Emergency department-initiated palliative care for advanced cancer patients: protocol for a pilot randomized controlled trial

Background

For patients with advanced cancer, visits to the emergency department (ED) are common. Such patients present to the ED with a specific profile of palliative care needs, including burdensome symptoms such as pain, dyspnea, or vomiting that cannot be controlled in other settings and a lack of well-defined goals of care. The goals of this study are: i) to test the feasibility of recruiting, enrolling, and randomizing patients with serious illness in the ED; and ii) to evaluate the impact of ED-initiated palliative care on health care utilization, quality of life, and survival.

Methods/Design

This is a protocol for a single center parallel, two-arm randomized controlled trial in ED patients with metastatic solid tumors comparing ED-initiated palliative care referral to a control group receiving usual care. We plan to enroll 125 to 150 ED-advanced cancer patients at Mount Sinai Hospital in New York, USA, who meet the following criteria: i) pass a brief cognitive screen; ii) speak fluent English or Spanish; and iii) have never been seen by palliative care. We will use balanced block randomization in groups of 50 to assign patients to the intervention or control group after completion of a baseline questionnaire. All research staff performing assessment or analysis will be blinded to patient assignment. We will measure the impact of the palliative care intervention on the following outcomes: i) timing and rate of palliative care consultation; ii) quality of life and depression at 12 weeks, measured using the FACT-G and PHQ-9; iii) health care utilization; and iv) length of survival. The primary analysis will be based on intention-to-treat.

Discussion

This pilot randomized controlled trial will test the feasibility of recruiting, enrolling, and randomizing patients with advanced cancer in the ED, and provide a preliminary estimate of the impact of palliative care referral on health care utilization, quality of life, and survival.

Trial registration

Clinical Trials.gov identifier: NCT01358110 (Entered 5/19/2011).

Evaluating the effects of inpatient palliative care consultations on subsequent hospice use and place of death in patients with advanced GI cancers

PURPOSE

Research has shown that patients with terminal illnesses prefer to die at home, yet more than 60% of patients with cancer are hospitalized in the last month of life. Less than half of these patients receive hospice care at the end of life. Inpatient palliative care consultations may serve as a bridge from hospitalization to receiving patient's preferred end-of-life care. GI tumors include some the deadliest cancers, and patients with these cancers may serve to benefit from palliative care services.

METHODS

The objective of this study was to evaluate the role of palliative care versus usual care on postdischarge outcomes and hospice use for patients with advanced GI cancers. Two hundred one adults, 82 of whom received a palliative care consult, were followed for 6 months after hospital discharge. Propensity scores were used to match palliative care patients to usual care patients. Outcome measures included hospice use, place of death, subsequent emergency department visits, hospital readmission, and survival.

RESULTS

Fifty-nine patients died in the 6 months postdischarge. Receiving a palliative care consult increased the odds of home death (odds ratio [OR] = 2.9; 95% CI, 1.02 to 8.44; P = .046) and decreased the odds of hospital death (OR = 0.159; 95% CI, 0.05 to 0.52; P = .002). At 2 and 4 months, more patients in the palliative care group were receiving hospice services at death, compared with the usual care group (75% v 18%, P = .001% and 93% v 30%, P = .000 respectively). There were no differences with respect to emergency department visits, hospital readmission, and survival.

CONCLUSION

Palliative care consultation was associated with increased hospice utilization, decreased likelihood of dying in a hospital, and increased likelihood of dying at home.

Methods for constructing and assessing propensity scores

OBJECTIVES

To model the steps involved in preparing for and carrying out propensity score analyses by providing step-by-step guidance and Stata code applied to an empirical dataset.

STUDY DESIGN

Guidance, Stata code, and empirical examples are given to illustrate (1) the process of choosing variables to include in the propensity score; (2) balance of propensity score across treatment and comparison groups; (3) balance of covariates across treatment and comparison groups within blocks of the propensity score; (4) choice of matching and weighting strategies; (5) balance of covariates after matching or weighting the sample; and (6) interpretation of treatment effect estimates.

EMPIRICAL APPLICATION

We use data from the Palliative Care for Cancer Patients (PC4C) study, a multisite observational study of the effect of inpatient palliative care on patient health outcomes and health services use, to illustrate the development and use of a propensity score.

CONCLUSIONS

Propensity scores are one useful tool for accounting for observed differences between treated and comparison groups. Careful testing of propensity scores is required before using them to estimate treatment effects.

National hospice survey results: for-profit status, community engagement, and service

IMPORTANCE The impact of the substantial growth in for-profit hospices in the United States on quality and hospice access has been intensely debated, yet little is known about how for-profit and nonprofit hospices differ in activities beyond service delivery. OBJECTIVE To determine the association between hospice ownership and (1) provision of community benefits, (2) setting and timing of the hospice population served, and (3) community outreach. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey (the National Hospice Survey), conducted from September 2008 through November 2009, of a national random sample of 591 Medicare-certified hospices operating throughout the United States. EXPOSURES For-profit or nonprofit hospice ownership. MAIN OUTCOMES AND MEASURES Provision of community benefits; setting and timing of the hospice population served; and community outreach. RESULTS A total of 591 hospices completed our survey (84% response rate). For-profit hospices were less likely than nonprofit hospices to provide community benefits including serving as training sites (55% vs 82%; adjusted relative risk [ARR], 0.67 [95% CI, 0.59-0.76]), conducting research (18% vs 23%; ARR, 0.67 [95% CI, 0.46-0.99]), and providing charity care (80% vs 82%; ARR, 0.88 [95% CI, 0.80-0.96]). For-profit compared with nonprofit hospices cared for a larger proportion of patients with longer expected hospice stays including those in nursing homes (30% vs 25%; P = .009). For-profit hospices were more likely to exceed Medicare's aggregate annual cap (22% vs 4%; ARR, 3.66 [95% CI, 2.02-6.63]) and had a higher patient disenrollment rate (10% vs 6%; P < .001). For-profit were more likely than nonprofit hospices to engage in outreach to low-income communities (61% vs 46%; ARR, 1.23 [95% CI, 1.05-1.44]) and minority communities (59% vs 48%; ARR, 1.18 [95% CI, 1.02-1.38]) and less likely to partner with oncology centers (25% vs 33%; ARR, 0.59 [95% CI, 0.44-0.80]). CONCLUSIONS AND RELEVANCE Ownership-related differences are apparent among hospices in community benefits, population served, and community outreach. Although Medicare's aggregate annual cap may curb the incentive to focus on long-stay hospice patients, additional regulatory measures such as public reporting of hospice disenrollment rates should be considered as the share of for-profit hospices in the United States continues to increase.

Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay

Despite its demonstrated potential to both improve quality of care and lower costs, the Medicare hospice benefit has been seen as producing savings only for patients enrolled 53-105 days before death. Using data from the Health and Retirement Study, 2002-08, and individual Medicare claims, and overcoming limitations of previous work, we found $2,561 in savings to Medicare for each patient enrolled in hospice 53-105 days before death, compared to a matched, nonhospice control. Even higher savings were seen, however, with more common, shorter enrollment periods: $2,650, $5,040, and $6,430 per patient enrolled 1-7, 8-14, and 15-30 days prior to death, respectively. Within all periods examined, hospice patients also had significantly lower rates of hospital service use and in-hospital death than matched controls. Instead of attempting to limit Medicare hospice participation, the Centers for Medicare and Medicaid Services should focus on ensuring the timely enrollment of qualified patients who desire the benefit.

Evaluating the role of palliative care consultations in patients with advanced gastrointestinal cancers

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Background: Though research shows that patients with terminal illnesses prefer to die at home, over 60% of patients with advanced cancer are hospitalized in the last month of life. Additionally, less than half of these patients receive any form of hospice care at the end of life, despite its demonstrated potential to improve quality of care. Inpatient palliative care (PC) consultations may serve as a bridge from hospitalization to receiving the kind of end-of-life care that patients prefer. Tumors of the gastrointestinal (GI) system include some of the most common and deadliest cancers and these patients can benefit from PC services, especially when the disease has reached an advanced stage. Our objective was to compare the effectiveness of inpatient PC consultations vs. usual care on post-discharge outcomes in patients with advanced GI cancers. Methods: 202 adults with advanced GI cancers admitted to 5 US hospitals were followed prospectively through hospitalization and 6 months post-discharge. 82 patients received a palliative care consult during hospitalization. Propensity scores were used to match treated to control patients, with exposure to a palliative care consult as the intervention. Outcome measures included: referral to hospice, subsequent ER visit, hospital readmission, and place of death. Results: Significantly more patients in the treatment group were referred to hospice upon hospital discharge (38% vs. 8%, p=0.000). 70 patients died in the 6-month follow-up period. Receiving a PC consult increased the odds of dying at home 3-fold (OR=2.9, p=0.046, 95% CI 1.02-8.44) and decreased the odds of dying in a hospital by 85% (OR=0.159, p=0.002, 95% CI 0.05-0.52). At 2 and 6 months post-discharge, significantly more patients in the treatment group were receiving hospice services at death (75% vs. 18%, p=0.001 and 82% vs. 24%, p=0.000 respectively). There were no significant differences between the two groups regarding hospital readmission and ER visits post-discharge. Conclusions: PC consults for patients with advanced GI cancers was associated with increased referral to hospice, decreased likelihood of dying in a hospital and increased likelihood of dying at home.

Standardized criteria for required palliative care consultation on the solid tumor oncology service

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Background: Studies have shown that routine integration of Palliative Care (PC) for patients with advanced cancer is associated with improved symptom control, clearer understanding of prognosis, lower utilization of health care resources, and increased hospice use. The 2012 ASCO guidelines call for incorporation of PC for any patient with metastatic cancer and/or high symptom burden. Despite a top-rated PC division at Mount Sinai, our Solid Tumor (ST) Division utilized PC and hospice less than other medical centers. Our inpatient ST service consistently demonstrated poor quality metrics. Our 2011-2012 UHC statistics were: mortality index, 1.35 (target <1), 30-day readmission rate, 21.7%, (target < 10.3%) and length of stay (LOS) index, 1.23 (target <1). We hypothesized that implementing standardized criteria for PC consultation would improve these metrics. Methods: During this 3-month pilot, criteria for PC consultation included patients with one or more of the following: stage IV disease, Stage III lung or pancreatic cancer, hospitalization within prior 30 days, >7 day hospitalization, uncontrolled symptoms (pain, nausea, dyspnea, delirium, distress). We looked at two baseline groups for comparison: 1) patients who met eligibility in a six week period prior to the intervention 2) For UHC index data, we used the hospital dashboard average over a 1-year period prior to the intervention. This included all ST patients who were eligible for the intervention (60%) and those who were not (40%). Primary outcomes were: hospice utilization, ST mortality index, 30-day readmission rate and LOS. Results: Comparing Group 1 to the Pilot Group, palliative care consultation doubled from 41% to 82%, 30-day readmission decreased from 36% to 17% (p= .022), and hospice utilization increased from 14% to 25% (p=.146). UHC data (Group 2 vs. Pilot) showed: mortality index improved (1.35 to .59) and 30-day readmission rates decreased (21.7% to 13.5%, p=.026). LOS was unchanged (1.23 to 1.25). Conclusions: Mandating palliative care consults for patients at the highest risk for in hospital death and readmission improved hospice utilization, 30-day readmission, oncology service mortality and adherence with ASCO guidelines.

Pain management in older adults

BACKGROUND

Chronic pain is prevalent among older adults but is underrecognized and undertreated. The approach to pain assessment and management in older adults requires an understanding of the physiology of aging, validated assessment tools, and common pain presentations among older adults.

OBJECTIVE

To identify the overall principles of pain management in older adults with a specific focus on common painful conditions and approaches to pharmacologic treatment.

METHODS

We searched PubMed for common pain presentations in older adults with heart failure, end-stage renal disease, dementia, frailty, and cancer. We also reviewed guidelines for pain management. Our review encompassed 2 guidelines, 10 original studies, and 22 review articles published from 2000 to the present. This review does not discuss nonpharmacologic treatments of pain.

RESULTS

Clinical guidelines support the use of opioids in persistent nonmalignant pain. Opioids should be used in patients with moderate or severe pain or pain not otherwise controlled but with careful attention to potential toxic effects and half-life. In addition, clinical practice guidelines recommend use of oral nonsteroidal anti-inflammatory drugs with extreme caution and for defined, limited periods.

CONCLUSION

An understanding of the basics of pain pathophysiology, assessment, pharmacologic management, and a familiarity with common pain presentations will allow clinicians to effectively manage pain for older adults.

Models of palliative care delivery in the United States

PURPOSE OF REVIEW

To summarize the current United States healthcare system and describe current models of palliative care delivery.

RECENT FINDINGS

Palliative care services in the USA have been heavily influenced by the public-private fee-for-service reimbursement system. Hospice provides care for 46% of adults at the end-of-life under the Medicare hospice benefit. Palliative care teams in hospitals have rapidly expanded to provide care for seriously ill patients irrespective of prognosis. To date, over two-thirds of all hospitals and over 85% of mid to large size hospitals report a palliative care team. With the passage of the Patient Protection and Affordable Care Act of 2010, healthcare reform provides an opportunity for new models of care.

SUMMARY

Palliative care services are well established within hospitals and hospice. Future work is needed to develop quality metrics, create care models that provide services in the community, and increase the palliative care workforce.

An update: NIH research funding for palliative medicine 2006 to 2010

BACKGROUND

Palliative care clinical and educational programs are expanding to meet the needs of seriously ill patients and their families. Multiple reports call for an enhanced palliative care evidence base.

OBJECTIVE

To examine current National Institutes of Health (NIH) funding of palliative medicine research and changes since our 2008 report.

METHODS

We sought to identify NIH funding of palliative medicine from 2006 to 2010 in two stages. First, we searched the NIH grants database RePorter for grants with key words "palliative care," "end-of-life care," "hospice," and "end of life." Second, we identified palliative care researchers likely to have secured NIH funding using three strategies: (1) We abstracted the first and last authors' names from original investigations published in major palliative medicine journals from 2008 to 2010; (2) we abstracted these names from a PubMed generated list of all original articles published in major medicine, nursing, and subspecialty journals using the above key words Medical Subject Headings (MESH) terms "palliative care," "end-of-life care," "hospice," and "end of life;" and (3) we identified editorial board members of palliative medicine journals and key members of palliative medicine research initiatives. We crossmatched the pooled names against NIH grants funded from 2006 to 2010.

RESULTS

The NIH RePorter search yielded 653 grants and the author search identified an additional 352 grants. Compared to 2001 to 2005, 589 (240%) more grants were NIH funded. The 391 grants categorized as relevant to palliative medicine represented 294 unique PIs, an increase of 185 (269%) NIH funded palliative medicine researchers. The NIH supported 21% of the 1253 original palliative medicine research articles identified. Compared to 2001 to 2005, the percentage of grants funded by institutes other than the National Cancer Institute (NCI), the National Institute for Nursing Research (NINR), and the National Institute of Aging (NIA) increased from 15% to 20% of all grants.

CONCLUSIONS

When compared to 2001-2005, more palliative medicine investigators received NIH funding; and research funding has improved. Nevertheless, additional initiatives to further support palliative care research are needed.

Palliative oncology: identity, progress, and the path ahead

Palliative care is a rapidly growing subspecialty of medicine entailing expert and active assessment, evaluation and treatment of the physical, psychological, social and spiritual needs of patients and families with serious illnesses. It provides an added layer of support to the patient's regular medical care. As cancer is detected earlier and its treatments improve, palliative care is increasingly playing a vital role in the oncology population. Because of these advances in oncology, the role of palliative care services for such patients is actively evolving. Herein, we will highlight emerging paradigms in palliative care and attempt to delineate key education, research and policy areas that lie ahead for the field of palliative oncology. Despite the critical need for improving multi-faceted and multi-specialty symptom management and patient-physician communication, we will focus on the interface between palliative care and oncology specialists, a relationship that can lead to better overall patient care on all of these levels.

Disability and decline in physical function associated with hospital use at end of life

BACKGROUND

Hospital use near the end of life is often undesirable to patients, represents considerable Medicare cost, and varies widely across regions.

OBJECTIVE

To concurrently examine regional and patient factors, including disability and functional decline, associated with end-of-life hospital use.

DESIGN/PARTICIPANTS

We sampled decedents aged 65 and older (n = 2,493) from the Health and Retirement Study (2000-2006), and linked data from individual Medicare claims and the Dartmouth Atlas of Health Care. Two-part regression models estimated the relationship between total hospital days in the last 6 months and patient characteristics including physical function, while adjusting for regional resources and hospital care intensity (HCI).

KEY RESULTS

Median hospital days was 7 (range = 0-183). 53% of respondents had functional decline. Compared with decedents without functional decline, those with severe disability or decline had more regression-adjusted hospital days (range 3.47-9.05, depending on category). Dementia was associated with fewer days (-3.02); while chronic kidney disease (2.37), diabetes (2.40), stroke or transient ischemic attack (2.11), and congestive heart failure (1.74) were associated with more days. African Americans and Hispanics had more days (5.91 and 4.61, respectively). Those with family nearby had 1.62 fewer days and hospice enrollees had 1.88 fewer days. Additional hospital days were associated with urban residence (1.74) and residence in a region with more specialists (1.97) and higher HCI (2.27).

CONCLUSIONS

Functional decline is significantly associated with end-of-life hospital use among older adults. To improve care and reduce costs, health care programs and policies should address specific needs of patients with functional decline and disability.

Characteristics of emergency department patients who receive a palliative care consultation

BACKGROUND

A large gap exists between the practice of emergency medicine and palliative care. Although hospice and palliative medicine has recently been recognized as a subspecialty of emergency medicine, few palliative care teams routinely interact with emergency providers, and primary palliative care skills among emergency providers are lacking.

OBJECTIVE

To identify the proportion and characteristics of patients who receive a palliative care consultation and arrive via the emergency department (ED).

METHODS

A descriptive study of adult ED patients from an urban, academic tertiary care hospital who received a palliative care consultation in January 2005 or January 2009.

RESULTS

In January 2005, 100 of the 161 consults (62%) arrived via the ED versus 63 of 124 consults (51%) in January 2009 (p=0.06). Mean days from admission to consultation in January 2005 were six days (standard deviation 11), versus nine days (SD 26) in January 2009 (p=0.35). Three of the 100 consultations (3%) in January 2005 were initiated in the ED, versus 4 of the 64 (6%) in January 2009.

CONCLUSIONS

At an urban academic medical center with a well-developed palliative care service, the majority of palliative care consultations were for patients who arrive via the ED. Despite this, only a small minority of consultations originated from emergency providers and consultation was on average initiated days into a patient's hospital stay.

Advanced dementia: state of the art and priorities for the next decade

Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.

Advanced dementia: state of the art and priorities for the next decade

Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.

Does palliative care have a future in the emergency department? Discussions with attending emergency physicians

CONTEXT

Palliative care focuses on the relief of pain and suffering and achieving the best possible quality of life for patients. Although traditionally delivered in the inpatient setting, emergency departments (EDs) are a new focus for palliative care consultation teams.

OBJECTIVES

To explore attitudes and beliefs among emergency care providers regarding the provision of palliative care services in the ED.

METHODS

Three semistructured focus groups were conducted with attending emergency physicians from an academic medical center, a public hospital center, and a community hospital. The discussions were digitally recorded and transcribed to conduct a thematic analysis using grounded theory. A coding scheme was iteratively developed to subsequently identify themes and subthemes that emerged from the interviews.

RESULTS

Twenty emergency physicians participated (mean age 41 years, range 31-61 years, median practice time nine years, 40% female). Providers acknowledged many benefits of palliative care presence in the ED, including provision of a specialized skill set, time to discuss goals of care, and an opportunity to intervene for seriously ill or injured patients. Providers believed that concerns about medicolegal issues impaired their ability to forgo treatments where risks outweigh benefits. Additionally, the culture of emergency medicine-to provide stabilization of acute medical emergencies-was sometimes at odds with the culture of palliative care, which balances quality of life with the burdens of invasive treatments. Some providers also felt it was the primary physician's responsibility, and not their own, to address goals of care. Finally, some providers expressed concern that palliative care consultation was only available on weekdays during daytime hours. Automatic consultation based on predetermined criteria was suggested as a way to avoid conflicts with patients and family.

CONCLUSION

Emergency providers identified many benefits to palliative care consultation. Solving logistical problems and developing clear indications for consultation might help increase the use of such services.

Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them

OBJECTIVE

There has been a growing recognition of the need for better pharmacologic management of chronic pain among older adults. To address this need, the National Institutes of Health Pain Consortium sponsored an "Expert Panel Discussion on the Pharmacological Management of Chronic Pain in Older Adults" conference in September 2010 to identify research gaps and strategies to address them. Specific emphasis was placed on ascertaining gaps regarding use of opioid and nonsteroidal anti-inflammatory medications because of continued uncertainties regarding their risks and benefits.

DESIGN

Eighteen panel members provided oral presentations; each was followed by a multidisciplinary panel discussion. Meeting transcripts and panelists' slide presentations were reviewed to identify the gaps and the types of studies and research methods panelists suggested could best address them.

RESULTS

Fifteen gaps were identified in the areas of treatment (e.g., uncertainty regarding the long-term safety and efficacy of commonly prescribed analgesics), epidemiology (e.g., lack of knowledge regarding the course of common pain syndromes), and implementation (e.g., limited understanding of optimal strategies to translate evidence-based pain treatments into practice). Analyses of data from electronic health care databases, observational cohort studies, and ongoing cohort studies (augmented with pain and other relevant outcomes measures) were felt to be practical methods for building an age-appropriate evidence base to improve the pharmacologic management of pain in later life.

CONCLUSION

Addressing the gaps presented in the current report was judged by the panel to have substantial potential to improve the health and well-being of older adults with chronic pain.

The palliative care model for emergency department patients with advanced illness

BACKGROUND

Large gaps in the delivery of palliative care services exist in the outpatient setting, where there is a failure to address goals of care and to plan for and treat predictable crises. While not originally considered an ideal environment to deliver palliative care services, the emergency department presents a key decision point at which providers set the course for a patient's subsequent trajectory and goals of care. Many patients with serious and life-threatening illness present to emergency departments because symptoms, such as pain or nausea and vomiting, cannot be controlled at home, in an assisted living facility, or in a provider's office. Even for patients in whom goals of care are clear, families often need support for their loved one's physical as well as mental distress. The emergency department is often the only place that can provide needed interventions (e.g., intravenous fluids or pain medications) as well as immediate access to advanced diagnostic tests (e.g. computed tomography or magnetic resonance imaging).

DISCUSSION

Palliative care services provide relief of burdensome symptoms, attention to spiritual and social concerns, goal setting, and patient-provider communication that are often not addressed in the acute care setting. While emergency providers could provide some of these services, there is a knowledge gap regarding palliative care in the emergency department setting. Emergency department-based palliative care programs are currently consultations for symptoms and/or goals of care, and have been initiated both by both the palliative care team and palliative care champions in the emergency department. Some programs have focused on the provision of hospice services through partnerships with hospice providers, which can potentially help emergency department providers with disposition.

CONCLUSION

Although some data on pilot programs are available, optimal models of delivery of emergency department-based palliative care have not been rigorously studied. Research is needed to determine how these services are best organized, what affect they will have on patients and caregivers, and whether they can decrease symptom burden and health care utilization.

Development of a mobile ultrasound-guided peripheral nerve block and catheter service

Ultrasound guidance is associated with improved efficiency and success of peripheral nerve blockade and a decreased incidence of vascular puncture, making these interventions safer. Patients with peripheral nerve blocks report decreased pain and increased satisfaction scores. We present the development of a mobile ultrasound-guided block service that allows for the safe and efficient placement of nerve blocks and perineural catheters at the nontraditional location of the patient's bedside and in the emergency department.

Balancing punishment and compassion for seriously ill prisoners

Compassionate release is a program that allows some eligible, seriously ill prisoners to die outside of prison before sentence completion. It became a matter of federal statute in 1984 and has been adopted by most U.S. prison jurisdictions. Incarceration is justified on 4 principles: retribution, rehabilitation, deterrence, and incapacitation. Compassionate release derives from the theory that changes in health status may affect these principles and thus alter justification for incarceration and sentence completion. The medical profession is intricately involved in this process because eligibility for consideration for compassionate release is generally based on medical evidence. Many policy experts are calling for broader use of compassionate release because of many factors, such as an aging prison population, overcrowding, the increasing deaths in custody, and the soaring medical costs of the criminal justice system. Even so, the medical eligibility criteria of many compassionate-release guidelines--which often assume a definitive prognosis--are clinically flawed, and procedural barriers may further limit their rational application. We propose changes to address these flaws.

Comparison of the mental health of female adult film performers and other young women in California

OBJECTIVE

This study compared self-reported mental health status and current depression of female adult film performers and other young women.

METHODS

A cross-sectional structured online survey adapted from the California Women's Health Survey (CWHS) was self-administered to a convenience sample of 134 current female adult film performers via the Internet. Bivariate and multivariate analyses were used to compare data for these women with data for 1,773 women of similar ages who responded to the 2007 CWHS. Main outcome measures were self-reported mental health status, measured with the Behavioral Risk Factor Surveillance Survey core-instrument quality-of-life questions, and current depression, measured with the Patient Health Questionnaire-8.

RESULTS

Performers reported a mean of 7.2 days of poor mental health in the past 30 days, compared with 4.8 days for CWHS respondents, and 33% met criteria for current depression, compared with 13% of CWHS respondents (p<.01). As children, the adult film performers were more likely to have been victims of forced sex (37% compared with 13% of CWHS respondents), to have lived in poverty (24% and 12%), and to have been placed in foster care (21% and 4%) (p<.01). In the past 12 months, 50% of the performers reported living in poverty and 34% reported experiencing domestic violence, compared with 36% and 6%, respectively, of CWHS respondents (p<.01). As adults, 27% had experienced forced sex, compared with 9% of CWHS respondents (p<.01).

CONCLUSIONS

Female adult film performers have significantly worse mental health and higher rates of depression than other California women of similar ages.

Resident perceptions of palliative care training in the emergency department

OBJECTIVES

To characterize the level of formal training and perceived educational needs in palliative care of emergency medicine (EM) residents.

METHODS

This descriptive study used a 16-question survey administered at weekly resident didactic sessions in 2008 to EM residency programs in New York City. Survey items asked residents to: (1) respond to Likert-scaled statements about the role of palliative care in the emergency department (ED); (2) quantify their level of formal training and personal comfort in symptom management, discussion of bad news and prognosis, legal issues, and withdrawing/withholding therapy; and (3) express their interest in future palliative care training.

RESULTS

Of 228 total residents, 159 (70%) completed the survey. Of those surveyed, 50% completed some palliative care training before residency; 71.1% agreed or strongly agreed that palliative care was an important competence for an EM physician. However, only 24.3% reported having a "clear idea of the role of palliative care in EM." The highest self-reported level of formal training was in the area of advanced directives or legal issues at the end of life; the lowest levels were in areas of patient management at the end of life. The highest level of self-reported comfort was in giving bad news and the lowest was in withholding/withdrawing therapy. A slight majority of residents (54%) showed positive interest in receiving future training in palliative care.

CONCLUSIONS

New York City EM residents reported palliative care as an important competency for emergency medicine physicians, yet also reported low levels of formal training in palliative care. The majority of residents surveyed favored additional training.

Determinants of medical expenditures in the last 6 months of life

BACKGROUND

End-of-life medical expenditures exceed costs of care during other years, vary across regions, and are likely to be unsustainable. Identifying determinants of expenditure variation may reveal opportunities for reducing costs.

OBJECTIVE

To identify patient-level determinants of Medicare expenditures at the end of life and to determine the contributions of these factors to expenditure variation while accounting for regional characteristics. It was hypothesized that race or ethnicity, social support, and functional status are independently associated with treatment intensity and controlling for regional characteristics, and that individual characteristics account for a substantial proportion of expenditure variation.

DESIGN

Using data from the Health and Retirement Study, Medicare claims, and The Dartmouth Atlas of Health Care, relationships were modeled between expenditures and patient and regional characteristics.

SETTING

United States, 2000 to 2006.

PARTICIPANTS

2394 Health and Retirement Study decedents aged 65.5 years or older.

MEASUREMENTS

Medicare expenditures in the last 6 months of life were estimated in a series of 2-level multivariable regression models that included patient, regional, and patient and regional characteristics.

RESULTS

Decline in function (rate ratio [RR], 1.64 [95% CI, 1.46 to 1.83]); Hispanic ethnicity (RR, 1.50 [CI, 1.22 to 1.85]); black race (RR, 1.43 [CI, 1.25 to 1.64]); and certain chronic diseases, including diabetes (RR, 1.16 [CI, 1.06 to 1.27]), were associated with higher expenditures. Nearby family (RR, 0.90 [CI, 0.82 to 0.98]) and dementia (RR, 0.78 CI, 0.71 to 0.87]) were associated with lower expenditures, and advance care planning had no association. Regional characteristics, including end-of-life practice patterns (RR, 1.09 [CI, 1.06 to 1.14]) and hospital beds per capita (RR, 1.01 [CI, 1.00 to 1.02]), were associated with higher expenditures. Patient characteristics explained 10% of overall variance and retained statistically significant relationships with expenditures after regional characteristics were controlled for.

LIMITATION

The study limitations include the decedent sample, proxy informants, and a large proportion of unexplained variation.

CONCLUSION

Patient characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby family, are important determinants of expenditures at the end of life, independent of regional characteristics.

PRIMARY FUNDING SOURCE

The Brookdale Foundation.

Writing abstracts and developing posters for national meetings

Presenting posters at national meetings can help fellows and junior faculty members develop a national reputation. They often lead to interesting and fruitful networking and collaboration opportunities. They also help with promotion in academic medicine and can reveal new job opportunities. Practically, presenting posters can help justify funding to attend a meeting. Finally, this process can be invaluable in assisting with manuscript preparation. This article provides suggestions and words of wisdom for palliative care fellows and junior faculty members wanting to present a poster at a national meeting describing a case study or original research. It outlines how to pick a topic, decide on collaborators, and choose a meeting for the submission. It also describes how to write the abstract using examples that present a general format as well as writing tips for each section. It then describes how to prepare the poster and do the presentation. Sample poster formats are provided as are talking points to help the reader productively interact with those that visit the poster. Finally, tips are given regarding what to do after the meeting. The article seeks to not only describe the basic steps of this entire process, but also to highlight the hidden curriculum behind the successful abstracts and posters. These tricks of the trade can help the submission stand out and will make sure the reader gets the most out of the hard work that goes into a poster presentation at a national meeting.

Hospital-based palliative care consultation: effects on hospital cost

CONTEXT

Palliative care consultation teams in hospitals are becoming increasingly more common. Palliative care improves the quality of hospital care for patients with advanced disease. Less is known about its effects on hospital costs.

OBJECTIVE

To evaluate the relationship between palliative care consultation and hospital costs in patients with advanced disease.

DESIGN, SETTING, AND PATIENTS

An observational study of 3321 veterans hospitalized with advanced disease between October 1, 2004 and September 30, 2006. The sample includes 606 (18%) veterans who received palliative care and 2715 (82%) who received usual hospital care. October 1, 2004 and September 30, 2006.

MAIN OUTCOME MEASURES

We studied the costs and intensive care unit (ICU) use of palliative versus usual care for patients in five Veterans Affairs hospitals over a 2-year period. We used an instrumental variable approach to control for unmeasured characteristics that affect both treatment and outcome.

RESULTS

The average daily total direct hospital costs were $464 a day lower for the 606 patients receiving palliative compared to the 2715 receiving usual care (p < 0.001). Palliative care patients were 43.7 percentage points less likely to be admitted to ICU during the hospitalization than usual care patients (p < 0.001).

COMMENTS

Palliative care for patients hospitalized with advanced disease results in lower costs of care and less utilization of intensive care compared to similar patients receiving usual care. Selection on unobserved characteristics plays an important role in the determination of costs of care.

The quality of emergency department pain care for older adult patients

OBJECTIVES

To determine whether there are differences in emergency department (ED) pain assessment and treatment for older and younger adults.

DESIGN

Retrospective observational cohort.

SETTING

Urban, academic tertiary care ED during July and December 2005.

PARTICIPANTS

Adult patients with conditions warranting ED pain care.

MEASUREMENTS

Age, Charlson comorbidity score, number of prior medications, sex, race and ethnicity, triage severity, degree of pain, treating clinician, and final ED diagnosis. Pain care process measures were pain assessment and treatment and time of activities.

RESULTS

One thousand thirty-one ED visits met inclusion criteria; 92% of these had a documented pain assessment. Of those reporting pain, 41% had follow-up pain assessments, and 59% received analgesic medication (58% of these as opioids, 24% as nonsteroidal anti-inflammatory drugs (NSAIDs)). In adjusted analyses, there were no differences according to age in pain assessment and receiving any analgesic. Older patients (65-84) were less likely than younger patients (18-64) to receive opioid analgesics for moderate to severe (odds ratio (OR) = 0.44, 95% confidence interval (CI) = 0.22-0.88) and were more likely to more likely to receive NSAIDs for mild pain (OR = 3.72, 95% CI = 0.97-14.24). Older adults had a lower reduction of initial to final recorded pain scores (P = .002).

CONCLUSION

There appear to be differences in acute ED pain care for older and younger adults. Lower overall reduction of pain scores and less opioid use for the treatment of painful conditions in older patients highlight disparities of concern. Future studies should determine whether these differences represent inadequate ED pain care.

A strategy to advance the evidence base in palliative medicine: formation of a palliative care research cooperative group

BACKGROUND

Palliative medicine has made rapid progress in establishing its scientific and clinical legitimacy, yet the evidence base to support clinical practice remains deficient in both the quantity and quality of published studies. Historically, the conduct of research in palliative care populations has been impeded by multiple barriers including health care system fragmentation, small number and size of potential sites for recruitment, vulnerability of the population, perceptions of inappropriateness, ethical concerns, and gate-keeping.

METHODS

A group of experienced investigators with backgrounds in palliative care research convened to consider developing a research cooperative group as a mechanism for generating high-quality evidence on prioritized, clinically relevant topics in palliative care.

RESULTS

The resulting Palliative Care Research Cooperative (PCRC) agreed on a set of core principles: active, interdisciplinary membership; commitment to shared research purposes; heterogeneity of participating sites; development of research capacity in participating sites; standardization of methodologies, such as consenting and data collection/management; agile response to research requests from government, industry, and investigators; focus on translation; education and training of future palliative care researchers; actionable results that can inform clinical practice and policy. Consensus was achieved on a first collaborative study, a randomized clinical trial of statin discontinuation versus continuation in patients with a prognosis of less than 6 months who are taking statins for primary or secondary prevention. This article describes the formation of the PCRC, highlighting processes and decisions taken to optimize the cooperative group's success.

Determinants of treatment intensity for patients with serious illness: a new conceptual framework

BACKGROUND

Research during the past few decades has greatly advanced our understanding of the cost, quality, and variability of medical care at the end of life. The current health-care policy debate has focused considerable attention on the unsustainable rate of spending and wide regional variation associated with medical treatments in the last year of life. New initiatives aim to standardize quality and reduce over-utilization at the end of life. We argue, however, that focusing exclusively on medical treatment at the end of life is not likely to lead to effective health-care policy reform or reduce costs. Specifically, end-of-life policy initiatives face the challenges of political feasibility, inaccurate prognostication, and gaps in the existing literature.

OBJECTIVES

With the ultimate aim of improving the quality and efficiency of care, we propose a research and policy agenda guided by a new conceptual framework of factors associated with treatment intensity for patients with serious and complicated medical illness. This model not only expands the population of interest to include all adults with serious illness, but also provides a blueprint for the thorough investigation of the diverse and interconnected determinants of treatment intensity.

CONCLUSIONS

The new conceptual framework presented in this paper can be used to develop future research and policy initiatives designed to improve the quality and efficiency of care for adults with serious illness.

Palliative care needs of seriously ill, older adults presenting to the emergency department

OBJECTIVES

The objective was to identify the palliative care needs of seriously ill, older adults in the emergency department (ED).

METHODS

The authors conducted a cross-sectional structured survey. A convenience sample of 50 functionally impaired adults 65 years or older with coexisting cancer, congestive heart failure, end-stage liver or renal disease, stroke, oxygen-dependent pulmonary disease, or dementia was recruited from an urban academic tertiary care ED. Face-to-face interviews were conducted using the Needs Near the End-of-Life Screening Tool (NEST), McGill Quality of Life Index (MQOL), and Edmonton Symptom Assessment Survey (ESAS) to assess 1) range and severity of symptoms, 2) goals of care, 3) psychological well-being, 4) health care utilization, 5) spirituality, 6) social connectedness, 7) financial burden, 8) the patient-clinician relationship, and 9) overall quality of life (QOL).

RESULTS

Mean (±SD) age was 74.3 (±6.5) years and cancer was the most common diagnosis. Mean (±SD) QOL on the MQOL was 3.6 (±2.9). Over half of the patients exceeded intratest severity-of-needs cutoffs in four categories of the NEST: physical symptoms (47/50, 94%), finances (36/50, 72%), mental health (31/50, 62%), and access to care (29/50, 58%). The majority of patients reported moderate to severe fatigue, pain, dyspnea, and depression on the ESAS.

CONCLUSIONS

Seriously ill, older adults in an urban ED have substantial palliative care needs. Future work should focus on the role of emergency medicine and the new specialty of palliative care in addressing these needs.

Geographic access to hospice in the United States

BACKGROUND

Despite a 41% increase in the number of hospices since 2000, more than 60% of Americans die without hospice care. Given that hospice care is predominantly home based, proximity to a hospice is important in ensuring access to hospice services. We estimated the proportion of the population living in communities within 30 and 60 minutes driving time of a hospice.

METHODS

We conducted a cross-sectional study of geographic access to U.S. hospices using the 2008 Medicare Provider of Services data, U.S. Census data, and ArcGIS software. We used multivariate logistic regression to identify gaps in hospice availability by community characteristics.

RESULTS

As of 2008, 88% of the population lived in communities within 30 minutes and 98% lived in communities within 60 minutes of a hospice. Mean time to the nearest hospice was 15 minutes and the range was 0 to 403 minutes. Community characteristics independently associated with greater geographic access to hospice included higher population density, higher median income, higher educational attainment, higher percentage of black residents, and the state not having a Certificate of Need policy. The percentage of each state's population living in communities more than 30 minutes from a hospice ranged from 0% to 48%.

CONCLUSIONS

Recent growth in the hospice industry has resulted in widespread geographic access to hospice care in the United States, although state and community level variation exists. Future research regarding variation and disparities in hospice use should focus on barriers other than geographic proximity to a hospice.

Impact of hospice disenrollment on health care use and medicare expenditures for patients with cancer

PURPOSE

Patients with cancer represent the largest diagnostic group of hospice users, with 560,000 referred for hospice in 2008. Oncologists rely on hospice teams to provide care for patients who have completed disease-directed treatment and desire to remain at home. However, 11% to 15% of hospice users disenroll from hospice, and little is known about their health care use and Medicare expenditures.

PATIENTS AND METHODS

We used Surveillance, Epidemiology and End Results-Medicare data for hospice users who died as a result of cancer between 1998 and 2002 (N = 90,826) to compare rates of hospitalization, emergency department, and intensive care unit admission and hospital death for hospice disenrollees and those who remained with hospice until death. We also compared per-day and total Medicare expenditures across the two groups.

RESULTS

Patients with cancer who disenrolled from hospice were more likely to be hospitalized (39.8% v 1.6%; P < .001), more likely to be admitted to the emergency department (33.9% v 3.1%; P < .001) or intensive care unit (5.7% v 0.1%; P < .001), and more likely to die in the hospital (9.6% v 0.2%; P < .001). Patients who disenrolled from hospice died a median of 24 days following disenrollment, suggesting that the reason for hospice disenrollment was not improved health. In multivariable analyses, hospice disenrollees incurred higher per-day Medicare expenditures than patients who remained with hospice until death (higher per-day expenditures of $124; P < .001).

CONCLUSION

Hospice disenrollment is a marker for higher health care use and expenditures for care. Strategies to manage a patient's care and support family caregivers following hospice disenrollment may be beneficial and should be explored.

Center to Advance Palliative Care palliative care clinical care and customer satisfaction metrics consensus recommendations

Data collection and analysis are vital for strategic planning, quality improvement, and demonstration of palliative care program impact to hospital administrators, private funders and policymakers. Since 2000, the Center to Advance Palliative Care (CAPC) has provided technical assistance to hospitals, health systems and hospices working to start, sustain, and grow nonhospice palliative care programs. CAPC convened a consensus panel in 2008 to develop recommendations for specific clinical and customer metrics that programs should track. The panel agreed on four key domains of clinical metrics and two domains of customer metrics. Clinical metrics include: daily assessment of physical/psychological/spiritual symptoms by a symptom assessment tool; establishment of patient-centered goals of care; support to patient/family caregivers; and management of transitions across care sites. For customer metrics, consensus was reached on two domains that should be tracked to assess satisfaction: patient/family satisfaction, and referring clinician satisfaction. In an effort to ensure access to reliably high-quality palliative care data throughout the nation, hospital palliative care programs are encouraged to collect and report outcomes for each of the metric domains described here.

Current status of palliative care--clinical implementation, education, and research

Palliative and end-of-life care is changing in the United States. This dynamic field is improving care for patients with serious and life-threatening cancer through creation of national guidelines for quality care, multidisciplinary educational offerings, research endeavors, and resources made available to clinicians. Barriers to implementing quality palliative care across cancer populations include a rapidly expanding population of older adults who will need cancer care and a decrease in the workforce available to give care. Methods of integrating current palliative care knowledge into care of patients include multidisciplinary national education and research endeavors, and clinician resources. Acceptance of palliative care as a recognized medical specialty provides a valuable resource for improvement of care. Although compilation of evidence for the importance of palliative care specialities is in its initial stages, national research grants have provided support to build the knowledge necessary for appropriate palliative care. Opportunities are available to clinicians for understanding and applying appropriate palliative and end-of-life care to patients with serious and life-threatening cancers.

Hospice characteristics and the disenrollment of patients with cancer

OBJECTIVE

To characterize the types of hospices with higher rates of patient disenrollment from the Medicare Hospice Benefit and the markets in which these hospices operate.

DATA SOURCE

Secondary analyses of Surveillance, Epidemiology and End Results-Medicare data. Analyses included patients who died of cancer from 1998 to 2002 and who used hospice (n=90,826).

STUDY DESIGN

We used generalized estimating equations to estimate the association of patient disenrollment with hospice size, years since Medicare certification, ownership, staff mix, competition, urban/rural status, region, and fiscal intermediary. Other covariates included patient demographic and clinical characteristics.

PRINCIPAL FINDINGS

Patients were more likely to disenroll from hospice if they were served by newer hospices (OR=1.14; 95 percent CI 1.03, 1.26), by smaller hospices (OR=1.11; 95 percent CI 1.02, 1.20), or by hospices in more competitive markets (OR=1.17; 95 percent CI 1.03, 1.35). There was an independent effect of the hospice's fiscal intermediary on disenrollment, particularly disenrollment after 6 months with hospice (Wald chi(2)=21.2, p=.007).

CONCLUSIONS

The reasons for higher disenrollment rates for newer hospices, for smaller hospices, and for hospices in highly competitive markets are likely complex; however, results suggest that there are organizational-level barriers to keeping patients with cancer enrolled with hospice. Variation across fiscal intermediaries may indicate that regulatory oversight, particularly of long-stay patients, influences hospice disenrollment.