The National Tumor Association Foundation (ANT): A 30 year old model of home palliative care

Abstract

Background: Models of palliative care delivery develop within a social, cultural, and political context. This paper describes the 30-year history of the National Tumor Association (ANT), a palliative care organization founded in the Italian province of Bologna, focusing on this model of home care for palliative cancer patients and on its evaluation.

Methods: Data were collected from the 1986-2008 ANT archives and documents from the Emilia-Romagna Region Health Department, Italy. Outcomes of interest were changed in: number of patients served, performance status at admission (Karnofsky Performance Status score [KPS]), length of participation in the program (days of care provided), place of death (home vs. hospital/hospice), and satisfaction with care. Statistical methods included linear and quadratic regressions. A linear and a quadratic regressions were generated; the independent variable was the year, while the dependent one was the number of patients from 1986 to 2008. Two linear regressions were generated for patients died at home and in the hospital, respectively. For each regression, the R square, the unstandardized and standardized coefficients and related P-values were estimated.

Results: The number of patients served by ANT has increased continuously from 131 (1986) to a cumulative total of 69,336 patients (2008), at a steady rate of approximately 121 additional patients per year and with no significant gender difference. The annual number of home visits increased from 6,357 (1985) to 904,782 (2008). More ANT patients died at home than in hospice or hospital; this proportion increased from 60% (1987) to 80% (2007). The rate of growth in the number of patients dying in hospital/hospice was approximately 40 patients/year (p < 0.01), vs. approximately 177 patients/year for patients who died at home. The percentage of patients with KPS < 40 at admission decreased from 70% (2003) to 30% (2008); the percentage of patients with KPS > 40 increased. Mean days of care for patients with KPS > 40 exceeded mean days for patients with KPS < 40 (p < 0.001). Patients and caregivers reported high satisfaction with care in each year of assessment; in 2008, among 187 interviewed caregivers, 95% judged the quality of doctors' assistance, and 91% judged the quality of nurses' assistance, to be "optimal."

Conclusions: The ANT home care model of palliative care delivery has been well-received, with progressively growing numbers of patients served. It has resulted in a greater proportion of home deaths and in patients' accessing palliative care at an earlier point in the disease trajectory. Changes in ANT chronicle palliative care trends in general.

Figure 1

The structure of the OHH unit (see text for details).

Figure 2

Distribution of OHHs in Italy in the years 1988, 1988, 2008. In 1988 the first ODO-ANT was founded in Taranto, in the south of Italy. Since that time, the number of periphery national offices has progressively increased. At the end of 2008 there were 23 OHHs in Italy.

Figure 3

The structure of the ANT organization (see text for details).

Figure 4

Until 1998, ANT was financed solely with private grants. From 1990 to 2000, contributions from bank foundations were added and in 2001, the public health system allocated funds. Private grants (blue square), Public Health Service (green square), Banks (yellow square).

Figure 5

Number of patients served by ANT from 1986 to 2008. Over this 23-year period, the number of patients has increased with a constant acceleration of approximately 121 patients per year. The independent variable is the year, while the dependent one is the total number of patients.

Figure 6

Number of patients deceased at home (blue square), and in the hospital (green triangle) from 1986 to 2008 and the related linear regression lines. Every year, more ANT patients died at home than died in hospice or hospital; this proportion increased from 60% in 1987 to 80% in 2007.

Figure 7

Percentage of patients with KPS <= 40 (blue circle) and KPS > 40 (red square) from 2003 to 2008, as well as the related linear regression lines. Change in KPS and days of care provided were evaluated. The percentage of patients with KPS < 40 at admission decreased from 70% in 2003 to 30% in 2008; the percentage of patients with KPS > 40 increased.

Figure 8

Mean days per patient according to the performance status (KPS). From the years 2003 to 2008 the mean number of days devoted to the assistance is lower for patients with KPS <= 40 (red triangle) and it is higher for patients with KPS > 40 (green square) in comparison to the total number of patients (blue circle) (P. values = 0.000)