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Background: Team-based palliative care interventions have shown positive results for patients at the end of life in both hospital and community settings. However, evidence on the effectiveness of transmural, that is, spanning hospital and home, team-based palliative care collaborations is limited. Aim: To systematically review whether transmural team-based palliative care interventions can prevent hospital admissions and increase death at home. Design: Systematic review and meta-analysis. Data sources: MEDLINE (Ovid), Embase (Ovid), CINAHL (Ebsco), PsychINFO (Ovid), and Cochrane Library (Wiley) were systematically searched until January 2021. Studies incorporating teams in which hospital and community professionals co-managed patients, hospital-based teams with community follow-up, and case-management interventions led by palliative care teams were included. Data was extracted by two researchers independently. Results: About 19 studies were included involving 6614 patients, of whom 2202 received an intervention. The overall pooled odds ratio of at least one hospital (re)admissions was 0.46 (95% confidence interval (CI) 0.34–0.68) in favor of the intervention group. The highest reduction in admission was in the hospital-based teams with community follow-up: OR 0.21 (95% CI 0.07–0.66). The pooled effect on home deaths was 2.19 (95% CI 1.26–3.79), favoring the intervention, with also the highest in the hospital-based teams: OR 4.77 (95% CI 1.23–18.47). However, studies had high heterogeneity regarding intervention, study population, and follow-up time. Conclusion: Transmural team-based palliative care interventions, especially hospital-based teams that follow-up patients at home, show an overall effect on lowering hospital admissions and increasing the number of patients dying at home. However, broad clinical and statistical heterogeneity of included studies results in uncertainty about the effect size.

Background: Palliative needs in older patients are often not timely identified. The Surprise Question (SQ) ‘would I be surprised if this patient died in the next year?’ is a well-researched tool that could aid in this effort. Most studies thus far involved physicians or specialist nurses, however the predictive value of the SQ when used by general nurses caring for hospitalized older patients is unknown. Objectives: To assess the predictive value of the SQ when used by general nurses and student nurses, in determining one year mortality in acutely hospitalized older patients. Design: Observational cohort study with an one year follow-up. Setting: One academic and one regional hospital in the Netherlands. Participants: Patients ≥70 years acutely hospitalized for at least 48 hours. Methods: Registered nurses and student nurses answered the SQ with ‘No’ (a positive SQ), ‘Yes’ or ‘Don't know’. Data on student nurses was analysed separately. The sensitivity, specificity, negative- and positive predictive values were calculated. Furthermore, logistic regression was performed to determine the odds of death. Results: 66 registered nurses answered the SQ for 252 patients of whom 77 (30.6%) died in the year after inclusion. Respectively, 44%, 14% and 22% died within the ‘No’, ‘Yes’ and ‘Don't know’ group. 85% of patients who died during admission or in the first three months post-discharge were identified. The sensitivity and specificity were 76.7% and 56.6%. The positive and negative predictive values were 43.7% and 84.6 %. Compared to persons in whom the SQ was answered with yes, a no answer was associated with an 4.7 times increased odds of dying in the next 12 months (odds ratio 4.71, 95% CI 2.43-9.12, p

Background A transitional care pathway (TCP) could improve care for older patients in the last months of life. However, barriers exist such as unidentified palliative care needs and suboptimal collaboration between care settings. The aim of this study was to determine the feasibility of a TCP, named PalliSupport, for older patients at the end of life, prior to a stepped-wedge randomized controlled trial. Methods A mixed-method feasibility study was conducted at one hospital with affiliated primary care. Patients were ≥ 60 years and acutely hospitalized. The intervention consisted of (1) training on early identification of the palliative phase and end of life conversations, (2) involvement of a transitional palliative care team during admission and post-discharge and (3) intensified collaboration between care settings. Outcomes were feasibility of recruitment, data collection, patient burden and protocol adherence. Experiences of 14 professionals were assessed through qualitative interviews. Results Only 16% of anticipated participants were included which resulted in difficulty assessing other feasibility criteria. The qualitative analysis identified misunderstandings about palliative care, uncertainty about professionals’ roles and difficulties in initiating end of life conversations as barriers. The training program was well received and professionals found the intensified collaboration beneficial for patient care. The patients that participated experienced low burden and data collection on primary outcomes and protocol adherence seems feasible. Discussion This study highlights the importance of performing a feasibility study prior to embarking on effectiveness studies. Moving forward, the PalliSupport care pathway will be adjusted to incorporate a more active recruitment approach, additional training on identification and palliative care, and further improvement on data collection.

Introduction - Marjon van Rijn (5 minutes): For the development, implementation and evaluation of a transitional integrated care pathway for older patient with palliative care needs we used the Medical Research (MRC) Framework. The overall aim of this transitional integrated care pathway is to test the effectiveness of a transitional integrated care pathway for older patients with palliative care needs. This pathway includes a better recognition of palliative care needs, end-of-life preference discussion, improved handover and involvement of informal caregivers. A transitional palliative care team will facilitate these interventions and consist of a general practitioner, community care nurse, professionals from the hospital, as well as professional specialized in the social and spiritual domain. In this workshop all steps of the MRC framework will be presented using the PalliSupport project as a best practice. The main aim of this workshop is to exchange experiences on the development, implementation and evaluation of complex integrated care interventions. Development, feasibility and pilot of a transitional integrated care pathway for older patient with palliative care needs, a process evaluation – Marjon van Rijn (20 minutes) Base on previous experiences and research findings we developed a transitional care pathway with a project group, including older persons. A first step is to investigate the feasibility and to conduct a pilot study. The process evaluation of this pilot study aims to gain insight into factors that influences the implementation of the care pathway. Semi-structured interviews were held with care professionals in both primary and hospital care and informal care givers. These results were then used to optimize the care path for the step wedge cluster randomized study. This presentation discusses experiences of those involved with training, conversations about the end of life, multidisciplinary consultation, the palliative care team and roles. PalliSupport – Implementation and evaluation of a transitional integrated care pathway for older patient with palliative care needs – Bianca Buurman (20 minutes) The transitional integrated care pathway will be implemented and evaluated using a stepped wedge cluster randomized study design. This study will be conducted in five regions, consisting of a hospital and the surrounding primary care organizations. 600 patients ≥65 years of age with acute hospitalization and a positive score on frailty scales participate in this study. The PalliSupport project consists of interventions at hospital level, palliative team and primary care level. The control group receives care as usual. The primary outcome is the number of patients with an unplanned readmission within six months after discharge. Secondary outcomes are death at place of preference, quality of life, symptom burden, informal caregiver burden and health care utilization. In addition, a process evaluation and cost-effectiveness analysis will be performed. Furthermore a business case is written to facilitate implementation after the study period. During this presentation the design, components of the intervention, implementation strategies and preliminary results of the research will be presented. Interactive discussion (15 minutes): The interactive discussion will facilitate exchange of experiences, ideas and advice for future practice and research on complex integrated care interventions.

Context Inadequate handovers between hospital and home can lead to adverse health outcomes. A group particularly at risk is patients at the end of life because of complex health problems, frequent care transitions, and involvement of many professionals. Objectives To investigate health care providers' views and experiences with regard to the transition from hospital to primary care in palliative care. Methods This was a descriptive qualitative study. Three focus group discussions were held with 28 nurses and two focus groups with nine physicians. Participants were recruited from primary and hospital care. The focus groups were audiorecorded, transcribed verbatim, and analyzed thematically. Results The following themes emerged from the data: lack of identification of and communication about the last phase of life; incomplete and insufficient handover; and uncertainty about responsibilities. Professionals emphasize the importance of proper handovers and transitional processes in these vulnerable patients. The transition between hospital to primary care is hindered by a lack of identification of the palliative phase and uncertainties about patient awareness. Direct communication between professionals is needed but lacking. The handover itself is currently primarily focused on physical aspects where psychosocial aspects were also found necessary. Furthermore, uncertainties with regard to physicians' responsibility for the patient seem to further hinder professionals in the transitional process. Conclusion Efforts should be made to enhance knowledge and skills around identification of palliative needs and communication with patients about the end of life, especially in the hospital setting.

Background Early start of palliative care improves the quality of life of eligible patients and their relatives. However, in hospital, patients who could benefit from palliative care are often not identified timely. The aim of this study is to assess how hospital-based nurses and physicians define the palliative phase, how they identify the palliative phase and what difficulties they face. Methods Semi-structured interviews were held with ten nurses and 18 physicians working at seven hospitals in the Netherlands. Data was analysed using thematic analysis. Results Nurses and physicians feel insecure about how to define the palliative phase and differentiate between an acute and extended phase. Great variation existed in what life expectancy is attributed to each phase. A variety of ways to identify the palliative phase were described: 1) Prognostication. 2) Treatment trade-off. 3) Assessment of patients’ preferences and needs. 4) Interprofessional collaboration. Professionals base prognostication on their experience but also search for clinical indicators. When benefits of treatment no longer outweigh the negatives, this was considered an, albeit late, identification point. To start a conversation on a patients’ palliative care needs was found to be difficult. Therefore, some respondents wait for patients to vocalize preferences themselves. Many professionals rely on interprofessional collaboration for identification, however uncertainty exist about responsibilities. Difficulties in identification occurred because of variance in definitions, unpredictability of non-oncological diseases, focus on treatment and difficulties in communication and collaboration. Conclusion These results provide insight into the challenges and difficulties hospital-based professionals experience in timely identification of patients with palliative care needs. Electronic supplementary material The online version of this article (10.1186/s12904-019-0439-0) contains supplementary material, which is available to authorized users.

Wnt/β-catenin signaling plays a crucial role in the regulation of colon tissue regeneration and the development of colon tumors. Under physiological conditions, β-catenin activity is tightly controlled. However, the majority of sporadic forms of colorectal cancer are characterized by inactivation of the tumor suppressor gene APC due to loss of heterozygosity (LOH), resulting in deregulation of the protein β-catenin. Apart from known β-catenin target genes like MYC, OPG, and DKK4, the gene TNFRSF19, a member of the TNF receptor superfamily, is regulated by β-catenin in mesenchymal stem cells (hMSC). We found that TNFRSF19 is frequently overexpressed in colorectal cancer cell lines and primary colorectal carcinomas. Further characterization revealed that both isoforms of TNFRSF19, TNFRSF19.1 and TNFRSF19.2, are regulated in a β-catenin dependent manner. The transcript TNFRSF19.2 encodes a 417 amino acid long protein containing a TRAF-binding site that links the TNFRSF19.2 to NF-κB signaling, whereas the isoform TNFRSF19.1 lacks this TRAF-binding site. Nevertheless both isoform 1 and 2 induced the activity of an NF-κB reporter gene. NF-κB signaling is important for inflammatory processes and chronic inflammatory diseases like ulcerative colitis and Crohn's disease, which are associated with increased risk for developing colorectal cancer. The observation that TNFRSF19 is a β-catenin target gene and TNFRSF19 receptor molecules activate NF-κB signaling shows that β-catenin regulates NF-κB activity via TNFRSF19, suggesting that TNFRSF19 may contribute to the development of colorectal tumors with deregulated β-catenin activity.

Wnt/β-catenin signaling plays a crucial role in the regulation of colon tissue regeneration and the development of colon tumors. Under physiological conditions, β-catenin activity is tightly controlled. However, the majority of sporadic forms of colorectal cancer are characterized by inactivation of the tumor suppressor gene APC due to loss of heterozygosity (LOH), resulting in deregulation of the protein β-catenin. Apart from known β-catenin target genes like MYC, OPG, and DKK4, the gene TNFRSF19, a member of the TNF receptor superfamily, is regulated by β-catenin in mesenchymal stem cells (hMSC). We found that TNFRSF19 is frequently overexpressed in colorectal cancer cell lines and primary colorectal carcinomas. Further characterization revealed that both isoforms of TNFRSF19, TNFRSF19.1 and TNFRSF19.2, are regulated in a β-catenin dependent manner. The transcript TNFRSF19.2 encodes a 417 amino acid long protein containing a TRAF-binding site that links the TNFRSF19.2 to NF-κB signaling, whereas the isoform TNFRSF19.1 lacks this TRAF-binding site. Nevertheless both isoform 1 and 2 induced the activity of an NF-κB reporter gene. NF-κB signaling is important for inflammatory processes and chronic inflammatory diseases like ulcerative colitis and Crohn's disease, which are associated with increased risk for developing colorectal cancer. The observation that TNFRSF19 is a β-catenin target gene and TNFRSF19 receptor molecules activate NF-κB signaling shows that β-catenin regulates NF-κB activity via TNFRSF19, suggesting that TNFRSF19 may contribute to the development of colorectal tumors with deregulated β-catenin activity.