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Lage DE, Burger AS, Cohn J, Hernand M, Jin E, Horick NK, Miller L, Kuhlman C, Krueger E, Olivier K, Haggett D, Meneely E, Ritchie C, Nipp RD, Traeger L, El-Jawahri A, Greer JA, Temel JS. Continuum: A Postdischarge Supportive Care Intervention for Hospitalized Patients With Advanced Cancer. J Pain Symptom Manage 2024:S0885-3924(24)00958-8. [PMID: 39197695 DOI: 10.1016/j.jpainsymman.2024.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 08/02/2024] [Accepted: 08/12/2024] [Indexed: 09/01/2024]
Abstract
CONTEXT Patients with advanced cancer are at increased risk for multiple hospitalizations and often have considerable needs postdischarge. Interventions to address patients' needs after transitioning home are lacking. OBJECTIVES We sought to demonstrate the feasibility and acceptability of a postdischarge intervention for this population. METHODS We conducted a single-arm pilot trial (n = 54) of a postdischarge intervention, consisting of a video visit with an oncology nurse practitioner (NP) within three days of discharge to address symptoms, medications, hospitalization-related issues, and care coordination. We enrolled English-speaking adults with advanced breast, gastrointestinal, genitourinary, or thoracic cancers experiencing an unplanned hospitalization and preparing for discharge home. The intervention was deemed feasible if ≥70% of approached patients enrolled and ≥70% of enrolled patients completed the intervention within three days of discharge. Two weeks after discharge, patients rated the ease and usefulness of the video technology on a 0-10 scale (higher scores indicate greater ease of use). NPs completed postintervention surveys to assess protocol adherence. RESULTS We enrolled 54 of 75 approached patients (77.3%). Of enrolled patients (median age = 65.0 years), 83.3% participated in the intervention within three days of discharge. The median ease of participating in the intervention was 9.0 (IQR: 6.0-10.0) and the median usefulness of the intervention was 7.0 (IQR: 4.5-8.0). The majority of visits focused on symptom management (85.7%), followed by posthospital medical issues (69.0%). CONCLUSION An oncology NP-delivered intervention immediately after hospital discharge is a feasible and acceptable approach to providing postdischarge care for hospitalized patients with advanced cancer.
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Affiliation(s)
- Daniel E Lage
- Memorial Sloan Kettering Cancer Center (D.E.L.), New York, NY, USA; Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA.
| | - Alane S Burger
- University of Colorado Boulder (A.S.B.), Boulder, CO, USA
| | | | - Max Hernand
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Evanna Jin
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Nora K Horick
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Laurie Miller
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Caroline Kuhlman
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Elizabeth Krueger
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Kara Olivier
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Dana Haggett
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Erika Meneely
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Christine Ritchie
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Ryan D Nipp
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA; Harvard Medical School (R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA; Univeristy of Oklahoma (R.D.N.), Oklahoma City, OK, USA
| | - Lara Traeger
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA; Harvard Medical School (R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA; University of Miami (L.T.), Miami, FL, USA
| | - Areej El-Jawahri
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA; Harvard Medical School (R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Joseph A Greer
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA; Harvard Medical School (R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
| | - Jennifer S Temel
- Massachusetts General Hospital (D.E.L., M.H., E.J., N.K.H., L.M., C.K., E.K., K.O., D.H., E.M., C.R., R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA; Harvard Medical School (R.D.N., L.T., A.E.J., J.A.G., J.S.T.), Boston, MA, USA
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Hwang IY, Woo GU, Lee SY, Yoo SH, Kim KH, Kim MS, Shin J, Jeong HJ, Jang MS, Baek SK, Jung EH, Lee DW, Cho B. Home-based supportive care in advanced cancer: systematic review. BMJ Support Palliat Care 2024; 14:132-148. [PMID: 38160048 PMCID: PMC11103295 DOI: 10.1136/spcare-2023-004721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES This study systematically reviewed the literature on the effect of home-based supportive care (HbSC) programmes on the quality of life (QoL) of patients with advanced cancer. METHODS The research question 'Do home-based supportive care programmes for patients with advanced cancer improve their QoL?' was addressed. After registering the plan with PROSPERO (CRD42022341237), literature published from 1 January 1990 to 30 May 2023 was searched on PubMed, Embase, Cochrane database, CINAHL and Web of Science, and reviewed for inclusion based on predefined criteria. This review only included trial studies published in English. RESULTS Of 5,276 articles identified, 17 studies were judged suitable for inclusion in this review. The components of HbSC programmes included home visits, patient and caregiver education, home nursing, psychotherapy, exercise, telephone consultation, and multidisciplinary team meetings. Nine studies reported improvements in QoL, including social functioning, emotional functioning, and subjective QoL. CONCLUSION HbSC programmes appear to enable the improvement of the QoL of patients with advanced cancer. The area of QoL that shows improvement could vary depending on the HbSC components. More studies that address HbSC programmes are needed to select patients at the proper time and provide suitable programmes for patients to benefit most.
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Affiliation(s)
- In Young Hwang
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Familly Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Go-Un Woo
- Department of Internal Medicine, Dongguk University Medical Center, Goyang, Republic of Korea
| | - Sun Young Lee
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Human System Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Shin Hye Yoo
- Department of Human System Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyae Hyung Kim
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min-Sun Kim
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeongmi Shin
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye Jin Jeong
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Human System Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Min Seol Jang
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sun Kyung Baek
- Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Eun Hee Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Dong-Wook Lee
- Department of Occupational and Environmental Medicine, Inha University Hospital, Inha University, Incheon, Republic of Korea
| | - Belong Cho
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Familly Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Human System Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Lee DW, Lee SY, Yoo SH, Kim KH, Kim MS, Shin J, Hwang IY, Hwang IG, Baek SK, Kim DY, Kim YJ, Kang B, Lee J, Cho B. SupporTive Care At Home Research (STAHR) for patients with advanced cancer: Protocol for a cluster non-randomized controlled trial. PLoS One 2024; 19:e0302011. [PMID: 38739589 PMCID: PMC11090303 DOI: 10.1371/journal.pone.0302011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/19/2024] [Indexed: 05/16/2024] Open
Abstract
Advancements in the treatment and management of patients with cancer have extended their survival period. To honor such patients' desire to live in their own homes, home-based supportive care programs have become an important medical practice. This study aims to investigate the effects of a multidimensional and integrated home-based supportive care program on patients with advanced cancer. SupporTive Care At Home Research is a cluster non-randomized controlled trial for patients with advanced cancer. This study tests the effects of the home-based supportive care program we developed versus standard oncology care. The home-based supportive care program is based on a specialized home-based medical team approach that includes (1) initial assessment and education for patients and their family caregivers, (2) home visits by nurses, (3) biweekly regular check-ups/evaluation and management, (4) telephone communication via a daytime access line, and (5) monthly multidisciplinary team meetings. The primary outcome measure is unplanned hospitalization within 6 months following enrollment. Healthcare service use; quality of life; pain and symptom control; emotional status; satisfaction with services; end-of-life care; advance planning; family caregivers' quality of life, care burden, and preparedness for caregiving; and medical expenses will be surveyed. We plan to recruit a total of 396 patients with advanced cancer from six institutions. Patients recruited from three institutions will constitute the intervention group, whereas those recruited from the other three institutions will comprise the control group.
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Affiliation(s)
- Dong-Wook Lee
- Department of Occupational and Environmental Medicine, Inha University Hospital, Inha University, Incheon, Republic of Korea
| | - Sun Young Lee
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Human System Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Shin Hye Yoo
- Department of Human System Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyae Hyung Kim
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min-Sun Kim
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeongmi Shin
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - In-Young Hwang
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - In Gyu Hwang
- Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Sun Kyung Baek
- Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Do yeun Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Yu Jung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Beodeul Kang
- Department of Internal Medicine, Bundang CHA Hospital, Seongnam, Republic of Korea
| | - Joongyub Lee
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Belong Cho
- Public Healthcare Center, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Human System Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute on Aging, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Human Systems Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Alim-Marvasti A, Jawad M, Ogbonnaya C, Naghieh A. Workforce diversity in specialist physicians: Implications of findings for religious affiliation in Anaesthesia & Intensive Care. PLoS One 2023; 18:e0288516. [PMID: 37611011 PMCID: PMC10446200 DOI: 10.1371/journal.pone.0288516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 06/29/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Minority ethnic identification between physician and patient can reduce communication and access barriers, improve physician-patient relationship, trust, and health outcomes. Religion influences health beliefs, behaviours, treatment decisions, and outcomes. Ethically contentious dilemmas in treatment decisions are often entangled with religious beliefs. They feature more in medical specialties such as Anaesthesia & Intensive Care, with issues including informed consent for surgery, organ donation, transplant, transfusion, and end-of-life decisions. METHODS We investigate diversity in religious affiliation in the UK medical workforce, using data from the General Medical Council (GMC) specialist register and Health Education England (HEE) trainee applications to medical specialties. We performed conservative Bonferroni corrections for multiple comparisons using Chi-squared tests, as well as normalised mutual-information scores. Robust associations that persisted on all sensitivity analyses are reported, investigating whether ethnicity or foreign primary medical qualification could explain the underlying association. FINDINGS The only significant and robust association in both GMC and HEE datasets affecting the same religious group and specialty was disproportionately fewer Anaesthesia & Intensive Care physicians with a religious affiliation of "Muslim", both as consultants (RR 0.57[0.47,0.7]) and trainee applicants (RR 0.27[0.19,0.38]. Associations were not explained by ethnicity or foreign training. We discuss the myriad of implications of the findings for multi-cultural societies. CONCLUSIONS Lack of physician workforce diversity has far-reaching consequences, especially for specialties such as Anaesthesia and Intensive Care, where ethically contentious decisions could have a big impact. Religious beliefs and practices, or lack thereof, may have unmeasured influences on clinical decisions and on whether patients identify with physicians, which in turn can affect health outcomes. Examining an influencing variable such as religion in healthcare decisions should be prioritised, especially considering findings from the clinician-patient concordance literature. It is important to further explore potential historical and socio-cultural barriers to entry of training medics into under-represented specialties, such as Anaesthesia and Intensive Care.
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Affiliation(s)
- Ali Alim-Marvasti
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Mohammed Jawad
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Chibueze Ogbonnaya
- Institute of Child Health, University College London, London, United Kingdom
| | - Ali Naghieh
- School of Public Policy, University College London, London, United Kingdom
- Middlesex University Business School, London, United Kingdom
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Bajaj SS, Jain B, Potter AL, Dee EC, Yang CFJ. Racial and ethnic disparities in end-of-life care for patients with oesophageal cancer: death trends over time. LANCET REGIONAL HEALTH. AMERICAS 2023; 17:100401. [PMID: 36776566 PMCID: PMC9904053 DOI: 10.1016/j.lana.2022.100401] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 10/17/2022] [Accepted: 11/03/2022] [Indexed: 05/20/2023]
Abstract
Background Given significant morbidity and mortality associated with oesophageal cancer, supportive, high-quality end-of-life care is critical. Most patients with advanced cancer prefer to die at home, but incongruence between preferred and actual place of death is common. Here, we examined trends and disparities in location of death among patients with oesophageal cancer. Methods Using the Centers for Disease Control and Prevention Wide-Range Online Data for Epidemiologic Research database, we utilized multinomial logistic regression to assess associations between sociodemographic characteristics and location of death for patients with oesophageal cancer (n = 237,063). Additionally, we utilized linear regression models to evaluate the significance of changes in location of death trends over time and disparities in the relative change in location of death trends across sociodemographic groups. Findings From 2003 to 2019, there was a decrease of deaths in hospitals, nursing homes, and outpatient medical facilities/emergency departments and an increase of deaths at home and in hospice. Relative to White decedents, Black and Asian decedents were less likely to die at home (relative risk ratio (RRR): 0.58 [95% confidence interval (CI): 0.56-0.60], RRR: 0.57 [95% CI: 0.53-0.61]) and in hospice (RRR: 0.67 [95% CI: 0.64-0.71], RRR: 0.49 [95% CI: 0.43-0.55]) when compared to the hospital. Similar disparities were noted for American Indian and Alaska Native (AIAN) decedents. These disparities persisted even upon stratifying by the number of listed causes of death, a proxy for severity of illness. Time trend analysis indicated that increases in deaths in hospice over time occurred at a slower rate for AIAN and Asian decedents relative to White decedents. Interpretation 2 in 5 patients with oesophageal cancer die at home, with an increasing proportion dying at home and in hospice-in line with general patient preferences. However, location of death disparities have largely persisted over time among racial and ethnic minority groups. Our findings suggest the importance of improving access to advance care planning and delivering tailored, person-centred interventions. Funding None.
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Affiliation(s)
- Simar S. Bajaj
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Bhav Jain
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Alexandra L. Potter
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chi-Fu Jeffrey Yang
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Corresponding author. Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
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Davis MP, Vanenkevort EA, Elder A, Young A, Correa Ordonez ID, Wojtowicz MJ, Ellison H, Fernandez C, Mehta Z, Behm B, Digwood G, Panikkar R. The Financial Impact of Palliative Care and Aggressive Cancer Care on End-of-Life Health Care Costs. Am J Hosp Palliat Care 2023; 40:52-60. [PMID: 35503515 DOI: 10.1177/10499091221098062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Medicare cancer expenditures in the last month of life have increased. Aggressive cancer care at the end-of-life (ACEOL) is considered poor quality care. We used Geisinger Health Plan (GHP) last month's costs for cancer patients who died in 2018 and 2019 to determine the costs of and influence of Palliative Care (PC) on ACEOL. METHOD Patients with GHP ages 18-99 who died in 2018 and 2019 were included. Demographic, clinical characteristics, and Charlson Comorbid Index were compared across care groups defined as no ACEOL indicator, 1 or more than 1 indicator. Differences between groups were compared with Kruskal-Wallis tests and one-way ANOVA for 3 groups. Median two-sample tests and independent t-tests compared groups of 2. A P-value </= .05 indicated statistical significance. RESULTS Of 608 eligible patients; 261 had no indicator, 133 had 1 and 214 > 1. There were incremental cost increases with each additional ACEOL indicator (p = < .0001). Palliative Care <90 days before death was associated with increased costs while consultations >90 days before death lowered cost (P < .0001) due to reduced chemotherapy in the last month. Completed ADs reduced cost by $4000. DISCUSSION ACEOL indicators multiply costs during the last month of life. Palliative care instituted >90 days before death reduces chemotherapy in the last month of life and AD reduces health care costs. CONCLUSION Cancer health care costs increase with indicators of ACEOL. Palliative care consultations >90 days before death; ADs reduce cancer health care costs.
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Patra L, Ghoshal A, Damani A, Salins N. Cancer palliative care referral: patients' and family caregivers' perspectives - a systematic review. BMJ Support Palliat Care 2022:spcare-2022-003990. [PMID: 36328397 DOI: 10.1136/spcare-2022-003990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Despite the evidence of palliative care benefits, referrals are infrequent and delayed. Patients and their caregivers are essential stakeholders in the referral process with valuable perspectives. This review systematically explored their perceived facilitators and barriers to palliative care referral. METHODS 4 subject-specific databases (PubMed, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and EMBASE), 3 multidisciplinary databases (SCOPUS, Web of Science and Cochrane database) and 11 journals from 1 January 1990 to 31 May 2022 were searched; and scored for their methodological rigour using Hawker's tool. Findings were synthesised using Popay's Narrative Synthesis method and interpreted using decision-making theory. RESULTS 4 themes were generated from 14 studies: (1) The timing of referral should be right and communication must be comprehensive. Delays in initiating serious illness conversations, prognostication, and decision-making hindered referral. In contrast, the presence of symptoms facilitated it. (2) Referral was equated to death, and as an inferior form of treatment, a rebranding might mitigate the stigma. (3) Referral made families feel emotional and devastated; explanation and team initiatives enabled the normalisation and positive coping. (4) Long-term holistic palliative care facilitated a positive care experience and a sense of reassurance and satisfaction, enabling a smooth transition from curative to comfort care. The late referral was associated with perceived inadequate symptom management, diminished quality of life and death and complicated bereavement issues. CONCLUSION Patients' and caregivers' predisposition to palliative care engagement was influenced by timely referral, comprehensive communication, perception and stigma about palliative care. Longitudinal association with the palliative care team mitigated negative perceptions and improved satisfaction and coping. PROSPERO REGISTRATION NUMBER CRD42018091481.
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Affiliation(s)
- Lipika Patra
- Bagchi-Karunashraya Palliative Care Centre, Bangalore Hospice Trust, Bhubaneswar, India
| | | | - Anuja Damani
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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The closing survival gap after liver transplantation for hepatocellular carcinoma in the United States. HPB (Oxford) 2022; 24:1994-2005. [PMID: 35981946 DOI: 10.1016/j.hpb.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Socio-economic inequalities among different racial/ethnic groups have increased in many high-income countries. It is unclear, however, whether increasing socio-economic inequalities are associated with increasing differences in survival in liver transplant (LT) recipients. METHODS Adults undergoing first time LT for hepatocellular carcinoma (HCC) between 2002 and 2017 recorded in the Scientific Registry of Transplant Recipients (SRTR) were included and grouped into three cohorts. Patient survival and graft survival stratified by race/ethnicity were compared among the cohorts using unadjusted and adjusted analyses. RESULTS White/Caucasians comprised the largest group (n=9,006, 64.9%), followed by Hispanic/Latinos (n=2,018, 14.5%), Black/African Americans (n=1,379, 9.9%), Asians (n=1,265, 9.1%) and other ethnic/racial groups (n=188, 1.3%). Compared to Cohort I (2002-2007), the 5-year survival of Cohort III (2012-2017) increased by 18% for Black/African Americans, by 13% for Whites/Caucasians, by 10% for Hispanic/Latinos, by 9% for patients of other racial/ethnic groups and by 8% for Asians (All P values<0.05). Despite Black/African Americans experienced the highest survival improvement, their overall outcomes remained significantly lower than other ethnic∕racial groups (adjusted HR for death=1.20; 95%CI 1.05-1.36; P=0.005; adjusted HR for graft loss=1.21; 95%CI 1.08-1.37; P=0.002). CONCLUSION The survival gap between Black/African Americans and other ethnic/racial groups undergoing LT for HCC has significantly decreased over time. However, Black/African Americans continue to have the lowest survival among all racial/ethnic groups.
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Li SR, Reitz KM, Kennedy J, Gabriel L, Phillips AR, Shireman PK, Eslami MH, Tzeng E. Epidemiology of age-, sex-, and race-specific hospitalizations for abdominal aortic aneurysms highlights gaps in current screening recommendations. J Vasc Surg 2022; 76:1216-1226.e4. [PMID: 35278654 PMCID: PMC9458770 DOI: 10.1016/j.jvs.2022.02.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/24/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND The detection and elective repair of abdominal aortic aneurysms (AAA) guided by known risk-factor specific screening decrease AAA-related mortality. However, minimal epidemiologic data exist for AAA in female persons and racial minority groups. We established the contemporary risk of US AAA hospitalization across age, sex, and race. METHODS National Inpatient Sample and US Census (2012-2018) data were used to quantify age-, sex-, and race-specific incidences and adjusted odds ratios (aOR) of AAA hospitalizations (≥18 years), associated risk factors, and in-hospital mortality. Interaction terms evaluated subgroups. RESULTS Among 1,728,374,183 US residents during the study period (51.3% female; 78.4% White, 12.7% Black, 5.7% Asian), 211,501,703 were hospitalized (aged 57.56 ± 0.04 years; 58.4% female; 64.9% White, 14.3% Black, 2.5% Asian) of which 291,850 were for AAA (aged 73.17 ± 0.04 years; 22.6% female; 81.8% White, 5.6% Black, 1.6% Asian). An estimated 15.2 (95% CI, 15.1-15.3) and 1.7 (95% CI, 1.7-1.7) hospitalizations per 100,000 residents were for intact AAA (iAAA) and ruptured AAA (rAAA) AAA, respectively. In addition, 16.2% of iAAA (83.8% male; 79.1% White) and 18.4% of rAAA (86.4% male; 75.0% White) hospitalizations occurred in patients less than 65 years of age. For iAAA, female sex (aOR, 0.27; 95% CI, 0.27-0.28) compared with male sex and both Black (0.47; 95% CI, 0.45-0.49) and Asian (0.86; 95% CI, 0.83-0.93) persons compared with White persons had a reduced aOR for hospitalization. For rAAA, the reduced aOR persisted for female sex (0.33; 95% CI, 0.32-0.36) and for Black persons (0.52; 95% CI, 0.46-0.58). Although female sex demonstrated an overall decreased odds of AAA hospitalization, female persons who were older, Black, or had peripheral vascular disease (Pinteractions < .001) had a relative increase in AAA hospitalization aOR. Female sex (aOR, 1.54; 95% CI, 1.38-1.70), but not Black or Asian race, was associated with increased mortality which was more pronounced for iAAA (1.93; 95% CI, 1.66-2.25) than rAAA (1.29; 95% CI, 1.13-1.48]; Pinteraction < .001). CONCLUSIONS We confirmed a substantially decreased adjusted risk of AAA hospitalization for females and racial minority groups; however, aging and comorbid peripheral vascular disease decreased these differences. The disparate risk of AAA hospitalization by sex and race highlights the importance of inclusivity in future AAA studies.
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Affiliation(s)
- Shimena R Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA.
| | - Jason Kennedy
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA; Department of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lucine Gabriel
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Amanda R Phillips
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX; University Health, San Antonio, TX
| | - Mohammad H Eslami
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
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10
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Tolle SW, Hedberg K. Effectiveness of Advance Care Planning: What Works, What Doesn’t, and What Needs to Change? THE JOURNAL OF CLINICAL ETHICS 2022. [DOI: 10.1086/jce2022333210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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11
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Elyn A, Gardette V, Renoux A, Sourdet S, Nourhashemi F, Sanou B, Dutech M, Muller P, Gallini A. Potential determinants of unfavourable healthcare utilisation trajectories during the last year of life of people with incident Alzheimer Disease or Related Syndromes: a nationwide cohort study using administrative data. Age Ageing 2022; 51:6554096. [PMID: 35348586 DOI: 10.1093/ageing/afac053] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/11/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND people approaching the end-of-life frequently face inappropriate care. With Alzheimer Disease or Related Syndromes (ADRS), end-of-life is characterised by progressive decline, but this period remains difficult to identify. This leads to a lack of anticipation and sometimes with unfavourable healthcare utilisation trajectories (HUTs). OBJECTIVE to quantify unfavourable HUTs during the last year of life and identify their potential determinants in both community and nursing-home settings. DESIGN nationwide cohort study using administrative database. SETTING French community and nursing-home residents. SUBJECTS incident ADRS people identified in 2012, who died up to 31 December 2017. METHODS we used multidimensional clustering to identify 15 clusters of HUTs, using 11 longitudinal healthcare dimensions during the last year of life. Clusters were qualitatively assessed by pluri-disciplinary experts as favourable or unfavourable HUTs. Individual and contextual potential determinants of unfavourable HUTs were studied by setting using logistic random-effect regression models. RESULTS 62,243 individuals died before 31 December 2017; 46.8% faced unfavourable end-of-life HUTs: 55.2% in the community and 31.8% in nursing-homes. Individual potential determinants were identified: younger age, male gender, ADRS identification through hospitalisation, shorter survival, life-limiting comorbidities, psychiatric disorders, acute hospitalisations and polypharmacy. In the community, deprivation and autonomy were identified as potential determinants. Contextual potential determinants raised mostly in the community, such as low nurse or physiotherapist accessibilities. CONCLUSIONS Nearly half of people with ADRS faced unfavourable HUTs during their last year of life. Individual potential determinants should help anticipate advance care planning and palliative care needs assessment. Contextual potential determinants suggest geographical disparities and health inequalities.
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Affiliation(s)
- Antoine Elyn
- CERPOP, UMR1295, Unité Mixte INSERM - Université Toulouse III Paul Sabatier, Axe Maintain, Aging Research Team, University Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000 Toulouse, France
- Pain Evaluation and Treatment Center, Neurosciences Department, University Hospital of Toulouse, Place du Dr Joseph Baylac, TSA 40031, 31059 Toulouse Cedex 9, France
- Forms – Occitanie’s Multiprofessional Health Care Centers Federation, 7 Clos de la Tuilerie, 31560 Nailloux, France
- University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
| | - Virginie Gardette
- CERPOP, UMR1295, Unité Mixte INSERM - Université Toulouse III Paul Sabatier, Axe Maintain, Aging Research Team, University Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000 Toulouse, France
- University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
- Department of Epidemiology, University Hospital of Toulouse, 37 Allées Jules Guesde, 31000 Toulouse, France
| | - Axel Renoux
- Department of Epidemiology, University Hospital of Toulouse, 37 Allées Jules Guesde, 31000 Toulouse, France
| | - Sandrine Sourdet
- CERPOP, UMR1295, Unité Mixte INSERM - Université Toulouse III Paul Sabatier, Axe Maintain, Aging Research Team, University Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000 Toulouse, France
- University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
- Geriatrics & Internal Medicine, University Hospital of Toulouse, Hôpital La Grave, Cité de la Santé, Place Lange, TSA 60033, 31059 Toulouse Cedex 9, France
| | - Fati Nourhashemi
- CERPOP, UMR1295, Unité Mixte INSERM - Université Toulouse III Paul Sabatier, Axe Maintain, Aging Research Team, University Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000 Toulouse, France
- University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
- Geriatrics & Internal Medicine, University Hospital of Toulouse, Hôpital La Grave, Cité de la Santé, Place Lange, TSA 60033, 31059 Toulouse Cedex 9, France
| | - Brigitte Sanou
- Réseau Relience - Territorial Network for Home-based Palliative Care, Chronic Pain and Chronic Disease, 39 Impasse de la Flambère, 31300 Toulouse, France
| | - Michel Dutech
- Forms – Occitanie’s Multiprofessional Health Care Centers Federation, 7 Clos de la Tuilerie, 31560 Nailloux, France
| | - Philippe Muller
- Department of Epidemiology, University Hospital of Toulouse, 37 Allées Jules Guesde, 31000 Toulouse, France
- CNRS UMR 5505 IRIT – Toulouse Institute for Research in Computer Science, University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
| | - Adeline Gallini
- CERPOP, UMR1295, Unité Mixte INSERM - Université Toulouse III Paul Sabatier, Axe Maintain, Aging Research Team, University Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31000 Toulouse, France
- University Toulouse III Paul Sabatier, 118 Route de Narbonne, F-31062 Toulouse Cedex 9, France
- Department of Epidemiology, University Hospital of Toulouse, 37 Allées Jules Guesde, 31000 Toulouse, France
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12
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Huh JY, Matsuoka Y, Kinoshita H, Ikenoue T, Yamamoto Y, Ariyoshi K. Premorbid Clinical Frailty Score and 30-day mortality among older adults in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12677. [PMID: 35224550 PMCID: PMC8847731 DOI: 10.1002/emp2.12677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/03/2022] [Accepted: 01/25/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES The association between frailty and short-term prognosis has not been established in critically ill older adults presenting to the emergency department. We sought to examine the association between premorbid frailty and 30-day mortality in this patient population. METHODS This is a retrospective observational study on older adults aged over 75 who were triaged as Level 1 resuscitation with subsequent admissions to intermediate units or intensive care units (ICUs) in a single critical care center, from January to December 2019. We excluded patients with out-of-hospital cardiac arrest or those transferred from other hospitals. Frailty was evaluated by the Clinical Frailty Scale (CFS) from the patients' chart reviews. The primary outcome was 30-day mortality, and we examined the association between frailty scored on the CFS and 30-day mortality using a multivariable logistic regression model with CFS 1-4 as a reference. RESULTS A total of 544 patients, median age: 82 years (interquartile rang 78 to 87), were included in the study. Of these, 29% were in shock and 33% were in respiratory failure. The overall 30-day mortality was 15.1%. The adjusted risk difference (95% confidence interval [CI]) in mortality for CFS 5, CFS 6, and CFS 7-9 was 6.3% (-3.4 to 15.9), 11.2% (0.4 to 22.0), and 17.7% (5.3 to 30.1), respectively; and the adjusted risk ratio (95% CI) was 1.45 (0.87 to 2.41), 1.85 (1.13 to 3.03), and 2.44 (1.50 to 3.96), respectively. CONCLUSION The risk of 30-day mortality increased as frailty advanced in critically ill older adults. Given this high risk of short-term outcomes, ED clinicians should consider goals of care conversations carefully to avoid unwanted medical care for these patients.
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Affiliation(s)
- Ji Young Huh
- Department of Emergency MedicineKobe City Medical Center General HospitalKyoto UniversityKyotoJapan
| | - Yoshinori Matsuoka
- Department of Emergency MedicineKobe City Medical Center General HospitalKyoto UniversityKyotoJapan
- Department of Healthcare EpidemiologyGraduate School of Medicine and Public HealthKyoto UniversityKyotoJapan
| | - Hiroki Kinoshita
- Department of Emergency MedicineKobe City Medical Center General HospitalKyoto UniversityKyotoJapan
| | - Tatsuyoshi Ikenoue
- Department of Human Health ScienceGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Yosuke Yamamoto
- Department of Healthcare EpidemiologyGraduate School of Medicine and Public HealthKyoto UniversityKyotoJapan
| | - Koichi Ariyoshi
- Department of Emergency MedicineKobe City Medical Center General HospitalKyoto UniversityKyotoJapan
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13
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Yeh JC, Newman J, Main R, Hunt LJ. Improving End-of-Life Care for Persons Living With Dementia: Bereaved Caregivers' Observations and Recommendations. J Pain Symptom Manage 2021; 62:579-586. [PMID: 33556499 DOI: 10.1016/j.jpainsymman.2021.01.133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/31/2020] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
CONTEXT Dementia is a terminal diagnosis that requires significant caregiving support across the trajectory of decline through to death. Experiences and perspectives from bereaved caregivers can help identify ways to improve the end-of-life care experience of persons dying with dementia. OBJECTIVES This exploratory study sought to assess satisfaction with, and elicit recommendations for improving end-of-life care experiences of decedents with dementia from the perspective of bereaved caregivers. METHODS A cross-sectional survey was conducted with caregivers of decedents with dementia (n = 53), from the San Francisco Bay Area, California. Multiple choice and open-ended questions were asked regarding end-of-life care discussions and decisions and respecting and honoring end-of-life needs and wishes. The Satisfaction with Care at the End of Life in Dementia instrument was adapted for the survey. RESULTS While approximately 75% of caregivers were satisfied with their person living with dementia's (PLWD) end-of-life care, 25% felt better care was needed. Qualitative findings revealed that gaps persist regarding communication with providers about disease progression, care continuity and coordination, and honoring death in a preferred location. While most caregivers felt ready to discuss end-of-life decisions with providers when their PLWD was near death, with retrospection, the majority would recommend that providers discuss end-of-life decisions with them during earlier stages of the disease. CONCLUSION End-of-life care for PLWD has significant room for improvement. Efforts to train healthcare providers should focus on helping them meet the complex informational, emotional, and social support needs of PLWD and their caregivers across the trajectory of decline.
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Affiliation(s)
- Jarmin C Yeh
- Institute for Health & Aging, School of Nursing, University of California, San Francisco, California, USA.
| | - Jeff Newman
- Institute for Health & Aging, School of Nursing, University of California, San Francisco, California, USA
| | - Rachel Main
- Alzheimer's Association of Northern California and Northern Nevada, San Francisco, California, USA
| | - Lauren J Hunt
- Department of Physiological Nursing, University of California, San Francisco, California, USA; San Francisco VA Health Care System, San Francisco, California, USA
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14
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Tennison JM, Rianon NJ, Manzano JG, Munsell MF, George MC, Bruera E. Thirty-day hospital readmission rate, reasons, and risk factors after acute inpatient cancer rehabilitation. Cancer Med 2021; 10:6199-6206. [PMID: 34313031 PMCID: PMC8446558 DOI: 10.1002/cam4.4154] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives To evaluate the 30‐day hospital readmission rate, reasons, and risk factors for patients with cancer who were discharged to home setting after acute inpatient rehabilitation. Design, Setting, and Participants This was a secondary retrospective analysis of participants in a completed prospective survey study that assessed the continuity of care and functional safety concerns upon discharge and 30 days after discharge in adults. Patients were enrolled from September 5, 2018, to February 7, 2020, at a large academic quaternary cancer center with National Cancer Institute Comprehensive Cancer Center designation. Main Outcomes and Measures Thirty‐day hospital readmission rate, descriptive summary of reasons for readmissions, and statistical analyses of risk factors related to readmission. Results Fifty‐five (21%) of the 257 patients were readmitted to hospital within 30 days of discharge from acute inpatient rehabilitation. The reasons for readmissions were infection (20, 7.8%), neoplasm (9, 3.5%), neurological (7, 2.7%), gastrointestinal disorder (6, 2.3%), renal failure (3, 1.1%), acute coronary syndrome (3, 1.1%), heart failure (1, 0.4%), fracture (1, 0.4%), hematuria (1, 0.4%), wound (1, 0.4%), nephrolithiasis (1, 0.4%), hypervolemia (1, 0.4%), and pain (1, 0.4%). Multivariate logistic regression modeling indicated that having a lower locomotion score (OR = 1.29; 95% CI, 1.07–1.56; p = 0.007) at discharge, having an increased number of medications (OR = 1.12; 95% CI, 1.01–1.25; p = 0.028) at discharge, and having a lower hemoglobin at discharge (OR = 1.31; 95% CI, 1.03–1.66; p = 0.031) were independently associated with 30‐day readmission. Conclusion and Relevance Among adult patients with cancer discharged to home setting after acute inpatient rehabilitation, the 30‐day readmission rate of 21% was higher than that reported for other rehabilitation populations but within the range reported for patients with cancer who did not undergo acute inpatient rehabilitation. Research is needed to determine the rates of and risk factors for 30‐day hospital readmission after acute inpatient cancer rehabilitation to understand the nature of this problem and to decrease costs associated with readmissions. Among adult patients with cancer discharged to a home setting after acute inpatient rehabilitation, the 30‐day readmission rate of 21% was higher than that reported for other rehabilitation populations but within the range reported for patients with cancer who did not undergo acute inpatient rehabilitation. Cancer rehabilitation patients may have unique risk factors for readmission.
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Affiliation(s)
- Jegy M Tennison
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nahid J Rianon
- Department of Family & Community Medicine and Joan & Stanford Alexander Division of Geriatric and Palliative Medicine, McGovern Medical School, The University of Texas Houston Health Science Center, Houston, TX, USA
| | - Joanna G Manzano
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark F Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina C George
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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15
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Chen K, Desai K, Sureshanand S, Adelson K, Schwartz JI, Gross CP, Chaudhry SI. Creating and Validating a Predictive Model for Suitability of Hospital at Home for Patients With Solid-Tumor Malignancies. JCO Oncol Pract 2021; 17:e556-e563. [PMID: 33417488 DOI: 10.1200/op.20.00663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Hospital at home (HaH) is a means of providing inpatient-level care at home. Selection of admissions potentially suitable for HaH in oncology is not well studied. We sought to create a predictive model for identifying admissions of patients with cancer, specifically solid-tumor malignancies, potentially suitable for HaH. METHODS In this observational study, we analyzed admissions of patients with solid-tumor malignancies and unplanned admissions (January 1, 2015, to June 12, 2019) at an academic, urban cancer hospital. Potential suitability for HaH was the primary outcome. Admissions were considered potentially suitable if they did not involve escalation of care, rapid response evaluation, in-hospital death, telemetry, surgical procedure, consultation to a procedural service, advanced imaging, transfusion, restraints, and nasogastric tube placement. Admission source, patient demographics, vital signs, laboratory test results, comorbidities, admission and active cancer diagnoses, and recent hospital utilization were included as candidate variables in a multivariable logistic regression model. RESULTS Of 3,322 admissions, 905 (27.2%) patients were potentially suitable for HaH. After variable selection in the derivation cohort (n = 1,097), thirteen factors predicted potential suitability: admission source; temperature and respiratory rate at presentation; hemoglobin; breast cancer, GI cancer, or malignancy of secondary or ill-defined origin; admission for genitourinary, musculoskeletal, or neurologic symptoms, intestinal obstruction or ileus, or evaluation of secondary malignancy; and emergency department visit in prior 90 days. Model c-statistics were 0.71 (95% CI, 0.68 to 0.75) and 0.63 (0.59 to 0.67) in the derivation and validation (n = 1,095) cohorts. CONCLUSION Hospital admissions of patients potentially suitable for HaH may be identifiable using data available at admission.
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Affiliation(s)
- Kevin Chen
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,National Clinician Scholars Program, Yale School of Medicine and VA Connecticut Healthcare System, New Haven, CT
| | - Keval Desai
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Soundari Sureshanand
- Joint Data Analytics Team, Yale University, New Haven, CT.,Yale Center for Clinician Investigation, New Haven, CT
| | - Kerin Adelson
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,Smilow Cancer Hospital at Yale New Haven Health, New Haven, CT
| | - Jeremy I Schwartz
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Cary P Gross
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,National Clinician Scholars Program, Yale School of Medicine and VA Connecticut Healthcare System, New Haven, CT
| | - Sarwat I Chaudhry
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,National Clinician Scholars Program, Yale School of Medicine and VA Connecticut Healthcare System, New Haven, CT
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16
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Communication in Palliative Care. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Carter C, Mohammed S, Upshur R, Kontos P. Biomedicalization of end-of-life conversations with medically frail older adults - Malleable and senescent bodies. Soc Sci Med 2020; 291:113428. [PMID: 34756384 DOI: 10.1016/j.socscimed.2020.113428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 11/15/2022]
Abstract
The common practice of delaying and/or avoiding end-of-life conversations with medically frail older adults is an important clinical issue. Most research investigating this practice focuses on clinician training and developing conversation skills. Little is known about the socio-political factors shaping the phenomenon of end-of-life conversations between clinicians and medically frail older patients. Using the critical lens of biomedicalization we consider how two dominant discourses, successful aging and frailty, and subsequent constructions of bodies as malleable or senescent, shape patient subjectivities and influence normative expectations about appropriate healthcare conversations and the consumption of biomedicine for medically frail adults. We highlight the uneven ways medically frail older adults are clinically positioned as successful or frail agers and briefly discuss how gender, class, and race may impact this tension and ambiguity. We conclude by arguing that end-of-life conversations with medically frail older adults is constrained by the pervasiveness of the successful aging discourse and the tendency within medical institutions to construct older bodies as malleable and in need of medical intervention to promote health and longevity.
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Affiliation(s)
- Celina Carter
- Dalla Lana School of Public Health, University of Toronto, 550 College St, Toronto, ON, M6G 1B1, Canada.
| | - Shan Mohammed
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada
| | - Ross Upshur
- Dalla Lana School of Public Health, University of Toronto, Canada
| | - Pia Kontos
- Dalla Lana School of Public Health, University of Toronto, Canada; KITE-Toronto Rehabilitation Institute, University Health Network, Canada
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18
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Xu W, Wu C, Fletcher J. Assessment of changes in place of death of older adults who died from dementia in the United States, 2000-2014: a time-series cross-sectional analysis. BMC Public Health 2020; 20:765. [PMID: 32522179 PMCID: PMC7288493 DOI: 10.1186/s12889-020-08894-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 05/11/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND As the mortality attributable to dementia-related diseases in the United States escalates, providing quality and equitable end-of-life care for dementia patients across care settings has become a major public health challenge. Previous research suggests that place of death may be an indicator of quality of end-of-life care. This study aims to examine the geographical variations and temporal trends in place of death of dementia decedents in the US and the relationships between place of death of dementia decedents and broad structural determinants. METHODS Using nationwide death certificates between 2000 and 2014, we described the changes in place of death of dementia decedents across states and over time. Chi-square test for trend in proportions was used to test significant linear trend in the proportion of dementia decedents at difference places. State fixed effects models were estimated to assess the relationships between the proportion of dementia decedents at difference places and state-level factors, particularly availability of care facility resources and public health insurance expenditures. RESULTS Dementia decedents were more likely to die at home and other places and less likely to die at institutional settings over the study period. There was wide inter-state and temporal variability in the proportions of deaths at different places. Among state-level factors, availability of nursing home beds was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on institutional long term supports and services was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on home and community based services, however, had a positive association with rates of home deaths. CONCLUSIONS There was a persistent shift in the place of death of dementia decedents from institutions to homes and communities. Increased investments in home and community based health services may help dementia patients to die at their homes. As home becomes an increasingly common place of death of dementia patients, it is critical to monitor the quality of end-of-life care at this setting.
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Affiliation(s)
- Wei Xu
- Center for Demography of Health and Aging, University of Wisconsin – Madison, Madison, WI USA
| | - Changshan Wu
- Department of Geography, University of Wisconsin – Milwaukee, Milwaukee, WI USA
| | - Jason Fletcher
- Center for Demography of Health and Aging, University of Wisconsin – Madison, Madison, WI USA
- La Follette School of Public Affairs, Departments of Sociology, Agricultural and Applied Economics, and Population Health Sciences, University of Wisconsin – Madison, Madison, WI USA
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19
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Nakanishi M, Ogawa A, Nishida A. Availability of home palliative care services and dying at home in conditions needing palliative care: A population-based death certificate study. Palliat Med 2020; 34:504-512. [PMID: 31971075 DOI: 10.1177/0269216319896517] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Avoiding inappropriate care transition and enabling people with chronic diseases to die at home have become important health policy issues. Availability of palliative home care services may be related to dying at home. AIM After controlling for the presence of hospital beds and primary care physicians, we examined the association between availability of home palliative care services and dying at home in conditions requiring such services. DESIGN Death certificate data in Japan in 2016 were linked with regional healthcare statistics. SETTING/PARTICIPANTS All adults (18 years or older) who died from conditions needing palliative care in 2016 in Japan were included. RESULTS There were 922,756 persons included for analysis. Malignant neoplasm (37.4%) accounted for most decedents, followed by heart disease including cerebrovascular disease (31.4%), respiratory disease (14.7%) and dementia/Alzheimer's disease/senility (11.5%). Of decedents, 20.8% died at home or in a nursing home and 79.2% died outside home (hospital/geriatric intermediate care facility). Death at home was more likely in health regions with fewer hospital beds and more primary care physicians, in total and per condition needing palliative care. Number of home palliative care services was negatively associated with death at home. The adjustment for home palliative care services disappeared in heart disease including cerebrovascular disease and reversed in respiratory disease. CONCLUSION Specialised home palliative care services may be suboptimal, and primary care services may serve as a key access point in providing baseline palliative care to people with conditions needing palliative care. Therefore, primary care services should aim to enhance their palliative care workforce.
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Affiliation(s)
- Miharu Nakanishi
- Mental Health and Nursing Research Team, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Asao Ogawa
- Exploratory Oncology Research and Clinical Trial Center, National Cancer Center Hospital East, Chiba, Japan
| | - Atsushi Nishida
- Mental Health Promotion Project, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
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Zhu Y, Stearns SC. Post‐Acute Care Locations: Hospital Discharge Destination Reports vs Medicare Claims. J Am Geriatr Soc 2019; 68:847-851. [DOI: 10.1111/jgs.16308] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/18/2019] [Accepted: 12/02/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Ye Zhu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester Minnesota
- Division of Health Care Policy and Research, Department of Health Sciences Research Mayo Clinic Rochester Minnesota
| | - Sally C. Stearns
- Department of Health Policy and Management The University of North Carolina at Chapel Hill, Gillings School of Global Public Health Chapel Hill North Carolina
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21
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Chang D, Parrish J, Kamangar N, Liebler J, Lee M, Neville T. Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses to Reduce Nonbeneficial Intensive Care Unit Treatments: Protocol for a Multicenter Quality Improvement Study. JMIR Res Protoc 2019; 8:e16301. [PMID: 31763988 PMCID: PMC6902129 DOI: 10.2196/16301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Invasive intensive care unit (ICU) treatments for patients with advanced medical illnesses and poor prognoses may prolong suffering with minimal benefit. Unfortunately, the quality of care planning and communication between clinicians and critically ill patients and their families in these situations are highly variable, frequently leading to overutilization of invasive ICU treatments. Time-limited trials (TLTs) are agreements between the clinicians and the patients and decision makers to use certain medical therapies over defined periods of time and to evaluate whether patients improve or worsen according to predetermined clinical parameters. For patients with advanced medical illnesses receiving aggressive ICU treatments, TLTs can promote effective dialogue, develop consensus in decision making, and set rational boundaries to treatments based on patients' goals of care. OBJECTIVE The aim of this study will be to examine whether a multicomponent quality-improvement strategy that uses protocoled TLTs as the default ICU care-planning approach for critically ill patients with advanced medical illnesses will decrease duration and intensity of nonbeneficial ICU care without changing hospital mortality. METHODS This study will be conducted in medical ICUs of three public teaching hospitals in Los Angeles County. In Aim 1, we will conduct focus groups and semistructured interviews with key stakeholders to identify facilitators and barriers to implementing TLTs among ICU patients with advanced medical illnesses. In Aim 2, we will train clinicians to use protocol-enhanced TLTs as the default communication and care-planning approach in patients with advanced medical illnesses who receive invasive ICU treatments. Eligible patients will be those who the treating ICU physicians consider to be at high risk for nonbeneficial treatments according to guidelines from the Society of Critical Care Medicine. ICU physicians will be trained to use the TLT protocol through a curriculum of didactic lectures, case discussions, and simulations utilizing actors as family members in role-playing scenarios. Family meetings will be scheduled by trained care managers. The improvement strategy will be implemented sequentially in the three participating hospitals, and outcomes will be evaluated using a before-and-after study design. Key process outcomes will include frequency, timing, and content of family meetings. The primary clinical outcome will be ICU length of stay. Secondary outcomes will include hospital length of stay, days receiving life-sustaining treatments (eg, mechanical ventilation, vasopressors, and renal replacement therapy), number of attempts at cardiopulmonary resuscitation, frequency of invasive ICU procedures, and disposition from hospitalization. RESULTS The study began in August 2017. The implementation of interventions and data collection were completed at two of the three hospitals. As of September 2019, the study was at the postintervention stage at the third hospital. We have completed focus groups with physicians at each medical center (N=29) and interviews of family members and surrogate decision makers (N=18). The study is expected to be completed in the first quarter of 2020, and results are expected to be available in mid-2020. CONCLUSIONS The successful completion of the aims in this proposal may identify a systematic approach to improve communication and shared decision making and to reduce nonbeneficial invasive treatments for ICU patients with advanced medical illnesses. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/16301.
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Affiliation(s)
- Dong Chang
- Los Angeles BioMedical Research Institute, Harbor-University of California Los Angeles Medical Center, Torrance, CA, United States
| | - Jennifer Parrish
- Los Angeles BioMedical Research Institute, Harbor-University of California Los Angeles Medical Center, Torrance, CA, United States
| | | | - Janice Liebler
- Los Angeles County-University of Southern California Medical Center, Los Angeles, CA, United States
| | - May Lee
- Los Angeles County-University of Southern California Medical Center, Los Angeles, CA, United States
| | - Thanh Neville
- Division of Pulmonary and Critical Care Medicine, University of California Los Angeles School of Medicine, Los Angeles, CA, United States
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22
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Austin AM, Carmichael DQ, Bynum JPW, Skinner JS. Measuring racial segregation in health system networks using the dissimilarity index. Soc Sci Med 2019; 240:112570. [PMID: 31585377 PMCID: PMC6810808 DOI: 10.1016/j.socscimed.2019.112570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 08/12/2019] [Accepted: 09/24/2019] [Indexed: 11/28/2022]
Abstract
Racial disparities in the end-of-life treatment of patients are a well observed fact of the U.S. healthcare system. Less is known about how the physicians treating patients at the end-of-life influence the care received. Social networks have been widely used to study interactions with the healthcare system using physician patient-sharing networks. In this paper, we propose an extension of the dissimilarity index (DI), classically used to study geographic racial segregation, to study differences in patient care patterns in the healthcare system. Using the proposed measure, we quantify the unevenness of referrals (sharing) by physicians in a given region by their patients' race and how this relates to the treatments they receive at the end-of-life in a cohort of Medicare fee-for-service patients with Alzheimer's disease and related dementias. We apply the measure nationwide to physician patient-sharing networks, and in a sub-study comparing four regions with similar racial distribution, Washington, DC, Greenville, NC, Columbus, GA, and Meridian, MS. We show that among regions with similar racial distribution, a large dissimilarity index in a region (Washington, DC DI = 0.86 vs. Meridian, MS DI = 0.55), which corresponds to more distinct referral networks for black and white patients by the same physician, is correlated with black patients with Alzheimer's disease and related dementias receiving more aggressive care at the end-of-life (including ICU and ventilator use), and less aggressive quality care (early hospice care).
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Affiliation(s)
- Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon.
| | - Donald Q Carmichael
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon
| | - Julie P W Bynum
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor MI, USA; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor MI, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, NH, Lebanon; Dartmouth College, Hanover, NH, USA; Department of Economics, Dartmouth College, Hanover NH, USA
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Puechl AM, Chino F, Havrilesky LJ, Davidson BA, Chino JP. Place of death by region and urbanization among gynecologic cancer patients: 2006-2016. Gynecol Oncol 2019; 155:98-104. [PMID: 31378375 DOI: 10.1016/j.ygyno.2019.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/10/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate associations between US region of residence and urbanization and the place of death among women with gynecologic malignancies in the United States. METHODS A retrospective cross-sectional study was performed using publicly available death certificate data from the National Center for Health Statistics. All gynecologic cancer deaths were included from 2006 to 2016. Comparisons among categories were performed with a two-tailed chi-square test, with p-values <0.05 considered significant. RESULTS From 2006 to 2016, 328,026 women died from gynecologic malignancies in the US. Of these deaths, 40.1% (n = 134,333) occurred in the patient's home, 24.9%(n = 81,823) in the hospital, and 11.3% (37,188) in an inpatient hospice facility. Place of death varied by geographic region. The Northeast had the largest percentage of gynecologic cancer patients (31.3%) die as a hospital inpatient. The West had the highest percentage of deaths (49.3%) at home. Deaths in a hospice facility were the highest (14.1%) in the South. Place of death varied by urbanization; patients residing in large central metro or rural counties were the most likely to die during hospital admission (28.7% and 27.1%, respectively). Patients living in medium-sized metro areas were the least likely to die in hospitals (21.8%) and most likely to die in a hospice facility (14.3%). All comparisons were significant by study definition. CONCLUSION The place of death for patients with gynecologic malignancies varies by US region and urbanization. These disparities are multifactorial in nature, likely influenced by both sociodemographic factors and regional resource availability. In this study, however, rural and central metro areas are identified as regions that may benefit from further hospice development and advocacy.
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Affiliation(s)
- Allison M Puechl
- Duke University Division of Gynecologic Oncology, Department of Radiation Oncology, Durham, NC, United States of America.
| | - Fumiko Chino
- Duke Cancer Institute, Department of Radiation Oncology, Durham, NC, United States of America
| | - Laura J Havrilesky
- Duke University Division of Gynecologic Oncology, Department of Radiation Oncology, Durham, NC, United States of America
| | - Brittany A Davidson
- Duke University Division of Gynecologic Oncology, Department of Radiation Oncology, Durham, NC, United States of America
| | - Junzo P Chino
- Duke Cancer Institute, Department of Radiation Oncology, Durham, NC, United States of America; Duke University Medical Center, Department of Radiation Oncology, Durham, NC, United States of America
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Al-ansari AM, Suroor SN, Aboserea SM, Abd-el-gawad WM. Harmonizing Palliative Care: National Survey to Evaluate the Knowledge and Attitude of Emergency Physicians towards Palliative Care.. [DOI: 10.1101/19003939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Background and AimAlthough the challenges of integrating palliative care practices across care settings are real and well recognized until now little is known about palliative care practice of emergency physicians (EPs) and their accessibility to palliative care services in Kuwait. So the aim of this study was to explore the attitude, and knowledge encountered by EPs in providing palliative care in all general hospitals in Kuwait.MethodA cross-sectional survey was performed in the emergency rooms of all general hospitals in Kuwait using Palliative Care Attitude and Knowledge (PCAK) questionnaire.ResultsOf the total number of physicians working in emergency rooms (n=156), 104 (66.67%) had completed the survey. 76.9% (n=80) of the EPs had either uncertain attitude toward palliative care. Most of the EPs (n=73, 70.28%) didn’t discuss the need of the patients to palliative care either with the patients or their families. Only 16 (15.4%) of the EPs responded correctly to the most of the questions while nearly half of the EPs (n=51, 49%) had poor knowledge especially in the most effective management of refractory dysnea (n=18, 17.3%). Experience ≥ 11yrs and better knowledge scores were independent predictors of positive attitude after adjustment of age, sex, qualifications, specialty, position, and nationality [OR: 5.747 (CI: 1.031-25.00), 1.458(CI: 1.148-1.851); p-value: 0.021, 0.002 respectively]..ConclusionsDespite recognizing palliative care as an important competence, the majority of the emergency physicians in Kuwait had uncertain attitude and poor knowledge towards palliative care. Lack of knowledge, direct accessibility to palliative care services and lack of support from palliative medicine specialists were the main reasons for uncertain and negative attitude. Efforts should be done to enhance physician training and provide palliative care resources in order to improve the quality of care given to patients visiting emergency departments.What this paper addsStudies proved that the emergency room may be a suitable place for early referral of patients who may benefit from palliative care especially old age to prevent upcoming undesired admissions and hospital deaths.The integration of palliative care concepts and consultation teams into emergency medicine may help to avoid unnecessary and burdensome treatments, tests, and procedures that are not aligned with patients’ goals of care.Although the challenges of integrating palliative care practices across care settings are real and well recognized until now little is known about palliative care practice of emergency physicians and their accessibility to palliative care services in Kuwait.Recently, a newly developed tool called Palliative Care Attitude and Knowledge (PCAK) questionnaire was created to assess the attitude and knowledge of non-palliative physicians toward palliative care. So the aim of this study was to explore the attitude, and knowledge encountered by emergency physicians in providing palliative care using PCAK 8 in emergency departments in all generalStudies showed that early palliative care consultation was shown to improve quality of life for cancer patients and may even lengthen their survival.What this study addsDespite recognizing palliative care as an important competence, the majority of the emergency physicians in Kuwait had uncertain attitude and poor knowledge towards palliative care. Lack of knowledge, direct accessibility to palliative care services and lack of support from palliative medicine specialists were the main reasons for uncertain and negative attitude.Efforts should be done to enhance physician training and provide palliative care resources in order to improve the quality of care given to patients visiting emergency departments.
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25
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Blom MC, Ashfaq A, Sant'Anna A, Anderson PD, Lingman M. Training machine learning models to predict 30-day mortality in patients discharged from the emergency department: a retrospective, population-based registry study. BMJ Open 2019; 9:e028015. [PMID: 31401594 PMCID: PMC6701621 DOI: 10.1136/bmjopen-2018-028015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 04/13/2019] [Accepted: 07/05/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES The aim of this work was to train machine learning models to identify patients at end of life with clinically meaningful diagnostic accuracy, using 30-day mortality in patients discharged from the emergency department (ED) as a proxy. DESIGN Retrospective, population-based registry study. SETTING Swedish health services. PRIMARY AND SECONDARY OUTCOME MEASURES All cause 30-day mortality. METHODS Electronic health records (EHRs) and administrative data were used to train six supervised machine learning models to predict all-cause mortality within 30 days in patients discharged from EDs in southern Sweden, Europe. PARTICIPANTS The models were trained using 65 776 ED visits and validated on 55 164 visits from a separate ED to which the models were not exposed during training. RESULTS The outcome occurred in 136 visits (0.21%) in the development set and in 83 visits (0.15%) in the validation set. The model with highest discrimination attained ROC-AUC 0.95 (95% CI 0.93 to 0.96), with sensitivity 0.87 (95% CI 0.80 to 0.93) and specificity 0.86 (0.86 to 0.86) on the validation set. CONCLUSIONS Multiple models displayed excellent discrimination on the validation set and outperformed available indexes for short-term mortality prediction interms of ROC-AUC (by indirect comparison). The practical utility of the models increases as the data they were trained on did not require costly de novo collection but were real-world data generated as a by-product of routine care delivery.
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Affiliation(s)
- Mathias Carl Blom
- Department of Clinical Sciences Lund, Medicine, Lund University, Medical Faculty, Lund, Sweden
| | - Awais Ashfaq
- Center for Applied Intelligent Systems Research (CAISR), Halmstad University, Halmstad, Sweden
- Halland Hospital, Region Halland, Halmstad, Sweden
| | - Anita Sant'Anna
- Center for Applied Intelligent Systems Research (CAISR), Halmstad University, Halmstad, Sweden
| | - Philip D Anderson
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Markus Lingman
- Halland Hospital, Region Halland, Halmstad, Sweden
- Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Wales J, Kalia S, Moineddin R, Husain A. The Impact of Socioeconomic Status on Place of Death Among Patients Receiving Home Palliative Care in Toronto, Canada: A Retrospective Cohort Study. J Palliat Care 2019; 35:167-173. [PMID: 31204570 DOI: 10.1177/0825859719855020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Socioeconomic disparities in home death have been noted in the literature. Home-based palliative care increases access to home death and has been suggested as a means to decrease these disparities. AIM Our study examines the association between socioeconomic status and other demographic factors on place of death in a population receiving home palliative care in Toronto, Canada. DESIGN This is a retrospective chart review of patients who died between August 2013 and August 2015 when admitted to a home-based palliative care service. Multivariate multinomial regression examined the relationship between the place of death (home, palliative care unit [PCU], or acute care) with age, gender, primary diagnosis, and income quintile. Bivariate logistic regression was fitted to calculate the odds ratio (OR) and probability of preference for home death. SETTING/PARTICIPANTS Patients receiving home-based palliative care services from the Latner Centre for Palliative Care in Toronto, Canada. RESULTS A total of 2066 patients were included in multivariate analysis. Patients in the lowest income quintile had increased odds of dying in acute care (OR = 2.41, P < .001) or dying in PCU (OR = 1.64, P = .008) than patients in highest income quintile. Patients in the next lowest income quintiles 2 and 3 were also more likely to die in acute care. The rate of preference for home death was significantly lower in the lowest income quintile (OR = 0.47, P = .0047). CONCLUSIONS Patients in lower income quintiles are less likely to die at home, despite receiving home-based palliative care, although they may also be less likely to prefer home death.
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Affiliation(s)
- Joshua Wales
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sumeet Kalia
- University of Toronto Practice Based Research Network, North York General Hospital, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amna Husain
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
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27
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Cross SH, Kamal AH, Taylor DH, Warraich HJ. Hospice Use Among Patients with Heart Failure. Card Fail Rev 2019; 5:93-98. [PMID: 31179019 PMCID: PMC6545999 DOI: 10.15420/cfr.2019.2.2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/26/2019] [Indexed: 12/11/2022] Open
Abstract
Despite its many benefits, hospice care is underused for patients with heart failure. This paper discusses the factors contributing to this underuse and offers recommendations to optimise use for patients with heart failure and proposes metrics to optimise quality of hospice care for this patient group.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University Durham, NC, US
| | - Arif H Kamal
- Duke Cancer Institute Durham, NC, US.,Duke Fuqua School of Business, Duke University Durham, NC, US
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University Durham, NC, US.,Margolis Center for Health Policy, Duke University Durham, NC, US.,Duke Clinical Research Institute Durham, NC, US
| | - Haider J Warraich
- Department of Medicine, Division of Cardiology, Duke University Medical Center Durham, NC, US
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Heyland DK, Lavery JV, Tranmer JE, Shortt S, Taylor SJ. Dying in Canada: Is It an Institutionalized, Technologically Supported Experience? J Palliat Care 2019. [DOI: 10.1177/082585970001601s04] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although preliminary evidence shows that people generally prefer to die at home, very little is known about where Canadians die. Understanding the epidemiology of dying in Canada may illuminate opportunities to improve quality of end-of-life care and related health policy. We conducted a cross-sectional analysis of death records in Canada to determine the proportions of deaths occurring in hospitals and special care units. Our analysis found that deaths in Canada occur in hospitals with provincial and territorial proportions ranging from 87% in Quebec to 52% in the Northwest Territories. In hospitals recording deaths in special care units, 18.64% of all deaths occurred in special care units. The proportion of deaths in special care units ranged from 25% in Manitoba to 7% in the Northwest Territories. The proportion of deaths in special care units varied by size and nature (teaching vs. non-teaching) of hospitals. It increased with the size of the hospital from 8% in hospitals with 1–49 beds, to 23% for hospitals with 400 or more beds. In teaching hospitals, 27% of deaths occurred in special care units, and in non-teaching hospitals the proportion was 15%. In conclusion, the majority of deaths in Canada occur in hospitals and a substantial proportion occur in special care units, raising questions about the appropriateness and quality of current end-of-life care practices in Canada.
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Affiliation(s)
- Daren K. Heyland
- Department of Medicine, Kingston General Hospital, and Department of Community Health and Epidemiology, Queen's University
| | - James V. Lavery
- Department of Community Health and Epidemiology and Queen's Health Policy Research Unit, Queen's University
| | - Joan E. Tranmer
- Department of Nursing, Kingston General Hospital, and School of Nursing, Queen's University
| | - S.E.D. Shortt
- Department of Community Health and Epidemiology and Queen's Health Policy Research Unit, Queen's University
| | - Sandra J. Taylor
- Department of Medicine, Kingston General Hospital, and School of Nursing and Department of Philosophy, Queen's University, Kingston, Ontario, Canada
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Tang ST, Mccorkle R. Determinants of Congruence between the Preferred and Actual Place of Death for Terminally Ill Cancer Patients. J Palliat Care 2019. [DOI: 10.1177/082585970301900403] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A prospective cohort study was conducted to explore the extent of congruence and to identify the determinants of congruence between the preferred and actual place of death of terminally ill cancer patients. A total of 180 terminally ill cancer patients were enrolled (87% response rate) and 127 died during the one-year study period. Nearly 90% of the subjects preferred to die at home. One-third achieved their preference for place of death. The kappa value of congruence (κ=0.11, 95% confidence interval=0.05–0.17) indicated poor to slight agreement between the preferred and actual place death. Important determinants of congruence between the preferred and actual place of death for terminally ill cancer patients included rehospitalisation and receiving hospice home care during the final days of life, perceived ability for family to help achieve preferred place of death, and residence in New Haven County. Conclusions This study directly confirms that the degree of congruence between the preferred and actual place death is unsatisfactory. Clinical interventions and health policies need to be developed to assist terminally ill cancer patients who may not be able to achieve their preference for place of end-of-life care and death.
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Affiliation(s)
- Siew Tzuh Tang
- National Yang-Ming University, School of Nursing, Taipei, Taiwan, and School of Nursing, Yale University
| | - Ruth Mccorkle
- School of Nursing, Yale University, New Haven, Connecticut, U.S.A
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Grande GE, Mckerral A, Addington-Hall JM, Todd CJ. Place of Death and Use of Health Services in the Last Year of Life. J Palliat Care 2019. [DOI: 10.1177/082585970301900408] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim To investigate whether health service input in the last year of life differs between cancer patients who die at home versus those dying in inpatient care. Methods Post hoc exploratory case-control study of 127 home deaths and 200 inpatient deaths. Retrospective electronic record linkage of patients’ community and inpatient care during the last year of life. Results Patients who died at home began their home nursing care closer to death than those who died as inpatients. Their first contact with inpatient hospice care began further from death. Before their final month, home death patients also had more specialist and district nursing than patients who died in inpatient care. Conclusions Patients who began their home nursing early were less likely to die at home than those who began such care late. This suggests that it may be difficult to sustain end-of-life care at home for an extended period. Further research incorporating assessment of informal care input and disease trajectory is required to investigate this issue.
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Affiliation(s)
- Gunn E. Grande
- School of Nursing, Midwifery and Health Visiting, University of Manchester, Manchester
| | | | | | - Chris J. Todd
- School of Nursing, Midwifery and Health Visiting, University of Manchester, Manchester, U.K
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Bradley EH, Fried TR, Kasl SV, Cicchetti DV, Johnson-Hurzeler R, Horwitz SM. Referral of Terminally Ill Patients for Hospice: Frequency and Correlates. J Palliat Care 2019. [DOI: 10.1177/082585970001600404] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Despite the central role of hospice in end-of-life care, little is known about the proportion of terminally ill patients referred for hospice and the physician factors associated with hospice referral. Methods Cross-sectional data from a self-administered survey of 231 physicians were used to estimate the proportion of terminally ill patients who were referred for hospice and to assess the independent effects of physician factors on hospice referral. Results On average, physicians reported referring about 55% of their terminally ill patients for hospice; 26.7% of the physicians referred less than one quarter of their terminally ill patients. Physician specialty, board certification, and physicians’ knowledge level about hospice were independently associated with the proportions of terminally ill patients referred for hospice. Conclusion Many terminally ill patients are not referred for hospice care and physician factors influence the use of hospice significantly. The study suggests effective factors and groups to target with interventions to enhance the appropriate use of hospice.
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Affiliation(s)
- Elizabeth H. Bradley
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Terri R. Fried
- VA Connecticut Healthcare System and Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Stanislav V. Kasl
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Domenic V. Cicchetti
- Child Study Center and Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Rosemary Johnson-Hurzeler
- John D. Thompson Hospice Institute for Training, Education, and Research, and The Connecticut Hospice, New Haven, Connecticut, U.S.A
| | - Sarah M. Horwitz
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, U.S.A
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Murray MA, O'Connor AM, Fiset V, Viola R. Women's Decision-Making Needs regarding Place of Care at End of Life. J Palliat Care 2019. [DOI: 10.1177/082585970301900305] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is known about the decision-making needs of terminally ill women who are considering options for place of care at the end of life. A pilot study was conducted with a sample of 20 terminally ill women with advanced cancer to identify factors taken into consideration in making this decision. Participants were interviewed using a semistructured questionnaire incorporating the domains of quality of end-of-life care and based on the Ottawa Decision Support Framework. Results suggested a gap between the preferred (home, n=13) and the actual (palliative care unit, n=16) place of care. Discrepancies about place of care may be related to conflicting subjective factors such as being a burden to family versus having the opportunity to strengthen relationships with family and friends. Participants who were actively engaged in making the decision scored the highest levels of decisional conflict. Previous studies have shown an association between high decisional conflict scores and decision delay. Although findings from this small study are preliminary, they suggest that the decision regarding place of terminal care is complex with multiple competing factors being considered.
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Affiliation(s)
- Mary Ann Murray
- Sisters of Charity of Ottawa (SCO) Health Service and University of Ottawa Institute of Palliative Care
| | | | | | - Raymond Viola
- University of Ottawa, Institute of Palliative Care, SCO Health Service, Ottawa, Ontario, Canada
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Johnson PC, Xiao Y, Wong RL, D'Arpino S, Moran SMC, Lage DE, Temel B, Ruddy M, Traeger LN, Greer JA, Hochberg EP, Temel JS, El-Jawahri A, Nipp RD. Potentially Avoidable Hospital Readmissions in Patients With Advanced Cancer. J Oncol Pract 2019; 15:e420-e427. [PMID: 30946642 DOI: 10.1200/jop.18.00595] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Patients with cancer often prefer to avoid time in the hospital; however, data are lacking on the prevalence and predictors of potentially avoidable readmissions (PARs) among those with advanced cancer. METHODS We enrolled patients with advanced cancer from September 2, 2014, to November 21, 2014, who had an unplanned hospitalization and assessed their patient-reported symptom burden (Edmonton Symptom Assessment System) at the time of admission. For 1 year after enrollment, we reviewed patients' health records to determine the primary reason for every hospital readmission and we classified readmissions as PARs using adapted Graham's criteria. We examined predictors of PARs using nonlinear mixed-effects models with binomial distribution. RESULTS We enrolled 200 (86.2%) of 232 patients who were approached. For these 200 patients, we reviewed 277 total hospital readmissions and identified 108 (39.0%) of these as PARs. The most common reasons for PARs were premature discharge from a prior hospitalization (30.6%) and failure of timely follow-up (28.7%). PAR hospitalizations were more likely than non-PAR hospitalizations to experience symptoms as the primary reason for admission (28.7% v 13.0%; P = .001). We found that married patients were less likely to experience PARs (odds ratio, 0.30; 95% CI, 0.15 to 0.57; P < .001) and that those with a higher physical symptom burden were more likely to experience PARs (odds ratio, 1.03; 95% CI, 1.01 to 1.05; P = .012). CONCLUSION We observed that a substantial proportion of hospital readmissions are potentially avoidable and found that patients' symptom burdens predict PARs. These findings underscore the need to assess and address the symptom burden of hospitalized patients with advanced cancer in this highly symptomatic population.
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Affiliation(s)
- P Connor Johnson
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Yian Xiao
- 2 Boston Medical Center, Boston University School of Medicine, Boston, MA
| | | | - Sara D'Arpino
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Samantha M C Moran
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Daniel E Lage
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Brandon Temel
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Margaret Ruddy
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Lara N Traeger
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Joseph A Greer
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Ephraim P Hochberg
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Jennifer S Temel
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Areej El-Jawahri
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Ryan D Nipp
- 1 Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
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Cortez D, Maynard DW, Campbell TC. Creating space to discuss end-of-life issues in cancer care. PATIENT EDUCATION AND COUNSELING 2019; 102:216-222. [PMID: 30007763 PMCID: PMC6571206 DOI: 10.1016/j.pec.2018.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 06/26/2018] [Accepted: 07/02/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Analyze entire oncology clinical visits and examine instances in which oncologists have to break the bad news that patients' treatments are no longer effective. METHODS Using conversation analysis we examine 128 audio recorded conversations between terminal cancer patients, their caregivers, and oncologists. RESULTS When oncologists break the bad news that a patient's treatment is no longer effective, they often use a conversational device we call an "exhausted current treatment" (ECT) statement, which avoids discussing prognosis in favor of further discussing treatment options. Analysis suggests that improving and prioritizing patient-centered care and shared decision making is possible if we first understand the social organization of clinical visits. CONCLUSIONS ECT statements and their movement towards discussing treatment options means that opportunities are bypassed for patients and caregivers to process or discuss scan results, and their prognostic implications. PRACTICE IMPLICATIONS When oncologists and patients, by fixating on treatment options, bypass opportunities to discuss the meaning of scan results, they fail to realize other goals associated with prognostic awareness. Talking about what scans mean may add minutes to that part of the clinic visit, but can create efficiencies that conserve overall time. We recommend that oncologists, after delivering scan news, ask, "Would you like discuss what this means?".
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Affiliation(s)
- Dagoberto Cortez
- Department of Sociology, University of Wisconsin-Madison, Madison, United States.
| | - Douglas W Maynard
- Department of Sociology, University of Wisconsin-Madison, Madison, United States
| | - Toby C Campbell
- Department of Internal Medicine, Division on Hematology-Oncology, University of Wisconsin-Madison, Madison, United States; School of Nursing, University of Wisconsin-Madison, Madison, United States
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Abstract
Introduction: High-quality palliative care may remain out of reach for rural people who are dying. The purpose of this study was to explore the opportunities and issues affecting the provision of high-quality palliative care from the perspective of nurses employed in two rural health regions. Method: Using an interpretive descriptive design, focus groups and in-depth individual interviews of 44 nurses were conducted. Results: Descriptions of challenges and opportunities fell into three themes: effectiveness and safety, patient-cen-tredness, and efficiency and timeliness. Patient-cen-tredness was seen as a major strength of rural palliative care. Major challenges included provision of adequate symptom management and support of home deaths. The scarcity of health human resources and the negative impact these shortages had on all dimensions of palliative care quality consistently underpinned the discussions. Conclusion: Implementing outcome measurements related to symptom management and home deaths may be a critical foundation for enhancing the quality of rural palliative care.
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Affiliation(s)
- Donna Goodridge
- D Goodridge (corresponding author): College of Nursing, University of Saskatchewan, 107 Wiggins Road, Saskatoon, Saskatchewan, Canada S7T 5E5
| | - Wendy Duggleby
- W Duggleby: Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Chai H, Guerriere DN, Zagorski B, Kennedy J, Coyte PC. The Size, Share, and predictors of Publicly Financed Healthcare Costs in the Home Setting over the Palliative Care Trajectory: A Prospective Study. J Palliat Care 2018. [DOI: 10.1177/082585971302900304] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: The increasing attention on home-based service provision for end-of-life care has resulted in greater financial demands being placed on family caregivers. The purpose of this study was to assess publicly financed costs within a home-based setting from a societal perspective. Methods: A pro spective cohort study design was employed. In all, 129 caregivers of palliative care patients were interviewed biweekly for a total of 667 interviews. Multiple regression analysis (log-linear regression and seemingly unrelated regression [SUR]) was conducted. Results: While publicly financed costs accounted for 20 percent of the full economic costs and increased with proximity to death, 76.7 percent of costs were borne by patients’ caregivers in the form of unpaid caregiving. The share of publicly financed healthcare costs was driven by patients’ and caregivers’ sociodemographic and clinical characteristics. Conclusion: These findings warrant affording greater attention to policies and interventions intended to reduce the economic burden on palliative patients and their caregivers.
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Affiliation(s)
- Huamin Chai
- PC Coyte (corresponding author): Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, McMurrich Building, 2nd floor, 12 Queen's Park Crescent West, Toronto, Canada M5S 1A8
| | - Denise N. Guerriere
- Department of Risk Management and Insurance, School of Economics, Nankai University, Tianjin, China, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Brandon Zagorski
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Julia Kennedy
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter C. Coyte
- PC Coyte (corresponding author): Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, McMurrich Building, 2nd floor, 12 Queen's Park Crescent West, Toronto, Canada M5S 1A8
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Chen CY, Naessens JM, Takahashi PY, McCoy RG, Borah BJ, Borkenhagen LS, Kimeu AK, Rojas RL, Johnson MG, Visscher SL, Cha SS, Thorsteinsdottir B, Hanson GJ. Improving Value of Care for Older Adults With Advanced Medical Illness and Functional Decline: Cost Analyses of a Home-Based Palliative Care Program. J Pain Symptom Manage 2018; 56:928-935. [PMID: 30165123 DOI: 10.1016/j.jpainsymman.2018.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 01/07/2023]
Abstract
CONTEXT Identifying high-value health care delivery for patients with clinically complex and high-cost conditions is important for future reimbursement models. OBJECTIVES The objective of this study was to assess the Medicare reimbursement savings of an established palliative care homebound program. METHODS This is a retrospective cohort study involving 50 participants enrolled in a palliative care homebound program and 95 propensity-matched control patients at Mayo Clinic in Rochester, Minnesota, between September 1, 2012, and March 31, 2013. Total Medicare reimbursement was compared in the year before enrollment with the year after enrollment for participants and controls. RESULTS No significant differences were observed in demographic characteristics or prognostic indices between the two groups. Total Medicare reimbursement per program participant the year before program enrollment was $16,429 compared with $14,427 per control patient, resulting in $2004 higher charges per program patient. In 12 months after program enrollment, mean annual payment was $5783 per patient among participants and $22,031 per patient among the matched controls. In the second year, the intervention group had a decrease of $10,646 per patient; the control group had an increase of $7604 per patient. The difference between the participant group and control group was statistically significant (P < 0.001) and favored the palliative care homebound program enrollees by $18,251 (95% CI, $11,268-$25,234). CONCLUSION The Mayo Clinic Palliative Care Homebound Program reduced annual Medicare expenditures by $18,251 per program participant compared with matched control patients. This supports the role of home-based palliative medicine in delivering high-value care to high-risk older adults.
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Affiliation(s)
- Christina Y Chen
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - James M Naessens
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA; Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul Y Takahashi
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rozalina G McCoy
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA; Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Bijan J Borah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA; Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ashley K Kimeu
- Certified Nurse Practitioners, Mayo Clinic, Rochester, Minnesota, USA
| | - Ricardo L Rojas
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Matt G Johnson
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sue L Visscher
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephen S Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Gregory J Hanson
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA; Mayo Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Patel MI, Moore D, Bhattacharya J, Milstein A, Coker TR. Perspectives of Health Care Payer Organizations on Cancer Care Delivery Redesign: A National Study. J Oncol Pract 2018; 15:e46-e55. [PMID: 30444666 DOI: 10.1200/jop.18.00331] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Despite advancements in cancer care, persistent gaps remain in the delivery of high-value end-of-life cancer care. The aim of this study was to examine views of health care payer organization stakeholders on approaches to the redesign of end-of-life cancer care delivery strategies to improve care. METHODS We conducted semistructured interviews with 34 key stakeholders (eg, chief medical officers, medical directors) in 12 health plans and 22 medical group organizations across the United States. We recorded, transcribed, and analyzed interviews using the constant comparative method of qualitative analysis. RESULTS Participants endorsed strategies to redesign end-of-life cancer care delivery to improve end-of-life care. Participants supported the use of nonprofessionals to deliver some cancer services through alternative formats (eg, telephone, Internet) and delivery of services in nonclinical settings. Participants reported that using nonprofessional providers to offer some services, such as goals of care discussions and symptom assessments, via telephone in community-based settings or in patients' homes, may be more effective and efficient ways to deliver high-value cancer care services. Participants described challenges to redesign, including coordination with and acceptance by oncology providers and payment models required to financially support clinical changes. Some participants suggested solutions, including providing funding and logistic support to encourage implementation of care delivery innovations and to financially reward practices for delivery of high-value end-of-life cancer care services. CONCLUSION Stakeholders from payer organizations endorsed opportunities to redesign cancer care delivery, and some are willing to provide logistic, design, and financial support to practices interested in improving end-of-life cancer care.
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Affiliation(s)
- Manali I Patel
- 1 Stanford University School of Medicine, Stanford, CA.,2 Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - David Moore
- 1 Stanford University School of Medicine, Stanford, CA
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Nipp RD, Tramontano AC, Kong CY, Hur C. Patterns and predictors of end-of-life care in older patients with pancreatic cancer. Cancer Med 2018; 7:6401-6410. [PMID: 30426697 PMCID: PMC6308041 DOI: 10.1002/cam4.1861] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Little is known about end-of-life care among patients with pancreatic adenocarcinoma (PDAC). We used the Surveillance, Epidemiology, and End Results-Medicare linked database to analyze patterns of hospice use and end-of-life treatment in patients with PDAC. METHODS We included patients diagnosed with PDAC between 2000-2011 and who had died by December 31, 2012. We assessed patterns of hospice use, chemotherapy receipt, and intensive care unit (ICU) admissions at end-of-life. We used multivariable logistic regression to investigate predictors of end-of-life care. RESULTS In our cohort of 16 309 patients, 70.5% enrolled in hospice, of which 29.1% enrolled in the last 7 days of life. Use of hospice increased over time, from 61.6% in 2000 to 77.5% in 2012 (P-value for trend <0.0001). Among the entire cohort, 6.4% received chemotherapy within the last 14 days of life and 13.1% were admitted to the ICU within the last 30 days of life. Late ICU admissions increased over time, while chemotherapy receipt at the end-of-life decreased. Patients who were older, female, with higher SES, or from the South or Midwest were more likely to enroll in hospice. Those who were younger or male were more likely to receive chemotherapy or have an ICU admission at the end-of-life. CONCLUSION Although hospice enrollment has increased among patients with PDAC, late enrollment still occurs in a substantial proportion of patients. While chemotherapy at the end-of-life has decreased slightly, ICU admissions at the end-of-life have continued to increase. Further research is needed to determine effective ways of enhancing end-of-life care for patients with PDAC.
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Affiliation(s)
- Ryan D Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chung Yin Kong
- Harvard Medical School, Boston, Massachusetts.,Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chin Hur
- Harvard Medical School, Boston, Massachusetts.,Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
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Chen B, Kuo CC, Huang N, Fan VY. Reducing costs at the end of life through provider incentives for hospice care: A retrospective cohort study. Palliat Med 2018; 32:1389-1400. [PMID: 29793393 DOI: 10.1177/0269216318774899] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Costs of medical care have been found to be highest at the end of life. AIM To evaluate the effect of provider reimbursement for hospice care on end-of-life costs. DESIGN The policy expanded access to hospice care for end-stage renal disease patients, a policy previously limited to cancer patients only. This study employed a difference-in-differences analysis using a generalized linear model. The main outcome is inpatient expenditures in the last 30 days of life. SETTING/PARTICIPANTS A cohort of 151,509 patients with chronic kidney disease or cancer, aged 65 years or older, who died between 2005 and 2012 in the National Health Insurance Research Database, which contains all enrollment and inpatient claims data for Taiwan. RESULTS Even as end-of-life costs for cancer are declining over time, expanding hospice care benefits to end-stage renal disease patients is associated with an additional reduction of 7.3% in end-of-life costs per decedent, holding constant patient and provider characteristics. On average, end-of-life costs are also high for end-stage renal disease (1.88 times higher than those for cancer). The cost savings were larger among older patients-among those who died at 80 years of age or higher, the cost reduction was 9.8%. CONCLUSION By expanding hospice care benefits through a provider reimbursement policy, significant costs at the end of life were saved.
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Affiliation(s)
- Bradley Chen
- 1 Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Chin-Chi Kuo
- 2 Big Data Center, China Medical University Hospital and China Medical University, Taichung, Taiwan.,3 Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Nicole Huang
- 1 Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,4 Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Victoria Y Fan
- 5 Office of Public Health Studies, Myron B. Thompson School of Social Work, University of Hawaii at Manoa, Honolulu, HI, USA.,6 Department of Global Health and Population and François-Xavier Bagnoud Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Bähler C, Signorell A, Blozik E, Reich O. Intensity of treatment in Swiss cancer patients at the end-of-life. Cancer Manag Res 2018; 10:481-491. [PMID: 29588617 PMCID: PMC5858839 DOI: 10.2147/cmar.s156566] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Current evidence on the care-delivering process and the intensity of treatment at the end-of-life of cancer patients is limited and remains unclear. Our objective was to examine the care-delivering processes in health care during the last months of life with real-life data of Swiss cancer patients. Patients and methods The study population consisted of adult decedents in 2014 who were insured at Helsana Group. Data on the final cause of death were provided additionally by the Swiss Federal Statistical Office. Of the 10,275 decedents, 2,710 (26.4%) died of cancer. Intensity of treatment and health care utilization (including transitions) at their end-of-life were examined. Intensity measures included the following: last dose of chemotherapy within 14 days of death, a new chemotherapy regimen starting <30 days before death, more than one hospital admission or spending >14 days in hospital in the last month, death in an acute care hospital, more than one emergency visit and ≥1 intensive care unit admission in the last month of life. Results In the last 6 months of life, 89.5% of cancer patients had ≥1 transition, with 87.2% being hospitalized. Within 30 days before death, 64.2% of the decedents had ≥1 intensive treatment, whereby 8.9% started a new chemotherapy. In the multinomial logistic regression model, older age, higher density of nursing home beds and home care nurses were associated with a decrease, while living in the Italian- or French-speaking part of Switzerland was associated with an increase in intensive care. Conclusion Swiss cancer patients insured by Helsana Group experience a considerable number of transitions and intensive treatments at the end-of-life, whereby treatment intensity declines with increasing age. Among others, increased home care nursing might be helpful to reduce unwarranted treatments and transitions, therefore leading to better care at the end-of-life.
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Affiliation(s)
- Caroline Bähler
- Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland
| | - Andri Signorell
- Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland.,Department of Medicine, University Medical Centre Freiburg, Freiburg im Breisgau, Germany
| | - Oliver Reich
- Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland
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Barnato AE, Chang CCH, Lave JR, Angus DC. The Paradox of End-of-Life Hospital Treatment Intensity among Black Patients: A Retrospective Cohort Study. J Palliat Med 2018; 21:69-77. [PMID: 29106315 PMCID: PMC5757087 DOI: 10.1089/jpm.2016.0557] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2017] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Black patients are more likely than white patients to die in the hospital with intensive care and life-sustaining treatments and less likely to use hospice. Regional concentration of high end-of-life (EOL) treatment intensity practice patterns may disproportionately affect black patients. We calculated and compared race-specific hospital-level EOL treatment intensity in Pennsylvania. METHODS We conducted a retrospective cohort analysis of Pennsylvania acute care hospital admissions, 2001-2007, among black and white admissions ≥21 years old at high probability of dying (HPD) (≥15% predicted probability of dying at admission). We calculated hospitals' race-specific observed, expected, and Bayes' shrunken observed-to-expected ratios of intensive care unit (ICU) admission, ICU length of stay (LOS), intubation/mechanical ventilation, hemodialysis, tracheostomy, and gastrostomy among HPD admissions; and an empirically weighted EOL treatment intensity index summing these ratios. RESULTS There were 35,609 black HPD admissions (27,576 unique patients) and 311,896 white HPD admissions (252,662 unique patients) to 182 hospitals. Among 95 hospitals with ≥30 black HPD admissions, 80% of black admissions were concentrated in 29 hospitals, where black-specific observed and expected EOL measures were usually higher than white-specific measures (p < 0.001 for all but 5/24 measures). Hospitals' black-specific and white-specific observed-to-expected ratios of ICU and life-sustaining treatment (LST) (rho 0.52-0.90) and EOL index (rho = 0.92) were highly correlated. However, black-specific observed-to-expected ratios and overall EOL intensity index were consistently lower than white-specific ratios (p < 0.001 for all except hemodialysis). CONCLUSIONS In Pennsylvania, black-serving hospitals have higher standardized EOL treatment intensity than nonblack-serving hospitals, contributing to black patients' relatively higher use of intensive treatment. However, conditional on being admitted to the same high-intensity hospital and after risk adjustment, blacks are less intensively treated than whites.
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Affiliation(s)
- Amber E. Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Chung-Chou H. Chang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Judith R. Lave
- Department of Health Care Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Department of Health Care Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Adelson K, Lee DKK, Velji S, Ma J, Lipka SK, Rimar J, Longley P, Vega T, Perez-Irizarry J, Pinker E, Lilenbaum R. Development of Imminent Mortality Predictor for Advanced Cancer (IMPAC), a Tool to Predict Short-Term Mortality in Hospitalized Patients With Advanced Cancer. J Oncol Pract 2017; 14:e168-e175. [PMID: 29206553 DOI: 10.1200/jop.2017.023200] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE End-of-life care for patients with advanced cancer is aggressive and costly. Oncologists inconsistently estimate life expectancy and address goals of care. Currently available prognostication tools are based on subjective clinical assessment. An objective prognostic tool could help oncologists and patients decide on a realistic plan for end-of-life care. We developed a predictive model (Imminent Mortality Predictor in Advanced Cancer [IMPAC]) for short-term mortality in hospitalized patients with advanced cancer. METHODS Electronic health record data from 669 patients with advanced cancer who were discharged from Yale Cancer Center/Smilow Cancer Hospital were extracted. Statistical learning techniques were used to develop a tool to estimate survival probabilities. Patients were randomly split into training (70%) and validation (30%) sets 20 times. We tested the predictive properties of IMPAC for mortality at 30, 60, 90, and 180 days past the day of admission. RESULTS For mortality within 90 days at a 40% sensitivity level, IMPAC has close to 60% positive predictive value. Patients estimated to have a greater than 50% chance of death within 90 days had a median survival time of 47 days. Patients estimated to have a less than 50% chance of death had a median survival of 290 days. Area under the receiver operating characteristic curve for IMPAC averaged greater than .70 for all time horizons tested. Estimated potential cost savings per patient was $15,413 (95% CI, $9,162 to $21,665) in 2014 constant dollars. CONCLUSION IMPAC, a novel prognostic tool, can generate life expectancy probabilities in real time and support oncologists in counseling patients about end-of-life care. Potentially avoidable costs are significant.
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Affiliation(s)
- Kerin Adelson
- Yale Cancer Center and Smilow Cancer Hospital, Yale School of Management, and Yale New Haven Health, New Haven, CT; and Massachusetts General Hospital, Boston, MA
| | - Donald K K Lee
- Yale Cancer Center and Smilow Cancer Hospital, Yale School of Management, and Yale New Haven Health, New Haven, CT; and Massachusetts General Hospital, Boston, MA
| | - Salimah Velji
- Yale Cancer Center and Smilow Cancer Hospital, Yale School of Management, and Yale New Haven Health, New Haven, CT; and Massachusetts General Hospital, Boston, MA
| | - Junchao Ma
- Yale Cancer Center and Smilow Cancer Hospital, Yale School of Management, and Yale New Haven Health, New Haven, CT; and Massachusetts General Hospital, Boston, MA
| | - Susan K Lipka
- Yale Cancer Center and Smilow Cancer Hospital, Yale School of Management, and Yale New Haven Health, New Haven, CT; and Massachusetts General Hospital, Boston, MA
| | - Joan Rimar
- Yale Cancer Center and Smilow Cancer Hospital, Yale School of Management, and Yale New Haven Health, New Haven, CT; and Massachusetts General Hospital, Boston, MA
| | - Peter Longley
- Yale Cancer Center and Smilow Cancer Hospital, Yale School of Management, and Yale New Haven Health, New Haven, CT; and Massachusetts General Hospital, Boston, MA
| | - Teresita Vega
- Yale Cancer Center and Smilow Cancer Hospital, Yale School of Management, and Yale New Haven Health, New Haven, CT; and Massachusetts General Hospital, Boston, MA
| | - Javier Perez-Irizarry
- Yale Cancer Center and Smilow Cancer Hospital, Yale School of Management, and Yale New Haven Health, New Haven, CT; and Massachusetts General Hospital, Boston, MA
| | - Edieal Pinker
- Yale Cancer Center and Smilow Cancer Hospital, Yale School of Management, and Yale New Haven Health, New Haven, CT; and Massachusetts General Hospital, Boston, MA
| | - Rogerio Lilenbaum
- Yale Cancer Center and Smilow Cancer Hospital, Yale School of Management, and Yale New Haven Health, New Haven, CT; and Massachusetts General Hospital, Boston, MA
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Nipp RD, El-Jawahri A, Moran SM, D'Arpino SM, Johnson PC, Lage DE, Wong RL, Pirl WF, Traeger L, Lennes IT, Cashavelly BJ, Jackson VA, Greer JA, Ryan DP, Hochberg EP, Temel JS. The relationship between physical and psychological symptoms and health care utilization in hospitalized patients with advanced cancer. Cancer 2017; 123:4720-4727. [PMID: 29057450 DOI: 10.1002/cncr.30912] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 06/28/2017] [Accepted: 07/05/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Patients with advanced cancer often experience frequent and prolonged hospitalizations; however, the factors associated with greater health care utilization have not been described. We sought to investigate the relation between patients' physical and psychological symptom burden and health care utilization. METHODS We enrolled patients with advanced cancer and unplanned hospitalizations from September 2014-May 2016. Upon admission, we assessed physical (Edmonton Symptom Assessment System [ESAS]) and psychological symptoms (Patient Health Questionnaire 4 [PHQ-4]). We examined the relationship between symptom burden and healthcare utilization using linear regression for hospital length of stay (LOS) and Cox regression for time to first unplanned readmission within 90 days. We adjusted all models for age, sex, marital status, comorbidity, education, time since advanced cancer diagnosis, and cancer type. RESULTS We enrolled 1,036 of 1,152 (89.9%) consecutive patients approached. Over one-half reported moderate/severe fatigue, poor well being, drowsiness, pain, and lack of appetite. PHQ-4 scores indicated that 28.8% and 28.0% of patients had depression and anxiety symptoms, respectively. The mean hospital LOS was 6.3 days, and the 90-day readmission rate was 43.1%. Physical symptoms (ESAS: unstandardized coefficient [B], 0.06; P < .001), psychological distress (PHQ-4 total: B, 0.11; P = .040), and depression symptoms (PHQ-4 depression: B, 0.22; P = .017) were associated with longer hospital LOS. Physical (ESAS: hazard ratio, 1.01; P < .001), and anxiety symptoms (PHQ-4 anxiety: hazard ratio, 1.06; P = .045) were associated with a higher likelihood for readmission. CONCLUSIONS Hospitalized patients with advanced cancer experience a high symptom burden, which is significantly associated with prolonged hospitalizations and readmissions. Interventions are needed to address the symptom burden of this population to improve health care delivery and utilization. Cancer 2017;123:4720-4727. © 2017 American Cancer Society.
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Affiliation(s)
- Ryan D Nipp
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Samantha M Moran
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sara M D'Arpino
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - P Connor Johnson
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Daniel E Lage
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Risa L Wong
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - William F Pirl
- Department of Psychiatry, Sylvester Comprehensive Cancer Center and University of Miami, Miami, Florida
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Inga T Lennes
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Barbara J Cashavelly
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Vicki A Jackson
- Department of Medicine, Division of Palliative Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David P Ryan
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Ephraim P Hochberg
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
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Hicks K, Downey L, Engelberg RA, Fausto JA, Starks H, Dunlap B, Sibley J, Lober W, Khandelwal N, Loggers ET, Curtis JR. Predictors of Death in the Hospital for Patients with Chronic Serious Illness. J Palliat Med 2017; 21:307-314. [PMID: 28926294 DOI: 10.1089/jpm.2017.0127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Most people prefer to die at home, yet most do not. Understanding factors associated with terminal hospitalization may inform interventions to improve care. OBJECTIVE Among patients with chronic illness receiving care in a multihospital healthcare system, we identified the following: (1) predictors of death in any hospital; (2) predictors of death in a hospital outside the system; and (3) trends from 2010 to 2015. DESIGN Retrospective cohort using death certificates and electronic health records. Settings/Subjects: Decedents with one of nine chronic illnesses. RESULTS Among 20,486 decedents, those most likely to die in a hospital were younger (odds ratio [OR] 0.977, confidence interval [CI] 0.974-0.980), with more comorbidities (OR 1.188, CI 1.079-1.308), or more outpatient providers (OR 1.031, CI 1.015-1.047); those with cancer or dementia, or more outpatient visits were less likely to die in hospital. Among hospital deaths, patients more likely to die in an outside hospital had lower education (OR 0.952, CI 0.923-0.981), cancer (OR 1.388, CI 1.198-1.608), diabetes (OR 1.507, CI 1.262-1.799), fewer comorbidities (OR 0.745, CI 0.644-0.862), or fewer hospitalizations within the system during the prior year (OR 0.900, CI 0.864-0.938). Deaths in hospital did not change from 2010 to 2015, but the proportion of hospital deaths outside the system increased (p < 0.022). CONCLUSIONS Patients dying in the hospital who are more likely to die in an outside hospital, and therefore at greater risk for inaccessibility of advance care planning, were more likely to be less well-educated and have cancer or diabetes, fewer comorbidities, and fewer hospitalizations. These findings may help target interventions to improve end-of-life care.
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Affiliation(s)
- Katy Hicks
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Department of Medicine, University of Washington , Seattle, Washington
| | - Lois Downey
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,3 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington
| | - Ruth A Engelberg
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Department of Medicine, University of Washington , Seattle, Washington.,3 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington
| | - James A Fausto
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington
| | - Helene Starks
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington.,5 Department of Bioethics and Humanities, University of Washington , Seattle, Washington
| | - Ben Dunlap
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,3 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington
| | - James Sibley
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,6 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - William Lober
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,6 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - Nita Khandelwal
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,7 Department of Anesthesiology and Pain Medicine, University of Washington , Seattle, Washington
| | - Elizabeth T Loggers
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Department of Medicine, University of Washington , Seattle, Washington.,8 Seattle Cancer Care Alliance , Seattle, Washington.,9 Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - J Randall Curtis
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Department of Medicine, University of Washington , Seattle, Washington.,3 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington.,5 Department of Bioethics and Humanities, University of Washington , Seattle, Washington
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46
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Contending With Preplanned Death: Questions for Clinicians. J Psychiatr Pract 2017; 23:366-374. [PMID: 28902070 DOI: 10.1097/pra.0000000000000260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The goal of this column is to assist readers in reflecting on their attitudes and responses toward clinical and nonclinical situations involving preplanned deaths by decisionally capable individuals. Such circumstances range from encountering individuals in one's personal and professional lives who desire and intend to end their lives under their own terms, to having such individuals request assistance with predeath and postdeath arrangements. METHODS Attending to pertinent literature, this essay uses Socratic inquiry to question conventional assumptions and attitudes, push readers' thoughts beyond typical comfort zones, and consider alternative modes of responding to challenges posed by preplanned death. RESULTS Studies indicate that, for their own end-of-life circumstances, physicians would prefer a briefer, higher quality life to prolonged low-quality life, dignity in infirmity and death, and avoidance of terminal suffering. Lay people generally endorse similar preferences. Although contemporary society generally shuns contemplating preplanned death, cultural attitudes regarding preplanned death are rapidly evolving, and variations of "Death with Dignity" legislation have gained traction in increasing numbers of US states as well as internationally. As yet, no broad consensus exists as to how clinicians should manage circumstances involving preplanned death. CONCLUSIONS Considerations regarding preplanned deaths merit greater professional and public discussion. Many options exist for improving how professionals address the quality of human experiences surrounding death.
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Kelley AS, Bollens-Lund E, Covinsky KE, Skinner JS, Morrison RS. Prospective Identification of Patients at Risk for Unwarranted Variation in Treatment. J Palliat Med 2017; 21:44-54. [PMID: 28772096 DOI: 10.1089/jpm.2017.0063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Understanding factors associated with treatment intensity may help ensure higher value healthcare. OBJECTIVE To investigate factors associated with Medicare costs among prospectively identified, seriously ill older adults and examine if baseline prognosis influences the impact of these factors. DESIGN/SUBJECTS Prospective observation of Health and Retirement Study cohort with linked Medicare claims. MEASUREMENTS We identified people with incident serious illness (a serious medical condition, for example, metastatic cancer or functional impairment); calculated subjects' one-year mortality risk; and then followed them for one year. We examined relationships between individual and regional characteristics and total Medicare costs, and then stratified analyses by one-year mortality risk: low, moderate, and high. RESULTS From 2002 to 2012, 5208 subjects had incident serious illness: mean age 78 years, 60% women, 76% non-Hispanic white, and 39% hospitalized in the past year. During one-year follow-up, 12% died. Total Medicare costs averaged $20,607. In multivariable analyses, indicators of poor health (e.g., cancer, advanced heart and lung disease, multimorbidity, functional impairment, and others) were significantly associated with higher costs (p < 0.05). However, among those with high mortality risk, health-related variables were not significant. Instead, African American race (rate ratio [RR] 1.56) and moderate-to-high spending regions (RR 1.31 and 1.54, respectively) were significantly associated with higher costs. For this high-risk population, residence in high-spending regions was associated with $31,476 greater costs among African Americans, and $11,162 among other racial groups, holding health constant. CONCLUSIONS Among seriously ill older adults, indicators of poor health are associated with higher costs. Yet, among those with poorest prognoses, nonmedical characteristics-race and regional practice patterns-have greater influence on treatment. This suggests there may be novel opportunities to improve care quality and value by assuring patient-centered, goal-directed care.
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Affiliation(s)
- Amy S Kelley
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Geriatric Research Education and Clinical Centers, James J Peters VA Medical Center , Bronx, New York
| | - Evan Bollens-Lund
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Kenneth E Covinsky
- 3 Division of Geriatrics, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Jonathan S Skinner
- 4 Department of Economics, Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice , Dartmouth Geisel School of Medicine, Lebanon , New Hampshire
| | - R Sean Morrison
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Geriatric Research Education and Clinical Centers, James J Peters VA Medical Center , Bronx, New York
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Does ambulance utilization differ between urban and rural regions: a study of 112 services in a populated city, Izmir. J Public Health (Oxf) 2017. [DOI: 10.1007/s10389-017-0802-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Hoverman JR, Taniguchi C, Eagye K, Mikan S, Kalisiak A, Ash-Lee S, Henschel R. If We Don't Ask, Our Patients Might Never Tell: The Impact of the Routine Use of a Patient Values Assessment. J Oncol Pract 2017; 13:e831-e837. [PMID: 28665744 DOI: 10.1200/jop.2017.022020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Good communication can be associated with better end-of-life outcomes. The US Oncology Network developed and tested a Values Assessment (VA) for facilitating advance care planning (ACP). The results of the first 1,268 patients are reported. METHODS The VA consists of 10 questions of the format "How valuable is it to me to…" (eg, "...know that I am not a burden to my family, friends, or helpers?"). Responses were on a four-point scale from unsure to very valuable. VA data on 1,286 patients with metastatic cancer from April 1, 2013, to July 31, 2015, were extracted from the electronic health record, including demographics, diagnosis, stage, chemotherapy, and outcomes (hospice enrollment, place of death). These demographics were compared by using the χ2 or Fisher's exact test or the Wilcoxon rank sum test for continuous variables. RESULTS A total of 1,268 patients completed the VA (56.7% were ≥ 65 years of age, 57.8% completed advance directives [ADs]). There were 438 deaths of which 308 had a place of death or a hospice enrollment recorded. Of these, 78% died at home or inpatient hospice; 14.6% died in the hospital. Hospice enrollment with ADs was 76.1% and without, 60.9%. Median length of stay in hospice was 21 days with ADs versus 12.5 days without. Chemotherapy in the last 14 days of life was 8.8% with ADs and 15.5% without. The VA was well accepted by patients. CONCLUSION A VA as a routine part of practice is feasible and scalable. It facilitates ACP discussions that lead to ADs. The results suggest that VA and ACP lead to less-aggressive care at the end of life.
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Affiliation(s)
- J Russell Hoverman
- Texas Oncology, Dallas; McKesson Specialty Health, The Woodlands; Texas Oncology, Austin, TX; McKesson Specialty Health, Westminster; Rocky Mountain Cancer Centers, Denver, CO; Compass Oncology, Portland, OR; and Minnesota Oncology Hematology, Minneapolis, MN
| | - Cynthia Taniguchi
- Texas Oncology, Dallas; McKesson Specialty Health, The Woodlands; Texas Oncology, Austin, TX; McKesson Specialty Health, Westminster; Rocky Mountain Cancer Centers, Denver, CO; Compass Oncology, Portland, OR; and Minnesota Oncology Hematology, Minneapolis, MN
| | - Kathryn Eagye
- Texas Oncology, Dallas; McKesson Specialty Health, The Woodlands; Texas Oncology, Austin, TX; McKesson Specialty Health, Westminster; Rocky Mountain Cancer Centers, Denver, CO; Compass Oncology, Portland, OR; and Minnesota Oncology Hematology, Minneapolis, MN
| | - Sabrina Mikan
- Texas Oncology, Dallas; McKesson Specialty Health, The Woodlands; Texas Oncology, Austin, TX; McKesson Specialty Health, Westminster; Rocky Mountain Cancer Centers, Denver, CO; Compass Oncology, Portland, OR; and Minnesota Oncology Hematology, Minneapolis, MN
| | - Angela Kalisiak
- Texas Oncology, Dallas; McKesson Specialty Health, The Woodlands; Texas Oncology, Austin, TX; McKesson Specialty Health, Westminster; Rocky Mountain Cancer Centers, Denver, CO; Compass Oncology, Portland, OR; and Minnesota Oncology Hematology, Minneapolis, MN
| | - Susan Ash-Lee
- Texas Oncology, Dallas; McKesson Specialty Health, The Woodlands; Texas Oncology, Austin, TX; McKesson Specialty Health, Westminster; Rocky Mountain Cancer Centers, Denver, CO; Compass Oncology, Portland, OR; and Minnesota Oncology Hematology, Minneapolis, MN
| | - Rhonda Henschel
- Texas Oncology, Dallas; McKesson Specialty Health, The Woodlands; Texas Oncology, Austin, TX; McKesson Specialty Health, Westminster; Rocky Mountain Cancer Centers, Denver, CO; Compass Oncology, Portland, OR; and Minnesota Oncology Hematology, Minneapolis, MN
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Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-area Analysis Using Insurance Claims Data. Med Care 2017; 55:155-163. [PMID: 27579912 PMCID: PMC5266421 DOI: 10.1097/mlr.0000000000000634] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Health care spending increases sharply at the end of life. Little is known about variation of cost of end of life care between regions and the drivers of such variation. We studied small-area patterns of cost of care in the last year of life in Switzerland. Methods: We used mandatory health insurance claims data of individuals who died between 2008 and 2010 to derive cost of care. We used multilevel regression models to estimate differences in costs across 564 regions of place of residence, nested within 71 hospital service areas. We examined to what extent variation was explained by characteristics of individuals and regions, including measures of health care supply. Results: The study population consisted of 113,277 individuals. The mean cost of care during last year of life was 32.5k (thousand) Swiss Francs per person (SD=33.2k). Cost differed substantially between regions after adjustment for patient age, sex, and cause of death. Variance was reduced by 52%–95% when we added individual and regional characteristics, with a strong effect of language region. Measures of supply of care did not show associations with costs. Remaining between and within hospital service area variations were most pronounced for older females and least for younger individuals. Conclusions: In Switzerland, small-area analysis revealed variation of cost of care during the last year of life according to linguistic regions and unexplained regional differences for older women. Cultural factors contribute to the delivery and utilization of health care during the last months of life and should be considered by policy makers.
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