Mogens Groenvold, MD, Chairman of the Danish Palliative Care Database, Head of the Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, and Associate Professor, University of Copenhagen, Denmark
As discussed in previous posts on this blog, WHO has proposed an indicator measuring ‘access to palliative care’:
“Access to palliative care assessed by morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer.”
Unfortunately, the proposed indicator has severe problems. The estimation requires knowledge of the opioid consumption by cancer patients (only). However, opioids are also consumed by patients with other diagnoses (as described on this blog). Most countries do not have separate statistics for cancer patients. Therefore, the indicator value will be misleading.
Furthermore, the indicator conveys no information about the proportion of cancer patients who receive opioids. A high value may even reflect overuse of opioids in non-malignant diseases, rather than access to palliative care for cancer patients.
Because the proposed indicator does not measure cancer patients’ access to palliative care and may be potentially misleading, it does not advance palliative care.
All health care indicators are simplifications and have weaknesses. However, such indicators may be justified if they can identify major flaws and can be used for meaningful comparisons. There should be a reasonably monotonic relationship between the indicator value and the quality of what it measures (a higher value reflects better health care). Furthermore, it should be possible to define a standard describing a reasonable target. The proposed indicator fails on these criteria.
In Denmark, as in several other countries, extensive work has been devoted to developing indicators measuring the quality of palliative care. National quality indicators have been in effect from 2010. One of these indicators measures access to palliative care: the proportion of patients dying from cancer who have been in contact with specialised palliative care. The suggested initial standard was 35%.
The first report from the Danish Palliative Care Database covering 2010 showed a national figure of 28% for this indicator with considerable inter-regional variation (21-33%).
The Danish indicator fulfils the criteria mentioned above. At the global level such an indicator would produce relevant information. Lack of access to specialised palliative care not only concerns the patients who do obtain such care, it also indicates that other health professionals may have limited access to consultation with, and education from, palliative care specialists.
The Danish indicator requires data that may not always be available. However, approximated data may still be meaningful. Other data on palliative care activity (as suggested by Scholten on this blog) may also be used. Such figures will identify the countries having the largest deficits and allow sensible comparisons between countries and within countries over time.
Therefore, an ‘access to palliative care indicator’ measuring the number of cancer patients in contact with specialist palliative care divided by the number of cancer deaths is preferable to the proposed drug consumption indicator.