Standardized Criteria for Palliative Care Consultation on a Solid Tumor Oncology Service Reduces Downstream Health Care Use

PURPOSE

Hospitalized patients with advanced cancer have a high symptom burden and need for support. Integration of palliative care (PC) improves symptom control and decreases unwanted health care use, yet many patients are never offered these services. In 2016, ASCO called for incorporation of PC into oncologic care for all patients with metastatic cancer. To improve the quality of cancer care, we developed standardized criteria, or triggers, for PC consultation on the inpatient solid tumor service.

METHODS

Patients were eligible for this prospective cohort study if they met at least one of the following eligibility criteria: had an advanced solid tumor; prior hospitalization within 30 days; hospitalization > 7 days; and active symptoms. During the intervention, patients who met the criteria received automatic PC consultation.

RESULTS

When we compared patients in the intervention group with control subjects, there were increases in PC consultations (19 of 48 [39%] to 52 of 65 [80%]; P ≤ .001) and hospice referrals (seven of 48 [14%] to 17 of 65 [26%]; P = .03), and there were declines in 30-day readmission rates (17 of 48 [35%] to 13 of 65 [18%]; P = .04) and receipt of chemotherapy after discharge (21 of 48 [44%] to 12 of 65 [18%]; P = .03). There was an overall increase in support measures following discharge ( P = .004). Length of stay was unaffected.

CONCLUSION

To our knowledge, this is the first study to demonstrate that among patients with advanced cancer admitted to an inpatient oncology service, the standardized use of triggers for PC consultation is associated with substantial impact on 30-day readmission rates, chemotherapy following discharge, hospice referrals, and use of support services following discharge. Expansion of this model to other hospitals and health systems should improve the value of cancer care.

How empowering is hospital care for older people with advanced disease? Barriers and facilitators from a cross-national ethnography in England, Ireland and the USA

Background

patient empowerment, through which patients become self-determining agents with some control over their health and healthcare, is a common theme across health policies globally. Most care for older people is in the acute setting, but there is little evidence to inform the delivery of empowering hospital care.

Objective

we aimed to explore challenges to and facilitators of empowerment among older people with advanced disease in hospital, and the impact of palliative care.

Methods

we conducted an ethnography in six hospitals in England, Ireland and the USA. The ethnography involved: interviews with patients aged ≥65, informal caregivers, specialist palliative care (SPC) staff and other clinicians who cared for older adults with advanced disease, and fieldwork. Data were analysed using directed thematic analysis.

Results

analysis of 91 interviews and 340 h of observational data revealed substantial challenges to empowerment: poor communication and information provision, combined with routinised and fragmented inpatient care, restricted patients' self-efficacy, self-management, choice and decision-making. Information and knowledge were often necessary for empowerment, but not sufficient: empowerment depended on patient-centredness being enacted at an organisational and staff level. SPC facilitated empowerment by prioritising patient-centred care, tailored communication and information provision, and the support of other clinicians.

Conclusions

empowering older people in the acute setting requires changes throughout the health system. Facilitators of empowerment include excellent staff-patient communication, patient-centred, relational care, an organisational focus on patient experience rather than throughput, and appropriate access to SPC. Findings have relevance for many high- and middle-income countries with a growing population of older patients with advanced disease.

The Use of a Brief 5-Item Measure of Family Satisfaction as a Critical Quality Indicator in Advanced Cancer Care: A Multisite Comparison

BACKGROUND

Although family satisfaction is recognized as a critical indicator of quality for patients with advanced cancer, it is rarely assessed as part of routine clinical care. Measurement burden may be one barrier to widespread use of family satisfaction measures.

OBJECTIVE

The goal of this study was to test the ability of a new, brief 5-item measure of family satisfaction with care to accurately capture differences across hospital settings.

DESIGN

Using data from the Palliative Care for Cancer Patients study, a prospective study of 1979 patients and caregivers, we used multivariate regression analysis to detect significant differences across five sites.

SETTINGS

Hospitalized patients with advanced cancer and their caregivers Methods: We used both the shortened 5-item version of the FAMCARE scale (previously developed using Item Response Theory) and the original 20-item FAMCARE to measure family satisfaction.

RESULTS

On the 5-item FAMCARE, sites ranged from mean scores of 5.5-6.9 out of a possible high score of 10. Family members at one care site (n = 783) were significantly (p < 0.05) less satisfied with their care than family members at four other care sites. The original 20-item measure failed to differentiate satisfaction levels between all hospital sites.

DISCUSSION

Variability in family satisfaction with advanced cancer care across hospital settings can be more sensitively detected using a brief 5-item questionnaire versus longer measures. The development of less lengthy and burdensome measures for monitoring family satisfaction, which are still valid, can facilitate routine assessments to maintain and promote high-quality care across care settings.

Identifying Older Adults with Serious Illness: A Critical Step toward Improving the Value of Health Care

OBJECTIVE

To create and test three prospective, increasingly restrictive definitions of serious illness.

DATA SOURCES

Health and Retirement Study, 2000-2012.

STUDY DESIGN

We evaluated subjects' 1-year outcomes from the interview date when they first met each definition: (A) one or more severe medical conditions (Condition) and/or receiving assistance with activities of daily living (Functional Limitation); (B) Condition and/or Functional Limitation and hospital admission in the last 12 months and/or residing in a nursing home (Utilization); and (C) Condition and Functional Limitation and Utilization. Definitions are increasingly restrictive, but not mutually exclusive.

DATA COLLECTION

Of 11,577 eligible subjects, 5,297 met definition A; 3,151 definition B; and 1,447 definition C.

PRINCIPAL FINDINGS

One-year outcomes were as follows: hospitalization 33 percent (A), 44 percent (B), 47 percent (C); total average Medicare costs $20,566 (A), $26,349 (B), and $30,828 (C); and mortality 13 percent (A), 19 percent (B), 28 percent (C). In comparison, among those meeting no definition, 12 percent had hospitalizations, total Medicare costs averaged $7,789, and 2 percent died.

CONCLUSIONS

Prospective identification of older adults with serious illness is feasible using clinically accessible criteria and may be a critical step toward improving health care value. These definitions may aid clinicians and health systems in targeting patients who could benefit from additional services.

Individual variation in sow aggressive behavior and its relationship with sow welfare

This study examined the relationships between individual sow aggressive behavior and sow welfare, based on aggression, skin injuries, and stress, in a total of 275 pregnant domestic sows. Over 4 time replicates, sows were randomly mixed into groups of 10 (floor space of 1.8 m/sow) within 7 d of insemination in both their first and second gestations (200 sows per gestation with 126 sows observed in both gestations). Measurements were taken on aggression (both delivered and received) at feeding, skin injuries, and plasma cortisol concentrations at d 2, 9, and 51 after mixing. Live weight gain, nonreproductive removals, litter size (born alive, total born, and stillborn piglets), and farrowing rate were also recorded. In both the first and the second gestations, sows were classified at d 2 after mixing as "submissive" (delivered little or no aggression at feeding relative to aggression received), "subdominant" (received more aggression at feeding than delivered), and "dominant" (delivered more aggression at feeding than received). In both gestations, sows classified as dominant at d 2 subsequently delivered more (gestation 1, < 0.01; gestation 2, < 0.01) and received less (gestation 1, < 0.01; gestation 2, < 0.01) aggression and gained the most weight (gestation 1, < 0.01; gestation 2, < 0.01). Dominant sows had the least skin injuries throughout gestation 1 ( = 0.04), and although submissive sows sustained the most skin injuries at d 9 and 51 of gestation 2, at d 2 the classifications did not differ in skin injuries ( < 0.01). Subdominant sows had the highest cortisol concentrations at d 2 of gestation 2, but there were no differences between classifications at d 9 and 51 in either gestation (gestation 1, > 0.05; gestation 2, = 0.02). There were no significant relationships between aggression classification and reproduction and nonreproductive removals ( > 0.05). In conclusion, sows classified as dominant at feeding at d 2 subsequently received less aggression at feeding, sustained fewer skin injuries, and had higher live weight gain. Submissive and subdominant sows in groups are likely to benefit from the provision of increased resources such as space and access to feed.

Validation of the V66.7 Code for Palliative Care Consultation in a Single Academic Medical Center

BACKGROUND

Use of administrative data to study the effectiveness of specialized palliative care is limited by the lack of a reliable method to identify patients receiving palliative care consultation. The International Classification of Diseases, Ninth Revision (ICD-9) code V66.7 has been used, but its validity for this purpose is unknown.

OBJECTIVE

To examine the validity of the ICD-9 code V66.7 for identifying whether hospitalized patients received palliative care consultation.

DESIGN

Retrospective cohort study.

SETTING/SUBJECTS

All patients of age ≥18 years admitted to a single academic medical center between August 2013 and August 2015.

MEASUREMENTS

Sensitivity and specificity of the V66.7 code for palliative care consultation for all patients and several a priori identified subgroups. The reference standard was the presence of a palliative care consultation note in the electronic medical record.

RESULTS

Of 100,910 admissions, 1999 received a palliative care consultation (2.0%) and 1846 (1.8%) had usage of the V66.7 code. Sensitivity and specificity for the V66.7 code were 49.9% and 99.1%, respectively. Sensitivity was considerably higher for certain subgroups, such as patients with dementia (76.3%) and metastatic cancer (66.3%); addition of age restrictions further improved sensitivity while maintaining high specificity. Specificity was substantially lower for patients who died during hospitalization (sensitivity 53.9%, specificity 75.1%).

CONCLUSIONS

In a single center, the ICD-9 code V66.7 had poor sensitivity and high specificity for identifying hospitalized patients who received a palliative care consultation. Appropriate use of this code for this purpose should take these characteristics into consideration.

Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial

OBJECTIVES

To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture.

DESIGN

Multisite randomized controlled trial from April 2009 to March 2013.

SETTING

Three New York hospitals.

PARTICIPANTS

Individuals with hip fracture (N = 161).

INTERVENTION

Participants were randomized to receive an ultrasound-guided, single-injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours (n = 79) or conventional analgesics (n = 82).

MEASUREMENTS

Pain (0-10 scale), distance walked on Postoperative Day (POD) 3, walking ability 6 weeks after discharge, opioid side effects.

RESULTS

Pain scores 2 hours after ED presentation favored the intervention group over controls (3.5 vs 5.3, P = .002). Pain scores on POD 3 were significantly better for the intervention than the control group for pain at rest (2.9 vs 3.8, P = .005), with transfers out of bed (4.7 vs 5.9, P = .005), and with walking (4.1 vs 4.8, P = .002). Intervention participants walked significantly further than controls in 2 minutes on POD 3 (170.6 feet, 95% confidence interval (CI) = 109.3-232 vs 100.0 feet, 95% CI = 65.1-134.9; P = .04). At 6 weeks, intervention participants reported better walking and stair climbing ability (mean Functional Independence Measure locomotion score of 10.3 (95% CI = 9.6-11.0) vs 9.1 (95% CI = 8.2-10.0), P = .04). Intervention participants were significantly less likely to report opioid side effects (3% vs 12.4%, P = .03) and required 33% to 40% fewer parenteral morphine sulfate equivalents.

CONCLUSION

Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.

Using Length of Stay to Control for Unobserved Heterogeneity When Estimating Treatment Effect on Hospital Costs with Observational Data: Issues of Reliability, Robustness, and Usefulness

OBJECTIVE

To evaluate the sensitivity of treatment effect estimates when length of stay (LOS) is used to control for unobserved heterogeneity when estimating treatment effect on cost of hospital admission with observational data.

DATA SOURCES/STUDY SETTING

We used data from a prospective cohort study on the impact of palliative care consultation teams (PCCTs) on direct cost of hospital care. Adult patients with an advanced cancer diagnosis admitted to five large medical and cancer centers in the United States between 2007 and 2011 were eligible for this study.

STUDY DESIGN

Costs were modeled using generalized linear models with a gamma distribution and a log link. We compared variability in estimates of PCCT impact on hospitalization costs when LOS was used as a covariate, as a sample parameter, and as an outcome denominator. We used propensity scores to account for patient characteristics associated with both PCCT use and total direct hospitalization costs.

DATA COLLECTION/EXTRACTION METHODS

We analyzed data from hospital cost databases, medical records, and questionnaires. Our propensity score weighted sample included 969 patients who were discharged alive.

PRINCIPAL FINDINGS

In analyses of hospitalization costs, treatment effect estimates are highly sensitive to methods that control for LOS, complicating interpretation. Both the magnitude and significance of results varied widely with the method of controlling for LOS. When we incorporated intervention timing into our analyses, results were robust to LOS-controls.

CONCLUSIONS

Treatment effect estimates using LOS-controls are not only suboptimal in terms of reliability (given concerns over endogeneity and bias) and usefulness (given the need to validate the cost-effectiveness of an intervention using overall resource use for a sample defined at baseline) but also in terms of robustness (results depend on the approach taken, and there is little evidence to guide this choice). To derive results that minimize endogeneity concerns and maximize external validity, investigators should match and analyze treatment and comparison arms on baseline factors only. Incorporating intervention timing may deliver results that are more reliable, more robust, and more useful than those derived using LOS-controls.

Impact of Inpatient Palliative Care on Treatment Intensity for Patients with Serious Illness

BACKGROUND

Palliative care is associated with decreased treatment intensity and improved quality for individual patients at the end of life, but little is known about how hospital-wide outcomes are affected by the diffusion of palliative care principles.

OBJECTIVE

We examined the relationship between presence of palliative care programs and hospitals' average treatment intensity, as indicated by mean intensive care unit (ICU) length of stay (LOS) and days under Medicare hospice coverage, in the last six months of life among Medicare beneficiaries aged 67 and over with serious chronic illness.

METHODS

We linked hospital-level data from the American Hospital Association Annual Survey, National Palliative Care Registry, and Dartmouth Atlas of Health Care to examine hospital-level treatment intensity for chronically ill Medicare beneficiaries who died in 2010. We used propensity score-adjusted linear regression to estimate the relationship between palliative care programs and hospitals' mean ICU LOS and hospice length of enrollment.

RESULTS

Among 974 hospitals meeting inclusion criteria, we compared 295 hospitals with palliative care programs to 679 hospitals without. Hospitals with palliative care programs were higher volume, more likely to be teaching hospitals, and have oncology services and less likely to be located in rural areas. In propensity score weighted analyses, the mean ICU LOS in hospitals with palliative care was shorter by 0.23 days (standard error [SE] = 0.26), but this was not statistically significant (p = 0.76). In addition, the mean length of hospice enrollment among beneficiaries served by hospitals with palliative care was longer by 0.22 days (SE = 0.61), but also was not statistically significant (p = 0.76).

CONCLUSIONS

Hospital-based palliative care programs alone may not be sufficient to impact ICU LOS or hospice length of enrollment for all chronically ill older adults admitted to hospitals. Future work should measure hospital-wide palliative care outcomes and effects of core palliative knowledge and skills provided by nonpalliative care specialists.

Emergency Department-Initiated Palliative Care in Advanced Cancer: A Randomized Clinical Trial

IMPORTANCE

The delivery of palliative care is not standard of care within most emergency departments (EDs).

OBJECTIVE

To compare quality of life, depression, health care utilization, and survival in ED patients with advanced cancer randomized to ED-initiated palliative care consultation vs care as usual.

DESIGN, SETTING, AND PARTICIPANTS

A single-blind, randomized clinical trial of ED-initiated palliative care consultation for patients with advanced cancer vs usual care took place from June 2011 to April 2014 at an urban, academic ED at a quaternary care referral center. Adult patients with advanced cancer who were able to pass a cognitive screen, had never been seen by palliative care, spoke English or Spanish, and presented to the ED met eligibility criteria; 136 of 298 eligible patients were approached and enrolled in the ED and randomized via balanced block randomization.

INTERVENTIONS

Intervention participants received a comprehensive palliative care consultation by the inpatient team, including an assessment of symptoms, spiritual and/or social needs, and goals of care.

MAIN OUTCOMES AND MEASURES

The primary outcome was quality of life as measured by the change in Functional Assessment of Cancer Therapy-General Measure (FACT-G) score at 12 weeks. Secondary outcomes included major depressive disorder as measured by the Patient Health Questionnaire-9, health care utilization at 180 days, and survival at 1 year.

RESULTS

A total of 136 participants were enrolled, and 69 allocated to palliative care (mean [SD], 55.1 [13.1] years) and 67 were randomized to usual care (mean [SD], 57.8 [14.7] years). Quality of life, as measured by a change in FACT-G score from enrollment to 12 weeks, was significantly higher in patients randomized to the intervention group, who demonstrated a mean (SD) increase of 5.91 (16.65) points compared with 1.08 (16.00) in controls (P = .03 using the nonparametric Wilcoxon test). Median estimates of survival were longer in the intervention group than the control group: 289 (95% CI, 128-453) days vs 132 (95% CI, 80-302) days, although this did not reach statistical significance (P = .20). There were no statistically significant differences in depression, admission to the intensive care unit, and discharge to hospice.

CONCLUSIONS AND RELEVANCE

Emergency department-initiated palliative care consultation in advanced cancer improves quality of life in patients with advanced cancer and does not seem to shorten survival; the impact on health care utilization and depression is less clear and warrants further study.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01358110.

Palliative Care Teams' Cost-Saving Effect Is Larger For Cancer Patients With Higher Numbers Of Comorbidities

Patients with multiple serious conditions account for a high proportion of health care spending. Such spending is projected to continue to grow substantially as a result of increased insurance eligibility, the ever-rising cost of care, the continued use of nonbeneficial high-intensity treatments at the end of life, and demographic changes. We evaluated the impact of palliative care consultation on hospital costs for adults with advanced cancer, excluding those with dementia. We found that compared to usual care, the receipt of a palliative care consultation within two days of admission was associated with 22 percent lower costs for patients with a comorbidity score of 2-3 and with 32 percent lower costs for those with a score of 4 or higher. Earlier consultation was also found to be systematically associated with a larger cost-saving effect for all subsamples defined by multimorbidity. Given ongoing workforce shortages, targeting early specialist palliative care to hospitalized patients with advanced cancer and higher numbers of serious concurrent conditions could improve care while complementing strategies to curb the growth of health spending.

Impact of Staffing on Access to Palliative Care in U.S. Hospitals

BACKGROUND

Over the past decade over two-thirds of U.S. hospitals have established palliative care programs. National data on palliative care program staffing and its association with operational outcomes are limited.

OBJECTIVE

The objective of this report is to examine the impact of palliative care program staffing on access to palliative care in U.S. hospitals.

METHODS

Data from the National Palliative Care Registry™ for 2014 were used to calculate staffing levels, palliative care service penetration, and time to initial palliative care consultation for 398 palliative care programs operating across 482 U.S. hospitals.

RESULTS

Hospital-based palliative care programs reported an average service penetration of 4.4%. Higher staffing levels were associated with higher service penetration; higher service penetration was associated with shorter time to initial palliative care consultation.

DISCUSSION

This report demonstrates that operational effectiveness, as measured by staffing and palliative care service penetration, is associated with shorter time to palliative care consultation.

Palliative care research skill development needs: Lessons from the Palliative Care Research Cooperative Group (PCRC)

174

Background: The field of palliative care (PC) has grown substantially over the past decade. PC research has not kept pace, however. One contributing factor is the paucity of clinical investigators equipped to conduct rigorous PC studies, especially multisite studies focused on interventions, dissemination and implementation. A core mission of the Palliative Care Research Cooperative (PCRC) is to enhance investigator capacity to conduct applied patient/caregiver-centered research. Methods: The PCRC Investigator Development Center (IDC) performed two needs assessments in 2015: 1) PCRC methodologic Core Directors; and 2) a subset of PCRC junior investigators. Results: Through these two assessments, PCRC identified the following knowledge/skills gaps in planning and implementing multisite clinical trials and implementation research: basic principles of clinical trials, nuts and bolts of multisite clinical trials, special considerations in behavioral and pragmatic clinical trials, testing treatment efficacy vs testing treatment effectiveness, selection of endpoints and measurement tools, recruitment and adherence issues unique to palliative care populations, data safety monitoring, budgeting and development of protocols/training for multi-site trials. These knowledge/skills gaps were identified by junior investigators as well as by senior investigators whose prior experience is primarily with single-site studies or secondary data analyses. Conclusions: Advancement of PC research requires upskilling of investigators n conduct of multisite studies. The PCRC is partnering with the National Palliative Care Research Center (NPCRC) to make available a range of investigator development resources, including one-on-one mentoring, grant review support, webinars and palliative care research boot camps.

A palliative radiation oncology consult service’s impact on care of advanced cancer patients with symptomatic bone metastases

110

Background: Single-fraction and ≤ 5 fraction radiation treatment (SF-RT and Hypo-RT, respectively) is underutilized despite strong evidence regarding its efficacy in symptom management. Established in 2013, the Palliative Radiation Oncology Consult Service (PROC) is a specialty service designed to provide individualized, efficient treatment for advanced cancer patients by a radiation oncology team with a dedicated palliative care focus. We assessed the impact of this new model of care on use of SF-RT, hypo-RT, pain improvement, palliative care utilization, and hospitalization among patients treated with palliative radiation (PRT) for painful bone metastases. Methods: We searched electronic charts of advanced cancer patients who had PRT for symptomatic bone mets from Dec 2010 to April 2015, extracting PRT details, demographics, cancer type, pain pre- and 1 month post-PRT, comorbidities (summarized using Charlson comorbidity index [CCI]), palliative care consults, and hospitalization. Comparisons were made before and after PROC using chi-square or t-tests. Multivariable logistic regression estimated the likelihood of SF-RT or hypo-RT, controlling for age, gender, cancer type, treatment site, and CCI. Results: We identified 334 patients, described in the table below. Patients were more likely to have SF-RT (OR 2.2, 95% CI [1.2-3.8], p = 0.007), or hypo-RT (OR 3.0, 95% CI [1.8-4.7], p < 0.001) after establishment of PROC. Conclusions: Establishment of a PROC service nearly doubled utilization of SF-RT and hypo-RT while maintaining pain improvement, and was associated with an increased use of palliative care consult services, decreased inpatient PRT use, and decreased length of stay. A dedicated service combining palliative care principles and radiation oncology improved quality of palliative cancer care. [Table: see text]

The Growth of Palliative Care in U.S. Hospitals: A Status Report

Background: Palliative care is expanding rapidly in the United States.

Objective: To examine variation in access to hospital palliative care.

Methods: Data were obtained from the American Hospital Association (AHA) Annual Surveys™ for Fiscal Years 2012 and 2013, the National Palliative Care Registry™, the Dartmouth Atlas of Healthcare, the American Census Bureau's American Community Survey (ACS), web searches, and telephone interviews of hospital administrators and program directors. Multivariable logistic regression was used to examine predictors of hospital palliative care programs.

Results: Sixty-seven percent of hospitals with 50 or more total facility beds reported a palliative care program. Institutional characteristics were strongly associated with the presence of a hospital palliative care program. Ninety percent of hospitals with 300 beds or more were found to have palliative care programs as compared to 56% of hospitals with fewer than 300 beds. Tax status was also a significant predictor. Not-for-profit hospitals and public hospitals were, respectively, 4.8 times and 7.1 times more likely to have a palliative care program as compared to for-profit hospitals. Palliative care penetration was highest in the New England (88% of hospitals), Pacific (77% of hospitals), and mid-Atlantic (77% of hospitals) states and lowest in the west south central (43% of hospitals) and east south central (42% of hospitals) states.

Conclusions: This study demonstrates continued steady growth in the number of hospital palliative care programs in the United States, with almost universal access to services in large U.S. hospitals and academic medical centers. Nevertheless access to palliative care remains uneven and depends on accidents of geography and hospital ownership.

Prospective Cohort Study of Hospital Palliative Care Teams for Inpatients With Advanced Cancer: Earlier Consultation Is Associated With Larger Cost-Saving Effect

PURPOSE

Previous studies report that early palliative care is associated with clinical benefits, but there is limited evidence on economic impact. This article addresses the research question: Does timing of palliative care have an impact on its effect on cost?

PATIENTS AND METHODS

Using a prospective, observational design, clinical and cost data were collected for adult patients with an advanced cancer diagnosis admitted to five US hospitals from 2007 to 2011. The sample for economic evaluation was 969 patients; 256 were seen by a palliative care consultation team, and 713 received usual care only. Subsamples were created according to time to consult after admission. Propensity score weights were calculated, matching the treatment and comparison arms specific to each subsample on observed confounders. Generalized linear models with a γ distribution and a log link were applied to estimate the mean treatment effect on cost within subsamples.

RESULTS

Earlier consultation is associated with a larger effect on total direct cost. Intervention within 6 days is estimated to reduce costs by -$1,312 (95% CI, -$2,568 to -$56; P = .04) compared with no intervention and intervention within 2 days by -$2,280 (95% CI, -$3,438 to -$1,122; P < .001); these reductions are equivalent to a 14% and a 24% reduction, respectively, in cost of hospital stay.

CONCLUSION

Earlier palliative care consultation during hospital admission is associated with lower cost of hospital stay for patients admitted with an advanced cancer diagnosis. These findings are consistent with a growing body of research on quality and survival suggesting that early palliative care should be more widely implemented.

Palliative Care for the Seriously Ill

Palliative care is the interdisciplinary specialty focused on improving quality of life for persons with serious illness and their families. Over the past decade,1 the field has undergone substantial growth and change, including an expanded evidence base, new care-delivery models, innovative payment mechanisms, and increasing public and professional awareness.

Use of an Item Bank to Develop Two Short-Form FAMCARE Scales to Measure Family Satisfaction With Care in the Setting of Serious Illness

CONTEXT

Family satisfaction is an important and commonly used research measure. Yet current measures of family satisfaction are lengthy and may be unnecessarily burdensome--particularly in the setting of serious illness.

OBJECTIVES

To use an item bank to develop short forms of the Family Satisfaction with End-of-Life Care (FAMCARE) scale, which measures family satisfaction with care.

METHODS

To shorten the existing 20-item FAMCARE measure, item response theory parameters from an item bank were used to select the most informative items. The psychometric properties of the new short-form scales were examined. The item bank was based on data from family members from an ethnically diverse sample of 1983 patients with advanced cancer.

RESULTS

Evidence for the new short-form scales supported essential unidimensionality. Reliability estimates from several methods were relatively high, ranging from 0.84 for the five-item scale to 0.94 for the 10-item scale across different age, gender, education, ethnic, and relationship groups.

CONCLUSION

The FAMCARE-10 and FAMCARE-5 short-form scales evidenced high reliability across sociodemographic subgroups and are potentially less burdensome and time-consuming scales for monitoring family satisfaction among seriously ill patients.

Emergency department-triggered palliative care in advanced cancer: proof of concept

BACKGROUND

The American College of Emergency Physicians and the American Society of Clinical Oncology recommend early palliative care consultation for patients with advanced, life-limiting illnesses, such as metastatic cancer.

OBJECTIVES

The objectives were to assess the process of early referral from the emergency department (ED) to palliative care for patients with advanced, incurable cancer as part of a randomized controlled trial and to compare the proportion and timing of consultation to a care as usual group.

METHODS

A single-blind randomized controlled trial (ClinicalTrials.gov ID NCT01358110) compared early, ED-based referrals to palliative care for patients admitted with advanced, incurable cancer to physician-driven consultation (i.e., care as usual). Participants had to speak English or Spanish and have no history of palliative care consultation. They were randomized via balanced block randomization to the intervention or control group. Each intervention subject was referred by a research staff member to the palliative care team for consultation. The usual care group received palliative care only if requested by the admitting physician. Analysis was based on intention to treat. A chart review was performed to assess proportion and timing of palliative care consults during the index admission, defined as: (1) completed palliative care consult documented in the chart and (2) days from admission to palliative care consult.

RESULTS

A total of 134 participants were enrolled and randomized. For patients in the intervention group, 88% (60 of 68) had documented palliative care consultations during their index admissions (95% confidence interval [CI] = 80.5 to 95.5), compared to 18% (12 of 66) in the control group (95% CI = 8.8 to 27.5; p < 0.01). The 60 intervention patients received palliative care consultations on average 1.48 days from admission (95% CI = 1.19 to 1.76), compared to 2.9 days from admission in the 12 control patients (95% CI = 1.03 to 4.79; p = 0.15).

CONCLUSIONS

This study documented a low baseline rate of palliative care involvement as part of usual care in patients with advanced cancer being admitted from the ED. Early referral to palliative care in the context of a research study significantly increased the likelihood that patients received a consult, thus meriting further investigation of how to generalize this approach.