BackgroundProviding palliative care patients living at home with timely access to medicines is critical to enable effective symptom management, minimise burden and reduce unplanned use of healthcare services. Little is known about how diverse community-based palliative care models influence medicine access.ObjectiveTo produce a critical overview of research on experiences and outcomes of medicine access in community-based palliative care models of service delivery through a systematic review and narrative synthesis.MethodsMEDLINE, CINAHL, EMBASE, PsycINFO, Cochrane Library databases and grey literature were systematically searched for all types of studies. Study quality was assessed using the Mixed Methods Appraisal Tool; a narrative synthesis was used to integrate and summarise findings.Results3331 articles were screened; 10 studies were included in the final sample. Studies included a focus on community pharmacy (n=4), hospice emergency medication kits (HEMKs) in the home (n=3), specialist community nurse prescribers (n=1), general practice (n=1) and one study included multiple service delivery components. Community pharmacy was characterised by access delays due to lack of availability of medicine stock and communication difficulties between the pharmacy and other healthcare professionals. HEMKs were perceived to reduce medicine access time out of hours and speed symptom control. However, the majority of studies comprised small, local samples, largely limited to self-reports of health professionals. There was a lack of data on outcomes, and no comparisons between service delivery models.ConclusionsFurther research is required to understand which models facilitate rapid and efficient access to medicines for community-based palliative care patients.
We performed a retrospective study of patients newly diagnosed with mCRPC in the year 2000 or later from eight Veterans Affairs Medical Centers. Patients were categorized based on prior local therapy (none, prostatectomy AE radiation or radiation alone). Overall and cancer specific survival was estimated by the Kaplan-Meier method. Cox proportional hazards regression models were used to test the association between prior local treatment and survival.RESULTS: Of the 729 patients with mCRPC, 284 (39%) underwent no local treatment, 176 (24%) underwent RP AE XRT and 269 (37%) underwent XRT alone. On multivariable analysis, men with prior RP AE XRT had improved OS (HR, 0.71; p¼0.005) and CSS (HR, 0.55; p<0.001) compared to men with no prior local therapy. This decreased risk of OS (HR, 0.89; p¼0.219) and CSS (HR, 0.87; p¼0.170) was not seen in men with prior XRT alone. After further adjusting for comorbidity with Charlson Comorbidity Index, patients with prior local therapy with RP AE XRT still had reduced OS (HR, 0.70; p¼0.003) while this was not seen in patients who received prior XRT alone (HR, 0.88, p¼0.185).CONCLUSIONS: Independent of patient and disease related factors, including comorbidity, men with mCRPC who had undergone prior RP had improved OS and CSS when compared to men with no prior local therapy. The finding of improved survival in men newly diagnosed with mCRPC who had undergone prior RP is consistent with previous reports in men newly diagnosed with metastatic castrationsensitive disease.
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