: Se realizó una revisión sistemática de los artículos encontrados en las bases de datos MEDLINE, Embase, Cochrane, OVID, LILACS, PROSPERO a partir del 1 de enero del 1995 hasta el 31 de julio del 2018, publicados en cinco idiomas. Se incluyeron aquellos estudios en los cuales se describe la administración de cualquier tipo de opioide para el manejo de la disnea en pacientes con insuficiencia cardiaca crónica estable, NYHA II, III o IV. Resultados: Se incluyeron cuatro ensayos clínicos para el análisis final, con un numero total de 70 pacientes, en los cuales se describe la administración de opioides para el manejo de la disnea en pacientes con insuficiencia cardiaca crónica estable, NYHA II, III, o IV. Conclusiones: En pacientes adultos con insuficiencia cardiaca crónica compensada en tratamiento óptimo, existe evidencia de baja calidad que muestra beneficio para el manejo de la disnea con opioides, deben realizarse estudios aleatorizados controlados con una cantidad de individuos mayor para poder generar una recomendación más fuerte.