Systematic Review of Unscheduled Care

Problem

Unscheduled Care is delivered in the UK by Accident & Emergency and GP Out-of-Hours departments. For patients dying of cancer, unscheduled care represents an unplanned and sporadic episode of care, which can be distressing, exhausting, and disruptive. Little is known as to why patients with terminal present to unscheduled care. Minimising unscheduled care use is desirable for patients and families and from a health economics standpoint.

Approach

This systematic review aims to conduct a systematic review of factors which influence use of unscheduled care by patients with cancer towards the end of life. Search Terms were grouped into ‘cancer’, ‘palliative care’ and ‘unscheduled care’ term sets. The search comprised six databases: MEDLINE, PubMed, Web-of-Science, Cochrane Database, CENTRAL and CINAHL. Search terms were determined by MeSH terms and expert consensus. Two reviewers independently reviewed all titles, abstracts and full texts. Article inclusion was by consensus with strong concordance.

Findings

Database searches yielded 122 titles, of which 64 were included for abstract searching, and 38 were included for full text article review. Twenty-two studies were included in the full thematic synthesis, of which 19 were quantitative, 2 qualitative and 1 mixed methods. Factors associated with either greater or lesser use of unscheduled care were: various demographic factors, clinical factors, cancer type, system factors and prescribed medication. Men, people of non-white ethnicity, adults aged over 50 years and people living alone were more likely to use A&E. Symptoms of pain, breathlessness and gastrointestinal symptoms made patients more likely to use unscheduled care, as did frailty and other non-cancer comorbidities. By cancer type, patients with lung cancer primaries or any metastatic cancer were most likely to use unscheduled care. Themes which were associated with less use of unscheduled care were: A&E referrals to palliative care, enrollment in hospice, good communication between primary and secondary care, GP continuity of care, at-home nursing care, home visit by GP, training or education of patients and carers and having a written palliative care plans. Themes which were associated with greater use of unscheduled care were: clinical follow-up, emotional distress, non-business hours, pain, and previous use of unscheduled care.

Consequences

This study provided baseline evidence of the nature and type of research undertaken in unscheduled care for patients with palliative cancer. There was a wide variety of methods and settings used for the included studies; however, there were no RCTs, few intervention studies, and most of the papers examined only small numbers of participants. Prescribing factors were rarely covered. Importantly, all the papers included in the review were set in either GP-OOH or A&E, but not in both. Further research examining patient cohorts across all domains of unscheduled care is required.