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Waterman BL, Ramsey SU, Whitsett MP, Patel AA, Radcliff JA, Kotler DL, Winters AC, Woodrell CD, Ufere NN, Serper M, Walling AM, Jones CA, Kelly SG. Top Ten Tips Palliative Care Clinicians Should Know About End-Stage Liver Disease. J Palliat Med 2021; 24:924-931. [PMID: 33733875 DOI: 10.1089/jpm.2021.0097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
End-stage liver disease (ESLD) is an increasingly prevalent condition with high morbidity and mortality, especially for those ineligible for liver transplantation. Patients with ESLD, along with their family caregivers, have significant needs related to their quality of life, and there is increasing attention being paid to integration of palliative care (PC) principles into routine care throughout the disease spectrum. To provide upstream care for these patients and their family caregivers, it is essential for PC providers to understand their complex psychosocial and physical needs and to be aware of the unique challenges around medical decision making and end-of-life care for this patient population. This article, written by a team of liver and PC experts, shares 10 high-yield tips to help PC clinicians provide better care for patients with advanced liver disease.
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Affiliation(s)
- Brittany L Waterman
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sinthana U Ramsey
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maureen P Whitsett
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arpan A Patel
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, California, USA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Jacob A Radcliff
- Department of Pharmacy and Palliative Care Program, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Drew L Kotler
- Division of Palliative Care, Department of Medicine, Main Line Health, Radnor, Pennsylvania, USA
| | - Adam C Winters
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Christopher D Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Nneka N Ufere
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne M Walling
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine University of California, Los Angeles, USA
| | - Christopher A Jones
- Department of Medicine and Palliative Care Program, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sean G Kelly
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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52
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Vieira Silva S, Freire E, Pessegueiro Miranda H. Palliative Care in End-Stage Liver Disease Patients Awaiting Liver Transplantation: Review. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:417-428. [PMID: 33251291 DOI: 10.1159/000507336] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/17/2020] [Indexed: 01/15/2023]
Abstract
Introduction End-stage liver disease (ESLD) is the advanced phase of most liver diseases. The cure is liver transplantation (LT), only available for a minority of patients. This review summarizes the evidence regarding palliative care (PC) in ESLD patients awaiting LT. Methods Review of the literature available in Medline, Scopus and Web of Knowledge, with keywords ESLD and PC. Results Fifteen of the 230 articles reviewed met the inclusion criteria. Ten main themes were addressed: symptom burden; perspectives of life-sustaining treatment and comfort for patients, families and health professionals; goals of care discussions; patient and family needs; quality of life; PC and survival; referral to PC, barriers and opportunities; integration of PC; outpatient care and cost-effectiveness analysis. The referral of patients to PC was only evaluated in a few studies, all of which reported low referral rates. Better knowledge of how PC professionals can support other professionals was considered important, and also better ways to integrate PC were considered essential. Conclusion ESLD patients awaiting LT have a significant need for PC and, despite the insufficient response, were reported to benefit from this type of care. Future research is essential to determine the means to overcome barriers and better integrate PC for ESLD patients awaiting LT.
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Affiliation(s)
- Sara Vieira Silva
- Equipa Intra-Hospitalar de Suporte de Cuidados Paliativos, Serviço de Medicina, Centro Hospitalar e Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Elga Freire
- Equipa Intra-Hospitalar de Suporte de Cuidados Paliativos, Serviço de Medicina, Centro Hospitalar e Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Helena Pessegueiro Miranda
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal.,Unidade de Transplantação Hepato-bilio-pancreática, Centro Hospitalar e Universitário do Porto, Porto, Portugal.,Instituto de Saúde Publica da Universidade do Porto (ISPUP), Universidade do Porto, Porto, Portugal
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53
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Donlan J, Ufere NN, Indriolo T, Jackson V, Chung RT, El-Jawahri A, Traeger L. Patient and Caregiver Perspectives on Palliative Care in End-Stage Liver Disease. J Palliat Med 2020; 24:719-724. [PMID: 32996824 DOI: 10.1089/jpm.2020.0551] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Specialty palliative care (PC) is underutilized for patients with end-stage liver disease (ESLD); however, studies exploring patient and caregiver perceptions of PC are lacking. Objectives: To explore patient and caregiver knowledge, perceptions, and preferences about PC in ESLD management. Setting/Subjects: Individuals with ESLD and their informal caregivers were recruited from a large academic medical center in the United States. Design: We conducted semistructured interviews with 15 patients with ESLD and 14 informal caregivers. Purposive sampling was used to balance both transplant-listed and transplant-ineligible patients. We used a brief description of PC to explore participants' knowledge, perceptions, and preferences about PC. Two raters coded interviews independently (κ = 0.95) using template analysis. Results: Participants' knowledge about PC came primarily from their loved ones' experiences with PC, with many conflating PC with end-of-life care. Transplant-listed patients expressed concern that a PC referral would negatively impact their likelihood of receiving a liver transplant. After hearing a brief description of PC, nearly all participants believed that patients with ESLD should learn about PC soon after diagnosis to help support their illness understanding and coping. Conclusions: Study participants reported limited knowledge of PC and often perceived it as hospice care. After receiving education on PC, nearly all participants, regardless of transplant eligibility, advocated for early introduction of PC in ESLD care. Interventions are needed to educate patients with ESLD and their caregivers on the potential role of PC to overcome misperceptions of PC and allow earlier integration of PC into ESLD management.
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Affiliation(s)
- John Donlan
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Teresa Indriolo
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond T Chung
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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54
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Hernaez R, Patel A, Jackson LK, Braun UK, Walling AM, Rosen HR. Considerations for Prognosis, Goals of Care, and Specialty Palliative Care for Hospitalized Patients With Acute-on-Chronic Liver Failure. Hepatology 2020; 72:1109-1116. [PMID: 32416642 DOI: 10.1002/hep.31316] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/26/2020] [Accepted: 04/02/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Ruben Hernaez
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, TX Center, Houston, TX.,VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX.,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Division of Gastroenterology and Hepatology, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, CA
| | - Leanne K Jackson
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX.,Section of Rehabilitation and Extended Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Ursula K Braun
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX.,Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX.,Section of Rehabilitation and Extended Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Anne M Walling
- Department of Medicine, University of California, Los Angeles, CA.,VA Greater Los Angeles Health System, Los Angeles, CA
| | - Hugo R Rosen
- Department of Medicine, University of Southern California (USC), Los Angeles, CA.,USC Research Center for Liver Diseases, Los Angeles, CA
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55
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Patel A, Asch S, Antonio AL, Kanwal F, Lorenz K, Riopelle D, Dickey A, Larkin J, Lee M, Walling A. Measuring the Quality of Palliative Care for Patients with End-Stage Liver Disease. Dig Dis Sci 2020; 65:2562-2570. [PMID: 31927765 PMCID: PMC7223418 DOI: 10.1007/s10620-019-05983-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/27/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND/AIMS We examined the quality of palliative care received by patients with decompensated cirrhosis using an explicit set of palliative care quality indicators (QIs) for patients with end-stage liver disease (PC-ESLD). METHODS We identified patients newly diagnosed with decompensated cirrhosis at a single veterans health center and followed up them for 2 years or until death. We piloted measurement of PC-ESLD QIs in all patients confirmed to have ESLD using a chart abstraction tool. RESULTS Out of 167 patients identified using at least one sampling strategy, 62 were confirmed to meet ESLD criteria with chart abstraction. Ninety-eight percent of veterans in the cohort were male, mean age at diagnosis was 61 years, and 74% were White. The overall QI pass rate was 68% (64% for information care planning QIs and 76% for supportive care QIs). Patients receiving specialty palliative care consultation were more likely to receive information care planning QIs (67% vs. 37%, p = 0.02). The best performing sampling strategy had a sensitivity of 62% and specificity of 60%. CONCLUSION Measuring the quality of palliative care for patients with ESLD is feasible in the veteran population. Our single-center data suggest that the quality of palliative care is inadequate in the veteran population with ESLD, though patients offered specialty palliative care consultation and those affected by homelessness, drug, and alcohol abuse may receive better care. Our combination of ICD-9 codes can be used to identify a cohort of patients with ESLD, though better sensitivity and specificity may be needed.
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Affiliation(s)
- Arpan Patel
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA.
| | - Steven Asch
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | | | - Fasiha Kanwal
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Karl Lorenz
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Deborah Riopelle
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Anna Dickey
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Jennifer Larkin
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Martin Lee
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
| | - Anne Walling
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA
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56
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O'Leary JG, Tandon P, Reddy KR, Biggins SW, Wong F, Kamath PS, Garcia-Tsao G, Maliakkal B, Lai J, Fallon M, Vargas HE, Thuluvath P, Subramanian R, Thacker LR, Bajaj JS. Underutilization of Hospice in Inpatients with Cirrhosis: The NACSELD Experience. Dig Dis Sci 2020; 65:2571-2579. [PMID: 32146602 DOI: 10.1007/s10620-020-06168-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Little is known about patients discharged to hospice following hospitalization for complications of cirrhosis. AIM We sought to understand the current pattern of hospice utilization in patients with cirrhosis by evaluating the North American Consortium for the Study of End-stage Liver Disease (NACSELD) cohort. METHODS Patients with cirrhosis from 14 tertiary-care hepatology centers across North America non-electively hospitalized and prospectively enrolled were evaluated. Exclusion criteria included HIV infection, transplantation or non-hepatic malignancy. Random computer-based propensity score matching was undertaken in a 1:2 ratio based on admission MELD score ± 3 points. RESULTS Totally, 2718 patients were enrolled, 5% (N = 132) were discharged to hospice, 6% (N = 171) died, and the rest were discharged alive. Patients discharged to hospice were older (60 vs. 57 years, p = 0.04), less likely to have had SBP (13% vs. 28%, p = 0.002) and be listed for liver transplantation (11% vs. 26%, p = 0.0007). Features, on multivariable modeling, associated with increased probability of discharge to hospice as opposed to being discharged alive: grade-3-4 hepatic encephalopathy, a higher Child-Turcotte-Pugh (CTP) score, and a higher discharge serum creatinine; however, a higher serum sodium, being listed for transplant and being prescribed rifaximin or a statin were protective from hospice discharge. CONCLUSION Patients with more advanced liver disease, hepatic encephalopathy, renal dysfunction, and those not candidates for liver transplantation were more likely to be discharged to hospice. However, in this sick multinational cohort of cirrhotic inpatients, it seems that hospice is markedly underutilized (5%) since 25% of patients not discharged to hospice died within 6 months.
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Affiliation(s)
- Jacqueline G O'Leary
- Department of Medicine, Dallas VA Medical Center, Dallas, TX, USA. .,Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott W Biggins
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | | | - Jennifer Lai
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Michael Fallon
- Department of Medicine, University of Texas, Health Science Center, Houston, TX, USA
| | - Hugo E Vargas
- Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Paul Thuluvath
- Department of Medicine, Mercy Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Leroy R Thacker
- Department of Biostatistics, McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Jasmohan S Bajaj
- Department of Medicine, McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA
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57
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Maley JH, Worsham CM, Landon BE, Stevens JP. Association between Palliative Care and End-of-Life Resource Use for Older Adults Hospitalized with Septic Shock. Ann Am Thorac Soc 2020; 17:974-979. [PMID: 32275846 PMCID: PMC7531025 DOI: 10.1513/annalsats.202001-038oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/09/2020] [Indexed: 12/15/2022] Open
Abstract
Rationale: The care of critically ill patients often involves complex discussions surrounding prognosis, goals, and end-of-life decision-making. Yet, physician and hospital practice patterns, rather than patient goals, remain a major determinant of the intensity of end-of-life care. For critically ill patients, palliative care may help promote treatments that are concordant with patients' goals, while minimizing the use of invasive and costly intensive care unit resources that may not be consistent with those goals.Objectives: To determine whether inpatient palliative care, delivered by specialist consultants or a primary medical team, is associated with reduced hospital length of stay and costs for older adults with septic shock at the end of life.Methods: This was a retrospective cohort using the National Inpatient Sample from 2013 to 2014, examining patients aged ≥65 years with septic shock who died during their hospitalization. The exposure of interest was inpatient palliative care encounter, including either generalist- or specialist-delivered palliative care. Outcomes were hospital length of stay, total cost for the hospitalization, and daily hospital cost. Patient and hospital-level confounders were used to derive inverse probability of treatment weights and estimate the association between palliative care and outcomes in a generalized linear model.Results: We studied 45,868 patients who died with a diagnosis of septic shock; 15,370 of these patients had a palliative care encounter. After inverse probability of treatment weighting, there were no appreciable differences between the population characteristics. Palliative care was associated with a shorter adjusted mean hospital length of stay (12.0 vs. 13.1 d; difference, -1.1 d; 95% confidence interval [CI], -1.4 to -0.9; P < 0.001), lower total hospital costs (69,700 vs. 76,800 U.S. dollars [USD]; difference, -7,100 USD; 95% CI, -8.5 to -5.2 thousand USD; P < 0.001), and lower daily hospital cost (5,900 vs. 6,200 USD; difference, -310 USD per day; 95% CI, -420 to -200 USD; P < 0.001) when compared with no palliative care.Conclusions: In a nationally representative sample of adults who died during a hospitalization with septic shock, receipt of palliative care was associated with shorter length of stay and lower total and daily hospital costs. This finding was robust to adjustment for patient- and hospital-level confounders, though unmeasured confounders still could be affecting these findings.
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Affiliation(s)
- Jason H. Maley
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Beth Israel Deaconess Center for Healthcare Delivery Science, and
| | - Christopher M. Worsham
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Bruce E. Landon
- Beth Israel Deaconess Center for Healthcare Delivery Science, and
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jennifer P. Stevens
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Beth Israel Deaconess Center for Healthcare Delivery Science, and
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58
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Kim S, Lee K, Kim S. Knowledge, attitude, confidence, and educational needs of palliative care in nurses caring for non-cancer patients: a cross-sectional, descriptive study. BMC Palliat Care 2020; 19:105. [PMID: 32652984 PMCID: PMC7354682 DOI: 10.1186/s12904-020-00581-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 05/19/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Palliative care is a patient-centred, integrated approach for improving quality of life for both patients facing life-threatening illnesses and for their families. Although there has been increased interest in palliative care for non-cancer patients, the palliative care competency of nurses who care for non-cancer patients has rarely been investigated. This study described the palliative care knowledge, attitude, confidence, and educational needs in nurses who care for patients with congestive heart failure, stroke, end-stage renal disease, and end-stage liver disease; explored the relationships between those variables; and identified factors affecting nurses' palliative care confidence. METHODS A cross-sectional, descriptive, correlational design was employed; data collection was conducted at a tertiary hospital in Seoul, Korea. Nurses who were working in general wards and intensive care units (N = 102) completed valid and reliable self-administered questionnaires. Descriptive statistics, frequencies, independent t-tests, one-way ANOVA, Pearson's correlations, and multiple regression were conducted to analyse the data. RESULTS Nurses' palliative care knowledge level was low (9.73 ± 2.10; range = 0-20) and their attitude toward palliative care was moderate (87.97 ± 6.93, range: 30-120). Knowledge was significantly correlated with attitude (r = .29, p = .003). Nurses were highly confident in pain and symptom management but demonstrated high educational needs for managing human and material resources to provide palliative care. Previous training in hospice, palliative, and EOL care was a significant and modifiable factor that affected nurses' confidence (std. β = 0.25, p = .010). CONCLUSIONS To facilitate high-quality palliative care for non-cancer patients and families, nursing education programs should be developed to address nurses' knowledge level, confidence level, and educational needs. This study provides relevant information that can be utilised to develop palliative care educational programs for nurses who care for non-cancer patients.
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Affiliation(s)
- Sanghee Kim
- Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kyunghwa Lee
- Konyang University College of Nursing, 158, Gwanjeodong-ro, Seo-gu, Daejeon, 35365, Republic of Korea.
| | - Sookyung Kim
- Department of Nursing, Yonsei University Graduate School, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
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59
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Macken L, Bremner S, Gage H, Touray M, Williams P, Crook D, Mason L, Lambert D, Evans CJ, Cooper M, Timeyin J, Steer S, Austin M, Parnell N, Thomson SJ, Sheridan D, Wright M, Isaacs P, Hashim A, Verma S. Randomised clinical trial: palliative long-term abdominal drains vs large-volume paracentesis in refractory ascites due to cirrhosis. Aliment Pharmacol Ther 2020; 52:107-122. [PMID: 32478917 DOI: 10.1111/apt.15802] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/12/2020] [Accepted: 04/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Palliative care remains suboptimal in end-stage liver disease. AIM To inform a definitive study, we assessed palliative long-term abdominal drains in end-stage liver disease to determine recruitment, attrition, safety/potential effectiveness, questionnaires/interview uptake/completion and make a preliminary cost comparison. METHODS A 12-week feasibility nonblinded randomised controlled trial comparing large-volume paracentesis vs long-term abdominal drains in refractory ascites due to end-stage liver disease with fortnightly home visits for clinical/questionnaire-based assessments. Study success criteria were attrition not >50%, <10% long-term abdominal drain removal due to complications, the long-term abdominal drain group to spend <50% ascites-related study time in hospital vs large-volume paracentesis group and 80% questionnaire/interview uptake/completion. RESULTS Of 59 eligible patients, 36 (61%) were randomised, 17 to long-term abdominal drain and 19 to large-volume paracentesis. Following randomisation, median number (IQR) of hospital ascitic drains (long-term abdominal drain group vs large-volume paracentesis group) were 0 (0-1) vs 4 (3-7); week 12 serum albumin (g/L) and serum creatinine (μmol/L) were 29 (26.5-32.5) vs 30 (25-35) and 104.5 (81-115.5) vs 127 (63-158) respectively. Total attrition was 42% (long-term abdominal drain group 47%, large-volume paracentesis group 37%). Median (IQR) fortnightly community/hospital/social care ascites-related costs and percentage study time in hospital were lower in the long-term abdominal drain group, £329 (253-580) vs £843 (603-1060) and 0% (0-0.74) vs 2.75% (2.35-3.84) respectively. Self-limiting cellulitis/leakage occurred in 41% (7/17) in the long-term abdominal drain group vs 11% (2/19) in the large-volume paracentesis group; peritonitis incidence was 6% (1/17) vs 11% (2/19) respectively. Questionnaires/interview uptake/completion were ≥80%; interviews indicated that long-term abdominal drains could transform the care pathway. CONCLUSIONS The REDUCe study demonstrates feasibility with preliminary evidence of long-term abdominal drain acceptability/effectiveness/safety and reduction in health resource utilisation. TRIAL REGISTRATION ISRCTN30697116, date assigned: 07/10/2015.
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60
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Patel A, Ufere NN. Integrating Palliative Care in the Management of Patients With Advanced Liver Disease. Clin Liver Dis (Hoboken) 2020; 15:136-140. [PMID: 32395238 PMCID: PMC7206323 DOI: 10.1002/cld.936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 01/26/2020] [Indexed: 02/04/2023] Open
Abstract
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-4-reading-patel a video presentation of this article.
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Affiliation(s)
- Arpan Patel
- Digestive DiseasesUniversity of California Los AngelesLos AngelesCA,GastroenterologyWest Los Angeles Veterans Affairs Medical CenterLos AngelesCA
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61
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Peng JK, Chang HH, Higginson IJ, Gao W. Intensive care utilization in patients with end-stage liver disease: A population-based comparative study of cohorts with and without comorbid hepatocellular carcinoma in taiwan. EClinicalMedicine 2020; 22:100357. [PMID: 32462117 PMCID: PMC7240333 DOI: 10.1016/j.eclinm.2020.100357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND End-of-life intensive care may be futile and can be a cause of distress to both patients and their families. This study aimed to understand the utilization of intensive care and its associated factors in patients with End-stage liver disease (ESLD) during terminal hospitalization. METHODS Population-based retrospective cohort study using the National Health Institute Research Database of Taiwan. All adult patients with ESLD who died during their hospitalization in 2010-2013 were included. FINDINGS Of the 14,247 patients with ESLD, the majority (60·8%) was comorbid with hepatocellular carcinoma (HCC). Patients with ESLD only were younger, more deprived, more alcohol-related, and less likely to receive palliative care prior to terminal hospitalization (6·0% vs 29·2% with HCC). Compared to patients with comorbid HCC, relatively more patients without HCC were admitted to ICU (59·6% vs 22·3%), receiving CPR (11·1% vs 4·3%) and mechanical ventilation (36·3% vs 12·5%) during terminal hospitalization. Etiology of alcoholic hepatitis, esophageal varices, septicemia, pneumonia and respiratory failure, and renal failure were associated with a higher probability of ICU admission (adjusted rate ratio (aRR) range: 1·09-2·09). Prior palliative care was associated with lower probability of ICU admission (aRR range: 0·24-0·38). INTERPRETATION The intensive care utilization by patients with ESLD in their terminal hospitalization was substantial in Taiwan. Those who are not comorbid with HCC need more attention, especially in terms of their palliative care needs, choices regarding intensive care, and their healthcare utilization. FUNDING National Institute of Health Research Health Applied Research Collaboration (ARC) South London.
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Affiliation(s)
- Jen-Kuei Peng
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Address: Bessemer Road, London, SE5 9PJ, United Kingdom
- Department of Family Medicine, National Taiwan University College of Medicine, Address: No.1 Jen-Ai Road, Section 1, Taipei 100, Taiwan
- Department of Family Medicine, National Taiwan University Hospital, Address: No.7, Chung Shan South Road, Taipei 100, Taiwan
- Corresponding author: Tel.: 886-2-928595969
| | - Hao-Hsiang Chang
- Department of Family Medicine, National Taiwan University College of Medicine, Address: No.1 Jen-Ai Road, Section 1, Taipei 100, Taiwan
- Department of Family Medicine, National Taiwan University Hospital, Address: No.7, Chung Shan South Road, Taipei 100, Taiwan
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Address: Bessemer Road, London, SE5 9PJ, United Kingdom
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Address: Bessemer Road, London, SE5 9PJ, United Kingdom
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Naik AD, Arney J, Clark JA, Martin LA, Walling AM, Stevenson A, Smith D, Asch SM, Kanwal F. Integrated Model for Patient-Centered Advanced Liver Disease Care. Clin Gastroenterol Hepatol 2020; 18:1015-1024. [PMID: 31357029 PMCID: PMC9319576 DOI: 10.1016/j.cgh.2019.07.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/11/2019] [Accepted: 07/24/2019] [Indexed: 02/07/2023]
Abstract
Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.
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Affiliation(s)
- Aanand D. Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Jennifer Arney
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Sociology, University of Houston-Clear Lake, Houston, Texas
| | - Jack A. Clark
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Lindsey A. Martin
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Anne M. Walling
- Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Autumn Stevenson
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Donna Smith
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Steven M. Asch
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Medical Center, Palo Alto, California,Division of Primary Care and Population Health, Stanford University, Palo Alto, California
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
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Patel A, Kogekar N, Agarwal R, Cohen C, Esteban JP, Pourmand K, Tsai E, Harty A, Pelham-Braithwaite A, Perumalswami P, Dieterich D, Schiano T. Improving Advance Care Planning in Outpatients With Decompensated Cirrhosis: A Pilot Study. J Pain Symptom Manage 2020; 59:864-870. [PMID: 31881290 DOI: 10.1016/j.jpainsymman.2019.12.355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/26/2019] [Accepted: 12/05/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite significant morbidity and mortality among patients with decompensated cirrhosis, reported rates of advance directive (AD) completion and goals of care discussions (GCDs) between patients and providers are very low. We aimed to improve these rates by implementing a hepatologist-led advance care planning (ACP) intervention. MEASURES Rates of AD and GCD completion, as well as self-reported barriers to ACP. INTERVENTION Provider-led ACP in patients with decompensated cirrhosis without a prior documented AD. OUTCOMES Sixty-two patients were seen over 115 clinic visits. After the intervention, AD completion rates increased from 8% to 31% and GCD completion rates rose from 0% to 51%. Women (P = 0.048) and nonmarried adults (P = 0.01) had greater changes in AD completion compared to men and married adults, respectively. Needing more time during visits was seen as the major barrier to ACP among providers. CONCLUSIONS/LESSONS LEARNED Addressing provider and system-specific barriers dramatically improved documentation rates of ACP.
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Affiliation(s)
- Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Division of Gastroenterology and Hepatology, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California, USA.
| | - Nina Kogekar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ritu Agarwal
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Cynthia Cohen
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James Phillip Esteban
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kamron Pourmand
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - Eugenia Tsai
- Texas Liver Institute, San Antonio, Texas, USA; Division of Gastroenterology, University of Texas Health Science Center, Houston, Texas, USA
| | - Alyson Harty
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andre Pelham-Braithwaite
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ponni Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - Douglas Dieterich
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas Schiano
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
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64
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Han H, Qin Y, Yu Y, Wei X, Guo H, Ruan Y, Cao Y, He J. Atrial fibrillation in hospitalized patients with end-stage liver disease: temporal trends in prevalence and outcomes. Liver Int 2020; 40:674-684. [PMID: 31705572 DOI: 10.1111/liv.14291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/29/2019] [Accepted: 10/31/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS End-stage liver disease (ESLD) happens due to the development and progression of chronic liver disease. This study aims to investigate the temporal trend, patient characteristics and outcomes of atrial fibrillation (AF) in hospitalized ESLD patients across the United States. METHODS Nationwide Inpatient Sample from 2003 to 2014 was utilized to retrospectively study the weighted prevalence of AF in hospitalized ESLD patients. Multivariable regression models were used to assess the association between AF with clinical factors, in-hospital mortality, length of stay (LOS) and cost. RESULTS 639 345 hospitalizations associated with ESLD were identified, of which 47 710 (7.48%) were diagnosed with AF. The prevalence of AF increased from 5.73% in 2003 to 9.75% in 2014 in ESLD and varied by age, race, income, insurance type and hospital characteristics. Factors associated with AF included advancing age, male, white race, high income and urban teaching hospital. AF presence was associated with significant higher in-hospital mortality (odds ratio, 1.40; 95% confidence interval, 1.35-1.45), 21% longer LOS and 22% higher cost. In addition, a significant decreasing trend in in-hospital mortality was observed (from 16.70% to 10.63% in patients with AF and from 10.74% to 7.50% in patients without AF). CONCLUSIONS The prevalence of AF in hospitalized ESLD patients has continued to increase from 2003 through 2014. AF is associated with poor prognosis and higher health resource utilization. Innovative anticoagulation strategies through improved collaboration between cardiologists and hepatologists are required for better management of hospitalized ESLD patients comorbid with AF.
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Affiliation(s)
- Hedong Han
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yingyi Qin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yamei Yu
- Department of Cardiology, Shanghai Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Wei
- Department of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Honglei Guo
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yiming Ruan
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Jia He
- Department of Health Statistics, Second Military Medical University, Shanghai, China.,Tongji University School of Medicine, Shanghai, China
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65
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Ufere NN, Halford JL, Caldwell J, Jang MY, Bhatt S, Donlan J, Ho J, Jackson V, Chung RT, El-Jawahri A. Health Care Utilization and End-of-Life Care Outcomes for Patients With Decompensated Cirrhosis Based on Transplant Candidacy. J Pain Symptom Manage 2020; 59:590-598. [PMID: 31655192 PMCID: PMC7024665 DOI: 10.1016/j.jpainsymman.2019.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/14/2019] [Accepted: 10/17/2019] [Indexed: 12/19/2022]
Abstract
CONTEXT Patients with decompensated cirrhosis have high rates of health care utilization at end of life (EOL). However, the impact of transplant candidacy on intensity of EOL care is currently unknown. OBJECTIVES To assess the relationship between transplant candidacy and intensity of EOL care in the last year of life in an ambulatory cohort of patients with decompensated cirrhosis. METHODS We performed a retrospective analysis of 230 patients with decompensated cirrhosis who were evaluated for liver transplantation in a large health care system between 1/1/2010 and 12/31/2017 and died by 6/20/2018. We compared health care utilization in the last year of life and EOL care outcomes between transplant-listed (n = 133) and nonlisted (n = 97) patients. We examined predictors of palliative and hospice care utilization using multivariate logistic regression. RESULTS During the last year of life, patients had a median of three hospitalizations (IQR 2-5) and spent a median of 31 days (IQR 16-49) in the hospital. In all, 80% of patients died in the hospital, with 70% dying in the intensive care unit. The majority (70.0%) received a life-sustaining procedure (mechanical ventilation, renal replacement therapy, or cardiopulmonary resuscitation) during their terminal hospitalization, which did not differ between transplant-listed and nonlisted patients (74.4% vs. 63.9%, P = 0.09). Transplant-listed patients had lower odds of receiving specialty palliative care (odds ratio 0.43, P = 0.005). Patients with hepatocellular carcinoma had higher odds of receiving hospice care (odds ratio 2.03, P = 0.049). CONCLUSION Patients with decompensated cirrhosis had intensive health care utilization during their last year of life regardless of transplant candidacy. Further work is needed to optimize their EOL care, particularly for patients who are ineligible for transplantation.
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Affiliation(s)
- Nneka N Ufere
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | | | | | | | - Sunil Bhatt
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Donlan
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Janet Ho
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond T Chung
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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66
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Holden JH, Shamseddeen H, Johnson AW, Byriel B, Subramoney K, Cheng YW, Saito A, Ghabril M, Chalasani N, Sachs GA, Orman ES. Palliative Care and Hospice Referrals in Patients with Decompensated Cirrhosis: What Factors Are Important? J Palliat Med 2020; 23:1066-1075. [PMID: 32091954 DOI: 10.1089/jpm.2019.0501] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Palliative care (PC) and hospice care are underutilized for patients with end-stage liver disease, but factors associated with these patterns of utilization are not well understood. Objective: We examined patient-level factors associated with both PC and hospice referrals in patients with decompensated cirrhosis (DC). Design: Retrospective cohort study. Setting/Subjects: Patients with DC hospitalized at a single tertiary center and followed for one year. Measurements: We assessed PC and hospice referrals during follow-up and examined patient-level factors associated with the receipt of PC and/or hospice, as well as associated clinical outcomes. We also examined late referrals (within one week of death). Results: Of 397 patients, 61 (15.4%) were referred to PC, 71 (17.9%) were referred to hospice, and 99 (24.9%) were referred to PC and/or hospice. Two hundred patients (50.4%) died during the one-year follow-up. In multivariable logistic regression, referral to PC was associated with increased comorbidity burden, ascites, increased MELD (Model for End-Stage Liver Disease)-Na score, lack of listing for liver transplant, and unmarried status. Hospice referral was associated with increased comorbidities, portal vein thrombosis, and hepatocellular carcinoma. PC referrals were late in 68.5% of cases, and hospice referrals were late in 62.7%. Late PC referrals were associated with younger age and married status. Late hospice referrals were associated with younger age and recent alcohol use. Conclusions: PC and hospice is underutilized in patients with DC, and most referrals are late. Patient-level factors associated with these referrals differ between PC and hospice.
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Affiliation(s)
- John H Holden
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Amy W Johnson
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA
| | - Benjamin Byriel
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Kavitha Subramoney
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA
| | - Yao-Wen Cheng
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California, USA
| | - Akira Saito
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Greg A Sachs
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA.,Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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67
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Dunn SH, Rogal SS, Maier MM, Chartier M, Morgan TR, Beste LA. Access to Comprehensive Services for Advanced Liver Disease in the Veterans Health Administration. Dig Dis Sci 2019; 64:3471-3479. [PMID: 31432344 DOI: 10.1007/s10620-019-05785-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 08/07/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND The Veterans Health Administration (VHA) provides care to the one of the largest cohorts of patients with advanced liver disease (ALD) in the USA. AIMS We performed a national survey to assess system-wide strengths and barriers to care for Veterans with ALD in this national integrated healthcare setting. METHODS A 52-item survey was developed to assess access and barriers to care in Veterans with ALD. The survey was distributed to all VHA medical centers in 2015. Results were analyzed using descriptive statistics. RESULTS One hundred and fifty-three sites responded to this survey. Multidisciplinary services were available on-site at > 80% of sites. Ninety-five percent of sites had mental health and addictions treatment available, with 14% co-locating these services within the liver clinic. Few sites (< 25%) provided pharmacologic treatment for alcohol use disorder in primary care or hepatology settings. Seventy-two percent of sites reported at least one barrier to liver-related care. Of the sites reporting at least one barrier, 53% reported barriers to liver transplant referral, citing complex processes and lack of staff/resources to coordinate referrals. Palliative care was widely available, but 61% of sites reported referring < 25% of their patients with ALD for palliative services. CONCLUSION Multidisciplinary services for Veterans with ALD are widely available at VHA sites, though barriers to optimal care remain. Opportunities for improvement include the expansion of providers with hepatology expertise, integrating pharmacotherapy for alcohol use disorder into hepatology and primary care, streamlining the transplant referral process, and expanding palliative care referrals for patients with ALD.
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Affiliation(s)
- S Hunter Dunn
- Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
| | - Shari S Rogal
- Departments of Surgery and Medicine, VA Pittsburgh Healthcare System, 1 University Drive, Pittsburgh, PA, 15240, USA
| | - Marissa M Maier
- Division of Infectious Diseases, VA Portland Health Care System, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA
| | - Maggie Chartier
- HIV, Hepatitis, and Related Conditions Programs Office of Specialty Care Services, U.S. Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC, 20571, USA
| | - Timothy R Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, 5901 E. Seventh Street, Long Beach, CA, 90822, USA
| | - Lauren A Beste
- General Medicine Service, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA
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68
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Ufere NN, Donlan J, Waldman L, Dienstag JL, Friedman LS, Corey KE, Hashemi N, Carolan P, Mullen AC, Thiim M, Bhan I, Nipp R, Greer JA, Temel JS, Chung RT, El-Jawahri A. Barriers to Use of Palliative Care and Advance Care Planning Discussions for Patients With End-Stage Liver Disease. Clin Gastroenterol Hepatol 2019; 17:2592-2599. [PMID: 30885884 PMCID: PMC6745282 DOI: 10.1016/j.cgh.2019.03.022] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/28/2019] [Accepted: 03/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Despite evidence for the benefits of palliative care (PC) referrals and early advance care planning (ACP) discussions for patients with chronic diseases, patients with end-stage liver disease (ESLD) often do not receive such care. We sought to examine physicians' perceptions of the barriers to PC and timely ACP discussions for patients with ESLD. METHODS We conducted a cross-sectional survey of hepatologists and gastroenterologists who provide care to adult patients with ESLD, recruited from the American Association for the Study of Liver Diseases 2018 membership registry. Using a questionnaire adapted from prior studies, we assessed physicians' perceptions of barriers to PC use and timely ACP discussions; 396 of 1236 eligible physicians (32%) completed the questionnaire. RESULTS The most commonly cited barriers to PC use were cultural factors that affect perception of PC (by 95% of respondents), unrealistic expectations from patients about their prognosis (by 93% of respondents), and competing demands for clinicians' time (by 91% of respondents). Most respondents (81%) thought that ACP discussions with patients who have ESLD typically occur too late in the course of illness. The most commonly cited barriers to timely ACP discussions were insufficient communication between clinicians and families about goals of care (by 84% of respondents) and insufficient cultural competency training about end-of-life care (81%). CONCLUSION There are substantial barriers to use of PC and timely discussions about ACP-most hepatologists and gastroenterologists believe that ACP occurs too late for patients with ESLD. Strategies are needed to overcome barriers and increase delivery of high-quality palliative and end-of-life care to patients with ESLD.
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Affiliation(s)
- Nneka N. Ufere
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - John Donlan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Lauren Waldman
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jules L. Dienstag
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | | | - Kathleen E. Corey
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Nikroo Hashemi
- Division of Gastroenterology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
| | - Peter Carolan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Alan C. Mullen
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Michael Thiim
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Irun Bhan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Ryan Nipp
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Joseph A. Greer
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jennifer S. Temel
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond T. Chung
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Areej El-Jawahri
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
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69
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Najafian N, Sack JS, DeLisle AM, Jakab S. Advance Care Planning for Patients with Cirrhosis in a Structured Inpatient/Outpatient Hepatology Program. J Palliat Med 2019; 22:1445-1448. [DOI: 10.1089/jpm.2018.0261] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Nilofar Najafian
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jordan S. Sack
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Angela M. DeLisle
- Northeast Medical Group, Yale New Haven Health, New Haven, Connecticut
| | - Simona Jakab
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
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70
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Ufere NN, O'Riordan DL, Bischoff KE, Marks AK, Eneanya N, Chung RT, Jackson V, Pantilat SZ, El-Jawahri A. Outcomes of Palliative Care Consultations for Hospitalized Patients With Liver Disease. J Pain Symptom Manage 2019; 58:766-773. [PMID: 31326503 PMCID: PMC6823143 DOI: 10.1016/j.jpainsymman.2019.07.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/10/2019] [Accepted: 07/12/2019] [Indexed: 12/17/2022]
Abstract
CONTEXT Although palliative care (PC) has been shown to improve symptoms and end-of-life (EOL) care for patients with cancer, data are lacking on the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease. OBJECTIVES We sought to characterize the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease compared with patients with cancer. METHODS We conducted an observational study using data from the Palliative Care Quality Network (PCQN). The PCQN contains prospectively collected data on 135,197 hospitalized patients receiving PC consultations at 88 PCQN sites between January 2013 and December 2017. The PCQN data set includes patient demographics, processes of care, and patient-level clinical outcomes. RESULTS The cohort included 44,933 patients, of whom 4402 (9.8%) had liver disease and 40,531 (90.2%) had cancer. Patients with liver disease were younger (58.9 years vs. 65.2 years, P < 0.0001) and had higher in-hospital mortality (28% vs. 16.8%, P < 0.0001). Patients with liver disease were more likely to receive PC consultations to address goals of care (81.7% vs. 67.9%, P < 0.0001) as opposed to pain management (10.9% vs. 34.9%, P < 0.0001). Both groups had similar rates of symptom improvement and change in resuscitation preferences after PC consultation. CONCLUSION Hospitalized patients with liver disease were more likely to have a PC referral to address goals of care compared with those with cancer and were more likely to die in the hospital. Despite late PC consultations, patients with liver disease experienced improvement in symptoms and clarification of their goals of care, similar to those with cancer.
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Affiliation(s)
- Nneka N Ufere
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - David L O'Riordan
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Kara E Bischoff
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Angela K Marks
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Nwamaka Eneanya
- Palliative and Advanced Illness Research Center, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raymond T Chung
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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71
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Barnes A, Woodman RJ, Kleinig P, Briffa M, To T, Wigg AJ. Early palliative care referral in patients with end stage liver disease is associated with reduced resource utilisation. J Gastroenterol Hepatol 2019; 35:840-845. [PMID: 31613397 DOI: 10.1111/jgh.14877] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/14/2019] [Accepted: 09/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Palliative care referral for end stage liver disease (ESLD) is uncommon and usually occurs late. We aimed to review the rate of early palliative care referral (EPCR) in ESLD patients, its associations, and its impacts on resource utilisation and survival. METHODS A retrospective review of all patients with ESLD admitted to a single hepatology unit between 2013 and 2016. Inclusion criteria for study entry were at least two admissions for decompensated liver disease within a six month period and not eligible for liver transplantation. The EPCR group was defined as those patients who received palliative care referral at least 30 days prior to mortality. RESULTS 74 patients were included in the study. EPCR rate was 19%. On multivariate analysis EPCR was associated with hepatocellular carcinoma (OR 4.47, 95% CI 1.02-19.5, p=0.047), and negatively associated with alcoholic liver disease (OR 0.16, 95% CI 0.032-0.88 p=0.035). There was no difference in survival based on EPCR status. Hospitalization costs were lower in the EPCR group (p=0.027). There was also a significantly lower number of endoscopies (p=0.009), and blood transfusions (p=0.001) in the EPCR group. EPCR was also associated with higher rates of outpatient palliative care and advanced care planning. CONCLUSIONS EPCR in ESLD was uncommon and associated with hepatocellular carcinoma and lack of alcoholic liver disease. EPCR was associated with decreased resource utilisation and further high quality studies are required to confirm the benefits of EPCR in ESLD.
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Affiliation(s)
- Alex Barnes
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, Australia
| | - Richard J Woodman
- Department of Epidemiliology and Biostatistics, College of Medicine and Public Health, Flinders University of South Australia, Australia
| | - Paul Kleinig
- Southern Adelaide Palliative Care Services, Australia
| | | | - Timothy To
- Southern Adelaide Palliative Care Services, Australia
| | - Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Australia
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Health Care Utilization and Costs for Patients With End-Stage Liver Disease Are Significantly Higher at the End of Life Compared to Those of Other Decedents. Clin Gastroenterol Hepatol 2019; 17:2339-2346.e1. [PMID: 30743007 DOI: 10.1016/j.cgh.2019.01.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/23/2019] [Accepted: 01/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with end-stage liver disease (ESLD) have progressively complex medical needs. However, little is known about their end-of-life health care utilization or associated costs. We performed a population-based study to evaluate the end-of-life direct utilization and costs for patients with ESLD among health care sectors in the province of Ontario. METHODS We used linked Ontario health administrative databases to conduct a population-based retrospective cohort study of all decedents from April 1, 2010, through March 31, 2013. Patients with ESLD were compared with patients without ESLD with regard to total health care utilization and costs in the last year and last 90 days of life. RESULTS The median age at death was significantly lower for ESLD decedents (65 y; interquartile range, 56-75 y) than for individuals without ESLD (80 y; interquartile range, 68-88 y). The median cost in the last year of life was significantly greater for patients with ESLD ($51,235 vs $44,456 without ESLD) (P < .001). Median ESLD end-of-life care costs also significantly exceeded those associated with 4 of the 5 most resource-intensive chronic conditions ($69,040 for ESLD vs $59,088 for non-ESLD) (P < .001). Cost differences were most pronounced in the final 90 days of life. During this period, patients with ESLD spent 4.7 more days in the hospital (95% CI, 4.3-5.1 d) than patients without ESLD (P < .0001), had significantly higher odds of dying in an institutional setting (odds ratio, 1.8; 95% CI, 1.7-1.9) (P < .0001), and incurred an additional $4201 in costs (95% CI, $3384-$5019; P < .0001). CONCLUSIONS In a population-based study in Canada, we found that patients with ESLD incur significantly higher end-of-life care costs than decedents without ESLD, predominantly owing to increased time in the hospital during the final 90 days of life.
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Kim D, Cholankeril G, Li AA, Kim W, Tighe SP, Hameed B, Kwo PY, Harrison SA, Younossi ZM, Ahmed A. Trends in hospitalizations for chronic liver disease-related liver failure in the United States, 2005-2014. Liver Int 2019; 39:1661-1671. [PMID: 31081997 DOI: 10.1111/liv.14135] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/11/2019] [Accepted: 05/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Current estimates of the population-based disease burden of liver failure or end-stage liver disease (ESLD) are lacking. We investigated recent trends in hospitalizations and in-hospital mortality among patients with ESLD in the United States (US). METHODS A retrospective analysis was performed utilizing the National Inpatient Sample from 2005 to 2014. We defined ESLD as either decompensated cirrhosis or hepatocellular carcinoma (HCC), criteria obtained from the International Classification of Diseases, Ninth Revision. Nationwide rates of hospitalization and in-hospital mortality were analysed from 2005 to 2014. RESULTS Hospitalization rates for decompensated cirrhosis during this period increased from 105.3/100 000 persons to 159.9/100 000 persons. In terms of HCC, hospitalization rates increased from 13.6/100 000 to 22.1/100 000. In patients with non-alcoholic fatty liver disease (NAFLD)-related decompensated cirrhosis, the hospitalization rate increased from 13.4/100 000 to 32.1/100 000 with an annual incremental increase of 10.6%, a magnitude twofold higher than other aetiologies. The proportion of NAFLD among hospitalizations with ESLD steadily increased from 12.7% to 20.1% for decompensated cirrhosis while the proportion of chronic hepatitis C (HCV) and alcoholic liver disease (ALD) declined (from 29.3% to 27.6% for HCV; from 39.0% to 37.4% for ALD). Although the overall in-hospital mortality rates for ESLD declined during the study, mortality rates for NAFLD-related decompensated cirrhosis showed no significant change. CONCLUSIONS Among aetiologies of chronic liver disease, NAFLD demonstrated the fastest growing rate of hospitalizations in non-HCC patients with ESLD in the US. Our study highlights the need for a focus on NAFLD-related hospitalizations and its impact on resource utilization.
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Affiliation(s)
- Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Andrew A Li
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea
| | - Sean P Tighe
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco - UCSF Health, San Francisco, California, USA
| | - Paul Y Kwo
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Stephen A Harrison
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Zobair M Younossi
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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74
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Adejumo AC, Kim D, Iqbal U, Yoo ER, Boursiquot BC, Cholankeril G, Wong RJ, Kwo PY, Ahmed A. Suboptimal Use of Inpatient Palliative Care Consultation May Lead to Higher Readmissions and Costs in End-Stage Liver Disease. J Palliat Med 2019; 23:97-106. [PMID: 31397615 DOI: 10.1089/jpm.2019.0100] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background/Aims: Patients with end-stage liver disease (ESLD) have a high risk for readmission. We studied the role of palliative care consultation (PCC) in ESLD-related readmissions with a focus on health care resource utilization in the United States. Methods: We performed a retrospective longitudinal analysis on patients surviving hospitalizations with ESLD from January 2010 to September 2014 utilizing the Nationwide Readmissions Database with a 90-day follow-up after discharge. We analyzed annual trends in PCC among patients with ESLD. We matched PCC to no-PCC (1:1) using propensity scores to create a pseudorandomized clinical study. We estimated the impact of PCC on readmission rates (30- and 90-day), and length of stay (LOS) and cost during subsequent readmissions. Results: Of the 67,480 hospitalizations with ESLD, 3485 (5.3%) received PCC, with an annual increase from 3.6% to 6.7% (p for trend <0.01). The average 30- and 90-day annual readmission rates were 36.2% and 54.6%, respectively. PCC resulted in a lower risk for 30- and 90-day readmissions (hazard ratio: 0.42, 95% confidence interval [CI]: 0.38-0.47 and 0.38, 95% CI: 0.34-0.42, respectively). On subsequent 30- and 90-day readmissions, PCC was associated with decreased LOS (5.6- vs. 7.4 days and 5.7- vs. 6.9 days, p < 0.01) and cost (US $48,752 vs. US $75,810 and US $48,582 vs. US $69,035, p < 0.01). Conclusion: Inpatient utilization of PCC for ESLD is increasing annually, yet still remains low in the United States. More importantly, PCC was associated with a decline in readmission rates resulting in a lower burden on health care resource utilization and improvement in cost savings during subsequent readmissions.
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Affiliation(s)
- Adeyinka Charles Adejumo
- Department of Medicine, North Shore Medical Center, Salem, Massachusetts.,Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Umair Iqbal
- Department of Medicine, Geisinger Medical Center, Danville, Pennsylvania
| | - Eric R Yoo
- Department of Internal Medicine, Santa Clara Valley Medical Center, San Jose, California
| | - Brian C Boursiquot
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System-Highland Hospital, Oakland, California
| | - Paul Y Kwo
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
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Wen Y, Jiang C, Koncicki HM, Horowitz CR, Cooper RS, Saha A, Coca SG, Nadkarni GN, Chan L. Trends and Racial Disparities of Palliative Care Use among Hospitalized Patients with ESKD on Dialysis. J Am Soc Nephrol 2019; 30:1687-1696. [PMID: 31387926 DOI: 10.1681/asn.2018121256] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 05/16/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Study findings show that although palliative care decreases symptom burden, it is still underused in patients with ESKD. Little is known about disparity in use of palliative care services in such patients in the inpatient setting. METHODS To investigate the use of palliative care consultation in patients with ESKD in the inpatient setting, we conducted a retrospective cohort study using the National Inpatient Sample from 2006 to 2014 to identify admitted patients with ESKD requiring maintenance dialysis. We compared palliative care use among minority groups (black, Hispanic, and Asian) and white patients, adjusting for patient and hospital variables. RESULTS We identified 5,230,865 hospitalizations of such patients from 2006 through 2014, of which 76,659 (1.5%) involved palliative care. The palliative care referral rate increased significantly, from 0.24% in 2006 to 2.70% in 2014 (P<0.01). Black and Hispanic patients were significantly less likely than white patients to receive palliative care services (adjusted odds ratio [aOR], 0.72; 95% confidence interval [95% CI], 0.61 to 0.84, P<0.01 for blacks and aOR, 0.46; 95% CI, 0.30 to 0.68, P<0.01 for Hispanics). These disparities spanned across all hospital subtypes, including those with higher proportions of minorities. Minority patients with lower socioeconomic status (lower level of income and nonprivate health insurance) were also less likely to receive palliative care. CONCLUSIONS Despite a clear increase during the study period in provision of palliative care for inpatients with ESKD, significant racial disparities occurred and persisted across all hospital subtypes. Further investigation into causes of racial and ethnic disparities is necessary to improve access to palliative care services for the vulnerable ESKD population.
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Affiliation(s)
- Yumeng Wen
- Department of Medicine, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, New York
| | - Changchuan Jiang
- Department of Medicine, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, New York
| | - Holly M Koncicki
- Division of Nephrology and.,Department of Medicine, Mount Sinai Hospital, New York, New York
| | - Carol R Horowitz
- Department of Medicine, Mount Sinai Hospital, New York, New York.,Department of Population Health Science and Policy and
| | - Richard S Cooper
- Department of Public Health Sciences, Loyola University, Maywood, Illinois
| | - Aparna Saha
- Department of Public Health Sciences, Loyola University, Maywood, Illinois
| | - Steven G Coca
- Division of Nephrology and.,Department of Medicine, Mount Sinai Hospital, New York, New York
| | - Girish N Nadkarni
- Division of Nephrology and .,Department of Medicine, Mount Sinai Hospital, New York, New York.,Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Lili Chan
- Division of Nephrology and .,Department of Medicine, Mount Sinai Hospital, New York, New York
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Ufere NN, Donlan J, Waldman L, Patel A, Dienstag JL, Friedman LS, Corey KE, Hashemi N, Carolan P, Mullen AC, Thiim M, Bhan I, Nipp R, Greer J, Temel J, Chung RT, El-Jawahri A. Physicians' Perspectives on Palliative Care for Patients With End-Stage Liver Disease: A National Survey Study. Liver Transpl 2019; 25:859-869. [PMID: 30963669 PMCID: PMC6529275 DOI: 10.1002/lt.25469] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/24/2019] [Indexed: 12/12/2022]
Abstract
Specialty palliative care (PC) is underused for patients with end-stage liver disease (ESLD). We sought to examine attitudes of hepatologists and gastroenterologists about PC for patients with ESLD. We conducted a cross-sectional survey of these specialists who provide care to patients with ESLD. Participants were recruited from the American Association for the Study of Liver Diseases membership directory. Using a questionnaire adapted from prior studies, we examined physicians' attitudes about PC and whether these attitudes varied based on patients' candidacy for liver transplantation. We identified predictors of physicians' attitudes about PC using linear regression. Approximately one-third of eligible physicians (396/1236, 32%) completed the survey. Most (95%) believed that centers providing care to patients with ESLD should have PC services, and 86% trusted PC clinicians to care for their patients. Only a minority reported collaborating frequently with inpatient (32%) or outpatient (11%) PC services. Most believed that when patients hear the term PC, they feel scared (94%) and anxious (87%). Most (83%) believed that patients would think nothing more could be done for their underlying disease if a PC referral was suggested. Physicians who believed that ESLD is a terminal condition (B = 1.09; P = 0.006) reported more positive attitudes about PC. Conversely, physicians with negative perceptions of PC for transplant candidates (B = -0.22; standard error = 0.05; P < 0.001) reported more negative attitudes toward PC. In conclusion, although most hepatologists and gastroenterologists believe that patients with ESLD should have access to PC, they reported rarely collaborating with PC teams and had substantial concerns about patients' perceptions of PC. Interventions are needed to overcome misperceptions of PC and to promote collaboration with PC clinicians for patients with ESLD.
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Affiliation(s)
- Nneka N. Ufere
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - John Donlan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Lauren Waldman
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Arpan Patel
- Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jules L. Dienstag
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | | | - Kathleen E. Corey
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Nikroo Hashemi
- Division of Gastroenterology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
| | - Peter Carolan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Alan C. Mullen
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Michael Thiim
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Irun Bhan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Ryan Nipp
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Joseph Greer
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jennifer Temel
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond T. Chung
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Areej El-Jawahri
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
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Fricker ZP, Serper M. Current Knowledge, Barriers to Implementation, and Future Directions in Palliative Care for End-Stage Liver Disease. Liver Transpl 2019; 25:787-796. [PMID: 30758901 DOI: 10.1002/lt.25434] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/10/2019] [Indexed: 02/07/2023]
Abstract
End-stage liver disease (ESLD) is associated with a high degree of morbidity and mortality as well as symptom burden. Despite this, the rate of consultation with palliative care (PC) providers remains low, and invasive procedures near the end of life are commonplace. Studies show that involvement of PC providers improves patient satisfaction, and evidence from other chronic diseases demonstrates reduced costs of care and potentially increased survival. Better integration of PC is imperative but hindered by patient and provider misconceptions about its role in the care of patients with ESLD, specifically among candidates for liver transplantation. Additionally, reimbursement barriers and lack of provider knowledge may contribute to PC underutilization. In this review, we discuss the benefits of PC in ESLD, the variability of its delivery, and key stakeholders' perceptions about its use. Additionally, we identify barriers to more widespread PC adoption and highlight areas for future research.
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Affiliation(s)
- Zachary P Fricker
- Division of Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marina Serper
- Division of Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Abstract
PURPOSE OF REVIEW End-stage liver disease (ESLD) is associated with high symptom burden, poor quality of life, and significant healthcare costs. Palliative care, which is not synonymous with hospice or end-of-life care, is a multidisciplinary model of care that focuses on patient-centered goals with the intent of improving quality of life and reducing suffering. This review will summarize current literature supporting the benefits of early integration of palliative care in patients in this population. RECENT FINDINGS Advance care planning (ACP) and goals of care discussions have been associated with improved quality of life, decreased anxiety, and improved satisfaction with care for both the patient and the caregiver. These discussions are beneficial to all patients with ESLD, including those listed for liver transplantation. SUMMARY Despite the resounding benefits of palliative care for patients with other advanced diseases, palliative care remains underutilized in liver disease. There is an urgent need for education of hepatology/transplant providers as well as development of society guidelines to help dissemination and acceptability of palliative care for patients with ESLD.
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Liu X, Shen JJ, Kim P, Kim SJ, Ukken J, Choi Y, Hwang IC, Lee JH, Chun SY, Hwang J, Choi H, Yeom H, Lee YJ, Yoo JW. Trends in the Utilization of Life-Sustaining Procedures and Palliative Care Consultation Among Dying Patients With Advanced Chronic Pancreas Illnesses in US Hospitals: 2005 to 2014. J Palliat Care 2019; 34:232-240. [PMID: 30767641 DOI: 10.1177/0825859719827313] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIM Pancreas cancer continues to carry a poor prognosis. Hospitalized patients with advanced chronic pancreatic illnesses increasingly receive palliative care due to its perceived clinical benefits. Meanwhile, a growing proportion of elderly patients are reportedly receiving life-sustaining procedures. Temporal trends in the utilization of life-sustaining procedures and palliative care consultation among dying patients with advanced chronic pancreatic illnesses in US hospitals were examined. METHODS AND MATERIALS A serial, cross-sectional analysis was carried out using the National Inpatient Sample Database. Decedents 18 years and older with a principal diagnosis of pancreas cancer or other advanced chronic pancreatic illnesses from 2005 through 2014. The compound annual growth rates (CAGRs) and Cochrane-Armitage correction of χ2 statistic were used. The receipt of life-sustaining systemic procedures, intra-abdominal local procedures and surgeries, and palliative care consultation were examined. Multilevel multivariate logistic regressions were performed to examine the association of various procedures with the utilization of palliative care consultation. RESULTS Among 77 394 183 hospitalizations, 29 515 patients were examined. The CAGRs of systemic procedures, intra-abdominal procedures, surgeries, and palliative care were -4.19% (P = .008), 2.17%, -1.40%, and 14.03% (P < .001), respectively. The receipt of systemic procedures (odds ratio [OR] = 2.40, 95% confidence interval [CI], 2.08-2.74), local intra-abdominal procedures (OR = 1.46, 95% CI, 1.27-1.70), and surgeries (OR = 2.51, 95% CI, 2.07-3.05) was associated with palliative care consultation (Ps < .001). CONCLUSIONS Among adults with pancreatic cancer or other advanced chronic pancreatic illnesses in the US hospitals from 2005 to 2014, the utilization of life-sustaining systemic procedures decreased while the prevalence of palliative care consultation increased.
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Affiliation(s)
- Xibei Liu
- Department of Medicine, University of Arizona College of Medicine, Tuscon, AZ, USA
| | - Jay J Shen
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Pearl Kim
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Sun Jung Kim
- Department of Health Administration and Management, Soon Chun Hyang University, Asan, Chungcheongnam-do, Korea
| | - Johnson Ukken
- University of Nevada Reno School of Medicine, Reno, NV, USA
| | - Younseon Choi
- Department of Family Medicine, Korea University of College of Medicine, Seoul, Korea
| | - In Choel Hwang
- Department of Family Medicine, Gachon University College of Medicine, Inchon, Korea
| | - Jae-Hoon Lee
- Department of Family Medicine, University of Nevada, Las Vegas
| | - Sung-Youn Chun
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Jinwook Hwang
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Haneul Choi
- Honors College, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Hyeyoung Yeom
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Yong-Jae Lee
- Department of Family Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
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Heller DR, Jean RA, Chiu AS, Feder SI, Kurbatov V, Cha C, Khan SA. Regional Differences in Palliative Care Utilization Among Geriatric Colorectal Cancer Patients Needing Emergent Surgery. J Gastrointest Surg 2019; 23:153-162. [PMID: 30328071 PMCID: PMC6751557 DOI: 10.1007/s11605-018-3929-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/10/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The benefits of palliative care (PC) in critical illness are validated across a range of diseases, yet it remains underutilized in surgical patients. This study analyzed patient and hospital factors predictive of PC utilization for elderly patients with colorectal cancer (CRC) requiring emergent surgery. METHODS The National Inpatient Sample was queried for patients aged ≥ 65 years admitted emergently with CRC from 2009 to 2014. Patients undergoing colectomy, enterectomy, or ostomy formation were included and stratified according to documentation of PC consultation during admission. Chi-squared testing identified unadjusted group differences, and multivariable logistic regression identified predictors of PC. RESULTS Of 86,573 discharges meeting inclusion criteria, only 3598 (4.2%) had PC consultation. Colectomy (86.6%) and ostomy formation (30.4%) accounted for the operative majority. PC frequency increased over time (2.9% in 2009 to 6.2% in 2014, P < 0.001) and was nearly twice as likely to occur in the West compared with the Northeast (5.7 vs. 3.3%, P < 0.001) and in not-for-profit compared with proprietary hospitals (4.5 vs. 2.3%, P < 0.001). PC patients were more likely to have metastases (60.1 vs. 39.9%, P < 0.001) and die during admission (41.5 vs. 6.4%, P < 0.001). On multivariable logistic regression, PC predictors (P < 0.05) included region outside the Northeast, increasing age, more recent year, and metastatic disease. CONCLUSIONS In the USA, PC consultation for geriatric patients with surgically managed complicated CRC is low. Regional variation appears to play an important role. With mounting evidence that PC improves quality of life and outcomes, understanding the barriers associated with its provision to surgical patients is paramount.
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Affiliation(s)
- Danielle R Heller
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208088, New Haven, CT, 06520-8088, USA
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Shelli I Feder
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208088, New Haven, CT, 06520-8088, USA
- US Department of Veterans Affairs, 950 Campbell Ave, West Haven, CT, 06516, USA
| | - Vadim Kurbatov
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Charles Cha
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, CT, 06520-8062, USA
| | - Sajid A Khan
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, CT, 06520-8062, USA.
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Place of death and factors associated with hospital death in patients who have died from liver disease in England: a national population-based study. Lancet Gastroenterol Hepatol 2019; 4:52-62. [DOI: 10.1016/s2468-1253(18)30379-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 12/13/2022]
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82
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Kim JW, Atkins C, Wilson AM. Barriers to specialist palliative care in interstitial lung disease: a systematic review. BMJ Support Palliat Care 2018; 9:130-138. [DOI: 10.1136/bmjspcare-2018-001575] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 10/23/2018] [Accepted: 11/07/2018] [Indexed: 12/14/2022]
Abstract
BackgroundCurrent guidelines recommend palliative care based on individual needs for patients with idiopathic pulmonary fibrosis. However, patients with interstitial lung disease (ILD) are less likely to receive specialist palliative care services compared with patients with malignant disease. The aim of this review is to summarise recent studies addressing barriers to referring patients to specialist palliative care services.MethodsPubMed, Embase, Medline and Web of Science were reviewed to identify relevant publications. Studies were selected if they examined the frequency of specialist palliative care referral and/or addressed issues surrounding access to palliative care services for patients with ILD.ResultsTen studies with a total of 4073 people with ILD, 27 caregivers and 18 healthcare professionals were selected and analysed. Frequency of palliative care referrals ranged from 0% to 38%. Delay in palliative care referrals and end-of-life decisions, patients’ fear of talking about the future, prognostic uncertainty and confusion about the roles of palliative care were identified as barriers to accessing palliative care services.ConclusionFurther research should concentrate on the early identification of patients who need specialist palliative care possibly with establishment of criteria to trigger referral ensuring that referrals are also based on patient’s needs.
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Oud L. Patterns of palliative care utilization among patients with end stage liver disease during end-of-life hospitalizations: A population-level analysis. J Crit Care 2018; 48:290-295. [PMID: 30269008 DOI: 10.1016/j.jcrc.2018.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/08/2018] [Accepted: 09/10/2018] [Indexed: 01/11/2023]
Abstract
PURPOSE To investigate the patterns and predictors of palliative care (PC) utilization across ICU- and non ICU-managed patients with end-stage liver disease (ESLD) during end-of-life hospitalization. MATERIALS AND METHODS The Texas Inpatient Public Use Data File was used to perform a retrospective, population-based cohort study of patients with ESLD and end-of-life hospitalization during 2005-2014. PC use among ICU- and non ICU-managed patients was examined. Logistic regression modeling was used to identify predictors of PC. RESULTS We studied 30,301 patients, of which 5484 (18.1%) had reported PC and 24,174 (79.8%) were admitted to ICU. Between 2005 and 2014 PC use among ICU- and non ICU-managed patients increased from 0.5% to 32.9% and 7.1% to 47.0%, respectively, while ICU admission rate rose from 76.5% to 82.9%. PC use was reduced with rising APR-DRG illness severity (adjusted odds ratio, "extreme" vs. "minor" 0.36 [95% confidence interval, 0.24-0.54]), ICU admission (0.60 [0.55-0.65]), and use of mechanical ventilation (0.75 [0.70-0.81]). CONCLUSIONS There was persistent gap in use of PC among ICU-managed patients with ESLD during end-of-life hospitalization. ICU utilization rose, unexpectedly, despite the increasing use of PC in this cohort, and PC utilization was, paradoxically, lower among patients with the highest need.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX 79763, USA.
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84
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Asrani SK, Kouznetsova M, Ogola G, Taylor T, Masica A, Pope B, Trotter J, Kamath P, Kanwal F. Increasing Health Care Burden of Chronic Liver Disease Compared With Other Chronic Diseases, 2004-2013. Gastroenterology 2018; 155:719-729.e4. [PMID: 29802851 DOI: 10.1053/j.gastro.2018.05.032] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 05/09/2018] [Accepted: 05/18/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIMS Chronic liver disease (CLD) is a common and expensive condition, and studies of CLD-related hospitalizations have underestimated the true burden of disease. We analyzed data from a large, diverse health care system to compare time trends in CLD-related hospitalizations with those in congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD). METHODS We collected data from a large health care system in Texas on hospitalizations related to CLD (n = 27,783), CHF (n = 60,415), and COPD (n = 34,199) from January 1, 2004 through December 31, 2013. We calculated annual hospitalization rates (per 100,000) and compared hospital course, inpatient mortality, ancillary services, and readmissions. RESULTS Compared with patients with CHF (median age, 71 years) or COPD (median age, 69 years), patients with CLD were significantly younger (median age, 57 years) (P < .01 vs CHF and COPD). Higher proportions of patients with CLD were uninsured (11.7% vs 5.4% for CHF and 5.4% for COPD, P < .01) and Hispanic (17% for CLD vs 9.3% for CHF and 5.0% for COPD, P < .01). A lower proportion of patients with CLD had Medicare (41.5% vs 68.6% with CHF and 70.1% with COPD, P < .01). From 2004 through 2013, the rate of CLD-related hospitalization increased by 92% (from 1295/100,000 to 2490/100,000), compared with 6.7% for CHF (from 3843/100,000 to 4103/100,000) and 48.8% for COPD (from 1775/100,000 to 2642/100,000). During this time period, CLD-related hospitalizations covered by Medicare increased from 31.8% to 41.5%, whereas hospitalizations covered by Medicare did not change for CHF (remained at 70%) or COPD (remained at 70%). Patients with CLD had longer hospital stays (7.3 days vs 6.2 days for CHF and 5.9 days for COPD, P < .01). A higher proportion of patients with CLD died or were discharged to hospice (14.2% vs 11.5% of patients with CHF and 9.3% of patients with COPD, P < .01), and a smaller proportion had access to postacute care (13.2% vs 23.2% of patients with CHF and 27.4% of patients with COPD, P < .01). A higher proportion of patients with CLD were readmitted to the hospital within 30 days (25% vs 21.9% of patients with CHF and 20.6% with COPD, P < .01). CONCLUSIONS Patients with CLD, compared with selected other chronic diseases, had increasing rates of hospitalization, longer hospital stays, more readmissions, and, despite these adverse outcomes, less access to postacute care. Disease management models for CLD are greatly needed to manage the anticipated increase in hospitalizations for CLD.
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Affiliation(s)
- Sumeet K Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, Texas.
| | - Maria Kouznetsova
- Center for Clinical Effectiveness, Baylor Scott and White, Dallas, Texas
| | - Gerald Ogola
- Center for Clinical Effectiveness, Baylor Scott and White, Dallas, Texas
| | | | - Andrew Masica
- Center for Clinical Effectiveness, Baylor Scott and White, Dallas, Texas
| | - Brandon Pope
- Center for Clinical Effectiveness, Baylor Scott and White, Dallas, Texas
| | - James Trotter
- Baylor University Medical Center, Baylor Scott and White, Dallas, Texas
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85
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Mudumbi SK, Bourgeois CE, Hoppman NA, Smith CH, Verma M, Bakitas MA, Brown CJ, Markland AD. Palliative Care and Hospice Interventions in Decompensated Cirrhosis and Hepatocellular Carcinoma: A Rapid Review of Literature. J Palliat Med 2018; 21:1177-1184. [PMID: 29698124 PMCID: PMC6104656 DOI: 10.1089/jpm.2017.0656] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Patients with decompensated cirrhosis (DC) and/or hepatocellular carcinoma (HCC) have a high symptom burden and mortality and may benefit from palliative care (PC) and hospice interventions. OBJECTIVE Our aim was to search published literature to determine the impact of PC and hospice interventions for patients with DC/HCC. METHODS We searched electronic databases for adults with DC/HCC who received PC, using a rapid review methodology. Data were extracted for study design, participant and intervention characteristics, and three main groups of outcomes: healthcare resource utilization (HRU), end-of-life care (EOLC), and patient-reported outcomes. RESULTS Of 2466 results, eight were included in final results. There were six retrospective cohort studies, one prospective cohort, and one quality improvement study. Five of eight studies had a high risk of bias and seven studied patients with HCC. A majority found a reduction in HRU (total cost of hospitalization, number of emergency department visits, hospital, and critical care admissions). Some studies found an impact on EOLC, including location of death (less likely to die in the hospital) and resuscitation (less likely to have resuscitation). One study evaluated survival and found hospice had no impact and another showed improvement of symptom burden. CONCLUSION Studies included suggest that PC and hospice interventions in patients with DC/HCC reduce HRU, impact EOLC, and improve symptoms. Given the few number of studies, heterogeneity of interventions and outcomes, and high risk of bias, further high-quality research is needed on PC and hospice interventions with a greater focus on DC.
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Affiliation(s)
- Sandhya K. Mudumbi
- Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Health Services and Outcomes Research Post-Doctoral Training Program, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Nicholas A. Hoppman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Catherine H. Smith
- Lister Hill Library of the Health Sciences, University of Alabama at Birmingham, Birmingham, Alabama
| | - Manisha Verma
- Division of Hepatology, Department of Transplantation, Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - Marie A. Bakitas
- Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
- University of Alabama at Birmingham School of Nursing, Birmingham, Alabama
| | - Cynthia J. Brown
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Veterans Affairs Birmingham/Atlanta Geriatric Research, Education and Clinical Center, Birmingham, Alabama
- Comprehensive Center for Healthy Aging, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alayne D. Markland
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Veterans Affairs Birmingham/Atlanta Geriatric Research, Education and Clinical Center, Birmingham, Alabama
- Comprehensive Center for Healthy Aging, University of Alabama at Birmingham, Birmingham, Alabama
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86
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Abstract
OBJECTIVE To describe liver disease related mortality in the United States during 1999-2016 by age group, sex, race, cause of liver disease, and geographic region. DESIGN Observational cohort study. SETTING Death certificate data from the Vital Statistics Cooperative, and population data from the US Census Bureau compiled by the Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (1999-2016). PARTICIPANTS US residents. MAIN OUTCOME MEASURE Deaths from cirrhosis and hepatocellular carcinoma, with trends evaluated using joinpoint regression. RESULTS From 1999 to 2016 in the US annual deaths from cirrhosis increased by 65%, to 34 174, while annual deaths from hepatocellular carcinoma doubled to 11 073. Only one subgroup-Asians and Pacific Islanders-experienced an improvement in mortality from hepatocellular carcinoma: the death rate decreased by 2.7% (95% confidence interval 2.2% to 3.3%, P<0.001) per year. Annual increases in cirrhosis related mortality were most pronounced for Native Americans (designated as "American Indians" in the census database) (4.0%, 2.2% to 5.7%, P=0.002). The age adjusted death rate due to hepatocellular carcinoma increased annually by 2.1% (1.9% to 2.3%, P<0.001); deaths due to cirrhosis began increasing in 2009 through 2016 by 3.4% (3.1% to 3.8%, P<0.001). During 2009-16 people aged 25-34 years experienced the highest average annual increase in cirrhosis related mortality (10.5%, 8.9% to 12.2%, P<0.001), driven entirely by alcohol related liver disease. During this period, mortality due to peritonitis and sepsis in the setting of cirrhosis increased substantially, with respective annual increases of 6.1% (3.9% to 8.2%) and 7.1% (6.1% to 8.4%). Only one state, Maryland, showed improvements in mortality (-1.2%, -1.7% to -0.7% per year), while many, concentrated in the south and west, observed disproportionate annual increases: Kentucky 6.8% (5.1% to 8.5%), New Mexico 6.0% (4.1% to 7.9%), Arkansas 5.7% (3.9% to 7.6%), Indiana 5.0% (3.8% to 6.1%), and Alabama 5.0% (3.2% to 6.8%). No state showed improvements in hepatocellular carcinoma related mortality, while Arizona (5.1%, 3.7% to 6.5%) and Kansas (4.3%, 2.8% to 5.8%) experienced the most severe annual increases. CONCLUSIONS Mortality due to cirrhosis has been increasing in the US since 2009. Driven by deaths due to alcoholic cirrhosis, people aged 25-34 have experienced the greatest relative increase in mortality. White Americans, Native Americans, and Hispanic Americans experienced the greatest increase in deaths from cirrhosis. Mortality due to cirrhosis is improving in Maryland but worst in Kentucky, New Mexico, and Arkansas. The rapid increase in death rates among young people due to alcohol highlight new challenges for optimal care of patients with preventable liver disease.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, MI, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, MI, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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87
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Tapper EB, Martinez-Macias R, Duarte-Rojo A. Is Exercise Beneficial and Safe in Patients with Cirrhosis and Portal Hypertension? ACTA ACUST UNITED AC 2018. [DOI: 10.1007/s11901-018-0404-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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88
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Life-Sustaining Procedures, Palliative Care Consultation, and Do-Not Resuscitate Status in Dying Patients With COPD in US Hospitals. J Palliat Care 2018; 33:159-166. [DOI: 10.1177/0825859718777375] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aim: Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in US hospitals. We examined temporal trends and the impact of palliative care on the use of life-sustaining procedures in this population. Materials and Methods: A retrospective nationwide cohort analysis was performed using weighted National Inpatient Sample (NIS) data obtained from 2010 to 2014. Decedents ≥18 years of age at the time of death and with a principal diagnosis of COPD were included. We examined the receipt of life-sustaining procedures, defined as1 ventilation (intubation, mechanical ventilation, and noninvasive ventilation),2 vasopressor use (infusion and intravascular monitoring),3 nutrition (enteral and parenteral infusion of concentrated nutrition),4 dialysis, and5 cardiopulmonary resuscitation as well as palliative care consultation and do not resuscitate (DNR). We used compound annual growth rates (CAGRs) and the Rao-Scott correction of the χ2 statistic to determine the statistical significance of temporal trends of life-sustaining procedures, palliative care utilization, and DNR status. Results: Among 37 312 324 hospitalizations, 38 425 patients were examined. The CAGRs of life-sustaining procedures were 6.61% and −9.73% among patients who underwent multiple procedures and patients who did not undergo any procedure, respectively (both P < .001). The CAGRs of palliative consultation and DNR were 5.25% and 36.62%, respectively (both P < .001). Conclusions: Among adults with COPD dying in US hospitals between 2010 and 2014, the utilization of life-sustaining procedures, palliative care, and DNR status increased.
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89
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Zou WY, El-Serag HB, Sada YH, Temple SL, Sansgiry S, Kanwal F, Davila JA. Determinants and Outcomes of Hospice Utilization Among Patients with Advance-Staged Hepatocellular Carcinoma in a Veteran Affairs Population. Dig Dis Sci 2018; 63:1173-1181. [PMID: 29508165 PMCID: PMC6010049 DOI: 10.1007/s10620-018-4989-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 02/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hospice provides integrative palliative care for advance-staged hepatocellular carcinoma (HCC) patients, but hospice utilization in HCC patients in the USA is not clearly understood. AIMS We examined hospice use and subsequent clinical course in advance-staged HCC patients. METHODS We conducted a retrospective study on a national, Veterans Affairs cohort with stage C or D HCC. We evaluated demographics, clinical factors, treatment, and clinical course in relation to hospice use. RESULTS We identified 814 patients with advanced HCC, of whom 597 (73.3%) used hospice. Oncologist management consistently predicted hospice use, irrespective of HCC treatment [no treatment: OR 2.25 (1.18-4.3), treatment: OR 1.80 (1.10-2.95)]. Among patients who received HCC treatment, hospice users were less likely to have insurance beyond VA benefits (47.2 vs. 60.0%, p = 0.01). Among patients without HCC treatment, hospice users were older (62.2 [17.2] vs. 60.2 [14.0] years, p = 0.05), white (62.1 vs. 52.9%, p = 0.01), resided in the Southern USA (39.5 vs. 31.8%, p = 0.05), and had a performance score ≥ 3 (41.9 vs. 31.8%, p = 0.01). The median time from hospice entry to death or end of study was 1.05 [2.96] months for stage C and 0.53 [1.18] months for stage D patients. CONCLUSIONS 26.7% advance-staged HCC patients never entered hospice, representing potential missed opportunities for improving end-of-life care. Age, race, location, performance, insurance, and managing specialty can predict hospice use. Differences in managing specialty and short-term hospice use suggest that interventions to optimize early palliative care are necessary.
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Affiliation(s)
- Winnie Y Zou
- Center of Innovation, Effectiveness and Quality, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, 2002 Holcombe Blvd. (MS152), Houston, TX, 77030, USA
- Sections of Health Services Research and Gastroenterology and Hepatology, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Hashem B El-Serag
- Center of Innovation, Effectiveness and Quality, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, 2002 Holcombe Blvd. (MS152), Houston, TX, 77030, USA
- Sections of Health Services Research and Gastroenterology and Hepatology, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Yvonne H Sada
- Center of Innovation, Effectiveness and Quality, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, 2002 Holcombe Blvd. (MS152), Houston, TX, 77030, USA
- Sections of Health Services Research and Gastroenterology and Hepatology, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Sarah L Temple
- Center of Innovation, Effectiveness and Quality, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, 2002 Holcombe Blvd. (MS152), Houston, TX, 77030, USA
| | - Shubhada Sansgiry
- Center of Innovation, Effectiveness and Quality, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, 2002 Holcombe Blvd. (MS152), Houston, TX, 77030, USA
- South Central Mental Illness Research, Education and Clinical Centers, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Fasiha Kanwal
- Center of Innovation, Effectiveness and Quality, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, 2002 Holcombe Blvd. (MS152), Houston, TX, 77030, USA
- Sections of Health Services Research and Gastroenterology and Hepatology, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Jessica A Davila
- Center of Innovation, Effectiveness and Quality, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, 2002 Holcombe Blvd. (MS152), Houston, TX, 77030, USA.
- Sections of Health Services Research and Gastroenterology and Hepatology, The Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA.
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90
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Langberg KM, Kapo JM, Taddei TH. Palliative care in decompensated cirrhosis: A review. Liver Int 2018; 38:768-775. [PMID: 29112338 DOI: 10.1111/liv.13620] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 10/30/2017] [Indexed: 12/16/2022]
Abstract
Decompensated cirrhosis is an illness that causes tremendous suffering. The incidence of cirrhosis is increasing and rates of liver transplant, the only cure, remain stagnant. Palliative care is focused on improving quality of life for patients with serious illness by addressing advanced care planning, alleviating physical symptoms and providing emotional support to the patient and family. Palliative care is used infrequently in patients with decompensated cirrhosis. The allure of transplant as a potential treatment option for cirrhosis, misperceptions about the role of palliative care and difficulty predicting prognosis in liver disease are potential contributors to the underutilization of palliative care in this patient population. Studies have demonstrated some benefit of palliative care in patients with decompensated cirrhosis but the literature is limited to small observational studies. There is evidence that palliative care consultation in other patient populations lowers hospital costs and ICU utilization and improves symptom control and patient satisfaction. Prospective randomized control trials are needed to investigate the effects of palliative care on traditional- and patient-reported outcomes as well as cost of care in decompensated cirrhosis for transplant eligible and ineligible patient populations.
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Affiliation(s)
- Karl M Langberg
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer M Kapo
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tamar H Taddei
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
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91
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Palliative Care for People With Hepatocellular Carcinoma, and Specific Benefits for Older Adults. Clin Ther 2018; 40:512-525. [PMID: 29571567 DOI: 10.1016/j.clinthera.2018.02.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 02/28/2018] [Accepted: 02/28/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE Hepatocellular carcinoma (HCC), the most common type of primary liver cancer, has a rapidly rising prevalence in the United States and a very poor overall rate of survival. This epidemic is driven by the cohort of aging Baby Boomers with hepatitis C viral infection and the increasing prevalence of cirrhosis as a result of nonalcoholic steatohepatitis. Because curative options are limited, the disease course creates, in patients and their families, distressing uncertainty around prognosis and treatment decisions. Older adults are disproportionately affected by HCC and have more comorbidities, adding to the complexity of the disease. This population would benefit from increased access to palliative care services, which can potentially complement the treatments throughout the disease trajectory. The purpose of this review was to use existing evidence to propose a new model of palliative care integration in patients with HCC. Thus, we focus on the HCC stage and the treatment algorithm, the ways that palliative care can offer support in this population at each stage, as well as elements that can enhance patient and family support throughout the entire disease trajectory, with an emphasis on the care of older adults with HCC. METHODS This is a narrative review in which we identify evidence-based ways that palliative care can help younger and older adults with HCC and their families, at each stage of HCC and throughout the disease trajectory. FINDINGS We propose ways to integrate HCC and palliative care based on the existing evidence in both fields. Palliative care offers support in symptom management, advanced care planning, and decision making in ways that are specific to each stage of HCC. We also discuss the evidence that illustrates the palliative care needs of patients with HCC that span the entire course of illness, including coping with the stigmatization of liver disease, addressing informational needs at different stages, and discussing quality of life longitudinally. IMPLICATIONS Integrating palliative care into the treatment of patients with HCC has the potential to improve outcomes, although more research is needed to build this evidence base.
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92
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Fukui N, Golabi P, Otgonsuren M, de Avila L, Bush H, Younossi ZM. Hospice care in Medicare patients with primary liver cancer: the impact on resource utilisation and mortality. Aliment Pharmacol Ther 2018; 47:680-688. [PMID: 29314093 DOI: 10.1111/apt.14484] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/01/2017] [Accepted: 12/03/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few studies have assessed the impact of hospice care in patients with primary liver cancer. AIM To examine the determinants of hospice care and its effects on resource utilisation and survival among Medicare beneficiaries with primary liver cancer. METHODS We utilised the Surveillance, Epidemiology and End result Registry (SEER) database from 2002 to 2009 for this cross-sectional study. A total of 3385 patients with primary liver cancer were included. We used logistic regression to discern variables associated with hospice and Cox proportional hazards models to evaluate one-year mortality risk. RESULTS Compared to patients who enrolled in a hospice, those patients who did not, were younger, non-White and sicker (P < .05 for all). Half of all patients with primary liver cancer died within six months of diagnosis, and one-year mortality was similar in both groups (P = .413). After adjusting for baseline characteristics [age at diagnosis, race, disease severity, tumour stage and treatment], shorter time to hospice care was associated with reduced mortality (HR per day: 0.99 [95% CI, 0.98-0.99]). Older age, decompensated cirrhosis and advanced tumours stage were associated with decreased time to hospice, while Asian/Pacific Islander race and history of radiosurgery were associated with increased time to hospice (all P < .05). Hospitalisations were more costly for those who never enrolled in a hospice compared to hospice enrollees (median $31 607 [$18 394-$54 254] vs $22 316 [$13 741-$36 170], P < .0001). CONCLUSIONS Hospice enrolment of patients with primary liver cancer provides survival and resource utilisation benefits. Some clinical and demographic factors may represent barriers to hospice enrolment. Further studies are needed to fully understand these barriers in patients with primary liver cancer.
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Affiliation(s)
- N Fukui
- Department of Medicine, Center For Liver Disease, Inova Fairfax Hospital, Falls Church, VA, USA
| | - P Golabi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - M Otgonsuren
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - L de Avila
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - H Bush
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Z M Younossi
- Department of Medicine, Center For Liver Disease, Inova Fairfax Hospital, Falls Church, VA, USA.,Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
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93
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Brisebois A, Tandon P. Early Integration of Advance Care Planning (ACP) into Cirrhosis Care: Why We Need It. ACTA ACUST UNITED AC 2018. [DOI: 10.1007/s11901-018-0391-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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94
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Thomson M, Tapper EB. Towards patient-centred and cost-effective care for patients with cirrhosis and ascites. Lancet Gastroenterol Hepatol 2018; 3:75-76. [DOI: 10.1016/s2468-1253(17)30339-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 10/10/2017] [Indexed: 11/25/2022]
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