title: Effects of a programme of interventions on regional comprehensive palliative care for patients with cancer: a mixed-methods study.
abstract: BACKGROUND
  Improvement of palliative care is an important public health issue, but knowledge about how to deliver palliative care throughout a region remains inadequate. We used surveys and in-depth interviews to assess changes in the quality of palliative care after regional interventions and to gain insights for improvement of palliative care at a regional level.
  
  
  METHODS
  In this mixed-methods study, a comprehensive programme of interventions for regional palliative care for patients with cancer was implemented from April 1, 2008, to March 31, 2011 in Tsuruoka, Kashiwa, Hamamatsu, and Nagasaki in Japan. Interventions included education, specialist support, and networking. We surveyed patients, bereaved family members, physicians, and nurses before and after the interventions were introduced. We also did qualitative interviews with health-care professionals after the interventions were introduced. Primary endpoints were numbers of home deaths, coverage of specialist services, and patient-reported and family-reported qualities of care. This trial is registered with UMIN Clinical Trial Registry, Japan (UMIN000001274).
  
  
  RESULTS
  859 patients, 1110 bereaved family members, 911 physicians, and 2378 nurses provided analysable preintervention surveys; 857 patients, 1137 bereaved family members, 706 physicians, and 2236 nurses provided analysable postintervention surveys. Proportions of home deaths increased significantly, from 348 of 5147 (6.76%) before the intervention programme to 581 of 5546 (10.48%) after the intervention programme (p<0.0001). Furthermore, 194 of 221 (87.78%) family members of patients who died at home answered that these patients had wanted to die at home. The ratio of patients who received palliative care services to all patients who died of cancer increased significantly (from 0.31 to 0.50; p<0.0001). The patient-reported (effect size 0.14; adjusted p=0.0027) and family-reported (0.23; p<0.0001) qualities of care were significantly better after interventions than before interventions. Physician-reported and nurse-reported difficulties decreased significantly after the introduction of the interventions. Qualitative interviews showed improved communication and cooperation between health-care professionals because of greater opportunities for interactions at various levels.
  
  
  CONCLUSIONS
  A regional programme of interventions could improve the quality of palliative care. Improvement of communication between health-care professionals is key to improvement of services.
  
  
  BACKGROUND
  Third Term Comprehensive Control Research for Cancer Health and Labor Sciences Research Grants of the Ministry of Health, Labour and Welfare of Japan.
authors.affiliation: Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan. tmorita@sis.seirei.or.jp
authors.forename: Tatsuya
authors.initials: T
authors.lastname: Morita
authors.forename: Mitsunori
authors.initials: M
authors.lastname: Miyashita
authors.forename: Akemi
authors.initials: A
authors.lastname: Yamagishi
authors.forename: Miki
authors.initials: M
authors.lastname: Akiyama
authors.forename: Nobuya
authors.initials: N
authors.lastname: Akizuki
authors.forename: Kei
authors.initials: K
authors.lastname: Hirai
authors.forename: Chizuru
authors.initials: C
authors.lastname: Imura
authors.forename: Masashi
authors.initials: M
authors.lastname: Kato
authors.forename: Yoshiyuki
authors.initials: Y
authors.lastname: Kizawa
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Shirahige
authors.forename: Takuhiro
authors.initials: T
authors.lastname: Yamaguchi
authors.forename: Kenji
authors.initials: K
authors.lastname: Eguchi
mesh_terms: D003191:Comprehensive Health Care / Q000592:standards*; D005190:Family; D005500:Follow-Up Studies; D006801:Humans; D009369:Neoplasms / Q000503:physiopathology / Q000534:rehabilitation* / Q000628:therapy; D009726:Nurses / Q000592:standards; D010166:Palliative Care / Q000379:methods* / Q000706:statistics & numerical data; D018802:Patient-Centered Care / Q000592:standards*; D010820:Physicians / Q000592:standards; D011379:Prognosis; D016730:Program Development; D011785:Quality Assurance, Health Care / Q000592:standards*