title: Reducing inequalities in care for patients with non-malignant diseases: Insights from a realist evaluation of an integrated palliative care pathway.
abstract: The need for palliative care is growing internationally with an increasing prevalence of non-malignant diseases. The integrated care pathway was implemented in primary care by multidisciplinary teams from 2009 in a locality in the North East of England. Fourteen general practitioner practices provided data for the study.
  
  
  
  To find whether, how, and under what circumstances palliative care registrations are made for patients with non-malignant diseases in primary care.
  
  
  
  General practitioner practice data were analysed statistically and qualitative data were collected from health care professionals and members of relevant organisations.
  
  
  
  A mixed-effects logistic model indicated a significant difference beyond the 0.1% level (p < 0.001) in registrations between the malignant and non-malignant groups in 2011, with an odds ratio of 0.09 (=exp(-2.4266)), indicating that patients in the non-malignant group are around 11 times (1/0.09) less likely to be registered than patients in the malignant group. However, patients with non-malignant diseases were significantly more likely to be registered in 2012 than in 2011 with an odds ratio of 1.46, significant beyond the 1% level. Qualitative analyses indicate that health care professionals find registering patients with non-malignant diseases stressful, yet feel that their confidence in treating this population is increasing.
  
  
  
  The integrated care pathway began to enable the reduction in inequalities in care by identifying, registering and managing an increasing number of palliative patients with non-malignant diseases. Consensual and inclusive definitions of palliative care were developed in order to legitimise the registration of such patients.
authors.affiliation: Department of Public Health and Wellbeing, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK; Fuse, The Centre for Translational Research in Public Health, Newcastle Upon Tyne, UK s.dalkin@northumbria.ac.uk.
authors.forename: Sonia Michelle
authors.initials: SM
authors.lastname: Dalkin
authors.affiliation: Northumbria University, Fuse, The Centre for Translational Research in Public Health, Newcastle Upon Tyne, UK.
authors.forename: Monique
authors.initials: M
authors.lastname: Lhussier
authors.affiliation: Northumbria University, Newcastle upon Tyne, UK.
authors.forename: Pete
authors.initials: P
authors.lastname: Philipson
authors.affiliation: Northumbria University, Newcastle upon Tyne, UK.
authors.forename: Diana
authors.initials: D
authors.lastname: Jones
authors.affiliation: Hadrian Primary Care Alliance, West Northumberland, UK.
authors.forename: William
authors.initials: W
authors.lastname: Cunningham
mesh_terms: D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D004739:England; D054625:Healthcare Disparities / Q000458:organization & administration / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D009369:Neoplasms / Q000523:psychology / Q000628:therapy*; D016017:Odds Ratio; D010166:Palliative Care / Q000458:organization & administration* / Q000523:psychology / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors
keywords: Palliative care; cancer; malignant; non-cancer; non-malignant; realist evaluation