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European Society for Medical Oncology (ESMO) Program for the Integration of Oncology and Palliative Care: a 5-year review of the Designated Centers’ incentive program
original article
Annals of Oncology 21: 362–369, 2010 doi:10.1093/annonc/mdp318 Published online 4 August 2009
European Society for Medical Oncology (ESMO) Program for the Integration of Oncology and Palliative Care: a 5-year review of the Designated Centers’ incentive program N. Cherny1*, R. Catane2, D. Schrijvers3, M. Kloke4 & F. Strasser5
Received 25 March 2009; revised 4 May 2009; accepted 5 May 2009
original article
Background: In 1999, the National Representatives of European Society for Medical Oncology (ESMO) created a Palliative Care Working Group to improve the delivery of supportive and palliative care (S + PC) by oncologists, oncology departments and cancer centers. They have addressed this task through initiatives in policy, education, research and incentives. As an incentive program for oncology departments and centers, ESMO developed a program of Designated Centers (DCs) for programs meeting predetermined targets of service development and delivery of a high level of S + PC. Method: The history, accreditation criteria and implementation of the DC incentive program is described. Results: Since 2004, 75 centers have applied for designation and 48 have been accredited including 34 comprehensive cancer centers (CCCs) in general hospitals and seven freestanding CCCs. Perceived benefits accrued from the accreditation included the following: improved status and role identification of the center, positive impact on daily work, positive impact on business activity and positive impact on funding for projects. Conclusions: The accreditation of DCs has been a central to the ESMO initiative to improve the palliative care provided by oncologists and oncology centers. It is likely that many other oncology departments and cancer centers already meet the criteria and ESMO strongly encourages them to apply for accreditation. Key words: European Society for Medical Oncology, education, Oncology, palliative care, supportive care
introduction Over the past 30 years, there have been major developments in the standards of practice in palliative and supportive care for patients with advanced cancer [1–3]. Importantly, it is now widely acknowledged that a palliative and supportive care approach to care should utilized whenever needs are identified, irrespective of the stage of the disease, and not only at the end of life [2, 4–9]. By implication, many patients receiving active disease-modifying treatment will need palliative and supportive care as part of a comprehensive care plan. For patients with advanced and refractory cancer, when the risks outweigh the benefits of anticancer treatments, palliative care becomes the most important paradigm of good cancer care [4, 5]. Despite these developments, a parallel literature also indicated that many oncologists and cancer clinics have not integrated these evolving standards into training programs [10– *Correspondence to: Dr N. Cherny, Department of Medical Oncology, Cancer Pain and Palliative Medicine Service, Shaare Zedek Medical Center, Jerusalem 91031, Israel. Tel: +972-2-6555111; Fax: +972-2-6666731; E-mail: [email protected]
13], routine practice [10, 14–19], research strategies [20, 21] or the resourcing of cancer departments and centers [10, 22]. The European Society for Medical Oncology (ESMO) recognizes that ensuring that patients with physical, psychological and social needs receive palliative and supportive care to address these issues is the responsibility of the medical oncology community. This does not imply that they must personally deliver all this care, but rather that they should ensure that these issues are being adequately addressed in cooperation with interdisciplinary professional team including home care services, nurses, social workers, physicians with expertise in palliative care, chaplains and mental healthcare professionals. Furthermore, ESMO recognizes that lack of uptake of standards in these aspects of cancer care is not only harming some patients and their families but also detrimental to the profession itself [9, 10]. In 1999, the National Representatives of ESMO created a Palliative Care Working Group (PCWG) to address this issue. The charter of the working group is to improve the delivery of supportive and palliative care (S + PC) by oncologists, oncology
ª The Author 2009. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: [email protected]
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1 Department of Oncology, Cancer Pain and Palliative Medicine, Shaare Zedek Medical Center, Jerusalem; 2Department of Oncology, Sheba Medical Center, Ramat Gan, Israel; 3Department of Hemato-Oncology, Ziekenhuisnetwerk Antwerpen-Middelheim, Antwerp, Belgium; 4Center for Palliative Medicine, Kliniken Essen Mitte, Essen, Germany and 5Oncological Palliative Care, Oncology Department Internal Medicine and Palliative Care Center, Cantonal Hospital, St Gallen, Switzerland
Annals of Oncology
development of the 13 criteria for accreditation The criteria for accreditation were drafted based on recommendation from the World Health Organization guidelines on the provision of palliative care for patients with cancer [26]. An original list of 22 items was presented to a full meeting of the members of the PCWG and this was reduced to 13 core requirements by a process of consensus. The 13 criteria were ratified by the National Representatives in 2003 as face valid, fair, appropriate, reasonably comprehensive and adequately, but not excessively, challenging (Table 1). application and accreditation Description of the DC Program, the accreditation criteria and the application process were published on the ESMO Web site and in ESMO newsletters. Starting in 2004, application was invited from all cancer centers and oncology departments meeting the criteria. The application, made by the head of the department or cancer center, is submitted to the ESMO education department. The application consists of two parts. The first is a checklist indicating compliance with each of the 13 criteria. The second part requires a narrative description as to how the center meets each of the 13 criteria. Compliance with each criterion is described on a separate page signed, for veracity, by the head of the department and head of institute.
ESMO Program for DCs in the Integration of Oncology and Palliative Care
Table 1. Thirteen criteria for accreditation as a Designated Center in the Integration of Oncology and Palliative Care (valid 2004–2008)
conceptual development of the DC Program In 1998, Catane and Cherny proposed the concept of an incentive program as part of the initial PCWG proposal that was presented to the National Representatives. The initial formulation had been to develop an accreditation program for centers of excellence for Integration of Oncology and Palliative Care, based on the model of the Comprehensive Cancer Center (CCC) designation by the National Cancer Institute [24, 25]. After the formation of the PCWG and at the request of the National Representatives, the concept of accrediting center of excellence was modified for two reasons; first, the identification and recognition of Centers of Excellence was considered too restrictive to be relevant to most oncology services or cancer centers, and secondly, it required a rigorous accreditation program in order to be credible. The concept was therefore modified to accredit centers which meet a challenging threshold for advanced program development. This threshold was considered to be medically substantial, readily achievable with due application and consistent with recognized international standards. This approach aimed for a threshold of service development that cancer centers could reasonably aim to attain even if they were starting from a low baseline of services, thus providing incentive to a wider range of institutions, not only those aiming for the pinnacle of excellence. This process was named the ESMO Program for DCs in the Integration of Oncology and Palliative Care.
1. The center provides closely integrated oncology and palliative care clinical services 2. The center is committed to a philosophy of continuity of care and nonabandonment 3. The center provides high-level home care with expert backup and coordination of home care with primary cancer clinicians 4. The center incorporates programmatic support of family members 5. The center provides routine patient assessment of physical and psychological symptoms and social supports and has an infrastructure that responds with appropriate interventions in a timely manner 6. The center incorporates expert medical and nursing care in the evaluation and relief of pain and other physical symptoms 7. The center incorporates expert care in the evaluation and relief of psychological and existential distress 8. The center provides emergency care of inadequately relieved physical and psychological symptoms 9. The center provides facilities and expert care for inpatient symptom stabilization 10. The center provides respite care for ambulatory patients for patients unable to cope at home or in cases of family fatigue 11. The center provides facilities and expert care for inpatient end-of-life care and is committed to providing adequate relief of suffering for dying patients 12. The center participates in basic or clinical research related to the quality of life of cancer patients 13. The center is involved in clinician education to improve the Integration of Oncology And Palliative Care
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departments and cancer centers. The PCWG and ESMO have addressed this task through initiatives in policy, education, research and incentives. In 2003, ESMO issued a policy document including definitions of S + PC, defining the responsibilities of the oncologist in the provision of palliative and supportive care, outlining training requirements for oncologists in relation to these aspect of patient care and establishing minimal standards for provision of palliative care in cancer centers [10]. These policies oblige individual members, associated organizations and affiliated centers to aspire to these standards. The ESMO policies regarding S + PC have been widely cited and, in some countries, ratified as national policy. The education initiatives of the PCWG program have included elucidation of the core elements of Palliative Care Education for Oncology trainees [10], the development of an ESMO Handbook of Advanced Cancer Care [23], incorporation of palliative and supportive care into ESMO conferences and sponsored educational activities and two incentive programs to further promote this endeavor. The first, and most novel, was to develop an incentive program for oncology departments and cancer centers by offering special recognition for meeting predetermined targets of service development and delivery of a high level of S + PC. This program is known as the ESMO Program for Designated Centers (DCs) in the Integration of Oncology and Palliative Care. It is commonly referred to by an abbreviated name: the DC Program.
original article
original article
Annals of Oncology
application history Since the inception of the DC Program in 2004, 75 centers have applied for designation and 48 have been accredited (Table 2). After first review, 33 applications were successful and 15 centers were asked to clarify or elaborate on items of their submissions. The items most commonly requiring clarification were 3 (home care), 5 (patient assessment and timely response), 6 (staff credentials), 10 (respite care) and 12 (research). All applications requiring clarification were subsequently approved. Eight of the 24 centers whose applications were initially unsuccessful during 2004–2007 reapplied in subsequent years, six of them reapplied successfully. The two centers which were twice rejected did not reapply further. Thirteen of the 15 centers accredited in the 2004 and 2005 applied for reaccreditation and all were successful. Most of the 27 unsuccessful applications failed to meet 6–8 of the criteria listed in Table 1. The most common unmet criteria
were items 2 (continuity of care), 5 (patients assessment and timely response), 6 (staff credentials), 9 (inpatient symptom stabilization), 10 (respite care), 12 (research) and 13 (education).
characteristics of the accredited centers Thirty-four of the DCs are CCCs in general hospitals, 24 of which are university affiliated. Seven of the centers are freestanding CCCs (Table 3). Among these, are major centers such as Institut Jules Bordet in Belgium, Institut de Cancerologie Gustave Roussy in France, Institut Catala d’Oncologia in Spain and Charite University Hospital in Germany. Others are medical oncology departments in general (2) or university hospitals (1) and one is an oncology department in a dermatology hospital. impact of ESMO accreditation on the DCs In early 2008, the program directors of the 27 cancer centers that were accredited before that time were surveyed to evaluate the impact of the application process and the accreditation. Program directors were asked six questions inviting both closed (yes/no) and open answers: (i) In preparing your application did you need to develop new services to meet the 13 required criteria? (ii) Has the recognition as ESMO DC of Integrated Oncology and Palliative Care affected: The daily work in your department? The business activity in your hospital? The identification of your center in you country? (iii) Do you use the ESMO Designation on stationery or letterhead? (iv) Has the recognition as ESMO DC of Integrated Oncology and Palliative Care affected the funding for your projects? (v) Since the ESMO Designation have you developed any new services? (vi) Would you suggest adding or removing any of the criteria for accreditation as a DC of Integrated Oncology and Palliative Care? Twenty-four responses were received. Four of the 24 centers had developed new services specifically to make themselves compliant with the 13 criteria. The perceived benefits accrued from the accreditation included improved status and role
Table 2. Application and accreditation history Initial applications Year
Applications new
2004 18 2005 13 2006 13 2007 6 2008 25 Reaccreditation applications Cohort Reapplications From centers 2004 From centers 2005
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Seven reapplied in 2007 out of eight Six reapplied in 2008 out of seven
Approved at first review
Rejected at first review
Required clarification
Clarifications successful
Total accredited
8 7 5 3 10
10 6 4 1 6
0 0 4 2 9
0 0 4 2 9
8 7 9 5 19
Approved at first review
Rejected at first review
Number needing clarification
Clarifications successful
Total accredited
7
0
5
0
7 1
1
6
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Completed applications are blinded by the education office and distributed to three reviewers drawn from the PCWG. Accreditation is made on the basis of meeting all 13 criteria as determined by a review committee drawn up from the membership of the PCWG. If two to three of three reviewers agree that a criterion is not adequately met, this decision holds. If one of three reviewers assess a criterion as not adequately met, then this is reviewed by the accreditation chairperson for final adjudication. If five or less criteria are deemed to be inadequately met, the applicant is given the opportunity to elaborate further regarding the specific concerns. If the feedback is deemed adequate to the chair, then this is returned to the committee for reevaluation. If six or more criteria are deemed to be inadequately met, the application is deemed unsuccessful. Unsuccessful applicants receive feedback on the specific shortcomings and are encouraged to use this constructively in their service development and to reapply. Accreditation is valid for 3 years and full reapplication is necessary for renewal. Certificates of accreditation are presented at the awards session of the ESMO or European Cancer Organization/ESMO congresses.
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Annals of Oncology
Table 3. Designated Centers in the Integration of Oncology and Palliative Care
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Belgium Germany Germany Ireland Italy Switzerland UK Israel
Israel Italy
Italy Spain Switzerland
Canada Czech Republic Germany Ireland Italy Italy Italy
Spain UK Belgium Germany Poland Spain Turkey Austria
Australia Belgium France
Sta¨dtische Kliniken Frankfurt Ho¨chst Klinikum Heidenheim Palliativstation 55 der Charite´ Department of Hematology and Medical Oncology University Hospital Regensburg St. Antonius-Hospital Department of Oncology, Hematology, Bone Marrow Transplantation with Section Pneumology (2. Medical Clinic), University Cancer Center Hamburg Klinikum Hanau GmbH Tuen Mun Hospital Department of Clinical Oncology Pamela Youde Nethersole Eastern Hospital S.M.S. Medical College & Attached Hospitals Bon Secours Cork Cancer Center Medical Oncology Unit S. Orsola-Malpighi Hospital Oncology and Hematology Department, Hospital of Piacenza Maria Sklodowska-Curie Memorial Cancer Center—Institute of Oncology Chelsea and Westminster NHS Foundation Trust
Germany Germany Germany Germany Germany Germany
Germany Hong Kong Hong Kong India Ireland Italy Italy Poland UK
identification of the center (18 of 24), positive impact on daily work (12 of 24), positive impact on business activity (11 of 24) and positive impact on funding for projects (6 of 24). Eight of the centers have incorporated the designation as part of their official letterhead. Seven of the centers demonstrated further program development with the development of additional services beyond those described in their original applications.
identifying and recognizing leadership In many countries, DCs have undertaken leadership roles in promoting palliative care for cancer patients. In 2009, the Italian Association of Medical Oncology invited the clinical leadership of the eight DCs in Italy to direct a new task force on palliative care in oncology. The charter for their working group is to promote the ESMO philosophy on simultaneous care model for oncology patients. ESMO grantee visits to DCs The second of the incentive programs of ESMO and the PCWG are the palliative care grants, awarded since 2006. These are special grants, of up to 5000 Euro, for oncologists or oncology fellows seeking additional experience in palliative care by spending 1–3 months of observation and/or research at one of the DCs. Candidates must be oncologists and ESMO members (or in process of application). The candidates must demonstrate approval of the project by their institutional
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2004 Designated Centers Reaccredited 2007 AZ Middelheim, Antwerp Kliniken Essen-Mitte, Essen Klinik Dr. Hancken GmbH, Stade Cork University Hospital, Wilton, Cork O.D.O. AVAPO, div. Oncologia medica, osp. SS. Giovanni e Paolo, Venezia Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona Velindre Cancer Center, Cardiff, Wales 2005 Designated centers Reaccredited 2008 Shaare Zedek Medical Center, Department of Oncology and Palliative Medicine, Jerusalem Ramban Medical Center, Oncology Division, Haifa Ospedale S. Giovanni Calibita , Fatebenefratelli Oncology Department, Rome Ospedale San Salvatore, U.O. Oncologia Medica, l’Aquila Hospital General Universitario G. Maranon, Madrid Kantonsspital St Gallen, Department of Internal Medicine; Oncology/ Hematology, St Gallen 2006 ESMO Designated Centers SMBD Jewish General Hospital, Montreal The Complex Oncology Center, Prague KTB Klinik for Tumorbiologie, Freiburg Cancer Center Beaumont Hospital, Dublin Medical Oncology University Hospital of Parma, Parma Ospedali Riuniti di Bergamo, Oncologia medica, Bergamo Istituto Dermopatico dell’Immacolata, Divisione di Oncologia e Oncologia dermatologica, Rome Hospital Universitario Salamanca, Salamanca Alaw Unit, Bangor, North Wales 2007 ESMO Designated Centers Oncology Center Virga Jesseziekenhuis, Hasselt Dr. Horst Schmidt Kliniken, Wiesbaden University Hospital of Lord’s Transfiguration, Poznan Institut Catala d’Oncologia, Hospitalet, Barcelona Anadolu Medical Center Gebze, Kocaeli 2008 ESMO Designated Centers Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University Graz Royal Adelaide Hospital Cancer Center Institut Jules Bordet Institut de Cancerologie Gustave Roussy
Table 3. (Continued)
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discussion
director and have agreement from a host institution which is one of the DCs. In the 3 years 2006–2008, there were 11 applications, 10 of which were successful (Table 4). Upon return, grantees must make a presentation of their experience to their home institute including research outcomes and observations that could be incorporated into local practice. Grantees must submit a report to ESMO.
revision of the accreditation criteria The DC Program has continually been under review by both the PCWG and the national representatives. Both groups expressed concern regarding difficulty in describing how centers meet each of the 13 criteria for accreditation. In 2007, the PCWG began a process to review the accreditation criteria and the manner in which submissions are made. Suggestions for amendments were solicited from the members of the PCWG in early 2008. They were edited, drafted and presented for critical discussion at the meeting of all the designed centers in June 2008. The criteria have been amended (Table 5) to better reflect the issues of integration (items 1 and 2), credentialing (items 3 and 4), service provision (items 5–11), research (item 12) and education (item 13). Furthermore, guidelines for describing each of the criteria are presented to help structure the applications and facilitate evaluation. These new criteria will apply from 2009.
1 Creating incentives: The DC initiative aims to improve the relative advantage of adopting high-quality palliative care by giving it status. In doing so, ESMO is trying to influence the culture of oncology to emphasize the commonality of purpose and goals between good cancer care and good supportive care and that they are an irreducible unity. 2 Education with structure: Through the DC Program, ESMO has tried to reduce perceived complexity of developing integrated palliative care services by providing concrete guidelines and achievable targets and through the identification of hospitals and services that can serve as models and mentors for the development of new programs. 3 Importance irrespective of scope: The recognition awarded is not dependent in the size of the institute or the number of patients treated. Both large cancer centers and relatively
Table 4. ESMO Palliative Care grantees for Observership or Research at a Designated Center Year
Grantee
From
Host Designated Center
2006 2006 2007
Gazealeh Sh. Razavi Valeria Pesceddu Jan Wierecky
Teheran, Iran Cagliari, Italy Hamburg, Germany
2007
Shamsudeen Moideen
Calicut, India
2007 2008 2008 2008
Tamari Rukhadze Gabriella Morar-Bolba Dana-Oana Donea Alexandu Grigorescu
Tbilisi, Georgia Cluj-Napoca, Romania Bucharest, Rumania Bucharest, Romania
2008 2008
Ioseb Abesadze Gadrun Pohl
Tbilisi, Georgia Vienna, Austria
Ospedale San SalvatoredEPT Medical Oncology, l’Aquila, Italy Velindre Cancer Center, Cardiff, Wales Kantonsspital St Gallen, Department of Internal Medicine; Oncology/ Hematology, St Gallen Kantonsspital St Gallen, Department of Internal Medicine; Oncology/ Hematology, St Gallen Shaare Zedek Medical Center, Jerusalem, Israel Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona Kantonsspital St Gallen, Department of Internal Medicine; Oncology/ Hematology, St Gallen Institut Catala d’Oncologia, Hospitalet, Barcelona Velindre Cancer Center, Cardiff, Wales
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meeting of the DCs, June 2008 ESMO organized a meeting of the DCs in Lugano in June 2008 which was attended by representatives from 21 of the 27 DCs at that time. Each center presented a summary of their activities, projects, research interest and special programs. Challenges to integration were discussed including problems related to communication between oncology and palliative medicine clinicians, differing cultures of care between oncology and palliative medicine and issues related to timing of referral of patients for palliative care interventions. The meeting provided a rich opportunities for cross-fertilization of ideas, innovations, research plans and educational initiatives.
The ESMO initiatives to improve the Integration of Oncology and Palliative Care have achieved wide recognition as a major public health undertaking that endeavors to change the culture and logistics of care. The program has received heavy endorsement form allied organizations including the International Association for Hospice and Palliative Care, the Open Society Institute, the European Association for Palliative Care and the Multinational Association for Supportive Care in Cancer, all of whom have featured the ESMO initiative prominently in their meetings and in their communications. ESMO’s efforts are now being emulated in North America by the American Society of Clinical Oncology [27]. The DC project is one of the more prominent elements of the ESMO initiative. In the world of oncology, it has sought to set a new standard for service development and delivery of integrated oncology and palliative care; a standard that is high enough to be worthy of special recognition, but not so high as to be beyond the reach of most centers. There are several characteristics of the DC Program that deserve emphasis:
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Annals of Oncology
Table 5. Amended criteria for Designated Center accreditation with structured guidelines for criteria narratives
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7.4. Describe how these aspects of care are monitored with ward rounds, case conferences, etc. 8. The center incorporates programmatic support of family members 8.1. Describe how the needs of the family members of patients with advanced cancer are routinely evaluated and managed 8.2. Describe the psychological and social supports to available to family members 9. The center provides high-level home care with expert backup and coordination of home care with primary cancer clinicians 9.1. Describe the availability of home care services and the expertise of the care providers 9.2. In the case that care is delivered by other community services 9.2.1. Describe the services and their credentials 9.2.2. Describe the ongoing relationship to those services in the care of your patients 10. The center provides respite care for ambulatory patients for patients unable to cope at home or in cases of family fatigue 10.1. Please describe the centers approach in situations when the patient and/or family request admission because either the patient is unable to cope at home or in situations of severe family fatigue 11. The center provides facilities and expert care for inpatient end-of-life (terminal) care and is committed to providing adequate relief of suffering for dying patients 11.1. Describe the management approach to dying patients who are unable to manage at home 11.2. When inpatients are dying, describe how adequacy of comfort is monitored and documented 11.3. Describe the management approach to refractory symptoms at the end of life 11.4. Describe the supports offered to comfort the patient and family 12. The center participates in basic or clinical research related to palliative care and the quality of life of cancer patients and their families 12.1. Please describe, open studies, completed studies and list all publications and presentation 12.1.1. Research may be related to physical, psychological or social aspects of patient care 12.1.2. Research may be related to quality assurance or improvement including models of care delivery 12.1.3. Please note that quality-of-life evaluation as part of routine oncological studies ‘does not’ constitute palliative care research for purposes of recognition 13. The center is involved in clinician education to improve the Integration of Oncology and Palliative Care 13.1. Please describe palliative cancer care teaching activities to: 13.1.1. Medical and nursing students 13.1.2. House staff 13.1.3. Oncology trainees 13.1.4. Others 13.2. Please describe any teaching publications 13.3. Pleases describe any conferences or symposia (past and planned) 13.4. Please describe any other teaching activities
small oncology departments can be accredited as long as they clearly demonstrate that oncology and palliative care are well integrated as evidenced by meeting accreditation criteria. 4 Quality of integration does not have implications for other aspects of care: Accreditation as a DC does not involve or
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1. The center is a cancer center or oncology department which provides closely integrated oncology and palliative care clinical services 1.1. Please describe the oncology department or cancer center 1.2. Describe how oncologists and palliative medicine services interact 1.3. When complex needs are identified, describe how the oncologists and palliative medicine services share responsibilities for patient care 1.4. Describe the availability of oncological care and evaluation for palliative care patients 2. The center is committed to a philosophy of continuity of care and nonabandonment 2.1. Please present an overview describing how the center provides continuity of care including, but not limited to, patients who are no longer benefiting of antitumor interventions 3. The center incorporates expert medical and nursing care in the evaluation and relief of pain and other physical symptoms 3.1. Please provide details about the medical and nursing clinicians involved in the program including their professional training and credentials in palliative care 4. The center incorporates expert care in the evaluation and relief of psychological and existential distress 4.1. Please provide details about the clinicians involved in psychooncologic care including their professional training and credentials in palliative care 4.2. Please provide details about the staff involved in chaplaincy, pastoral care or spiritual care including their professional training and credentials in palliative care 5. The center provides routine patient assessment of physical and psychological symptoms and social support and has an infrastructure that responds with appropriate interventions in a timely manner 5.1. Describe how physical and psychological symptoms of patients with advanced cancer are evaluated in outpatient and inpatient settings 5.1.1. Describe how severity of symptoms is recorded 5.1.2. When inadequately controlled symptoms are identified, describe the approach to evaluation and treatment 5.2. Describe how psychosocial problems or inadequate of patients with advanced cancer are evaluated in outpatient and inpatient settings 5.2.1. Describe how these problems are recorded 5.2.2. When inadequately controlled symptoms are identified, describe the approach to evaluation and treatment 6. The center provides emergency care of inadequately relieved physical and psychological symptoms 6.1. Describe the availability and type of urgent care for inadequately controlled severe symptoms or psychosocial problems during office hours 6.2. Describe the availability and type of urgent care for inadequately controlled severe symptoms or psychosocial problems outside office hours 7. The center provides facilities and expert care for inpatient symptom stabilization 7.1. Describe the criteria for admission for inpatient care of patients with poorly controlled symptoms in need of symptom stabilization 7.2. Describe where they are physically cared for (oncology ward, medical ward, palliative care ward) 7.3. Describe who manages the care of patients needing symptom stabilization
Table 5. (Continued)
original article imply any statement about the quality of oncological antitumor care. Standards of antitumor care are not evaluated in this process and accreditation does not imply that the center offers the best of cancer care. It implies only that oncological and palliative care are well integrated and that this itself is worthy of special recognition since is such an important aspect of cancer care delivery.
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palliative care. This was followed by a guided visit of the facilities, highlighting how the facility functions and meets the ESMO criteria and an interdisciplinary team discussion. The information gleaned from these visits supported the validity of the accreditation process. The centers all lived up to the expectations generated by their submissions for candidacy. These visits rendered useful information for purposes of modeling different ways to integrate oncology and palliative care services. Furthermore, the centers were offered constructive suggestions for program development in a formal report by the visiting representatives and this feedback was appreciated. Reports on these visits are available through the ESMO Web site. Addressing these intrinsic factors, the ESMO’s initiative aims to improve the relative advantage of adopting high-quality palliative care by giving it a status and creating incentives. ESMO is trying to influence the culture of oncology to emphasize the commonality of purpose and goals between good cancer care and good supportive care and by emphasizing that they are an irreducible unity. Through its DC Program, ESMO has tried to reduce perceived complexity of developing integrated palliative care services by providing concrete guidelines and achievable targets and through the identification of hospitals and services that can serve as models and mentors for the development of new programs.
Conclusions The accreditation of DCs in the Integration of Oncology and Palliative Care has been a key element in the ESMO initiative to improve the palliative care provided by oncologists and oncology centers. The DC initiative emphasized the priority of this endeavor. The 48 centers that have achieved accreditation serve as a valuable nucleus for education and role modeling. The modifications made to the program will improve the application and evaluation processes. It is likely that many other oncology departments and cancer centers already meet the criteria, and ESMO strongly encourages them to apply for accreditation. Furthermore, to improve quality of cancer care, ESMO urges oncology units and cancer centers which do not yet meet these standards, to develop programs in order to meet these pragmatic and clinically significant benchmarks and thus further improve cancer care in Europe and beyond.
acknowledgements The authors wish to acknowledge colleagues the ESMO National Representatives who supported this initiative, the members of the PCWG who have helped to develop and maintain this program and Reto Guelli, Doris Vola and Svetlana Jezdic of the ESMO office and the ESMO executive who continue to provide encouragement and support to this initiative.
references 1. Doyle D, Hanks G, Cherny N, Callman K. Oxford Textbook of Palliative Medicine, 3rd edition. Oxford: Oxford University Press 2005. 2. Gysels M, Higginson IJ. Improving Supportive and Palliative Care for Adults with Cancer: Research Evidence Manual. London: National Institute for Clinical Excellence 2004 p. 384.
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The DC Program has not been without its critics. Issues of concern have included perceived difficulty in describing how centers meet each of the accreditation criteria, the underrepresentation of major centers among those that have achieved accreditation and the validity of the accreditation process. The PCWG have attempted to address each of these concerns. The PCWG acknowledged the difficulties in addressing the narrative requirement of the application process and have revised the accreditation process accordingly. The revised criteria are clearer and the application process more structured with the incorporation of directive subpoints to be addressed in the application narratives. Well-recognized major cancer centers have less marginal benefit in prestige accrued from accreditation as a DC in the Integration of Oncology and Palliative Care and this may be one of the reasons for the predominance of smaller centers to date. This situation appears to change, and the 2008 cohort of successful candidacies included Institute Jules Bordet in Belgium and Institute de Cancerologie Gustave Roussy in France. We believe that the participation of major centers is important; it enhances the role modeling effect of the initiative and emphasizes their leadership in clinical and service development. We anticipate the participation of other major centers in 2009. Although there have been few successful applications from centers in the Former Soviet Union or from developing countries, those that have been successful are particularly notable. The PCWG have received many expressions of interest from centers in these regions and we are aware of programs using the criteria as a model for ongoing program development. The PCWG and the ESMO Executives considered the introduction of validation site visits. After weighing the matter, the ESMO Executives felt the organization should not undertake auditing responsibility. Given that the aim of the project was to reward threshold achievements rather than excellence, it was agreed that the current system of blinded evaluation of applications by multiple independent reviewers is sufficiently valid for this purpose. This process relies on the integrity of the program directors and medical directors who attest, by their signature, to the accuracy of the submitted description of each of the required criteria in the application process. In 2008, the PCWG undertook a series of site visits to document the work being done at the DCs and to study the ways in which centers had developed successful integrative programs. Visits were undertaken by members of the PCWG and representatives of the ESMO education office. Centers were asked to deliver a verbal presentation of the care facility, the department structure including a description of the healthcare team members and the activities which fulfill the current ESMO requirements for accreditation in integrated oncology and
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16.
17.
18.
19.
20.
21. 22. 23. 24.
25. 26. 27.
prospective survey using the PASQOC questionnaire. Support Care Cancer 2008; 16(6): 567–575. Homsi J, Walsh D, Rivera N et al. Symptom evaluation in palliative medicine: patient report vs systematic assessment. Support Care Cancer 2006; 14(5): 444–453. Yennurajalingam S, Zhang T, Bruera E. The impact of the palliative care mobile team on symptom assessment and medication profiles in patients admitted to a comprehensive cancer center. Support Care Cancer 2007; 15(5): 471–475. Osta BE, Palmer JL, Paraskevopoulos T et al. Interval between first palliative care consult and death in patients diagnosed with advanced cancer at a comprehensive cancer center. J Palliat Med 2008; 11(1): 51–57. Fadul N, Elsayem A, Palmer JL et al. Predictors of access to palliative care services among patients who died at a Comprehensive Cancer Center. J Palliat Med 2007; 10(5): 1146–1152. Tassinari D, Maltoni M, Sartori S et al. Outcome research in palliative care: could it represent a new dimension of clinical research or clinical practice? Support Care Cancer 2005; 13(3): 176–181. Kaasa S, Radbruch L. Palliative care research—priorities and the way forward. Eur J Cancer 2008. Field MJ, Cassel EK (eds): Approaching Death: Improving Care at the End of Life. Washington, DC: National Academy Press 1997. Catane R, Cherny NI, Kloke M, Tanneberger S, Schrijvers D (eds): ESMO Handbook of Advanced Cancer Care. London: Taylor and Francis 2005. National Cancer Institutes. The Cancer Centers Branch of the National Cancer Institute Policies and Guidelines Relating to the Cancer Center Support Grant. 2008; 56–http://cancercenters.cancer.gov/documents/CCSG_IGuide9_08r1.pdf Newman ME. New guidelines established for comprehensive cancer centers. J Natl Cancer Inst 1990 Jan 3; 82(1): 14–15. World Health Organization. Cancer Pain Relief and Palliative Care. Geneva: World Health Organization 1990. Ferris FD, Bruera E, Cherny N et al. Palliative cancer care a decade later: accomplishments, the need, next steps—from the American Society of Clinical Oncology. J Clin Oncol 2009 in press.
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3. Lorenz KA, Lynn J, Dy SM et al. Evidence for improving palliative care at the end of life: a systematic review. Ann Intern Med 2008; 148(2): 147–159. 4. World Health Organization. National Cancer Control Programmes: Policies and Managerial Guidelines, 2nd edition. Geneva 2002. 5. World Health Organization. Palliative Care. Cancer control : knowledge into action : WHO guide for effective programmes Module 5. Geneva: World Health Organization 2007 p. 42. 6. National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines: Palliative Care V1. 2009; http://www.nccn.org/professionals/physician_gls/PDF/ palliative.pdf 7. Palliative Care Australia. Standards for Providing Quality Palliative Care for All Australians. Canberra 2005. 8. Brennan F, Gwyther L, Harding R. Palliative Care as a Human Right. New York: Open Society Institute Public Health Program 2008. 9. Cherny NI, Catane R, Kosmidis P. ESMO takes a stand on supportive and palliative care. Ann Oncol 2003; 14(9): 1335–1337. 10. Cherny NI, Catane R. Attitudes of medical oncologists toward palliative care for patients with advanced and incurable cancer: report on a survery by the European Society of Medical Oncology Taskforce on Palliative and Supportive Care. Cancer 2003; 98(11): 2502–2510. 11. Emanuel EJ, Fairclough D, Clarridge BC et al. Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide. Ann Intern Med 2000; 133(7): 527–532. 12. Hilden JM, Emanuel EJ, Fairclough DL et al. Attitudes and practices among pediatric oncologists regarding end-of-life care: results of the 1998 American Society of Clinical Oncology Survey. J Clin Oncol 2001; 19(1): 205–212. 13. Buss MK, Lessen DS, Sullivan AM et al. Survey of oncology fellows’ end-of-life training. 2005 ASCO Annual Meeting Proceedings. J Clin Oncol 2005; 23(Suppl 1): (Abstr 8032). 14. Dhillon N, Kopetz S, Pei BL et al. Clinical findings of a palliative care consultation team at a comprehensive cancer center. J Palliat Med 2008; 11(2): 191–197. 15. Feyer P, Kleeberg UR, Steingraber M et al. Frequency of side effects in outpatient cancer care and their influence on patient satisfaction—a
Annals of Oncology 21: 362–369, 2010 doi:10.1093/annonc/mdp318 Published online 4 August 2009
European Society for Medical Oncology (ESMO) Program for the Integration of Oncology and Palliative Care: a 5-year review of the Designated Centers’ incentive program N. Cherny1*, R. Catane2, D. Schrijvers3, M. Kloke4 & F. Strasser5
Received 25 March 2009; revised 4 May 2009; accepted 5 May 2009
original article
Background: In 1999, the National Representatives of European Society for Medical Oncology (ESMO) created a Palliative Care Working Group to improve the delivery of supportive and palliative care (S + PC) by oncologists, oncology departments and cancer centers. They have addressed this task through initiatives in policy, education, research and incentives. As an incentive program for oncology departments and centers, ESMO developed a program of Designated Centers (DCs) for programs meeting predetermined targets of service development and delivery of a high level of S + PC. Method: The history, accreditation criteria and implementation of the DC incentive program is described. Results: Since 2004, 75 centers have applied for designation and 48 have been accredited including 34 comprehensive cancer centers (CCCs) in general hospitals and seven freestanding CCCs. Perceived benefits accrued from the accreditation included the following: improved status and role identification of the center, positive impact on daily work, positive impact on business activity and positive impact on funding for projects. Conclusions: The accreditation of DCs has been a central to the ESMO initiative to improve the palliative care provided by oncologists and oncology centers. It is likely that many other oncology departments and cancer centers already meet the criteria and ESMO strongly encourages them to apply for accreditation. Key words: European Society for Medical Oncology, education, Oncology, palliative care, supportive care
introduction Over the past 30 years, there have been major developments in the standards of practice in palliative and supportive care for patients with advanced cancer [1–3]. Importantly, it is now widely acknowledged that a palliative and supportive care approach to care should utilized whenever needs are identified, irrespective of the stage of the disease, and not only at the end of life [2, 4–9]. By implication, many patients receiving active disease-modifying treatment will need palliative and supportive care as part of a comprehensive care plan. For patients with advanced and refractory cancer, when the risks outweigh the benefits of anticancer treatments, palliative care becomes the most important paradigm of good cancer care [4, 5]. Despite these developments, a parallel literature also indicated that many oncologists and cancer clinics have not integrated these evolving standards into training programs [10– *Correspondence to: Dr N. Cherny, Department of Medical Oncology, Cancer Pain and Palliative Medicine Service, Shaare Zedek Medical Center, Jerusalem 91031, Israel. Tel: +972-2-6555111; Fax: +972-2-6666731; E-mail: [email protected]
13], routine practice [10, 14–19], research strategies [20, 21] or the resourcing of cancer departments and centers [10, 22]. The European Society for Medical Oncology (ESMO) recognizes that ensuring that patients with physical, psychological and social needs receive palliative and supportive care to address these issues is the responsibility of the medical oncology community. This does not imply that they must personally deliver all this care, but rather that they should ensure that these issues are being adequately addressed in cooperation with interdisciplinary professional team including home care services, nurses, social workers, physicians with expertise in palliative care, chaplains and mental healthcare professionals. Furthermore, ESMO recognizes that lack of uptake of standards in these aspects of cancer care is not only harming some patients and their families but also detrimental to the profession itself [9, 10]. In 1999, the National Representatives of ESMO created a Palliative Care Working Group (PCWG) to address this issue. The charter of the working group is to improve the delivery of supportive and palliative care (S + PC) by oncologists, oncology
ª The Author 2009. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: [email protected]
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1 Department of Oncology, Cancer Pain and Palliative Medicine, Shaare Zedek Medical Center, Jerusalem; 2Department of Oncology, Sheba Medical Center, Ramat Gan, Israel; 3Department of Hemato-Oncology, Ziekenhuisnetwerk Antwerpen-Middelheim, Antwerp, Belgium; 4Center for Palliative Medicine, Kliniken Essen Mitte, Essen, Germany and 5Oncological Palliative Care, Oncology Department Internal Medicine and Palliative Care Center, Cantonal Hospital, St Gallen, Switzerland
Annals of Oncology
development of the 13 criteria for accreditation The criteria for accreditation were drafted based on recommendation from the World Health Organization guidelines on the provision of palliative care for patients with cancer [26]. An original list of 22 items was presented to a full meeting of the members of the PCWG and this was reduced to 13 core requirements by a process of consensus. The 13 criteria were ratified by the National Representatives in 2003 as face valid, fair, appropriate, reasonably comprehensive and adequately, but not excessively, challenging (Table 1). application and accreditation Description of the DC Program, the accreditation criteria and the application process were published on the ESMO Web site and in ESMO newsletters. Starting in 2004, application was invited from all cancer centers and oncology departments meeting the criteria. The application, made by the head of the department or cancer center, is submitted to the ESMO education department. The application consists of two parts. The first is a checklist indicating compliance with each of the 13 criteria. The second part requires a narrative description as to how the center meets each of the 13 criteria. Compliance with each criterion is described on a separate page signed, for veracity, by the head of the department and head of institute.
ESMO Program for DCs in the Integration of Oncology and Palliative Care
Table 1. Thirteen criteria for accreditation as a Designated Center in the Integration of Oncology and Palliative Care (valid 2004–2008)
conceptual development of the DC Program In 1998, Catane and Cherny proposed the concept of an incentive program as part of the initial PCWG proposal that was presented to the National Representatives. The initial formulation had been to develop an accreditation program for centers of excellence for Integration of Oncology and Palliative Care, based on the model of the Comprehensive Cancer Center (CCC) designation by the National Cancer Institute [24, 25]. After the formation of the PCWG and at the request of the National Representatives, the concept of accrediting center of excellence was modified for two reasons; first, the identification and recognition of Centers of Excellence was considered too restrictive to be relevant to most oncology services or cancer centers, and secondly, it required a rigorous accreditation program in order to be credible. The concept was therefore modified to accredit centers which meet a challenging threshold for advanced program development. This threshold was considered to be medically substantial, readily achievable with due application and consistent with recognized international standards. This approach aimed for a threshold of service development that cancer centers could reasonably aim to attain even if they were starting from a low baseline of services, thus providing incentive to a wider range of institutions, not only those aiming for the pinnacle of excellence. This process was named the ESMO Program for DCs in the Integration of Oncology and Palliative Care.
1. The center provides closely integrated oncology and palliative care clinical services 2. The center is committed to a philosophy of continuity of care and nonabandonment 3. The center provides high-level home care with expert backup and coordination of home care with primary cancer clinicians 4. The center incorporates programmatic support of family members 5. The center provides routine patient assessment of physical and psychological symptoms and social supports and has an infrastructure that responds with appropriate interventions in a timely manner 6. The center incorporates expert medical and nursing care in the evaluation and relief of pain and other physical symptoms 7. The center incorporates expert care in the evaluation and relief of psychological and existential distress 8. The center provides emergency care of inadequately relieved physical and psychological symptoms 9. The center provides facilities and expert care for inpatient symptom stabilization 10. The center provides respite care for ambulatory patients for patients unable to cope at home or in cases of family fatigue 11. The center provides facilities and expert care for inpatient end-of-life care and is committed to providing adequate relief of suffering for dying patients 12. The center participates in basic or clinical research related to the quality of life of cancer patients 13. The center is involved in clinician education to improve the Integration of Oncology And Palliative Care
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departments and cancer centers. The PCWG and ESMO have addressed this task through initiatives in policy, education, research and incentives. In 2003, ESMO issued a policy document including definitions of S + PC, defining the responsibilities of the oncologist in the provision of palliative and supportive care, outlining training requirements for oncologists in relation to these aspect of patient care and establishing minimal standards for provision of palliative care in cancer centers [10]. These policies oblige individual members, associated organizations and affiliated centers to aspire to these standards. The ESMO policies regarding S + PC have been widely cited and, in some countries, ratified as national policy. The education initiatives of the PCWG program have included elucidation of the core elements of Palliative Care Education for Oncology trainees [10], the development of an ESMO Handbook of Advanced Cancer Care [23], incorporation of palliative and supportive care into ESMO conferences and sponsored educational activities and two incentive programs to further promote this endeavor. The first, and most novel, was to develop an incentive program for oncology departments and cancer centers by offering special recognition for meeting predetermined targets of service development and delivery of a high level of S + PC. This program is known as the ESMO Program for Designated Centers (DCs) in the Integration of Oncology and Palliative Care. It is commonly referred to by an abbreviated name: the DC Program.
original article
original article
Annals of Oncology
application history Since the inception of the DC Program in 2004, 75 centers have applied for designation and 48 have been accredited (Table 2). After first review, 33 applications were successful and 15 centers were asked to clarify or elaborate on items of their submissions. The items most commonly requiring clarification were 3 (home care), 5 (patient assessment and timely response), 6 (staff credentials), 10 (respite care) and 12 (research). All applications requiring clarification were subsequently approved. Eight of the 24 centers whose applications were initially unsuccessful during 2004–2007 reapplied in subsequent years, six of them reapplied successfully. The two centers which were twice rejected did not reapply further. Thirteen of the 15 centers accredited in the 2004 and 2005 applied for reaccreditation and all were successful. Most of the 27 unsuccessful applications failed to meet 6–8 of the criteria listed in Table 1. The most common unmet criteria
were items 2 (continuity of care), 5 (patients assessment and timely response), 6 (staff credentials), 9 (inpatient symptom stabilization), 10 (respite care), 12 (research) and 13 (education).
characteristics of the accredited centers Thirty-four of the DCs are CCCs in general hospitals, 24 of which are university affiliated. Seven of the centers are freestanding CCCs (Table 3). Among these, are major centers such as Institut Jules Bordet in Belgium, Institut de Cancerologie Gustave Roussy in France, Institut Catala d’Oncologia in Spain and Charite University Hospital in Germany. Others are medical oncology departments in general (2) or university hospitals (1) and one is an oncology department in a dermatology hospital. impact of ESMO accreditation on the DCs In early 2008, the program directors of the 27 cancer centers that were accredited before that time were surveyed to evaluate the impact of the application process and the accreditation. Program directors were asked six questions inviting both closed (yes/no) and open answers: (i) In preparing your application did you need to develop new services to meet the 13 required criteria? (ii) Has the recognition as ESMO DC of Integrated Oncology and Palliative Care affected: The daily work in your department? The business activity in your hospital? The identification of your center in you country? (iii) Do you use the ESMO Designation on stationery or letterhead? (iv) Has the recognition as ESMO DC of Integrated Oncology and Palliative Care affected the funding for your projects? (v) Since the ESMO Designation have you developed any new services? (vi) Would you suggest adding or removing any of the criteria for accreditation as a DC of Integrated Oncology and Palliative Care? Twenty-four responses were received. Four of the 24 centers had developed new services specifically to make themselves compliant with the 13 criteria. The perceived benefits accrued from the accreditation included improved status and role
Table 2. Application and accreditation history Initial applications Year
Applications new
2004 18 2005 13 2006 13 2007 6 2008 25 Reaccreditation applications Cohort Reapplications From centers 2004 From centers 2005
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Seven reapplied in 2007 out of eight Six reapplied in 2008 out of seven
Approved at first review
Rejected at first review
Required clarification
Clarifications successful
Total accredited
8 7 5 3 10
10 6 4 1 6
0 0 4 2 9
0 0 4 2 9
8 7 9 5 19
Approved at first review
Rejected at first review
Number needing clarification
Clarifications successful
Total accredited
7
0
5
0
7 1
1
6
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Completed applications are blinded by the education office and distributed to three reviewers drawn from the PCWG. Accreditation is made on the basis of meeting all 13 criteria as determined by a review committee drawn up from the membership of the PCWG. If two to three of three reviewers agree that a criterion is not adequately met, this decision holds. If one of three reviewers assess a criterion as not adequately met, then this is reviewed by the accreditation chairperson for final adjudication. If five or less criteria are deemed to be inadequately met, the applicant is given the opportunity to elaborate further regarding the specific concerns. If the feedback is deemed adequate to the chair, then this is returned to the committee for reevaluation. If six or more criteria are deemed to be inadequately met, the application is deemed unsuccessful. Unsuccessful applicants receive feedback on the specific shortcomings and are encouraged to use this constructively in their service development and to reapply. Accreditation is valid for 3 years and full reapplication is necessary for renewal. Certificates of accreditation are presented at the awards session of the ESMO or European Cancer Organization/ESMO congresses.
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Annals of Oncology
Table 3. Designated Centers in the Integration of Oncology and Palliative Care
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Belgium Germany Germany Ireland Italy Switzerland UK Israel
Israel Italy
Italy Spain Switzerland
Canada Czech Republic Germany Ireland Italy Italy Italy
Spain UK Belgium Germany Poland Spain Turkey Austria
Australia Belgium France
Sta¨dtische Kliniken Frankfurt Ho¨chst Klinikum Heidenheim Palliativstation 55 der Charite´ Department of Hematology and Medical Oncology University Hospital Regensburg St. Antonius-Hospital Department of Oncology, Hematology, Bone Marrow Transplantation with Section Pneumology (2. Medical Clinic), University Cancer Center Hamburg Klinikum Hanau GmbH Tuen Mun Hospital Department of Clinical Oncology Pamela Youde Nethersole Eastern Hospital S.M.S. Medical College & Attached Hospitals Bon Secours Cork Cancer Center Medical Oncology Unit S. Orsola-Malpighi Hospital Oncology and Hematology Department, Hospital of Piacenza Maria Sklodowska-Curie Memorial Cancer Center—Institute of Oncology Chelsea and Westminster NHS Foundation Trust
Germany Germany Germany Germany Germany Germany
Germany Hong Kong Hong Kong India Ireland Italy Italy Poland UK
identification of the center (18 of 24), positive impact on daily work (12 of 24), positive impact on business activity (11 of 24) and positive impact on funding for projects (6 of 24). Eight of the centers have incorporated the designation as part of their official letterhead. Seven of the centers demonstrated further program development with the development of additional services beyond those described in their original applications.
identifying and recognizing leadership In many countries, DCs have undertaken leadership roles in promoting palliative care for cancer patients. In 2009, the Italian Association of Medical Oncology invited the clinical leadership of the eight DCs in Italy to direct a new task force on palliative care in oncology. The charter for their working group is to promote the ESMO philosophy on simultaneous care model for oncology patients. ESMO grantee visits to DCs The second of the incentive programs of ESMO and the PCWG are the palliative care grants, awarded since 2006. These are special grants, of up to 5000 Euro, for oncologists or oncology fellows seeking additional experience in palliative care by spending 1–3 months of observation and/or research at one of the DCs. Candidates must be oncologists and ESMO members (or in process of application). The candidates must demonstrate approval of the project by their institutional
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2004 Designated Centers Reaccredited 2007 AZ Middelheim, Antwerp Kliniken Essen-Mitte, Essen Klinik Dr. Hancken GmbH, Stade Cork University Hospital, Wilton, Cork O.D.O. AVAPO, div. Oncologia medica, osp. SS. Giovanni e Paolo, Venezia Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona Velindre Cancer Center, Cardiff, Wales 2005 Designated centers Reaccredited 2008 Shaare Zedek Medical Center, Department of Oncology and Palliative Medicine, Jerusalem Ramban Medical Center, Oncology Division, Haifa Ospedale S. Giovanni Calibita , Fatebenefratelli Oncology Department, Rome Ospedale San Salvatore, U.O. Oncologia Medica, l’Aquila Hospital General Universitario G. Maranon, Madrid Kantonsspital St Gallen, Department of Internal Medicine; Oncology/ Hematology, St Gallen 2006 ESMO Designated Centers SMBD Jewish General Hospital, Montreal The Complex Oncology Center, Prague KTB Klinik for Tumorbiologie, Freiburg Cancer Center Beaumont Hospital, Dublin Medical Oncology University Hospital of Parma, Parma Ospedali Riuniti di Bergamo, Oncologia medica, Bergamo Istituto Dermopatico dell’Immacolata, Divisione di Oncologia e Oncologia dermatologica, Rome Hospital Universitario Salamanca, Salamanca Alaw Unit, Bangor, North Wales 2007 ESMO Designated Centers Oncology Center Virga Jesseziekenhuis, Hasselt Dr. Horst Schmidt Kliniken, Wiesbaden University Hospital of Lord’s Transfiguration, Poznan Institut Catala d’Oncologia, Hospitalet, Barcelona Anadolu Medical Center Gebze, Kocaeli 2008 ESMO Designated Centers Division of Oncology with affiliated Unit of Palliative Medicine, Department of Internal Medicine, Medical University Graz Royal Adelaide Hospital Cancer Center Institut Jules Bordet Institut de Cancerologie Gustave Roussy
Table 3. (Continued)
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discussion
director and have agreement from a host institution which is one of the DCs. In the 3 years 2006–2008, there were 11 applications, 10 of which were successful (Table 4). Upon return, grantees must make a presentation of their experience to their home institute including research outcomes and observations that could be incorporated into local practice. Grantees must submit a report to ESMO.
revision of the accreditation criteria The DC Program has continually been under review by both the PCWG and the national representatives. Both groups expressed concern regarding difficulty in describing how centers meet each of the 13 criteria for accreditation. In 2007, the PCWG began a process to review the accreditation criteria and the manner in which submissions are made. Suggestions for amendments were solicited from the members of the PCWG in early 2008. They were edited, drafted and presented for critical discussion at the meeting of all the designed centers in June 2008. The criteria have been amended (Table 5) to better reflect the issues of integration (items 1 and 2), credentialing (items 3 and 4), service provision (items 5–11), research (item 12) and education (item 13). Furthermore, guidelines for describing each of the criteria are presented to help structure the applications and facilitate evaluation. These new criteria will apply from 2009.
1 Creating incentives: The DC initiative aims to improve the relative advantage of adopting high-quality palliative care by giving it status. In doing so, ESMO is trying to influence the culture of oncology to emphasize the commonality of purpose and goals between good cancer care and good supportive care and that they are an irreducible unity. 2 Education with structure: Through the DC Program, ESMO has tried to reduce perceived complexity of developing integrated palliative care services by providing concrete guidelines and achievable targets and through the identification of hospitals and services that can serve as models and mentors for the development of new programs. 3 Importance irrespective of scope: The recognition awarded is not dependent in the size of the institute or the number of patients treated. Both large cancer centers and relatively
Table 4. ESMO Palliative Care grantees for Observership or Research at a Designated Center Year
Grantee
From
Host Designated Center
2006 2006 2007
Gazealeh Sh. Razavi Valeria Pesceddu Jan Wierecky
Teheran, Iran Cagliari, Italy Hamburg, Germany
2007
Shamsudeen Moideen
Calicut, India
2007 2008 2008 2008
Tamari Rukhadze Gabriella Morar-Bolba Dana-Oana Donea Alexandu Grigorescu
Tbilisi, Georgia Cluj-Napoca, Romania Bucharest, Rumania Bucharest, Romania
2008 2008
Ioseb Abesadze Gadrun Pohl
Tbilisi, Georgia Vienna, Austria
Ospedale San SalvatoredEPT Medical Oncology, l’Aquila, Italy Velindre Cancer Center, Cardiff, Wales Kantonsspital St Gallen, Department of Internal Medicine; Oncology/ Hematology, St Gallen Kantonsspital St Gallen, Department of Internal Medicine; Oncology/ Hematology, St Gallen Shaare Zedek Medical Center, Jerusalem, Israel Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona Istituto Oncologico della Svizzera Italiana, Ospedale San Giovanni, Bellinzona Kantonsspital St Gallen, Department of Internal Medicine; Oncology/ Hematology, St Gallen Institut Catala d’Oncologia, Hospitalet, Barcelona Velindre Cancer Center, Cardiff, Wales
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meeting of the DCs, June 2008 ESMO organized a meeting of the DCs in Lugano in June 2008 which was attended by representatives from 21 of the 27 DCs at that time. Each center presented a summary of their activities, projects, research interest and special programs. Challenges to integration were discussed including problems related to communication between oncology and palliative medicine clinicians, differing cultures of care between oncology and palliative medicine and issues related to timing of referral of patients for palliative care interventions. The meeting provided a rich opportunities for cross-fertilization of ideas, innovations, research plans and educational initiatives.
The ESMO initiatives to improve the Integration of Oncology and Palliative Care have achieved wide recognition as a major public health undertaking that endeavors to change the culture and logistics of care. The program has received heavy endorsement form allied organizations including the International Association for Hospice and Palliative Care, the Open Society Institute, the European Association for Palliative Care and the Multinational Association for Supportive Care in Cancer, all of whom have featured the ESMO initiative prominently in their meetings and in their communications. ESMO’s efforts are now being emulated in North America by the American Society of Clinical Oncology [27]. The DC project is one of the more prominent elements of the ESMO initiative. In the world of oncology, it has sought to set a new standard for service development and delivery of integrated oncology and palliative care; a standard that is high enough to be worthy of special recognition, but not so high as to be beyond the reach of most centers. There are several characteristics of the DC Program that deserve emphasis:
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Table 5. Amended criteria for Designated Center accreditation with structured guidelines for criteria narratives
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7.4. Describe how these aspects of care are monitored with ward rounds, case conferences, etc. 8. The center incorporates programmatic support of family members 8.1. Describe how the needs of the family members of patients with advanced cancer are routinely evaluated and managed 8.2. Describe the psychological and social supports to available to family members 9. The center provides high-level home care with expert backup and coordination of home care with primary cancer clinicians 9.1. Describe the availability of home care services and the expertise of the care providers 9.2. In the case that care is delivered by other community services 9.2.1. Describe the services and their credentials 9.2.2. Describe the ongoing relationship to those services in the care of your patients 10. The center provides respite care for ambulatory patients for patients unable to cope at home or in cases of family fatigue 10.1. Please describe the centers approach in situations when the patient and/or family request admission because either the patient is unable to cope at home or in situations of severe family fatigue 11. The center provides facilities and expert care for inpatient end-of-life (terminal) care and is committed to providing adequate relief of suffering for dying patients 11.1. Describe the management approach to dying patients who are unable to manage at home 11.2. When inpatients are dying, describe how adequacy of comfort is monitored and documented 11.3. Describe the management approach to refractory symptoms at the end of life 11.4. Describe the supports offered to comfort the patient and family 12. The center participates in basic or clinical research related to palliative care and the quality of life of cancer patients and their families 12.1. Please describe, open studies, completed studies and list all publications and presentation 12.1.1. Research may be related to physical, psychological or social aspects of patient care 12.1.2. Research may be related to quality assurance or improvement including models of care delivery 12.1.3. Please note that quality-of-life evaluation as part of routine oncological studies ‘does not’ constitute palliative care research for purposes of recognition 13. The center is involved in clinician education to improve the Integration of Oncology and Palliative Care 13.1. Please describe palliative cancer care teaching activities to: 13.1.1. Medical and nursing students 13.1.2. House staff 13.1.3. Oncology trainees 13.1.4. Others 13.2. Please describe any teaching publications 13.3. Pleases describe any conferences or symposia (past and planned) 13.4. Please describe any other teaching activities
small oncology departments can be accredited as long as they clearly demonstrate that oncology and palliative care are well integrated as evidenced by meeting accreditation criteria. 4 Quality of integration does not have implications for other aspects of care: Accreditation as a DC does not involve or
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1. The center is a cancer center or oncology department which provides closely integrated oncology and palliative care clinical services 1.1. Please describe the oncology department or cancer center 1.2. Describe how oncologists and palliative medicine services interact 1.3. When complex needs are identified, describe how the oncologists and palliative medicine services share responsibilities for patient care 1.4. Describe the availability of oncological care and evaluation for palliative care patients 2. The center is committed to a philosophy of continuity of care and nonabandonment 2.1. Please present an overview describing how the center provides continuity of care including, but not limited to, patients who are no longer benefiting of antitumor interventions 3. The center incorporates expert medical and nursing care in the evaluation and relief of pain and other physical symptoms 3.1. Please provide details about the medical and nursing clinicians involved in the program including their professional training and credentials in palliative care 4. The center incorporates expert care in the evaluation and relief of psychological and existential distress 4.1. Please provide details about the clinicians involved in psychooncologic care including their professional training and credentials in palliative care 4.2. Please provide details about the staff involved in chaplaincy, pastoral care or spiritual care including their professional training and credentials in palliative care 5. The center provides routine patient assessment of physical and psychological symptoms and social support and has an infrastructure that responds with appropriate interventions in a timely manner 5.1. Describe how physical and psychological symptoms of patients with advanced cancer are evaluated in outpatient and inpatient settings 5.1.1. Describe how severity of symptoms is recorded 5.1.2. When inadequately controlled symptoms are identified, describe the approach to evaluation and treatment 5.2. Describe how psychosocial problems or inadequate of patients with advanced cancer are evaluated in outpatient and inpatient settings 5.2.1. Describe how these problems are recorded 5.2.2. When inadequately controlled symptoms are identified, describe the approach to evaluation and treatment 6. The center provides emergency care of inadequately relieved physical and psychological symptoms 6.1. Describe the availability and type of urgent care for inadequately controlled severe symptoms or psychosocial problems during office hours 6.2. Describe the availability and type of urgent care for inadequately controlled severe symptoms or psychosocial problems outside office hours 7. The center provides facilities and expert care for inpatient symptom stabilization 7.1. Describe the criteria for admission for inpatient care of patients with poorly controlled symptoms in need of symptom stabilization 7.2. Describe where they are physically cared for (oncology ward, medical ward, palliative care ward) 7.3. Describe who manages the care of patients needing symptom stabilization
Table 5. (Continued)
original article imply any statement about the quality of oncological antitumor care. Standards of antitumor care are not evaluated in this process and accreditation does not imply that the center offers the best of cancer care. It implies only that oncological and palliative care are well integrated and that this itself is worthy of special recognition since is such an important aspect of cancer care delivery.
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palliative care. This was followed by a guided visit of the facilities, highlighting how the facility functions and meets the ESMO criteria and an interdisciplinary team discussion. The information gleaned from these visits supported the validity of the accreditation process. The centers all lived up to the expectations generated by their submissions for candidacy. These visits rendered useful information for purposes of modeling different ways to integrate oncology and palliative care services. Furthermore, the centers were offered constructive suggestions for program development in a formal report by the visiting representatives and this feedback was appreciated. Reports on these visits are available through the ESMO Web site. Addressing these intrinsic factors, the ESMO’s initiative aims to improve the relative advantage of adopting high-quality palliative care by giving it a status and creating incentives. ESMO is trying to influence the culture of oncology to emphasize the commonality of purpose and goals between good cancer care and good supportive care and by emphasizing that they are an irreducible unity. Through its DC Program, ESMO has tried to reduce perceived complexity of developing integrated palliative care services by providing concrete guidelines and achievable targets and through the identification of hospitals and services that can serve as models and mentors for the development of new programs.
Conclusions The accreditation of DCs in the Integration of Oncology and Palliative Care has been a key element in the ESMO initiative to improve the palliative care provided by oncologists and oncology centers. The DC initiative emphasized the priority of this endeavor. The 48 centers that have achieved accreditation serve as a valuable nucleus for education and role modeling. The modifications made to the program will improve the application and evaluation processes. It is likely that many other oncology departments and cancer centers already meet the criteria, and ESMO strongly encourages them to apply for accreditation. Furthermore, to improve quality of cancer care, ESMO urges oncology units and cancer centers which do not yet meet these standards, to develop programs in order to meet these pragmatic and clinically significant benchmarks and thus further improve cancer care in Europe and beyond.
acknowledgements The authors wish to acknowledge colleagues the ESMO National Representatives who supported this initiative, the members of the PCWG who have helped to develop and maintain this program and Reto Guelli, Doris Vola and Svetlana Jezdic of the ESMO office and the ESMO executive who continue to provide encouragement and support to this initiative.
references 1. Doyle D, Hanks G, Cherny N, Callman K. Oxford Textbook of Palliative Medicine, 3rd edition. Oxford: Oxford University Press 2005. 2. Gysels M, Higginson IJ. Improving Supportive and Palliative Care for Adults with Cancer: Research Evidence Manual. London: National Institute for Clinical Excellence 2004 p. 384.
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The DC Program has not been without its critics. Issues of concern have included perceived difficulty in describing how centers meet each of the accreditation criteria, the underrepresentation of major centers among those that have achieved accreditation and the validity of the accreditation process. The PCWG have attempted to address each of these concerns. The PCWG acknowledged the difficulties in addressing the narrative requirement of the application process and have revised the accreditation process accordingly. The revised criteria are clearer and the application process more structured with the incorporation of directive subpoints to be addressed in the application narratives. Well-recognized major cancer centers have less marginal benefit in prestige accrued from accreditation as a DC in the Integration of Oncology and Palliative Care and this may be one of the reasons for the predominance of smaller centers to date. This situation appears to change, and the 2008 cohort of successful candidacies included Institute Jules Bordet in Belgium and Institute de Cancerologie Gustave Roussy in France. We believe that the participation of major centers is important; it enhances the role modeling effect of the initiative and emphasizes their leadership in clinical and service development. We anticipate the participation of other major centers in 2009. Although there have been few successful applications from centers in the Former Soviet Union or from developing countries, those that have been successful are particularly notable. The PCWG have received many expressions of interest from centers in these regions and we are aware of programs using the criteria as a model for ongoing program development. The PCWG and the ESMO Executives considered the introduction of validation site visits. After weighing the matter, the ESMO Executives felt the organization should not undertake auditing responsibility. Given that the aim of the project was to reward threshold achievements rather than excellence, it was agreed that the current system of blinded evaluation of applications by multiple independent reviewers is sufficiently valid for this purpose. This process relies on the integrity of the program directors and medical directors who attest, by their signature, to the accuracy of the submitted description of each of the required criteria in the application process. In 2008, the PCWG undertook a series of site visits to document the work being done at the DCs and to study the ways in which centers had developed successful integrative programs. Visits were undertaken by members of the PCWG and representatives of the ESMO education office. Centers were asked to deliver a verbal presentation of the care facility, the department structure including a description of the healthcare team members and the activities which fulfill the current ESMO requirements for accreditation in integrated oncology and
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