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Burt M, Kamal AH. Practical Strategies for Optimizing and Integrating Palliative Care in Cancer. Curr Oncol Rep 2018; 20:97. [PMID: 30421161 DOI: 10.1007/s11912-018-0742-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW Recent reforms in medical payment coupled with a rapidly evolving pharmacotherapeutic armamentarium is creating a transition in the field of oncology. This transition represents a key period for conceptual reevaluation, providing an opportunity for furthered strategic integration of palliative care within the realm of oncology. RECENT FINDINGS Historically, oncologists have relied upon prognostic assessments to gauge appropriateness for referrals to specialty palliative care. Recent literature has elucidated on the early palliative burdens of cancer, demonstrated the importance of complexity-based palliative referrals, and begun the conversation to define provider-specific roles. Herein, we describe a model that overlaps complexity with oncology capacity, to target specialty services to those who could benefit most. This article will review the role of palliative care as a care philosophy, the enduring and important role of the oncologist in providing palliative care, and the important areas for integration of specialty services when needed.
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Affiliation(s)
- Michael Burt
- Duke University Health, 20 Medicine Circle, Box 2715, Durham, NC, 27710, USA
| | - Arif H Kamal
- Duke University Health, 20 Medicine Circle, Box 2715, Durham, NC, 27710, USA. .,Duke Cancer Institute, Durham, NC, USA. .,Duke Fuqua School of Business, Durham, NC, USA. .,Department of Population Health Sciences, Duke University, Durham, NC, USA.
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Dudley N, Ritchie CS, Rehm RS, Chapman SA, Wallhagen MI. Facilitators and Barriers to Interdisciplinary Communication between Providers in Primary Care and Palliative Care. J Palliat Med 2018; 22:243-249. [PMID: 30383468 DOI: 10.1089/jpm.2018.0231] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Community-based palliative care (CBPC) plays an integral role in addressing the complex care needs of older adults with serious chronic illnesses, but is premised on effective communication and collaboration between primary care providers (PCPs) and the providers of specialty palliative care (SPC). Optimal strategies to achieve the goal of coordinated care are ill-defined. OBJECTIVE The objective of this study was to understand the facilitators and barriers to optimal, coordinated interdisciplinary provision of CBPC. METHODS This was a qualitative study using a constructivist grounded theory approach. Thirty semistructured interviews were conducted with primary and palliative care interdisciplinary team members in academic and community settings. RESULTS Major categories emerging from the data that positively or negatively influence optimal provision of coordinated care included feedback loops and interactions; clarity of roles; knowledge of palliative care, and workforce and structural constraints. Facilitators were frequent in-person, e-mail, or electronic medical record-based communication; defined role boundaries; and education of PCPs to distinguish elements of generalist palliative care (GPC) and more complex elements or situations requiring SPC. Barriers included inadequate communication that prevented a shared understanding of patients' needs and goals of care, limited time in primary care to provide GPC, and limited workforce in SPC. CONCLUSIONS Our findings suggest that processes are needed that promote communication, including structured communication strategies between PCPs and SPC providers, clarification of role boundaries, enrichment of nonspecialty providers' competence in GPC, and enhanced access to CBPC.
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Affiliation(s)
- Nancy Dudley
- 1 Department of Social and Behavioral Sciences, School of Nursing, University of California , San Francisco, California.,2 San Francisco Veterans Affairs Medical Center , Geriatrics, Palliative, and Extended Care, San Francisco, California
| | - Christine S Ritchie
- 3 Division of Geriatrics, Department of Medicine, University of California , San Francisco, California
| | - Roberta S Rehm
- 4 Department of Family Health Care Nursing and School of Nursing, University of California , San Francisco, California
| | - Susan A Chapman
- 1 Department of Social and Behavioral Sciences, School of Nursing, University of California , San Francisco, California
| | - Margaret I Wallhagen
- 5 Department of Physiological Nursing, School of Nursing, University of California , San Francisco, California
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Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol 2018; 19:e588-e653. [DOI: 10.1016/s1470-2045(18)30415-7] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/16/2018] [Accepted: 05/22/2018] [Indexed: 02/06/2023]
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Bonsignore L, Bloom N, Steinhauser K, Nichols R, Allen T, Twaddle M, Bull J. Evaluating the Feasibility and Acceptability of a Telehealth Program in a Rural Palliative Care Population: TapCloud for Palliative Care. J Pain Symptom Manage 2018; 56:7-14. [PMID: 29551433 DOI: 10.1016/j.jpainsymman.2018.03.013] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/09/2018] [Accepted: 03/10/2018] [Indexed: 12/25/2022]
Abstract
CONTEXT The impact of telehealth and remote patient monitoring has not been well established in palliative care populations in rural communities. OBJECTIVES The objectives of this study were to 1) describe a telehealth palliative care program using the TapCloud remote patient monitoring application and videoconferencing; 2) evaluate the feasibility, usability, and acceptability of a telehealth system in palliative care; and 3) use a quality data assessment collection tool in addition to TapCloud ratings of symptom burden and hospice transitions. METHODS A mixed-methods approach was used to assess feasibility, usability, and acceptability. Quantitative assessments included patient symptom burden and improvement, hospice transitions, and advanced directives. Qualitative semistructured interviews on a subpopulation of telehealth patients, caregivers, and providers were performed to learn about their experiences using TapCloud. RESULTS One-hundred one palliative care patients in rural Western North Carolina were enrolled in the program. The mean age of patients enrolled was 72 years, with a majority (60%) being female and a pulmonary diagnosis accounting for the largest percentage of patients (23%). Remote patient monitoring using TapCloud resulted in improved symptom management, and patients in the model had a hospice transition rate of 35%. Patients, caregivers, and providers reported overwhelmingly positive experiences with telehealth with three main advantages: 1) access to clinicians, 2) quick responses, and 3) improved efficiency and quality of care. CONCLUSION This is one of the first articles to describe a telehealth palliative care program and to demonstrate acceptability, feasibility, and usability as well as describe symptom outcomes and hospice transitions.
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Affiliation(s)
| | - Nicholas Bloom
- Duke University Medical Center, Durham, North Carolina, USA
| | | | - Reginald Nichols
- Four Seasons Compassion for Life, Flat Rock, North Carolina, USA
| | - Todd Allen
- Four Seasons Compassion for Life, Flat Rock, North Carolina, USA
| | | | - Janet Bull
- Four Seasons Compassion for Life, Flat Rock, North Carolina, USA
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Community-Based Palliative Care Leader Perspectives on Staffing, Recruitment, and Training. J Hosp Palliat Nurs 2018; 20:146-152. [DOI: 10.1097/njh.0000000000000419] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Jones CA, Kamal AH. The Palliative Care Specialists Series: Equipping the Field for Upstream Care. J Palliat Med 2018; 21:249. [PMID: 29393771 DOI: 10.1089/jpm.2017.0677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Christopher A Jones
- 1 Department of Medicine, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,2 Palliative and Advanced Illness Research Center, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Arif H Kamal
- 3 Duke Cancer Institute and Duke Fuqua School of Business, Duke University , Durham, North Carolina
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Dudley N, Ritchie CS, Wallhagen MI, Covinsky KE, Cooper BA, Patel K, Stijacic Cenzer I, Chapman SA. Characteristics of Older Adults in Primary Care Who May Benefit From Primary Palliative Care in the U.S. J Pain Symptom Manage 2018; 55:217-225. [PMID: 28916294 DOI: 10.1016/j.jpainsymman.2017.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/01/2017] [Accepted: 09/01/2017] [Indexed: 12/25/2022]
Abstract
CONTEXT Older adults with advanced illness and associated symptoms may benefit from primary palliative care, but limited data exist to identify older adults in U.S. primary care to benefit from this care. OBJECTIVES To describe U.S. primary care visits among adults aged 65 years and older with advanced illness. METHODS Cross-sectional analysis of the National Ambulatory and Hospital Ambulatory Medical Care Surveys (2009-2011) was conducted using Chi-squared tests to compare visits without and with advanced illness with U.S. primary care defined by National Committee for Quality Assurance Palliative and End-of-Life Care Physician Performance Measurement Set International Classification of Diseases, Ninth Revision (ICD-9) codes for end-stage illness. RESULTS Among visits by older adults to primary care, 7.9% visits were related to advanced illness. A higher proportion of advanced illness visits was among men vs. women (8.9% vs. 7.2%; P = 0.03) and adults aged 75 years and older, non-Hispanic whites (8.3%) and blacks (8.2%) vs. Hispanic (6.7%) and non-Hispanic other (2.5%) (P = 0.02), dually eligible for Medicare and Medicaid, and from patient ZIP Codes with lower median household incomes (below $32,793). A higher percentage of visits with advanced illness conditions to primary care was chronic obstructive pulmonary disease, congestive heart failure, dementia, and cancer, and symptoms reported with these visits were mostly pain, depression, anxiety, fatigue, and insomnia. CONCLUSION In the U.S., approximately 8% primary care visits among older adults was related to advanced illness conditions. Advanced illness visits were most common among those most likely to be socioeconomically vulnerable and highlight the need to focus efforts for high-quality palliative care for these populations.
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Affiliation(s)
- Nancy Dudley
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, California, USA; San Francisco Veterans' Affair Medical Center, Geriatrics, Palliative & Extended Care, San Francisco, California, USA.
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Margaret I Wallhagen
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, California, USA
| | - Kenneth E Covinsky
- San Francisco Veterans' Affair Medical Center, Geriatrics, Palliative & Extended Care, San Francisco, California, USA; Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Bruce A Cooper
- Dean's Office, School of Nursing, University of California, San Francisco, California, USA
| | - Kanan Patel
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Irena Stijacic Cenzer
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Susan A Chapman
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, California, USA
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Bull J, Kamal AH, Harker M, Bonsignore L, Morris J, Massie L, Singh Bhullar P, Hendrix M, Bennett D, Taylor D. Tracking Patients in Community-Based Palliative Care through the Centers for Medicare & Medicaid Services Healthcare Innovation Project. J Palliat Med 2017; 20:1231-1236. [DOI: 10.1089/jpm.2017.0080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Janet Bull
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Arif H. Kamal
- Duke University Medical Center, Durham, North Carolina
| | | | | | - John Morris
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Lisa Massie
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | | | - Mark Hendrix
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Deeana Bennett
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Don Taylor
- Duke Sanford School of Policy, Durham, North Carolina
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Kamal AH, Taylor DH, Neely B, Harker M, Bhullar P, Morris J, Bonsignore L, Bull J. One Size Does Not Fit All: Disease Profiles of Serious Illness Patients Receiving Specialty Palliative Care. J Pain Symptom Manage 2017; 54:476-483. [PMID: 28751079 DOI: 10.1016/j.jpainsymman.2017.07.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Understanding the symptom profiles of seriously ill patients who receive palliative care, especially noncancer diagnoses where the data are sparse and are critical to better targeting our resources to the needs of patients. METHODS We performed a retrospective, multicohort study of patients evaluated during their first consultative palliative care visit in a community-based palliative care registry. We placed into one of seven major disease categories based on clinician-reported primary diagnosis for consultation. Our primary aim of this analysis was to determine the univariate association between several patient-specific characteristics (e.g., demographics, care of setting, initial screening score) and the primary diagnosis. RESULTS We evaluated the first visit consultation records of 1615 patients. Most prevalent diagnosis was Neurologic (564; 35%), followed by Cardiovascular (266; 16%), Pulmonary (229; 14%), and Cancer (208; 13%). Patients in the study with the highest symptom burden were those diagnosed with cancer or pulmonary disease, with 45% and 37% of cancer and pulmonary patients, respectively, having two or more moderate-to-severe symptoms; 26% of cardiovascular disease patients reported two or more moderate-to-severe symptoms, whereas 11% reported three or more. Patients with a neurologic or infectious diagnosis had less symptom burden, but a large percentage of neurologic patients were unable to respond. DISCUSSION This study is one of the first to describe symptom burden and functional scores by diagnostic categories and care settings across a community-based interdisciplinary specialty palliative care program. Results demonstrated statistically significant and clinically relevant differences among settings of care, functional status, and symptom profiles between patients with various serious illnesses.
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Affiliation(s)
- Arif H Kamal
- Duke Cancer Institute and Fuqua School of Business, Duke University, Durham, USA.
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Benjamin Neely
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Matthew Harker
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - John Morris
- Four Seasons, Hendersonville, North Carolina, USA
| | | | - Janet Bull
- Four Seasons, Hendersonville, North Carolina, USA
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Bajwah S, Yi D, Grande G, Todd C, Costantini M, Murtagh FE, Evans CJ, Higginson IJ. The effectiveness and cost‐effectiveness of inpatient specialist palliative care in acute hospitals for adults with advanced illness and their caregivers. Cochrane Database Syst Rev 2017; 2017:CD012780. [PMCID: PMC6483755 DOI: 10.1002/14651858.cd012780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
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Affiliation(s)
- Sabrina Bajwah
- Cicely Saunders Institute, King's College LondonDepartment of Palliative Care, Policy and RehabilitationBessemer RoadLondonUKSE5 9PJ
| | - Deokhee Yi
- Cicely Saunders Institute, King's College LondonDepartment of Palliative Care, Policy and RehabilitationBessemer RoadLondonUKSE5 9PJ
| | - Gunn Grande
- University of ManchesterSchool of Health Sciences, and Manchester Academic Health Science CentreJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Chris Todd
- University of ManchesterSchool of Health Sciences, and Manchester Academic Health Science CentreJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | | | - Fliss E Murtagh
- King's College LondonDepartment of Palliative Care, Policy and Rehabilitation, Cicely Saunders InstituteLondonUK
| | - Catherine J Evans
- King's College LondonDepartment of Palliative Care, Policy and Rehabilitation, Cicely Saunders InstituteLondonUK
| | - Irene J Higginson
- King's College LondonDepartment of Palliative Care, Policy and Rehabilitation, Cicely Saunders InstituteLondonUK
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Riedel RF, Slusser K, Power S, Jones CA, LeBlanc TW, Kamal AH, Desai D, Allen D, Yu Y, Wolf S, Galanos AN. Improvements in Patient and Health System Outcomes Using an Integrated Oncology and Palliative Medicine Approach on a Solid Tumor Inpatient Service. J Oncol Pract 2017; 13:e738-e748. [DOI: 10.1200/jop.2017.022749] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose: Early palliative care (PC) improves outcomes for outpatients with advanced cancer. Its effect on hospitalized patients with cancer is unknown. Herein, we report on the influence of a novel, fully integrated inpatient medical oncology and PC partnership at a tertiary medical center during its first year of implementation. Methods: We conducted a retrospective, longitudinal, pre- and postintervention cohort study at Duke University Hospital. Pre- and postintervention cohorts were defined as all patients admitted to the solid tumor inpatient service from September 1, 2009, to June 30, 2010, and September 1, 2011 to June 30, 2012, respectively. We extracted patient data, including demographics, cancer diagnosis, disease status, length of stay, intensive care unit transfer rate, discharge disposition, time to emergency department return, time to readmission, and 7- and 30-day emergency department return and readmission rates. Nursing and physician surveys assessed satisfaction. Descriptive statistics, and Kruskal-Wallis and Χ2 tests were used to describe and compare cohorts. A generalized estimating equation accounted for repeated measures. Results: Pre- and postintervention analysis cohorts included 731 and 783 patients, respectively, representing a total of 1,514 patients and 2,353 encounters. Cohorts were similar in baseline characteristics. Statistically significant lower odds in 7-day readmission rates were observed in the postintervention cohort (adjusted odds ratio, 0.76; 95% CI, 0.58 to 1.00; P = .0482). Patients in the postintervention group had a decrease in mean length of stay (−0.30 days; 95% CI, −0.62 to 0.02); P = .0651). We observed a trend for increasing hospice referrals ( P = .0837) and a 15% decrease in intensive care unit transfers ( P = .61). Physicians and nurses universally favored the model. Conclusion: A fully integrated inpatient partnership between PC and medical oncology is associated with significant and clinically meaningful improvements in key health system–related outcomes and indicators of quality cancer care.
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Affiliation(s)
- Richard F. Riedel
- Duke University Health System; Duke University School of Medicine, Durham NC; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kim Slusser
- Duke University Health System; Duke University School of Medicine, Durham NC; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Steve Power
- Duke University Health System; Duke University School of Medicine, Durham NC; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christopher A. Jones
- Duke University Health System; Duke University School of Medicine, Durham NC; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Thomas W. LeBlanc
- Duke University Health System; Duke University School of Medicine, Durham NC; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Arif H. Kamal
- Duke University Health System; Duke University School of Medicine, Durham NC; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Devi Desai
- Duke University Health System; Duke University School of Medicine, Durham NC; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Deborah Allen
- Duke University Health System; Duke University School of Medicine, Durham NC; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yinxi Yu
- Duke University Health System; Duke University School of Medicine, Durham NC; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Steven Wolf
- Duke University Health System; Duke University School of Medicine, Durham NC; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Anthony N. Galanos
- Duke University Health System; Duke University School of Medicine, Durham NC; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Bull J, Kamal AH, Harker M, Taylor DH, Bonsignore L, Morris J, Massie L, Singh Bhullar P, Howell M, Hendrix M, Bennett D, Abernethy A. Standardization and Scaling of a Community-Based Palliative Care Model. J Palliat Med 2017; 20:1237-1243. [PMID: 28813635 DOI: 10.1089/jpm.2017.0027] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although limited, the descriptions of Community-Based Palliative Care (CBPC) demonstrates variability in team structures, eligibility, and standardization across care settings. OBJECTIVE In 2014, Four Seasons Compassion for Life, a nonprofit hospice and palliative care (PC) organization in Western North Carolina (WNC), was awarded a Centers for Medicare and Medicaid Services Health Care Innovation (CMMI) Award to expand upon their existing innovative model to implement, evaluate, and demonstrate CBPC in the United States. The objective of this article is to describe the processes and challenges of scaling and standardizing the CBPC model. DESIGN Four Season's CBPC model serves patients in both inpatient and outpatient settings using an interdisciplinary team to address symptom management, psychosocial/spiritual care, advance care planning, and patient/family education. Medicare beneficiaries who are ≥65 years of age with a life-limiting illness were eligible for the CMMI project. RESULTS The CBPC model was scaled across numerous counties in WNC and Upstate South Carolina. Over the first two years of the project, scaling occurred into 21 counties with the addition of 2 large hospitals, 52 nursing facilities, and 2 new clinics. To improve efficiency and effectiveness, a PC screening referral guide and a risk stratification approach were developed and implemented. Care processes, including patient referral and initial visit, were mapped. CONCLUSION This article describes an interdisciplinary CBPC model in all care settings to individuals with life-limiting illness and offers guidance for risk stratification assessments and mapping care processes that may help PC programs as they develop and work to improve efficiencies.
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Affiliation(s)
- Janet Bull
- 1 Four Seasons Compassion for Life , Flat Rock, North Carolina
| | - Arif H Kamal
- 2 Duke University Medical Center , Durham, North Carolina
| | - Matthew Harker
- 2 Duke University Medical Center , Durham, North Carolina
| | | | | | - John Morris
- 1 Four Seasons Compassion for Life , Flat Rock, North Carolina
| | - Lisa Massie
- 1 Four Seasons Compassion for Life , Flat Rock, North Carolina
| | | | - Mary Howell
- 1 Four Seasons Compassion for Life , Flat Rock, North Carolina
| | - Mark Hendrix
- 1 Four Seasons Compassion for Life , Flat Rock, North Carolina
| | - Deeana Bennett
- 1 Four Seasons Compassion for Life , Flat Rock, North Carolina
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Kaufmann TL, Kamal AH. Oncology and Palliative Care Integration: Cocreating Quality and Value in the Era of Health Care Reform. J Oncol Pract 2017; 13:580-588. [PMID: 28682666 DOI: 10.1200/jop.2017.023762] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Recent payment reforms in health care have spurred thinking regarding how strengthened partnerships can cocreate quality and value. Oncology is an important area in which to consider further collaborations in patient care, as a result of increasing treatment complexity from an expanding armamentarium of interventions, large resource expenditures related to cancer care, and a growing disease prevalence related to an aging population. Many have highlighted the important role of palliative care in the routine care of patients with advanced cancer and high symptom burden. Yet, how integration can occur that translates research into usual clinical practice while prioritizing the right patients and settings to maximize outcomes of interest has been inadequately described. We review the evidence for integration of palliative care into routine oncology care and then map the benefits to the requirements put forward by the Centers for Medicare and Medicaid Services Oncology Care Model as a use case; we also discuss applications to other evolving payment models.
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Affiliation(s)
- Tara L Kaufmann
- University of Pennsylvania, Philadelphia, PA; and Duke Cancer Institute, Durham, NC
| | - Arif H Kamal
- University of Pennsylvania, Philadelphia, PA; and Duke Cancer Institute, Durham, NC
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Correa-Casado M, Granero-Molina J, Hernández-Padilla JM, Fernández-Sola C. [Transferring palliative-care patients from hospital to community care: A qualitative study]. Aten Primaria 2017; 49:326-334. [PMID: 27842728 PMCID: PMC6876029 DOI: 10.1016/j.aprim.2016.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/14/2016] [Accepted: 09/02/2016] [Indexed: 11/05/2022] Open
Abstract
AIM To know the experience of case-manager nurses with regard to transferring palliative-care patients from the hospital to their homes. DESIGN Qualitative phenomenological study carried out in 2014-2015. SETTING Poniente and Almería health districts, which referral hospitals are Poniente Hospital and Torrecárdenas Hospital, respectively. PARTICIPANTS A purposive sample comprised of 12 case-manager nurses was recruited from the aforementioned setting. METHOD Theoretical data saturation was achieved after performing 7 in-depth individual interviews and 1 focus group. Data analysis was performed following Colaizzi's method. RESULTS Three themes emerged: (1) 'Case-management nursing as a quality, patient-centred service' (2) 'Failures of the information systems', with the subthemes "patients" insufficient and inadequate previous information" and "ineffective between-levels communication channels for advanced nursing"; (3) 'Deficiencies in discharge planning', with the subthemes "deficient management of resources on admission", "uncertainty about discharge" and "insufficient human resources to coordinate the transfer". CONCLUSIONS Case-manager nurses consider themselves a good-quality service. However, they think there are issues with coordination, information and discharge planning of palliative patients from hospital. It would be useful to review the communication pathways of both care and discharge reports, so that resources needed by palliative patients are effectively managed at the point of being transferred home.
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Affiliation(s)
- Matías Correa-Casado
- Agencia Pública Empresarial Sanitaria Hospital de Poniente, El Ejido, Almería, España
| | - José Granero-Molina
- Departamento de Enfermería, Fisioterapia y Medicina, Universidad de Almería, Investigador asociado, Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Temuco, Chile
| | | | - Cayetano Fernández-Sola
- Departamento de Enfermería, Fisioterapia y Medicina, Universidad de Almería, Investigador asociado, Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Temuco, Chile.
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Kamal AH, Kaufmann T. Making the Right Thing Easier to Do: Standardized Integration of Oncology and Palliative Care. J Oncol Pract 2017; 13:291-292. [DOI: 10.1200/jop.2017.021717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Arif H. Kamal
- Duke University School of Medicine, Fuqua School of Business, and Duke Cancer Institute, Durham, NC; and University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Tara Kaufmann
- Duke University School of Medicine, Fuqua School of Business, and Duke Cancer Institute, Durham, NC; and University of Pennsylvania School of Medicine, Philadelphia, PA
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Reid MC, Ghesquiere A, Kenien C, Capezuti E, Gardner D. Expanding palliative care's reach in the community via the elder service agency network. ANNALS OF PALLIATIVE MEDICINE 2017; 6:S104-S107. [PMID: 28595429 DOI: 10.21037/apm.2017.03.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 02/06/2017] [Indexed: 11/06/2022]
Abstract
Over the past two decades, palliative care has established itself as a promising approach to address the complex needs of individuals with advanced illness. Palliative care is well-established in US hospitals and has recently begun to expand outside of the hospital setting to meet the needs of non-hospitalized individuals. Experts have called for the development of innovative community-based models that facilitate delivery of palliative care to this target population. Elder service agencies are important partners that researchers should collaborate with to develop new and promising models. Millions of older adults receive aging network services in the U.S., highlighting the potential reach of these models. Recent health care reform efforts provide support for community-based initiatives, where coordination of care and services, delivered via health and social service agencies, is highly prioritized. This article describes the rationale for developing such approaches, including efforts to educate elder service agency clients about palliative care; training agency staff in palliative care principles; building capacity for elder services providers to screen individuals for palliative care needs; embedding palliative care "champions" in agencies to educate staff and clients and coordinate access to services among those with palliative care needs; and leveraging telehealth resources to conduct comprehensive assessments by hospital palliative care teams for elder service clients who have palliative care needs. We maintain that leveraging the resources of elder service agencies could measurably expand the reach of palliative care in the community.
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Affiliation(s)
- M Carrington Reid
- Department of Medicine, Weill Cornell Medical Center, New York, NY, USA.
| | - Angela Ghesquiere
- Brookdale Center for Healthy Aging, Hunter College of CUNY, New York, NY, USA
| | - Cara Kenien
- Department of Medicine, Weill Cornell Medical Center, New York, NY, USA
| | - Elizabeth Capezuti
- Hunter-Bellevue School of Nursing, Hunter College of CUNY, New York, NY, USA
| | - Daniel Gardner
- Brookdale Center for Healthy Aging, Hunter College of CUNY, New York, NY, USA
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67
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Pimentel LE, De La Cruz M, Wong A, Castro D, Bruera E. Snapshot of an Outpatient Supportive Care Center at a Comprehensive Cancer Center. J Palliat Med 2017; 20:433-436. [DOI: 10.1089/jpm.2016.0370] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lindsey E. Pimentel
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Maxine De La Cruz
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Angelique Wong
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Debra Castro
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Ankuda CK, Kersting K, Guetterman TC, Haefner J, Fonger E, Paletta M, Hopp F. What Matters Most? A Mixed Methods Study of Critical Aspects of a Home-Based Palliative Program. Am J Hosp Palliat Care 2017; 35:236-243. [PMID: 28166640 DOI: 10.1177/1049909117691929] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Home-based palliative care programs have shown value in improving quality of care and lowering costs for seriously ill patients. It is unknown what specific elements of these programs matter most to patients and caregivers. AIM To identify what services are critical and why they matter to patients in a home-based palliative program. SETTING/PARTICIPANTS A mixed methods study of 18 participants in the At Home Support (AHS) program in Southeast Michigan. MEASUREMENTS Two semistructured interviews were conducted for each participant, one while enrolled in AHS and another 3 months after the program ended to elicit the impact of AHS on their care. Qualitative theme data were merged with quantitative data on demographics, social and financial resources, symptoms, medical conditions, functional status, and utilization of health care while in AHS. RESULTS Four major themes of critical services reported by distinct populations of participants were described-medical support, endorsed by nearly every participant; emotional and spiritual support, endorsed by those with serious illness and symptom burden; practical assistance, endorsed by those with functional disability and isolation; and social services, endorsed by those in poverty. Medical monitoring was also described as critical but only by healthier participants. CONCLUSION This study presents a conceptual model of the critical services in home-based palliative care and why these services are important to high-risk patients. This model may be used to guide further research and evaluation work on the benefits of home-based palliative care.
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Affiliation(s)
- Claire K Ankuda
- 1 Robert Wood Johnson Clinical Scholars Program, University of Michigan, Ann Arbor, MI, USA.,2 Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kaileen Kersting
- 3 School of Social Work, University of Michigan, Ann Arbor, MI, USA
| | | | - Jessica Haefner
- 1 Robert Wood Johnson Clinical Scholars Program, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Faith Hopp
- 5 School of Social Work, Wayne State University, Detroit, MI, USA
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Lester PE, Kawai F, Rodrigues L, Lolis J, Martins-Welch D, Shalshin A, Fazzari MJ, Pan CX. Palliative Care in New York State Nursing Homes: A Descriptive Study. Am J Hosp Palliat Care 2017; 35:203-210. [DOI: 10.1177/1049909117691229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To describe the current landscape of palliative care (PC) in nursing homes (NHs) in New York State (NYS). Measurements: A statewide survey was completed by 149 respondents who named 61 different NHs as their workplace. Questions were related to presence, type, and composition of PC programs; perceptions of PC; barriers to implementing PC; and qualifying medical conditions. Results: Hospice is less available than palliative or comfort care programs, with three-fourths of NYS NH responded providing a PC program. In general, medical directors and physicians were more similar in perspective about the role/impact of PC compared to nursing and others. There was general agreement about the positive impact and role of PC in the NH. Funding and staffing were recognized as barriers to implementing PC. Conclusion: There is growing penetration of PC programs in NH facilities in NYS, with good perception of the appropriate utilization of PC programs. Financial reimbursement and staffing are barriers to providing PC in the NH and need to be addressed by the health-care system.
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Affiliation(s)
- Paula E. Lester
- Division of Geriatric Medicine, Winthrop University Hospital, Mineola, NY, USA
| | - Fernando Kawai
- Division of Geriatrics and Palliative Care Medicine, Weill Cornell Medical College, New York–Presbyterian Queens, Flushing, NY, USA
| | - Lucan Rodrigues
- Division of Palliative Care, Flushing Hospital Medical Center, Flushing, NY, USA
| | - James Lolis
- Division of Geriatric and Palliative Medicine, Hofstra Northwell School of Medicine, Great Neck, NY, USA
- Department of Medicine, Highfield Gardens Care Center, Great Neck, NY, USA
| | - Diana Martins-Welch
- Division of Geriatric and Palliative Medicine, Hofstra Northwell School of Medicine, Great Neck, NY, USA
- Department of Medicine, Highfield Gardens Care Center, Great Neck, NY, USA
| | - Alexander Shalshin
- Division of Palliative Medicine, Plainview–Syosset Hospitals, Northwell Health, Great Neck, NY, USA
| | - Melissa J. Fazzari
- Department of Biostatistics, Stony Brook University School of Medicine, Winthrop University Hospital, Mineola, NY, USA
| | - Cynthia X. Pan
- Division of Geriatrics and Palliative Care Medicine, Weill Cornell Medical College, New York–Presbyterian Queens, Flushing, NY, USA
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Seymour J, Cassel B. Palliative care in the USA and England: a critical analysis of meaning and implementation towards a public health approach. ACTA ACUST UNITED AC 2016. [DOI: 10.1080/13576275.2016.1270262] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jane Seymour
- School of Nursing and Midwifery, the University of Sheffield, Barber House Annex, Sheffield, UK
| | - Brian Cassel
- Cancer Informatics, Massey Cancer Centre, Virginia Commonwealth University, Richmond, VA, USA
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Kamal AH. "Who Does What?" Ensuring High-Quality and Coordinated Palliative Care With Our Oncology Colleagues. J Pain Symptom Manage 2016; 52:e1-e2. [PMID: 27686601 DOI: 10.1016/j.jpainsymman.2016.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 08/21/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Arif H Kamal
- Division of Medical Oncology and Duke Palliative Care, Duke Cancer Institute, Duke School of Medicine, Durham, North Carolina, USA.
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Kavalieratos D, Corbelli J, Zhang D, Dionne-Odom JN, Ernecoff NC, Hanmer J, Hoydich ZP, Ikejiani DZ, Klein-Fedyshin M, Zimmermann C, Morton SC, Arnold RM, Heller L, Schenker Y. Association Between Palliative Care and Patient and Caregiver Outcomes: A Systematic Review and Meta-analysis. JAMA 2016; 316:2104-2114. [PMID: 27893131 PMCID: PMC5226373 DOI: 10.1001/jama.2016.16840] [Citation(s) in RCA: 705] [Impact Index Per Article: 88.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE The use of palliative care programs and the number of trials assessing their effectiveness have increased. OBJECTIVE To determine the association of palliative care with quality of life (QOL), symptom burden, survival, and other outcomes for people with life-limiting illness and for their caregivers. DATA SOURCES MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL to July 2016. STUDY SELECTION Randomized clinical trials of palliative care interventions in adults with life-limiting illness. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data. Narrative synthesis was conducted for all trials. Quality of life, symptom burden, and survival were analyzed using random-effects meta-analysis, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-palliative care scale (FACIT-Pal) instrument (range, 0-184 [worst-best]; minimal clinically important difference [MCID], 9 points); and symptom burden translated to the Edmonton Symptom Assessment Scale (ESAS) (range, 0-90 [best-worst]; MCID, 5.7 points). MAIN OUTCOMES AND MEASURES Quality of life, symptom burden, survival, mood, advance care planning, site of death, health care satisfaction, resource utilization, and health care expenditures. RESULTS Forty-three RCTs provided data on 12 731 patients (mean age, 67 years) and 2479 caregivers. Thirty-five trials used usual care as the control, and 14 took place in the ambulatory setting. In the meta-analysis, palliative care was associated with statistically and clinically significant improvements in patient QOL at the 1- to 3-month follow-up (standardized mean difference, 0.46; 95% CI, 0.08 to 0.83; FACIT-Pal mean difference, 11.36] and symptom burden at the 1- to 3-month follow-up (standardized mean difference, -0.66; 95% CI, -1.25 to -0.07; ESAS mean difference, -10.30). When analyses were limited to trials at low risk of bias (n = 5), the association between palliative care and QOL was attenuated but remained statistically significant (standardized mean difference, 0.20; 95% CI, 0.06 to 0.34; FACIT-Pal mean difference, 4.94), whereas the association with symptom burden was not statistically significant (standardized mean difference, -0.21; 95% CI, -0.42 to 0.00; ESAS mean difference, -3.28). There was no association between palliative care and survival (hazard ratio, 0.90; 95% CI, 0.69 to 1.17). Palliative care was associated consistently with improvements in advance care planning, patient and caregiver satisfaction, and lower health care utilization. Evidence of associations with other outcomes was mixed. CONCLUSIONS AND RELEVANCE In this meta-analysis, palliative care interventions were associated with improvements in patient QOL and symptom burden. Findings for caregiver outcomes were inconsistent. However, many associations were no longer significant when limited to trials at low risk of bias, and there was no significant association between palliative care and survival.
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Affiliation(s)
- Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania2Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania3Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Jennifer Corbelli
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Di Zhang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Natalie C Ernecoff
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Janel Hanmer
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Zachariah P Hoydich
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dara Z Ikejiani
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Camilla Zimmermann
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada8Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania2Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lucas Heller
- Division of Endocrinology, Department of Medicine, University of Pittsburgh, Pittsburgh
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania2Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Enhancing psychosocial and spiritual palliative care: Four-year results of the program of comprehensive care for people with advanced illnesses and their families in Spain. Palliat Support Care 2016; 15:98-109. [DOI: 10.1017/s1478951516000857] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractObjective:We aimed to describe the overall quantitative and qualitative results of a “La Caixa” Foundation and World Health Organization Collaborating Center Program entitled “Comprehensive Care for Patients with Advanced Illnesses and their Families” after four years of experience.Method:Qualitative and quantitative methods were employed to assess the program. Quasiexperimental, prospective, multicenter, single-group, and pretest/posttest methods were utilized to assess the quantitative data. The effectiveness of psychosocial interventions was assessed at baseline (visit 1) and after four follow-up visits. The following dimensions were assessed: mood state, discomfort, anxiety, degree of adjustment or adaptation to disease, and suffering. We also assessed the four dimensions of the spiritual pain scale: faith or spiritual beliefs, valuable faith or spiritual beliefs, meaning in life, and peace of mind/forgiveness. Qualitative analyses were performed via surveys to evaluate stakeholder satisfaction.Results:We built 29 psychosocial support teams involving 133 professionals—mainly psychologists and social workers. During the study period, 8,964 patients and 11,810 family members attended. Significant improvements were observed in the psychosocial and spiritual dimensions assessed. Patients, family members, and stakeholders all showed high levels of satisfaction.Significance of Results:This model of psychosocial care could serve as an example for other countries that wish to improve psychosocial and spiritual support. Our results confirm that specific psychosocial interventions delivered by well-trained experts can help to ease suffering and discomfort in end-of-life and palliative care patients, particularly those with high levels of pain or emotional distress.
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74
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Evans BC, Coon DW. The "Reckoning Point" as a Marker for Formal Palliative and End-of-Life Care in Mexican American Families. JOURNAL OF FAMILY NURSING 2016; 22:606-630. [PMID: 27903942 DOI: 10.1177/1074840716677994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Palliative and end-of-life care (PEOLC) in Mexican American (MA) caregiving families remains unexplored. Its onset was uncovered in our mixed methods, multisite, interdisciplinary, qualitative descriptive study of 116 caregivers, most of whom had provided long-term informal home care for chronically ill, disabled older family members. This subanalysis used Life Course Perspective to examine the "point of reckoning" in these families, where an older person is taken in for care, or care escalates until one recognizes oneself as the primary caregiver. Ninety-three of 116 caregivers recognized and spontaneously reported a "reckoning point" that initiated the caregiving trajectory, while eight cited "gradual decline" into caregiving for elders in their homes. This "reckoning point," which marks the assumption of this role, may afford a fertile opportunity for referral to community resources or initiation of formal PEOLC, thereby improving the quality of life for these older individuals and their families.
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75
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Daveson BA, Smith M, Yi D, McCrone P, Grande G, Todd C, Gysels M, Costantini M, Murtagh FE, Higginson IJ, Evans CJ. The effectiveness and cost-effectiveness of inpatient specialist palliative care in acute hospitals for adults with advanced illness and their caregivers. Hippokratia 2016. [DOI: 10.1002/14651858.cd011619.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Barbara A Daveson
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
| | - Melinda Smith
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
| | - Deokhee Yi
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
| | - Paul McCrone
- King's College London; Institute of Psychiatry; Box P024 De Crespigny Park London UK SE5 8AF
| | - Gunn Grande
- University of Manchester; School of Nursing, Midwifery and Social Work; Jean McFarlane Building Oxford Road Manchester Greater Manchester UK M13 9PL
| | - Chris Todd
- University of Manchester; School of Nursing, Midwifery and Social Work; Jean McFarlane Building Oxford Road Manchester Greater Manchester UK M13 9PL
| | - Marjolein Gysels
- University of Amsterdam; Amsterdam Institute of Social Science Research; Amsterdam Netherlands
| | - Massimo Costantini
- IRCCS Arcispedale S. Maria Nuova; Palliative Care Unit; Reggio Emilia Italy
| | - F E Murtagh
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
| | - Irene J Higginson
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
| | - Catherine J Evans
- King's College London; Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute; London UK
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76
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Rabow MW, Dahlin C, Calton B, Bischoff K, Ritchie C. New Frontiers in Outpatient Palliative Care for Patients With Cancer. Cancer Control 2016; 22:465-74. [PMID: 26678973 DOI: 10.1177/107327481502200412] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Although much evidence has accumulated demonstrating its benefit, relatively little is known about outpatient palliative care in patients with cancer. METHODS This paper reviews the literature and perspectives from content experts to describe the current state of outpatient palliative care in the oncology setting and current areas of innovation and promise in the field. RESULTS Evidence, including from controlled trials, documents the benefits of outpatient palliative care in the oncology setting. As a result, professional medical organizations have guidelines and recommendations based on the key role of palliative care in oncology. Six elements of the practice sit at the frontier of outpatient oncology palliative care, including the setting and timing of palliative care integration into outpatient oncology, the relationships between primary and specialty palliative care, quality and measurement, research, electronic and technical innovations, and finances. CONCLUSIONS Evidence of clinical and health care system benefits supports the recommendations of professional organizations to integrate palliative care into the routine treatment of patients with advanced cancer.
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77
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Spetz J, Dudley N, Trupin L, Rogers M, Meier DE, Dumanovsky T. Few Hospital Palliative Care Programs Meet National Staffing Recommendations. Health Aff (Millwood) 2016; 35:1690-7. [DOI: 10.1377/hlthaff.2016.0113] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Joanne Spetz
- Joanne Spetz ( ) is a professor of economics at the Philip R. Lee Institute for Health Policy Studies and the Healthforce Center at the University of California, San Francisco (UCSF)
| | - Nancy Dudley
- Nancy Dudley is a VA Quality Scholars fellow with the UCSF Department of Geriatrics and the San Francisco Veterans Affairs Medical Center
| | - Laura Trupin
- Laura Trupin is an epidemiologist in the Philip R. Lee Institute for Health Policy Studies at UCSF
| | - Maggie Rogers
- Maggie Rogers is senior research associate at the Center to Advance Palliative Care, in New York City
| | - Diane E. Meier
- Diane E. Meier is the director of the Center to Advance Palliative Care and a professor in the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, in New York City
| | - Tamara Dumanovsky
- Tamara Dumanovsky is a vice president for research and analytics at the Center to Advance Palliative Care
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78
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Riggs A, Breuer B, Dhingra L, Chen J, Hiney B, McCarthy M, Portenoy RK, Knotkova H. Hospice Enrollment After Referral to Community-Based, Specialist-Level Palliative Care: Incidence, Timing, and Predictors. J Pain Symptom Manage 2016; 52:170-7. [PMID: 27208866 DOI: 10.1016/j.jpainsymman.2016.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 02/11/2016] [Accepted: 02/29/2016] [Indexed: 11/29/2022]
Abstract
CONTEXT Referral to community-based palliative care may increase the likelihood of hospice enrollment. OBJECTIVES This retrospective cohort study evaluated the incidence, timing, and predictors of hospice enrollment after referral to a community-based palliative care program. METHODS Data from 1505 homebound patients referred to community-based palliative care during 2010-2013 were analyzed using multivariate linear and logistic regression. RESULTS Mean (SD) age was 70.4 (16.7) years; 58.8% were women, and race/ethnicity was diverse (white 32.9%, black 29.8%, Hispanic 28.6%, Asian 5.4%). Patients received palliative care services for a mean (SD) of 10.2 (10.2) months (median 6.9; range 0.03-52.2 months). A total of 362 patients (24.1%) were enrolled in hospice after receiving palliative care services for a mean (SD) of 4.8 (6.8) months (median 7.9; range 0.09-25.7 months). The median hospice length of stay was approximately twice as long as other patients enrolled in hospice during the same period. The probability of hospice enrollment increased with shorter duration of palliative care, cancer diagnosis, poorer performance status, and a lower likelihood of poverty. Similarly, significant predictors of a shorter duration of palliative care services before hospice enrollment included both sociodemographic and clinical factors. CONCLUSION Almost one-quarter of patients were enrolled in hospice while receiving community-based palliative care, and hospice length of stay was relatively long for those who did. Both sociodemographic and clinical characteristics were associated with hospice-related outcomes. Studies are needed to further explore predictors and outcomes of hospice enrollment from palliative care.
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Affiliation(s)
- Alexa Riggs
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Brenda Breuer
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Bronx, New York, USA
| | - Jack Chen
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Barbara Hiney
- MJHS Hospice and Palliative Care, New York, New York, USA
| | - Maureen McCarthy
- The Center for Hospice & Palliative Care, New York, New York, USA
| | - Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Bronx, New York, USA; Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Helena Knotkova
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Bronx, New York, USA.
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79
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Kaiser F, Sohm M, Illig D, Vehling-Kaiser U, Haas M. [Four years of specialized outpatient palliative care in a rural area : Cooperation and acceptability from general practitioners' view]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016; 59:916-20. [PMID: 27273302 DOI: 10.1007/s00103-016-2363-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In 2011, a specialized palliative home care was introduced in the counties of Landshut and Dingolfing. OBJECTIVES The aim of the current survey was to evaluate the cooperation, acceptance and need of palliative measures for patients particulary from the general practitioner's perspective. METHODS From January to March 2015, 198 general practitioners from the counties of Landshut and Dingolfing were contacted with questionnaires. The questionnaires consisted of 16 questions covering five different issues, and drew upon the practical experiences of the authors and earlier surveys from the literature. The questionnaires were sent by post containing a self-addressed and postpaid envelope. RESULTS Completed questionnaires from 40 out of 198 contacted general practitioners (33 % female and 53 % male). Of these 85 % had cooperated with a SAPV team, 23 % had taken part in training for palliative medicine, 10 % intended to acquire a qualification and 10 % could imagine working in a SAPV team. In addition, 75 % stated that hospitalizations were avoided through the use of SAPV while 73 % felt that time and costs were saved for their own practices. The majority of general practitioners were satisfied with the work provided by the SAPV and the cooperation. Regarding additional palliative care for geriatric patients, 60 % believed that this was sensible. One main critique was that the information about including a patient in the SAPV program was transferred to the general practitioner too late. CONCLUSION The current data show that general practitioners recognize the need for palliative medicine skills and predominately welcome the work of a specialized palliative care team in treating their patients. However, close cooperation and communication is necessary for a successful network between generalists and specialists in palliative care.
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Affiliation(s)
- Florian Kaiser
- Klinik für Hämatologie und Medizinische Onkologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - Michael Sohm
- Onkologisch-palliativmedizinisches Netzwerk Landshut, Landshut, Deutschland
| | - Daniela Illig
- Onkologisch-palliativmedizinisches Netzwerk Landshut, Landshut, Deutschland
| | | | - Michael Haas
- Onkologisch-palliativmedizinisches Netzwerk Landshut, Landshut, Deutschland
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Hochman MJ, Wolf S, Zafar SY, Portman D, Bull J, Kamal AH. Comparing Unmet Needs to Optimize Quality: Characterizing Inpatient and Outpatient Palliative Care Populations. J Pain Symptom Manage 2016; 51:1033-1039.e3. [PMID: 27046299 DOI: 10.1016/j.jpainsymman.2015.12.338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 12/11/2015] [Accepted: 12/22/2015] [Indexed: 11/26/2022]
Abstract
CONTEXT Palliative care (PC) consultation services are available in most hospitals; outpatient services are rapidly growing to meet the needs of patients at earlier stages of the disease trajectory. OBJECTIVES We aimed to compare the unmet needs of PC patients by location of care to better characterize these populations. METHODS This cross-sectional secondary analysis examined patients receiving hospital and outpatient-based PC across 10 community and academic organizations in the Global Palliative Care Quality Alliance. We identified unmet symptom, advance care planning, and functional needs within our database from October 23, 2012 to January 22, 2015. Kruskal-Wallis, chi-square, and Fisher exact tests were performed. RESULTS We evaluated 633 unique patients. Inpatients (n = 216) were older than outpatients (n = 417; 73 vs. 64 years, P < 0.0001). Seventy-six inpatients (38%) had a Palliative Performance Scale score ≤30%; no outpatients did (P < 0.0001). More inpatients rated their quality of life as poor compared with outpatients (39% vs. 21%, P = 0.0001). We found that outpatients presented with more unresolved pain than inpatients (58.5% vs. 4.1%, P < 0.0001). Conversely, more inpatients presented with unresolved anorexia (52.3% vs. 35.8%, P = 0.002) and dysphagia (28.1% vs. 5.4%, P < 0.0001) than outpatients. We found that inpatient setting was independently associated with lower performance status (odds ratio = 0.068, 95% confidence interval = 0.038-0.120, P < 0.0001). CONCLUSION Compared with inpatients, outpatients are more burdened by pain at first PC encounter yet experience higher quality of life and better performance status. These findings suggest different clinician skillsets, and assessments are needed depending on the setting of PC consultation.
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Affiliation(s)
| | - Steven Wolf
- Duke Biostatistics Core, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Syed Yousuf Zafar
- Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Diane Portman
- Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Janet Bull
- Four Seasons Compassion for Life, Hendersonville, North Carolina, USA
| | - Arif H Kamal
- Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA; Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
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Van Hoover C, Holt L. Midwifing the End of Life: Expanding the Scope of Modern Midwifery Practice to Reclaim Palliative Care. J Midwifery Womens Health 2016; 61:306-14. [PMID: 27148997 DOI: 10.1111/jmwh.12454] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 01/17/2016] [Accepted: 01/21/2016] [Indexed: 11/27/2022]
Abstract
Historically, midwives held an important role in society as cradle-to-grave practitioners who eased individuals, families, and communities through difficult transitions across the life span. In the United States, during the first half of the 20th century, physicians assumed care for people during birth and death, moving these elements of the human experience from homes into the hospital setting. These changes in practice resulted in a dehumanization of birth and death experiences and led to detachment from what it means to be human among members of society. There is a current movement across the United States to incorporate palliative care and hospice care into both the home setting and the inpatient setting. Through their education and training, certified nurse-midwives/certified midwives (CNMs/CMs) are well equipped to serve as hospice and palliative care clinicians. Current midwives, skilled in assisting women and families through the transition of pregnancy to motherhood, can use their education and skills to help individuals and their families through the transition from life to death. The similarities between these states of the human experience (pregnancy to birth and terminal illness to death) allow for a fluidity between these experiences from the midwife perspective. The many parallels between these 2 elements of the human condition include stress, anxiety, and pain. Training in holistic approaches to symptom management and supporting individuals through difficult experiences (eg, birth) gives midwives a unique perspective that is readily translatable to assist individuals and families through the passage between life and death.
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Kamal AH, Bull J, Ritchie CS, Kutner JS, Hanson LC, Friedman F, Taylor DH. Adherence to Measuring What Matters Measures Using Point-of-Care Data Collection Across Diverse Clinical Settings. J Pain Symptom Manage 2016; 51:497-503. [PMID: 26854995 DOI: 10.1016/j.jpainsymman.2015.12.313] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 12/15/2015] [Accepted: 12/24/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT Measuring What Matters (MWM) for palliative care has prioritized data collection efforts for evaluating quality in clinical practice. How these measures can be implemented across diverse clinical settings using point-of-care data collection on quality is unknown. OBJECTIVES To evaluate the implementation of MWM measures by exploring documentation of quality measure adherence across six diverse clinical settings inherent to palliative care practice. METHODS We deployed a point-of-care quality data collection system, the Quality Data Collection Tool, across five organizations within the Palliative Care Research Cooperative Group. Quality measures were recorded by clinicians or assistants near care delivery. RESULTS During the study period, 1989 first visits were included for analysis. Our population was mostly white, female, and with moderate performance status. About half of consultations were seen on hospital general floors. We observed a wide range of adherence. The lowest adherence involved comprehensive assessments during the first visit in hospitalized patients in the intensive care unit (2.71%); the highest adherence across all settings, with an implementation of >95%, involved documentation of management of moderate/severe pain. We observed differences in adherence across clinical settings especially with MWM Measure #2 (Screening for Physical Symptoms, range 45.7%-81.8%); MWM Measure #5 (Discussion of Emotional Needs, range 46.1%-96.1%); and MWM Measure #6 (Documentation of Spiritual/Religious Concerns, range 0-69.6%). CONCLUSION Variations in clinician documentation of adherence to MWM quality measures are seen across clinical settings. Additional studies are needed to better understand benchmarks and acceptable ranges for adherence tailored to various clinical settings.
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Affiliation(s)
| | - Janet Bull
- Four Seasons, Flat Rock, North Carolina, USA
| | | | - Jean S Kutner
- University of Colorado at Denver, Denver, Colorado, USA
| | - Laura C Hanson
- Palliative Care Program, Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Kamal AH, Bull J, Wolf S, Samsa GP, Swetz KM, Myers ER, Shanafelt TD, Abernethy AP. Characterizing the Hospice and Palliative Care Workforce in the U.S.: Clinician Demographics and Professional Responsibilities. J Pain Symptom Manage 2016; 51:597-603. [PMID: 26550934 DOI: 10.1016/j.jpainsymman.2015.10.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 10/21/2015] [Accepted: 10/23/2015] [Indexed: 11/25/2022]
Abstract
CONTEXT Palliative care services are growing at an unprecedented pace. Yet, the characteristics of the clinician population who deliver these services are not known. Information on the roles, motivations, and future plans of the clinician workforce would allow for planning to sustain and grow the field. OBJECTIVES To better understand the characteristics of clinicians within the field of hospice and palliative care. METHODS From June through December 2013, we conducted an electronic survey of American Academy of Hospice and Palliative Medicine members. We queried information on demographics, professional roles and responsibilities, motivations for entering the field, and future plans. We compared palliative care and hospice populations alongside clinician roles using chi-square analyses. Multivariable logistic regression was used to identify predictors of leaving the field early. RESULTS A total of 1365 persons, representing a 30% response rate, participated. Our survey findings revealed a current palliative care clinician workforce that is older, predominantly female, and generally with less than 10 years clinical experience in the field. Most clinicians have both clinical hospice and palliative care responsibilities. Many cite personal or professional growth or influential experiences during training or practice as motivations to enter the field. CONCLUSION Palliative care clinicians are a heterogeneous group. We identified motivations for entering the field that can be leveraged to sustain and grow the workforce.
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Affiliation(s)
- Arif H Kamal
- Duke Cancer Control and Population Sciences, Duke University, Durham, North Carolina, USA; Duke Cancer Institute, Duke University, Durham, North Carolina, USA.
| | - Janet Bull
- Four Seasons, Flat Rock, North Carolina, USA
| | - Steven Wolf
- Duke Cancer Control and Population Sciences, Duke University, Durham, North Carolina, USA
| | - Gregory P Samsa
- Duke Cancer Control and Population Sciences, Duke University, Durham, North Carolina, USA
| | | | - Evan R Myers
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA; Division of Clinical and Epidemiologic Research, Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
| | | | - Amy P Abernethy
- Duke Cancer Control and Population Sciences, Duke University, Durham, North Carolina, USA; Duke Cancer Institute, Duke University, Durham, North Carolina, USA
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Kamal AH, Bull J, Wolf SP, Portman D, Strand J, Johnson KS. Unmet Needs of African Americans and Whites at the Time of Palliative Care Consultation. Am J Hosp Palliat Care 2016; 34:461-465. [PMID: 26888883 DOI: 10.1177/1049909116632508] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
CONTEXT Differences among patient populations that present to consultative palliative care are not known. Such an appreciation would inform health-care delivery tailored to unique populations. OBJECTIVES We aimed to compare characteristics and palliative care needs of African Americans (AAs) and whites during initial palliative care consultation. METHODS We analyzed patient-reported, clinician-entered clinical encounter data from a large, multisite community-based, nonhospice palliative care collaborative. We included first specialty palliative care consultations from January 1, 2014, to July 2, 2015, across 15 sites within the Global Palliative Care Quality Alliance registry. Demographics, disease, performance status, advance care planning, and symptom prevalence/severity were compared. RESULTS Of 775 patients, 12.9% (N = 100) were AA. African Americans were younger (63 vs 75.4 years, P < .0001). A larger proportion of AAs had a diagnosis of cancer (45.0% vs 36.3%, P = .09) and in the hospital (71% vs 61.8%, P = .07). African Americans were more likely to have a Palliative Performance Score of 0 to 30 (35.6% vs 23.7%, P = .049). Around 50% in both racial groups were full code; slightly more than 40% had an advance directive. Nearly two-thirds in both racial groups reported 3 or more symptoms of any severity; one-third reported 3 or more moderate or severe symptoms. A larger proportion of Africans than whites reported pain of any severity (66.0% vs 56.1%, P = .06). CONCLUSION All patients present to palliative care consultations with significant symptom and advance care planning needs. Further research is needed to identify how to deliver palliative care: earlier, in noncancer conditions, and improve pain management in AA populations.
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Affiliation(s)
| | | | - Steven P Wolf
- 3 Duke Department of Biostatistics, Duke University, Durham, NC, USA
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Abstract
In May 2014, the World Health Assembly, of the World Health Organization (WHO), unanimously adopted a palliative care (PC) resolution, which outlines clear recommendations to the United Nations member states, such as including PC in national health policies and in the undergraduate curricula for health care professionals, and highlights the critical need for countries to ensure that there is an adequate supply of essential PC medicines, especially those needed to alleviate pain. This resolution also carries great challenges: Every year over 20 million patients (of which 6% are children) need PC at the end of life (EOL). However, in 2011, approximately three million patients received PC, and only one in ten people in need is currently receiving it. We describe this public health situation and systems failure, the history and evolution of PC, and the components of the WHO public health model. We propose a role for public health for PC integration in community settings to advance PC and relieve suffering in the world.
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Affiliation(s)
- Liliana De Lima
- International Association for Hospice and Palliative Care, Houston, Texas 77007;
| | - Tania Pastrana
- Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, Aachen 52074, Germany;
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Kamal AH, Harrison KL, Bakitas M, Dionne-Odom JN, Zubkoff L, Akyar I, Pantilat SZ, O'Riordan DL, Bragg AR, Bischoff KE, Bull J. Improving the Quality of Palliative Care Through National and Regional Collaboration Efforts. Cancer Control 2015; 22:396-402. [PMID: 26678966 PMCID: PMC5504698 DOI: 10.1177/107327481502200405] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The measurement and reporting of the quality of care in the field of palliation has become a required task for many health care leaders and specialists in palliative care. Such efforts are aided when organizations collaborate together to share lessons learned. METHODS The authors reviewed examples of quality-improvement collaborations in palliative care to understand the similarities, differences, and future directions of quality measurement and improvement strategies in the discipline. RESULTS Three examples were identified that showed areas of robust and growing quality-improvement collaboration in the field of palliative care: the Global Palliative Care Quality Alliance, Palliative Care Quality Network, and Project Educate, Nurture, Advise, Before Life Ends. These efforts exemplify how shared-improvement activities can inform improved practice for organizations participating in collaboration. CONCLUSIONS National and regional collaboratives can be used to enhance the quality of palliative care and are important efforts to standardize and improve the delivery of palliative care for persons with serious illness, along with their friends, family, and caregivers.
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87
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Teno JM, Freedman VA, Kasper JD, Gozalo P, Mor V. Is Care for the Dying Improving in the United States? J Palliat Med 2015; 18:662-6. [PMID: 25922970 DOI: 10.1089/jpm.2015.0039] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Striking changes occurred in health care in the United States between 2000 and 2013, including growth of hospice and hospital-based palliative care teams, and changes in Medicare payment policies. OBJECTIVE The aim of this study was to compare informants' reports and ratings of the quality of end-of-life care for decedents between 2000 and 2011-2013. METHODS The study design comprised retrospective national surveys. Subjects were decedents age 65 years and older residing in the community from two time periods. Similar survey questions were asked at the two time periods. Bivariate and multivariate analyses were conducted, using appropriate survey weights to examine response differences between time periods, after adjusting for the decedent's age, race, pattern of functional decline, and the presence of a cancer diagnosis, as well as the respondent's relationship to the decedent. RESULTS A total of 1208 informants were interviewed; 622 in 2000 and 586 in 2011-2013. Respondents from deaths in 2011-2013 were more likely to state that their loved ones experienced an unmet need for pain management (25.2% versus 15.5% in 2000, adjusted odds ratio [AOR] 1.9, 95% confidence interval [CI] 1.1-3.3). More respondents reported that religion and spirituality were addressed in the later time period (72.4% not addressed compared with 58.3%, AOR 1.4, 95% CI 1.1-1.9). High rates of unmet need for palliation of dyspnea and anxiety/depression remained. The overall rating of quality did not improve but decreased (with 56.7% stating care was excellent in 2000 and 47.0% in the later survey, AOR 0.70, 95% CI 0.52-0.95). CONCLUSIONS Substantial unmet needs in end-of-life care remain. Continued efforts are needed to improve the quality of end-of-life care.
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Affiliation(s)
- Joan M Teno
- 1 Department of Health Services, Policy, and Practice, Brown University School of Public Health , Providence, Rhode Island
| | - Vicki A Freedman
- 2 Institute for Social Research, University of Michigan , Ann Arbor, Michigan
| | - Judith D Kasper
- 3 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Pedro Gozalo
- 1 Department of Health Services, Policy, and Practice, Brown University School of Public Health , Providence, Rhode Island
| | - Vincent Mor
- 1 Department of Health Services, Policy, and Practice, Brown University School of Public Health , Providence, Rhode Island
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Daveson BA, Smith M, Yi D, McCrone P, Grande G, Todd C, Gysels M, Costantini M, Murtagh FE, Higginson IJ, Evans CJ. The effectiveness and cost-effectiveness of inpatient specialist palliative care in acute hospitals for adults with advanced illness and their caregivers. Cochrane Database Syst Rev 2015. [DOI: 10.1002/14651858.cd011619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Kamal AH, Nipp RD, Bull J, Stinson CS, Abernethy AP. Symptom Burden and Performance Status among Community-Dwelling Patients with Serious Illness. J Palliat Med 2015; 18:542-4. [PMID: 25789759 DOI: 10.1089/jpm.2014.0381] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Predicting when burdensome symptoms will arise or worsen is important to preserving quality of life in patients with serious illness. OBJECTIVES We explored the relationship between prevalence and severity of symptoms and underlying performance status. METHODS We performed a retrospective cohort analysis of patients receiving community palliative care, investigating relationships between symptom burden and performance status. Patient data were obtained from the Carolinas Palliative Care Consortium Database, a central registry of community consultation data for research and quality improvement. We measured symptom prevalence and severity using the McCorkle Symptom Distress Scale and performance status using the Palliative Performance Scale. RESULTS We analyzed data of 4994 patients, most (90%) with noncancer, serious illnesses. Thirty percent had one or more moderate/severe symptoms. In addition to identifying the high prevalence of fatigue and pain, we found distinct groupings of symptoms with high burden associated with different levels of performance status. This includes high prevalence of fatigue, anorexia, and dyspnea in patients with high performance. Patients with low performance status, however, reported more pain, depression, and constipation. CONCLUSION Bothersome symptoms change as patients' performance status worsens. Using performance status as a common language, both medical professionals and informal caregivers can monitor impending changes in symptom burden. This should inform development of community-based delivery systems to detect and manage distress in patients with palliative care needs.
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Affiliation(s)
- Arif H Kamal
- 1Center for Learning Health Care, Duke Clinical Research Institute, Durham, North Carolina
| | - Ryan D Nipp
- 2Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Janet Bull
- 3Four Seasons, Flat Rock, North Carolina
| | - Charles S Stinson
- 4Novant Health, Forsyth Medical Center Palliative Care, Winston-Salem, North Carolina
| | - Amy P Abernethy
- 1Center for Learning Health Care, Duke Clinical Research Institute, Durham, North Carolina
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Charvet LE, Kasschau M, Datta A, Knotkova H, Stevens MC, Alonzo A, Loo C, Krull KR, Bikson M. Remotely-supervised transcranial direct current stimulation (tDCS) for clinical trials: guidelines for technology and protocols. Front Syst Neurosci 2015; 9:26. [PMID: 25852494 PMCID: PMC4362220 DOI: 10.3389/fnsys.2015.00026] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 02/13/2015] [Indexed: 11/13/2022] Open
Abstract
The effect of transcranial direct current stimulation (tDCS) is cumulative. Treatment protocols typically require multiple consecutive sessions spanning weeks or months. However, traveling to clinic for a tDCS session can present an obstacle to subjects and their caregivers. With modified devices and headgear, tDCS treatment can be administered remotely under clinical supervision, potentially enhancing recruitment, throughput, and convenience. Here we propose standards and protocols for clinical trials utilizing remotely-supervised tDCS with the goal of providing safe, reproducible and well-tolerated stimulation therapy outside of the clinic. The recommendations include: (1) training of staff in tDCS treatment and supervision; (2) assessment of the user’s capability to participate in tDCS remotely; (3) ongoing training procedures and materials including assessments of the user and/or caregiver; (4) simple and fail-safe electrode preparation techniques and tDCS headgear; (5) strict dose control for each session; (6) ongoing monitoring to quantify compliance (device preparation, electrode saturation/placement, stimulation protocol), with corresponding corrective steps as required; (7) monitoring for treatment-emergent adverse effects; (8) guidelines for discontinuation of a session and/or study participation including emergency failsafe procedures tailored to the treatment population’s level of need. These guidelines are intended to provide a minimal level of methodological rigor for clinical trials seeking to apply tDCS outside a specialized treatment center. We outline indication-specific applications (Attention Deficit Hyperactivity Disorder, Depression, Multiple Sclerosis, Palliative Care) following these recommendations that support a standardized framework for evaluating the tolerability and reproducibility of remote-supervised tDCS that, once established, will allow for translation of tDCS clinical trials to a greater size and range of patient populations.
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Affiliation(s)
- Leigh E Charvet
- Department of Neurology, Stony Brook Medicine Stony Brook, NY, USA
| | | | | | | | - Michael C Stevens
- Olin Neuropsychiatry Research Center, Yale University School of Medicine New Haven, CT, USA
| | - Angelo Alonzo
- School of Psychiatry, University of New South Wales, Black Dog Institute Randwick, Australia
| | - Colleen Loo
- School of Psychiatry, University of New South Wales, Black Dog Institute Randwick, Australia
| | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital Memphis, Tennessee, USA
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York of CUNY NY, USA
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Kamal AH, Hanson LC, Casarett DJ, Dy SM, Pantilat SZ, Lupu D, Abernethy AP. The quality imperative for palliative care. J Pain Symptom Manage 2015; 49:243-53. [PMID: 25057987 PMCID: PMC4405112 DOI: 10.1016/j.jpainsymman.2014.06.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 06/09/2014] [Accepted: 06/25/2014] [Indexed: 12/25/2022]
Abstract
Palliative medicine must prioritize the routine assessment of the quality of clinical care we provide. This includes regular assessment, analysis, and reporting of data on quality. Assessment of quality informs opportunities for improvement and demonstrates to our peers and ourselves the value of our efforts. In fact, continuous messaging of the value of palliative care services is needed to sustain our discipline; this requires regularly evaluating the quality of our care. As the reimbursement mechanisms for health care in the U.S. shift from fee-for-service to fee-for-value models, palliative care will be expected to report robust data on quality of care. We must move beyond demonstrating to our constituents (including patients and referrers), "here is what we do," and increase the focus on "this is how well we do it" and "let us see how we can do it better." It is incumbent on palliative care professionals to lead these efforts. This involves developing standardized methods to collect data without adding additional burden, comparing and sharing our experiences to promote discipline-wide quality assessment and improvement initiatives, and demonstrating our intentions for quality improvement on the clinical frontline.
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Affiliation(s)
- Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA; Center for Learning Health Care, Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David J Casarett
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sydney M Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Steven Z Pantilat
- Palliative Care Program, Division of Hospital Medicine, University of California, San Francisco, California, USA
| | - Dale Lupu
- Center for Aging, Health and Humanities, George Washington University, Washington, DC, USA
| | - Amy P Abernethy
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA; Center for Learning Health Care, Duke Clinical Research Institute, Durham, North Carolina, USA
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Leff B, Carlson CM, Saliba D, Ritchie C. The Invisible Homebound: Setting Quality-Of-Care Standards For Home-Based Primary And Palliative Care. Health Aff (Millwood) 2015; 34:21-9. [DOI: 10.1377/hlthaff.2014.1008] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Bruce Leff
- Bruce Leff ( ) is a professor of medicine at the Johns Hopkins University School of Medicine, in Baltimore, Maryland
| | - Charlotte M. Carlson
- Charlotte M. Carlson is an associate medical director at On Lok Senior Health Services, in San Francisco, California
| | - Debra Saliba
- Debra Saliba is director of the University of California, Los Angeles, Borun Center and a research physician in the Veterans Affairs Greater Los Angeles Healthcare System
| | - Christine Ritchie
- Christine Ritchie is a professor in the Department of Medicine at the University of California, San Francisco
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Lester PE, Stefanacci RG, Feuerman M. Prevalence and Description of Palliative Care in US Nursing Homes. Am J Hosp Palliat Care 2014; 33:171-7. [DOI: 10.1177/1049909114558585] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To describe rates and policies in U.S. Nursing Homes (NH) related to palliative care, comfort care, and hospice care based on a nationwide survey of directors of nursing. Measurements: A national survey was distributed online and was completed by 316 directors of nursing of NHs (11% response rate). The directors of nursing were asked about availability and policies in their facilities. Specifically, questions were related to policies, referral patterns, discussion about such care, and types of medical conditions qualifying for such services. Results: Hospice is significantly more available than palliative or comfort care programs; also, for-profit facilities, compared to non-profits, are significantly more likely to have palliative care programs and medical directors for palliative care. Social workers and nurses were most likely to suggest palliative type programs. Only 42% of facilities with palliative program provide consultation by a palliative certified physician. Residents with non-healing pressure ulcers, frequent hospitalizations, or severe/uncontrolled pain or non-pain symptoms were less likely to be referred. Conclusions: There is limited availability of palliative type programs in NH facilities and underutilization in those NH with programs.
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Affiliation(s)
- Paula E. Lester
- Winthrop University Hospital, Mineola, NY, USA
- SUNY Stony Brook, Stony Brook, NY, USA
| | | | - Martin Feuerman
- Office of Academic Affairs, Winthrop University Hospital, Mineola, NY, USA
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Scheffey C, Kestenbaum MG, Wachterman MW, Connor SR, Fine PG, Davis MS, Muir JC. Clinic-based outpatient palliative care before hospice is associated with longer hospice length of service. J Pain Symptom Manage 2014; 48:532-9. [PMID: 24680626 DOI: 10.1016/j.jpainsymman.2013.10.017] [Citation(s) in RCA: 14] [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: 07/19/2013] [Revised: 10/17/2013] [Accepted: 10/30/2013] [Indexed: 12/25/2022]
Abstract
CONTEXT Outpatient nonhospice palliative care has been shown to provide many benefits to patients facing advanced illness, but such services remain uncommon in the U.S. Little is known about the association between clinic-based outpatient palliative care consultation and the timing of hospice enrollment. OBJECTIVES To determine whether there are differences in hospice length of service (LOS) between patients who were seen vs. patients who were not seen in an outpatient palliative care clinic before enrollment in hospice. METHODS Using a retrospective study of medical records, a "prior palliative care clinic" group was formed of those hospice patients who had had a nonhospice clinic-based outpatient palliative care consult before hospice admission (n = 354). For those patients, "control" hospice patients without prior clinic-based palliative care were chosen who were matched by age, gender, median income of their zip code, and diagnostic group. Both groups were restricted to patients who died while enrolled in hospice. LOS for these two groups was compared using standard statistical methods of survival analysis. RESULTS Prior palliative care clinic patients had a median LOS of 24 days, whereas control patients had a median LOS of 15 days (95% CI for difference between the medians 5-13 days). The difference between the LOS distribution curves was statistically significant by the log-rank test (P < 0.001). CONCLUSION Hospice patients who had clinic-based outpatient palliative consults before hospice enrollment tended, on average, to have a longer LOS in hospice than patients who did not.
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Affiliation(s)
| | | | - Melissa W Wachterman
- Capital Caring, Falls Church, Virginia, USA; Veterans Affairs Healthcare System, Boston, Massachusetts, USA
| | | | - Perry G Fine
- Pain Research Center, University of Utah School of Medicine, Salt Lake City, Utah, USA
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95
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Kamal AH, Bull J, Stinson CS, Blue DL, Abernethy AP. Conformance with supportive care quality measures is associated with better quality of life in patients with cancer receiving palliative care. J Oncol Pract 2014; 9:e73-6. [PMID: 23942504 DOI: 10.1200/jop.2013.000948] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE As palliative care further integrates into cancer care, descriptions of how supportive care quality measures improve patient outcomes are necessary to establish best practices. METHODS We assessed the relationship between conformance to 18 palliative care quality measures and quality of life from data obtained using our novel point-of-care, electronic quality monitoring system, the Quality Data Collection Tool for Palliative Care (QDACT-PC). All patients with cancer from January 2008 through March 2011 seen in the Carolinas Palliative Care Consortium were evaluated for demographic, disease, prognostic, performance status, and measure conformance variables. Using univariate and multivariate regression, we examined the relationship between these variable and high quality of life at the initial specialty palliative care consultation. RESULTS Our cohort included 459 patients, the majority of whom were over age 65 years (66%) and white (84%). Lung (29.1%) and GI (24.7%) cancers were most common. In univariate analyses, conformance to assessment of comprehensive symptoms, fatigue and constipation assessment, timely management of pain and constipation, and timely emotional well-being assessment were associated with highest levels of quality of life (all Ps < .05). In a multivariate model (C-stat = 0.66), performance status (odds ratio [OR], 5.21; P = .003), estimated life expectancy (OR, 22.6; P = .003), conformance to the measure related to emotional well-being assessment (OR, 1.60; P = .026), and comprehensive screening of symptoms (OR, 1.74, P = .008) remained significant. CONCLUSION Oncology care pathways that routinely incorporate supportive care principles, such as comprehensive symptom and emotional well-being assessments, may improve patient outcomes.
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Affiliation(s)
- Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA.
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96
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Kavalieratos D, Mitchell EM, Carey TS, Dev S, Biddle AK, Reeve BB, Abernethy AP, Weinberger M. "Not the 'grim reaper service'": an assessment of provider knowledge, attitudes, and perceptions regarding palliative care referral barriers in heart failure. J Am Heart Assoc 2014; 3:e000544. [PMID: 24385453 PMCID: PMC3959712 DOI: 10.1161/jaha.113.000544] [Citation(s) in RCA: 175] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 11/17/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although similar to cancer patients regarding symptom burden and prognosis, patients with heart failure (HF) tend to receive palliative care far less frequently. We sought to explore factors perceived by cardiology, primary care, and palliative care providers to impede palliative care referral for HF patients. METHODS AND RESULTS We conducted semistructured interviews regarding (1) perceived needs of patients with advanced HF; (2) knowledge, attitudes, and experiences with specialist palliative care; (3) perceived indications for and optimal timing of palliative care referral in HF; and (4) perceived barriers to palliative care referral. Two investigators analyzed data using template analysis, a qualitative technique. We interviewed 18 physician, nurse practitioner, and physician assistant providers from 3 specialties: cardiology, primary care, and palliative care. Providers had limited knowledge regarding what palliative care is, and how it can complement traditional HF therapy to decrease HF-related suffering. Interviews identified several potential barriers: the unpredictable course of HF; lack of clear referral triggers across the HF trajectory; and ambiguity regarding what differentiates standard HF therapy from palliative care. Nevertheless, providers expressed interest for integrating palliative care into traditional HF care, but were unsure of how to initiate collaboration. CONCLUSIONS Palliative care referral for HF patients may be suboptimal due to limited provider knowledge and misperceptions of palliative care as a service reserved for those near death. These factors represent potentially modifiable targets for provider education, which may help to improve palliative care referral for HF patients with unresolved disease-related burden.
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Affiliation(s)
- Dio Kavalieratos
- Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (D.K.)
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill,
| | - Emma M. Mitchell
- School of Nursing and Health Studies, University of Miami, FL (E.M.M.)
| | - Timothy S. Carey
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill,
| | - Sandesh Dev
- Phoenix Veterans Affairs Medical Center, Phoenix, AZ (S.D.)
| | - Andrea K. Biddle
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill,
| | - Bryce B. Reeve
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill,
| | - Amy P. Abernethy
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill,
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.P.A.)
- Division of Medical Oncology, Duke University School of Medicine, Duke University, Durham, NC (A.P.A.)
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill,
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill,
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC (M.W.)
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97
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Kamal AH. Getting to proven: evaluating quality across all of palliative care. J Pain Symptom Manage 2014; 47:e1-2. [PMID: 24291298 DOI: 10.1016/j.jpainsymman.2013.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 09/18/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Arif Hossain Kamal
- Division of Medical Oncology and Duke Palliative Care, Duke University Medical Center, Durham, North Carolina, USA.
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98
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Rabow M, Kvale E, Barbour L, Cassel JB, Cohen S, Jackson V, Luhrs C, Nguyen V, Rinaldi S, Stevens D, Spragens L, Weissman D. Moving upstream: a review of the evidence of the impact of outpatient palliative care. J Palliat Med 2013; 16:1540-9. [PMID: 24225013 DOI: 10.1089/jpm.2013.0153] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND There is good evidence for the efficacy of inpatient palliative care in improving clinical care, patient and provider satisfaction, quality of life, and health care utilization. However, the evidence for the efficacy of nonhospice outpatient palliative care is less well known and has not been comprehensively reviewed. OBJECTIVE To review and assess the evidence of the impact of outpatient palliative care. METHODS Our study was a review of published, peer-reviewed outcomes research, including both observational studies and controlled trials of nonhospice outpatient palliative care services. We assessed patient, family caregiver, and clinician satisfaction; clinical outcomes including symptom management, quality of life, and mortality; and heath care utilization outcomes including readmission rates, hospice use, and cost. RESULTS Four well-designed randomized interventions as well as a growing body of nonrandomized studies indicate that outpatient palliative care services can: 1) improve patient satisfaction, 2) improve symptom control and quality of life, 3) reduce health care utilization, and 4) lengthen survival in a population of lung cancer patients. CONCLUSIONS The available evidence supports the ongoing expansion of innovative outpatient palliative care service models throughout the care continuum to all patients with serious illness.
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Affiliation(s)
- Michael Rabow
- 1 Department of Internal Medicine, University of California , San Francisco, California
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