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Sedhom R, Gupta A, Shah M, Hsu M, Messmer M, Murray J, Browner I, Smith TJ, Marrone K. Oncology Fellow-Led Quality Improvement Project to Improve Rates of Palliative Care Utilization in Patients With Advanced Cancer. JCO Oncol Pract 2020; 16:e814-e822. [PMID: 32339469 DOI: 10.1200/jop.19.00714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. First-year oncology fellows at our institution identified low rates of PC utilization in their longitudinal clinic as a metric needing improvement. METHODS A fellow-led multidisciplinary team aimed to increase PC utilization for patients with advanced cancer followed in he first-year fellows' clinic from a baseline of 11.5% (5 of 43 patients, July to December of 2018) to 30% over a 6-month period. Utilization was defined as evaluation in the outpatient PC clinic hosted in the cancer center. The team identified the following barriers to referral: orders difficult to find in the electronic medical record (EMR), multiple consulting mechanisms (EMR, by phone, or in person), EMR request not activating formal consult, no centralized scheduler to contact or confirm appointment, and poor awareness of team structure. Plan-Do-Study-Act (PDSA) cycles were implemented based on identified opportunities. Data were obtained from the EMR. RESULTS The first PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and disseminating process changes. PDSA cycles were implemented from January to June of 2019. Rates of PC use increased from 11.5% before the intervention to 48.4% (48 of 99 patients) after the intervention. CONCLUSION A multidisciplinary approach and classic quality improvement methodology improved PC use in patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stakeholders, and institutional and leadership support. Straightforward EMR interventions and ancillary staff use are effective in addressing underreferrals.
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Affiliation(s)
- Ramy Sedhom
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Mirat Shah
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Melinda Hsu
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Marcus Messmer
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Joseph Murray
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Ilene Browner
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Thomas J Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Kristen Marrone
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
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Conduit C, Thompson M, Thomas R, Nott L, Wuttke M. Implementing 'Goals of Care' discussion and palliative care referral for patients with advanced lung cancer: an outpatient-based pilot project. Intern Med J 2020; 51:540-547. [PMID: 32202060 DOI: 10.1111/imj.14817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Early involvement of palliative care and advance care planning improves quality-of-life outcomes and survival for patients with advanced lung cancer; however, there are barriers to implementation. AIMS A single-centre prospective audit reviewing 'Goals of Care' (GOC) form completion and palliative care referrals in an oncology clinic was undertaken with the aim of increasing GOC completion and palliative care referrals for patients with advanced lung cancer. METHODS Involved physicians attended a communication skills course and then received a communication-priming intervention. Clinicopathological factors associated with GOC completion and palliative care referral were explored. RESULTS A total of 84 patients receiving palliative treatment for advanced lung cancer was enrolled. Clinicopathological factors, such as poorer performance status, were associated with higher likelihood of GOC completion (P = 0.018) prior to the intervention. Male sex (P = 0.023), absence of sensitising epidermal growth factor receptor mutation or anaplastic lymphoma kinase rearrangement (P = 0.017), type of systemic therapy (P = 0.031) and poorer performance status (P < 0.001) were associated with higher likelihood of palliative care referral. The intervention improved GOC completion (relative risk (RR) 1.29, P = 0.004); however, this was not sustained in a follow-up audit (RR 0.98, P = 0.92) and there was no change in palliative care referral rate (RR 2.5, P = 0.16). Predictors of palliative referral following clinical review included age (RR 1.16, P = 0.001), male sex (RR 14.2, P = 0.02) and poorer performance status (RR 1.76, P < 0.001). CONCLUSIONS Communication-priming interventions can improve GOC completion for patients with advanced lung cancer. Further investigation is needed to pursue sustainable options for managing this complex patient group and improve guideline-adherence and patient care.
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Affiliation(s)
| | | | - Robyn Thomas
- Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Louise Nott
- Royal Hobart Hospital, Hobart, Tasmania, Australia
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May P, Normand C, Morrison RS. Economics of Palliative Care for Cancer: Interpreting Current Evidence, Mapping Future Priorities for Research. J Clin Oncol 2020; 38:980-986. [PMID: 32023166 DOI: 10.1200/jco.18.02294] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2019] [Indexed: 05/25/2024] Open
Abstract
The National Cancer Institute estimates that $154 billion will be spent on care for people with cancer in 2019, distributed across the year after diagnosis (31%), the final year of life (31%), and continuing care between those two (38%). Projections of future costs estimate persistent growth in care expenditures. Early research studies on the economics of palliative care have reported a general pattern of cost savings during inpatient hospital admissions and the end-of-life phase. Recent research has demonstrated more complex dynamics, but expanding palliative care capacity to meet clinical guidelines and population health needs seems to save costs. Quantifying these cost savings requires additional research, because there is significant variance in estimates of the effects of treatment on costs, depending on the timing of intervention, the primary diagnosis, and the overall illness burden. Because ASCO guidelines state that palliative care should be provided concurrently with other treatment from the point of diagnosis onward for all metastatic cancer, new and ambitious research is required to evaluate the cost effects of palliative care across the entire disease trajectory. We propose a series of ways to reach the guideline goals.
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Affiliation(s)
- Peter May
- Trinity College Dublin, Dublin, Ireland
- The Irish Longitudinal Study on Ageing (TILDA), Dublin, Ireland
| | - Charles Normand
- Trinity College Dublin, Dublin, Ireland
- King's College London, London, United Kingdom
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai, New York, NY
- James J. Peters VA Medical Center, New York, NY
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Ferrell BR, Chung V, Koczywas M, Smith TJ. Dissemination and Implementation of Palliative Care in Oncology. J Clin Oncol 2020; 38:995-1001. [PMID: 32023151 PMCID: PMC7082157 DOI: 10.1200/jco.18.01766] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2019] [Indexed: 12/24/2022] Open
Abstract
Palliative care began in academic centers with specialty consultation services, and its value to patients, families, and health systems has been evident. The demand for palliative care to be integrated throughout the cancer trajectory, combined with a limited palliative care workforce, means that new models of care are needed. This review discusses evidence regarding the need for integration of palliative care into routine oncology care and describes best practices recognized for dissemination of palliative care. The available evidence suggests that palliative care be widely adopted by clinicians in all oncology settings to benefit patients with cancer and their families. Efforts are needed to adapt and integrate palliative care into community practice. Limitations of these models are discussed, as are future directions to continue implementation efforts. The benefits of palliative care can only be realized through effective dissemination of these principles of care, with more primary palliative care delivered by oncology clinicians.
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Affiliation(s)
| | | | | | - Thomas J. Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medicine, Baltimore, MD
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Kamal AH, Bausewein C, Casarett DJ, Currow DC, Dudgeon DJ, Higginson IJ. Standards, Guidelines, and Quality Measures for Successful Specialty Palliative Care Integration Into Oncology: Current Approaches and Future Directions. J Clin Oncol 2020; 38:987-994. [PMID: 32023165 DOI: 10.1200/jco.18.02440] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Although robust evidence demonstrates that specialty palliative care integrated into oncology care improves patient and health system outcomes, few clinicians are familiar with the standards, guidelines, and quality measures related to integration. These types of guidance outline principles of best practice and provide a framework for assessing the fidelity of their implementation. Significant advances in the understanding of effective methods and procedures to guide integration of specialty palliative care into oncology have led to a proliferation of guidance documents around the world, with several areas of commonality but also some key differences. Commonalities originate from a shared vision for integration; differences arise from diverse roles of palliative care specialists within cancer care globally. In this review we discuss three of the most cited standards/guidelines, as well as quality measures related to integrated palliative and oncology care. We also recommend changes to the quality measurement framework for palliative care and a new way to match palliative care services to patients with advanced cancer on the basis of care complexity and patient needs, irrespective of prognosis.
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Affiliation(s)
| | - Claudia Bausewein
- Ludwig-Maximilians University (LMU) Hospital, LMU Munich, Munich, Germany
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Milazzo S, Hansen E, Carozza D, Case AA. How Effective Is Palliative Care in Improving Patient Outcomes? Curr Treat Options Oncol 2020; 21:12. [PMID: 32025964 DOI: 10.1007/s11864-020-0702-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OPINION STATEMENT As palliative care (PC) continues its rapid growth, an emerging body of evidence is demonstrating that its approach of interdisciplinary supportive care benefits many patient populations, including in the oncology setting. As studies and data proliferate, however, questions persist about who, what, why, when, and how PC as well as the ideal time for a PC consult and length of involvement. When comparing outcomes from chemotherapy trials, it is important to consider the dosing regimens used in the various studies. In the same way, it is important to account for the "dose" of the PC interventions utilized across studies, and apples to apples comparisons are needed in order to draw accurate conclusions about PC's benefits. Studies which include a true interdisciplinary PC intervention consistently show improvements in patient quality of life, as well as cost savings, with further study needed for other outcomes. These benefits cannot be extrapolated to care which may be labeled "palliative care," but which does not meet the standard of true interdisciplinary PC. The ultimate question is: Does PC indeed improve outcomes?
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Affiliation(s)
- Sarah Milazzo
- Department of Pediatrics State University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Eric Hansen
- Department of Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Medicine, Division of Geriatrics and Palliative Medicine, State University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Desi Carozza
- Department of Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Medicine, Division of Geriatrics and Palliative Medicine, State University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Amy A Case
- Department of Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA. .,Department of Medicine, Division of Geriatrics and Palliative Medicine, State University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.
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Palliative Care, Hospice, and Physical Therapy: Where Have We Been? Where Are We Now? Where Are We Going? REHABILITATION ONCOLOGY 2020. [DOI: 10.1097/01.reo.0000000000000197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Scott M, Shaver N, Lapenskie J, Isenberg SR, Saunders S, Hsu AT, Tanuseputro P. Does inpatient palliative care consultation impact outcomes following hospital discharge? A narrative systematic review. Palliat Med 2020; 34:5-15. [PMID: 31581888 DOI: 10.1177/0269216319870649] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND While most patients desire to die at home or in a community-based hospice, the transition from hospital to community settings often lacks streamlined coordination of care to ensure that adequate support is provided in the preferred care setting. The impact of hospital-based palliative care consultations on post-discharge care and outcomes has not been extensively studied. AIM The aim of this study was to appraise available research on the impact of inpatient palliative care consultations on transitions from hospital to community settings. DESIGN We conducted a narrative systematic review and used the Effective Public Health Practice Project tool to appraise the quality of selected studies. Studies were included if they assessed the transition from hospital to community and examined outcomes after an inpatient palliative care consultation. A protocol for this study was registered and published in PROSPERO, Centre for Reviews and Dissemination (ID: CRD42018094924). DATA SOURCES We searched for quantitative studies indexed in PubMED, CINAHL and Cochrane and published between 1 January 1 2000 and 11 March 2018. RESULTS Our search retrieved 2749 articles. From these, 123 articles were full-text screened and 15 studies met our inclusion criteria. Studies reported that inpatient palliative care consultations are associated with high rates of discharge to community settings, greater provision of services post-discharge, improved coordination and lower rates of rehospitalization. CONCLUSION Existing evidence suggest that inpatient palliative care consultations have a positive impact on patient outcomes and transitions to the community, demonstrating the potential to improve patient quality of life and relieve overburdened acute care systems.
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Affiliation(s)
- Mary Scott
- Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Julie Lapenskie
- Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sarina R Isenberg
- Temmy Latner Centre for Palliative Care and Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada.,Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Stephanie Saunders
- Temmy Latner Centre for Palliative Care and Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Cheng RK, Kirkpatrick JN, Sorror ML, Barac A. Cardio-Oncology and the Intersection of Cancer and Cardiotoxicity: The Role of Palliative Care. JACC: CARDIOONCOLOGY 2019; 1:314-317. [PMID: 34396199 PMCID: PMC8352189 DOI: 10.1016/j.jaccao.2019.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Richard K Cheng
- Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - James N Kirkpatrick
- Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Mohamed L Sorror
- Fred Hutchinson Cancer Research Center and Division of Oncology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ana Barac
- Division of Cardiology, MedStar Washington Hospital Center, Medstar Heart and Vascular Institute, Washington, DC, USA
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Ernecoff NC, Wessell KL, Hanson LC, Lee AM, Shea CM, Dusetzina SB, Weinberger M, Bennett AV. Electronic Health Record Phenotypes for Identifying Patients with Late-Stage Disease: a Method for Research and Clinical Application. J Gen Intern Med 2019; 34:2818-2823. [PMID: 31396813 PMCID: PMC6854193 DOI: 10.1007/s11606-019-05219-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Systematic identification of patients allows researchers and clinicians to test new models of care delivery. EHR phenotypes-structured algorithms based on clinical indicators from EHRs-can aid in such identification. OBJECTIVE To develop EHR phenotypes to identify decedents with stage 4 solid-tumor cancer or stage 4-5 chronic kidney disease (CKD). DESIGN We developed two EHR phenotypes. Each phenotype included International Classification of Diseases (ICD)-9 and ICD-10 codes. We used natural language processing (NLP) to further specify stage 4 cancer, and lab values for CKD. SUBJECTS Decedents with cancer or CKD who had been admitted to an academic medical center in the last 6 months of life and died August 26, 2017-December 31, 2017. MAIN MEASURE We calculated positive predictive values (PPV), false discovery rates (FDR), false negative rates (FNR), and sensitivity. Phenotypes were validated by a comparison with manual chart review. We also compared the EHR phenotype results to those admitted to the oncology and nephrology inpatient services. KEY RESULTS The EHR phenotypes identified 271 decedents with cancer, of whom 186 had stage 4 disease; of 192 decedents with CKD, 89 had stage 4-5 disease. The EHR phenotype for stage 4 cancer had a PPV of 68.6%, FDR of 31.4%, FNR of 0.5%, and 99.5% sensitivity. The EHR phenotype for stage 4-5 CKD had a PPV of 46.4%, FDR of 53.7%, FNR of 0.0%, and 100% sensitivity. CONCLUSIONS EHR phenotypes efficiently identified patients who died with late-stage cancer or CKD. Future EHR phenotypes can prioritize specificity over sensitivity, and incorporate stratification of high- and low-palliative care need. EHR phenotypes are a promising method for identifying patients for research and clinical purposes, including equitable distribution of specialty palliative care.
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Affiliation(s)
- Natalie C Ernecoff
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Kathryn L Wessell
- Sheps Center for Health Services Research, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Laura C Hanson
- Sheps Center for Health Services Research, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
- Division of Geriatric Medicine & Palliative Care Program, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Adam M Lee
- North Carolina Translational and Clinical Sciences Institute, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Christopher M Shea
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Antonia V Bennett
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
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Moffat GT, Epstein AS, O’Reilly EM. Pancreatic cancer-A disease in need: Optimizing and integrating supportive care. Cancer 2019; 125:3927-3935. [PMID: 31381149 PMCID: PMC6819216 DOI: 10.1002/cncr.32423] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/05/2019] [Accepted: 07/08/2019] [Indexed: 12/24/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that continues to be challenging to treat. PDAC has the lowest 5-year relative survival rate compared with all other solid tumor malignancies and is expected to become the second-leading cause of cancer-related death in the United States by 2030. Given the high mortality, there is an increasing role for concurrent anticancer and supportive care in the management of patients with PDAC with the aims of maximizing length of life, quality of life, and symptom control. Emerging trends in supportive care that can be integrated into the clinical management of patients with PDAC include standardized supportive care screening, early integration of supportive care into routine cancer care, early implementation of outpatient-based advance care planning, and utilization of electronic patient-reported outcomes for improved symptom management and quality of life. The most common symptoms experienced are nausea, constipation, weight loss, diarrhea, anorexia, and abdominal and back pain. This review article includes current supportive management strategies for these and others. Common disease-related complications include biliary and duodenal obstruction requiring endoscopic procedures and venous thromboembolic events. Patients with PDAC continue to have a poor prognosis. Systemic therapy options are able to palliate the high symptom burden but have a modest impact on overall survival. Early integration of supportive care can lead to improved outcomes.
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Affiliation(s)
- Gordon T. Moffat
- Memorial Sloan Kettering Cancer Center (MSK), New York, New York, USA
| | - Andrew S. Epstein
- Memorial Sloan Kettering Cancer Center (MSK), New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Eileen M. O’Reilly
- Memorial Sloan Kettering Cancer Center (MSK), New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
- David M. Rubenstein Center for Pancreatic Cancer Research, MSK
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Emiloju OE, Djibo DAM, Ford JG. Association Between the Timing of Goals-of-Care Discussion and Hospitalization Outcomes in Patients With Metastatic Cancer. Am J Hosp Palliat Care 2019; 37:433-438. [PMID: 31635471 DOI: 10.1177/1049909119882891] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Patients with cancer often require acute hospitalizations, many of which are unplanned. These hospitalizations have been shown to increase in frequency near the end of life. The American College of Physicians recommends that goals-of-care (GOC) discussions be initiated early for metastatic cancers. We hypothesized that discussing GOC during hospitalization could help reduce readmissions. Our aim was to examine the association between the timing of GOC discussion, length of hospital stay, and the time to readmission. METHODS We conducted a retrospective review of medical records of patients with stage IV cancers hospitalized between August 2017 and July 2018. We recorded timing of GOC discussion, use of palliative care services, and hospital readmissions within 90 days. χ2 tests were used to identify independent associations with GOC discussion, and logistic regression was used to examine association with readmission within 90 days. RESULTS Of all study patients (N = 241), 40.6% were female, 46% (n = 112) had a GOC discussion, and 34% (n = 82) had a palliative care consultation. Having a palliative care consult and being admitted to critical care were independently associated with having a GOC discussion. Early timing of GOC discussion was inversely associated with admission to critical care units (P < .05). Thirty-eight percent (n = 92) had unplanned hospital readmission within 90 days. Having a GOC discussion was independently associated with a reduction in the odds of an unplanned hospital readmission within 90 days by 79% (odds ratio = 0.21, 95% confidence interval: 0.12-0.37). CONCLUSION Among hospitalized patients with stage IV cancer, performing an early GOC discussion has an important association with lower hospital readmission rates and increased rates of goal-congruent patient care.
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Affiliation(s)
| | - Djeneba Audrey M Djibo
- Division of Research, Department of Medicine, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Jean G Ford
- Department of Medicine, Einstein Healthcare Network, Philadelphia, PA, USA
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Brinkman-Stoppelenburg A, Polinder S, Meerum-Terwogt J, de Nijs E, van der Padt-Pruijsten A, Peters L, van der Vorst M, van Zuylen L, Lingsma H, van der Heide A. The COMPASS study: A descriptive study on the characteristics of palliative care team consultation for cancer patients in hospitals. Eur J Cancer Care (Engl) 2019; 29:e13172. [PMID: 31571338 DOI: 10.1111/ecc.13172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/03/2019] [Accepted: 09/04/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To describe the characteristics of palliative care team (PCT) consultation for patients with cancer who are admitted in hospital and to investigate when and why PCTs are consulted. METHODS In this descriptive study in ten Dutch hospitals, the COMPASS study, we compared characteristics of patients with cancer for whom a PCT was or was not consulted (substudy 1). We also collected information about the process of PCT consultations and the disciplines involved (substudy 2). RESULTS In substudy 1, we included 476 patients. A life expectancy <3 months, unplanned hospitalisation and lack of options for anti-cancer treatment increased the likelihood of PCT consultation. In substudy 2, 64% of 550 consultations concerned patients with a life expectancy of <3 months. The most frequently mentioned problems that were identified by the PCTS were complex pain problems (56%), issues around the organisation of care (31%), fatigue (27%) and dyspnoea (27%). There was much variance between hospitals in the disciplines that were involved in consultations. CONCLUSION Palliative care teams in Dutch hospitals are most often consulted for patients with a life expectancy of <3 months who have an unplanned hospital admission because of physical symptoms or problems. We found much variance between hospitals in the composition and activities of PCTs.
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Affiliation(s)
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jetske Meerum-Terwogt
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Ellen de Nijs
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Liesbeth Peters
- Department of Pulmonary Diseases, Northwest Clinics, Den Helder, The Netherlands
| | - Maurice van der Vorst
- Department of Medical Oncology, Cancer Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.,Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Hester Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Marcell A. The Glass Is Already Broken: A Meditation on Impermanence. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2019; 15:129-132. [PMID: 31633470 DOI: 10.1080/15524256.2019.1660296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Alison Marcell
- Palliative Care, Norwalk Hospital, Western Connecticut Medical Group Inc , Norwalk , Connecticut , USA
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Saunders S, Killackey T, Kurahashi A, Walsh C, Wentlandt K, Lovrics E, Scott M, Mahtani R, Bernstein M, Howard M, Tanuseputro P, Goldman R, Zimmermann C, Aslakson RA, Isenberg SR. Palliative Care Transitions From Acute Care to Community-Based Care-A Systematic Review. J Pain Symptom Manage 2019; 58:721-734.e1. [PMID: 31201875 DOI: 10.1016/j.jpainsymman.2019.06.005] [Citation(s) in RCA: 14] [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: 01/04/2019] [Revised: 05/31/2019] [Accepted: 06/05/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT Although the literature on transitions from hospital to the community is extensive, little is known about this experience within the context of palliative care (PC). OBJECTIVE We conducted a systematic review to investigate the impact of receiving palliative care in hospital on the transition from hospital to the community. METHODS We systematically searched MEDLINE, Embase, ProQuest, and CINAHL from 1995 until April 10, 2018, and extracted relevant references. Eligible articles were published in English, included adult patients receiving PC as inpatients, and explored transitions from hospital to the community. RESULTS A total of 1514 studies were identified and eight met inclusion criteria. Studies were published recently (>2012; n = 7, 88%). Specialist PC interventions were delivered by multidisciplinary care teams as part of inpatient PC triggers, discharge planning programs, and transitional care programs. Common outcomes reported with significant findings consisted of length of stay (n = 5), discharge support (n = 5), and hospital readmissions (n = 6) for those who received inpatient PC. Most studies were at high risk of bias. CONCLUSION Heterogeneity of study designs, outcomes, findings, and poor methodological quality renders it challenging to draw conclusions regarding PC's impact on the transition from hospital to home. Further research should use standardized outcomes with randomized controlled trial and/or propensity matched cohort designs.
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Affiliation(s)
- Stephanie Saunders
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Tieghan Killackey
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Allison Kurahashi
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Chris Walsh
- Library Services, Sinai Health System, Toronto, Ontario, Canada; School of Communications and Nursing, George Brown College, Toronto, Ontario, Canada
| | - Kirsten Wentlandt
- Division of Palliative Care, University Health Network, Toronto, Ontario, Canada; Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Emily Lovrics
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Mary Scott
- Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Ramona Mahtani
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Mark Bernstein
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Russell Goldman
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Division of Palliative Care, University Health Network, Toronto, Ontario, Canada; Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca A Aslakson
- Department of Medicine and Anesthesiology, Stanford University, Stanford, California, USA
| | - Sarina R Isenberg
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
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Outcomes of hypercalcemia of malignancy in patients with solid cancer: a national inpatient analysis. Med Oncol 2019; 36:90. [DOI: 10.1007/s12032-019-1315-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 09/08/2019] [Indexed: 11/26/2022]
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Kamal AH, Wolf S, Nicolla JM, Friedman F, Xuan M, Bennett AV, Samsa G. Usability of PCforMe in Patients With Advanced Cancer Referred to Outpatient Palliative Care: Results of a Randomized, Active-Controlled Pilot Trial. J Pain Symptom Manage 2019; 58:382-389. [PMID: 31163259 DOI: 10.1016/j.jpainsymman.2019.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 11/22/2022]
Abstract
CONTEXT Low utilization of palliative care services warrant testing of new solutions to educate and engage patients around the benefits of palliative care. OBJECTIVES We sought out to develop and test a novel, mobile health solution to prepare patients for an upcoming outpatient palliative care appointment. METHODS After developing a web-based tool called PCforMe (Palliative Care for Me), we conducted a randomized, active-controlled, trial of PCforMe. The primary outcome was the score on the System Usability Scale (SUS). Secondary outcomes were patient self-efficacy and change in knowledge. We compared PCforMe to three common online resources for patients seeking information about palliative care. RESULTS A total of 80 patients were randomized. There were no significant demographic differences. Mean SUS score for PCforMe was 78.2, significantly above the normative average SUS score of 68 (P-value < 0.0001). Mean change in Perceived Efficacy in Patient-Physician Interactions score was -2.2 for PCforMe and -1.7 for control group (P-value = 0.72). Preparedness for an upcoming palliative care visit increased 50% in the intervention group and 13.3% in the control group. Difference in the number of patients with improved knowledge regarding palliative care approached significance (P = 0.06). Lastly, we found that the no-show rate was lower during Q1 2017 (during trial) and Q1 2016 (before trial), at 11.7% and 21%, respectively (P < 0.05). Comparing the full calendar year (CY) 2016 with 2017, we did not find a statistical difference (CY 2016 of 18.8% and 15% in CY 2017; P = 0.22). CONCLUSION PCforMe is a usable mobile health tool to prepare patients for an upcoming palliative care appointment. Further research is needed to test effectiveness.
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Affiliation(s)
- Arif H Kamal
- Duke Cancer Institute, Durham, North Carolina, USA; Duke Fuqua School of Business, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University, Durham, North Carolina, USA.
| | - Steven Wolf
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | | | | | - Mengdi Xuan
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Antonia V Bennett
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Greg Samsa
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
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Wong A, Vidal M, Prado B, Hui D, Epner M, Balankari VR, De La Cruz VJ, Cantu HP, Zapata KP, Liu DD, Williams JL, Lim T, Bruera E. Patients' Perspective of Timeliness and Usefulness of an Outpatient Supportive Care Referral at a Comprehensive Cancer Center. J Pain Symptom Manage 2019; 58:275-281. [PMID: 31029808 DOI: 10.1016/j.jpainsymman.2019.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT Current guidelines recommend early referral to palliative care for patients with advanced cancer; however, no studies have examined the optimal timing of referral from the patients' perspective. OBJECTIVES To examine patients' perceptions of timeliness of referral and its association with survival among patients with advanced cancer referred to an outpatient supportive care (SC) clinic. METHODS This cross-sectional prospective study in an SC clinic at a comprehensive cancer center included patients aged 18 years or older with locally advanced, recurrent, or metastatic cancer. Patients were asked to complete an anonymous survey regarding the timeliness and perceived usefulness of SC referral within four weeks of their first SC consultation. RESULTS Of 253 eligible patients, 209 (83%) enrolled in the study and 200 completed the survey. Median survival was 10.3 months. Most patients (72%) perceived that referral occurred "just in time," whereas 21% felt it was "late," and 7% felt "early." A majority (83%) found the referral useful, and 88% would recommend it to other patients with cancer. The perception of being referred early was associated with lower reported levels of pain (P = 0.043), fatigue (P = 0.004), drowsiness (P = 0.005), appetite loss (P = 0.041), poor well-being (P = 0.041), and lower physical (P = 0.001) and overall symptom distress (P = 0.001). No other associations were found between perceived timeliness and usefulness and patients' baseline characteristics. CONCLUSION Most patients with a median survival of 10 months perceived that SC referral was timely and useful. Patient care needs rather than the timing of advanced cancer diagnosis drove this perception of referral timing. Lower symptom burden was associated with the perception of being referred to early.
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Affiliation(s)
- Angelique Wong
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Marieberta Vidal
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bernard Prado
- Department of Oncology and Hematology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - David Hui
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Margeaux Epner
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vishidha Reddy Balankari
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vera J De La Cruz
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hilda P Cantu
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kresnier Perez Zapata
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane D Liu
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Janet L Williams
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Taekyu Lim
- Division of Hematology and Oncology, Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, South Korea
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Radiation Oncologists' Role in End-of-Life Care: A Perspective From Medical Oncologists. Pract Radiat Oncol 2019; 9:362-370. [PMID: 31202831 DOI: 10.1016/j.prro.2019.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/29/2019] [Accepted: 04/01/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Multidisciplinary communication and collaboration are key to planning and delivering end-of-life care for patients with advanced and metastatic cancer. We sought to characterize medical oncologists' perspectives on the role of radiation oncologists in end-of-life care. MATERIALS AND METHODS A sample of US medical oncologists was recruited using snowball sampling methods. Audio recordings of 4 professionally moderated focus groups were transcribed. Investigators from diverse backgrounds (medical oncology, radiation oncology, critical care medicine, palliative care, and public health) independently reviewed each transcript. Qualitative content analysis was used to create consensus codes that were applied to subsequent focus group transcripts in an iterative process. RESULTS Medical oncologists expressed complex views regarding the role of radiation oncologists in end-of-life care. Identified themes included the limited role of radiation oncologists, territorial concerns, capability, and desire of radiation oncologists in this realm, and the need for communication between providers. Radiation oncologists were compared with surgeons, whose interaction with patients ceased after their service had been performed. In this regard, control of palliative care referral or end-of-life care discussions was thought to be in the territory of medical oncologists who had longitudinal relationships with patients from diagnosis. Medical oncologists were concerned about the capability of radiation oncologists to accurately prognosticate, and stated radiation oncologists lacked knowledge of subsequent lines of systemic therapy available to patients. Radiation oncologists' fear of upsetting medical oncologists was thought to be justified if they engaged in end-of-life care planning without direct permission from the referring medical oncologist. CONCLUSIONS Participation of radiation oncologists in end-of-life care planning was viewed with skepticism by medical oncologists. Radiation oncologists should focus on increasing open communication and teamwork with medical oncologists and demonstrate their ability to prognosticate and counsel patients regarding end-of-life care decisions.
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Molin Y, Gallay C, Gautier J, Lardy-Cleaud A, Mayet R, Grach MC, Guesdon G, Capodano G, Dubroeucq O, Bouleuc C, Bremaud N, Fogliarini A, Henry A, Caunes-Hilary N, Villet S, Villatte C, Frasie V, Triolaire V, Barbarot V, Commer JM, Hutin A, Chvetzoff G. PALLIA-10, a screening tool to identify patients needing palliative care referral in comprehensive cancer centers: A prospective multicentric study (PREPA-10). Cancer Med 2019; 8:2950-2961. [PMID: 31055887 PMCID: PMC6558580 DOI: 10.1002/cam4.2118] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/15/2019] [Accepted: 03/08/2019] [Indexed: 12/23/2022] Open
Abstract
Purpose The identification and referral of patients in need of palliative care should be improved. The French society for palliative support and care recommended to use the PALLIA‐10 questionnaire and its score greater than 3 to refer patients to palliative care. We explored the use of the PALLIA‐10 questionnaire and its related score in a population of advanced cancer patients. Methods This prospective multicentric study is to be conducted in authorized French comprehensive cancer centers on hospitalized patients on a given day. We aimed to use the PALLIA‐10 score to determine the proportion of palliative patients with a score >3. Main secondary endpoints were to determine the proportion of patients already managed by palliative care teams at the study date or referred to palliative care in six following months, the prevalence of patients with a score greater than 5, and the overall survival using the predefined thresholds of 3 and 5. Results In 2015, eighteen French cancer centers enrolled 840 patients, including 687 (82%) palliative patients. 479 (69.5%) patients had a score >3, 230 (33.5%) had a score >5, 216 (31.4%) patients were already followed‐up by a palliative care team, 152 patients were finally referred to PC in the six subsequent months. The PALLIA‐10 score appeared as a reliable predictive (adjusted ORRef≤3: 1.9 [1.17‐3.16] and 3.59 [2.18‐5.91]) and prognostic (adjusted HRRef≤3 = 1.58 [95%CI 1.20‐2.08] and 2.18 [95%CI 1.63‐2.92]) factor for patients scored 4‐5 and >5, respectively. Conclusion The PALLIA‐10 questionnaire is an easy‐to‐use tool to refer cancer inpatients to palliative care in current practice. However a score greater than 5 using the PALLIA‐10 questionnaire would be more appropriate for advanced cancer patients hospitalized in comprehensive cancer center.
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Affiliation(s)
| | | | - Julien Gautier
- Direction of Clinical Research and Innovation, Cancer center Léon Bérard, Lyon, France
| | - Audrey Lardy-Cleaud
- Direction of Clinical Research and Innovation, Cancer center Léon Bérard, Lyon, France
| | - Romaine Mayet
- Direction of Clinical Research and Innovation, Cancer center Léon Bérard, Lyon, France
| | | | | | | | | | | | | | | | - Aline Henry
- Cancer Institute of Lorraine - Alexis Vautrin, Nancy, France
| | | | | | | | | | | | - Véronique Barbarot
- West Cancer Institute, Saint Herblain, René Gauducheau Center, Nantes, France
| | | | - Agnès Hutin
- Eugène Marquis Cancer Center, Rennes, France
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Solomon R, Egorova N, Adelson K, Smith CB, Franco R, Bickell NA. Thirty-Day Readmissions in Patients With Metastatic Cancer: Room for Improvement? J Oncol Pract 2019; 15:e410-e419. [DOI: 10.1200/jop.18.00500] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Purpose: Cancer, with readmission rates as high as 27%, has thus far been excluded from most readmission reduction efforts. However, some readmissions for patients with advanced disease may be avoidable. We assessed the prevalence of potentially preventable readmissions and associated factors in patients with metastatic cancer. Patients and Methods: Using a merged longitudinal data set of New York State hospital discharges and vital records, we measured 30-day readmissions for anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, and sepsis among patients with metastatic cancer between 2012 and 2014. We used competing-risk models to assess the effects of demographics, comorbidities, hospital type, payer, and discharge disposition. Results: A total of 11,275 patients had 19,307 hospitalizations. The 30-day readmission rate was 24.5%; 11.9% (n = 565) of readmissions were potentially preventable. Higher readmission rates occurred in black (hazard rate [HR], 1.26; 95% CI, 1.17 to 1.35), Hispanic (HR, 1.19; 95% CI, 1.09 to 1.31), and younger patients (HR per 10 years, 0.94; 95% CI, 0.90 to 0.97). Lower rates were associated with female sex (HR, 0.95; 95% CI, 0.91 to 0.99), private insurance (HR, 0.87; 95% CI, 0.87 to 0.81), teaching hospitals, and hospice discharge (HR, 0.62; 95% CI, 0.42 to 0.91). Discharge home with services (HR, 1.21; 95% CI, 1.14 to 1.27) or to a skilled nursing facility (HR, 1.11; 95% CI, 1.01 to 1.23) increased readmission likelihood. Potentially preventable readmissions were associated with younger age (HR per 10 years, 0.98; 95% CI, 0.98 to 0.99) and discharge home with services (HR, 1.25; 95% CI, 1.04 to 1.50). Likelihood decreased if care was received at a teaching hospital (HR, 0.76; 95% CI, 0.59 to 0.99). Payer, sex, race, and comorbidities did not contribute. Conclusion: Although the overall rate of potentially preventable readmissions among patients with metastatic cancer is low, higher readmission rates among those discharged home with help suggest that services supplied may not be sufficient to address health needs.
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Affiliation(s)
| | | | - Kerin Adelson
- Smilow Cancer Hospital at Yale New Haven, Yale University School of Medicine, New Haven, CT
| | | | - Rebeca Franco
- Icahn School of Medicine at Mount Sinai, New York, NY
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Abstract
The integration of palliative care and hospice into standard gynecologic oncology care is associated with cost-savings, longer survival, lower symptom burden, and better quality of life for patients and caregivers. Consequently, this comprehensive approach is formally recognized and endorsed by the Society of Gynecologic Oncology, the National Comprehensive Cancer Network, and the American Society of Clinical Oncology. This article reviews the background, benefits, barriers, and most practical delivery models of palliative care. It also discusses management of common symptoms experienced by gynecologic oncology patients.
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Affiliation(s)
- Mary M Mullen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, Alvin J. Siteman Cancer Center, 660 South Euclid Avenue, Mail Stop 8064-37-905, St Louis, MO 63110, USA
| | - James C Cripe
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, Alvin J. Siteman Cancer Center, 660 South Euclid Avenue, Mail Stop 8064-37-905, St Louis, MO 63110, USA
| | - Premal H Thaker
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, Alvin J. Siteman Cancer Center, 660 South Euclid Avenue, Mail Stop 8064-37-905, St Louis, MO 63110, USA.
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May P, Garrido MM, Del Fabbro E, Noreika D, Normand C, Skoro N, Cassel JB. Evaluating Hospital Readmissions for Persons With Serious and Complex Illness: A Competing Risks Approach. Med Care Res Rev 2019; 77:574-583. [PMID: 30658539 DOI: 10.1177/1077558718823919] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Hospital readmission rate is a ubiquitous measure of efficiency and quality. Individuals with life-limiting illnesses account heavily for admissions but evaluation is complicated by high-mortality rates. We report a retrospective cohort study examining the association between palliative care (PC) and readmissions while controlling for postdischarge mortality with a competing risks approach. Eligible participants were adult inpatients admitted to an academic, safety-net medical center (2009-2015) with at least one diagnosis of cancer, heart failure, chronic obstructive pulmonary disease, liver failure, kidney failure, AIDS/HIV, and selected neurodegenerative conditions. PC was associated with reduced 30-, 60-, and 90-day readmissions (subhazard ratios = 0.57, 0.53, and 0.52, respectively [all p < .001]). Hospital PC is associated with a reduction in readmissions, and this is not explained by higher mortality among PC patients. Performance measures only counting those alive at a given end point may underestimate systematically the effects of treatments with a high-mortality rate.
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Affiliation(s)
- Peter May
- Trinity College Dublin, Dublin, Ireland
| | - Melissa M Garrido
- James J. Peters VA Medical Center, Bronx, NY, USA.,Icahn School of Medicine at Mount Sinai, NY, USA
| | | | | | - Charles Normand
- Trinity College Dublin, Dublin, Ireland.,King's College London, England, UK
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Cruz-Oliver DM, Abshire M, Cepeda O, Burhanna P, Johnson J, Velazquez DV, Chen J, Diab K, Christopher K, Rodin M. Adherence to Measuring What Matters: Description of an Inpatient Palliative Care Service of an Urban Teaching Hospital. J Palliat Med 2019; 22:75-79. [DOI: 10.1089/jpm.2018.0182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Dulce M. Cruz-Oliver
- Palliative Medicine Program, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Oscar Cepeda
- Division of Geriatrics, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri
| | | | | | - David Vera Velazquez
- Department of Internal Medicine, Spectrum Health/Michigan State University Internal Medicine Residency Program, Grand Rapids, Michigan
| | - Jennifer Chen
- Division of Geriatrics, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri
| | - Karim Diab
- Division of Geriatrics, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri
| | | | - Miriam Rodin
- Division of Geriatrics, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri
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Rosenblum R, Huo R, Scarborough B, Goldstein N, Smith CB. Comparison of Quality Oncology Practice Initiative Metrics in Solid Tumor Oncology Clinic With or Without Concomitant Supportive Oncology Consultation. J Oncol Pract 2018; 14:e786-e793. [PMID: 30537452 DOI: 10.1200/jop.18.00380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Quality Oncology Practice Initiative (QOPI) is a quality measurement and improvement program designed to assess practice performance for various consensus-based and evidence-based measures. In this study, we evaluated differences in QOPI metrics met among patients with advanced solid cancer receiving routine oncologic care alone (routine care) compared with patients receiving integrated oncology and specialty-level palliative care (supportive care). METHODS We conducted a retrospective chart review of 100 randomly selected patients treated between June 2013 and June 2015 from our supportive care group and matched these patients to 100 routine care group patients on the basis of tumor type and initial oncology visit date. We used the electronic medical record to collect data regarding patient demographics, palliative care-specific QOPI metrics, intensive care unit admissions, and hospice enrollment. We performed multivariate analysis comparing differences between the two groups. RESULTS A total of 200 patients were included. Both groups had similar baseline characteristics. Supportive care consultation improved the absolute number of QOPI metrics met ( P = .01). The QOPI metrics more likely to be met included the following: pain appropriately addressed ( P < .01), advance care directives documented by third office visit ( P < .01), and longer hospice enrollment ( P < .01). CONCLUSION Integrating palliative care consultation with routine oncologic care improved pain management and end-of-life planning and care. Properly addressing pain and guiding advance care discussions require specialized skills. These data support the need for increased primary palliative care education for oncologists and further development of supportive oncology practices.
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Affiliation(s)
- Rachel Rosenblum
- Icahn School of Medicine at Mount Sinai, New York, NY; and The Everett Clinic, Providence Regional Medical Center, Everett, WA
| | - Ran Huo
- Icahn School of Medicine at Mount Sinai, New York, NY; and The Everett Clinic, Providence Regional Medical Center, Everett, WA
| | - Bethann Scarborough
- Icahn School of Medicine at Mount Sinai, New York, NY; and The Everett Clinic, Providence Regional Medical Center, Everett, WA
| | - Nathan Goldstein
- Icahn School of Medicine at Mount Sinai, New York, NY; and The Everett Clinic, Providence Regional Medical Center, Everett, WA
| | - Cardinale B Smith
- Icahn School of Medicine at Mount Sinai, New York, NY; and The Everett Clinic, Providence Regional Medical Center, Everett, WA
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Ray EM, Riedel RF, LeBlanc TW, Rushing CN, Galanos AN. Assessing the Impact of a Novel Integrated Palliative Care and Medical Oncology Inpatient Service on Health Care Utilization before Hospice Enrollment. J Palliat Med 2018; 22:420-423. [PMID: 30394821 DOI: 10.1089/jpm.2018.0235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Evidence increasingly supports the integration of specialist palliative care (PC) into routine cancer care. A novel, fully integrated PC and medical oncology inpatient service was developed at Duke University Hospital in 2011. OBJECTIVE To assess the impact of PC integration on health care utilization among hospitalized cancer patients before hospice enrollment. METHODS Retrospective cohort study. Patients in the solid tumor inpatient unit who were discharged to hospice between September 1, 2009, and June 30, 2010 (pre-PC integration), and September 1, 2011, to June 30, 2012 (postintegration). Cohorts were compared on the following outcomes from their final hospitalization before hospice enrollment: intensive care unit days, invasive procedures, subspecialty consultations, radiographic studies, hospital length of stay, and use of chemotherapy or radiation. Cohort differences were examined with descriptive statistics and nonparametric tests. RESULTS Two hundred ninety-six patients were included in the analysis (133 pre-PC integration; 163 post-PC integration). Patient characteristics were similar between cohorts. Health care utilization was relatively low in both groups, although 26% and 24% were receiving chemotherapy at the time of admission or during hospitalization in the pre- and post-PC integration cohorts, respectively, and 6.8% in each cohort spent time in an intensive care unit. We found no significant differences in utilization between cohorts. DISCUSSION PC integration into an inpatient solid tumor service may not impact health care utilization during the final hospitalization before discharge to hospice. This likely reflects the greater benefits of integrating PC farther upstream from the terminal hospitalization, if one hopes to meaningfully impact utilization near the end of life.
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Affiliation(s)
- Emily M Ray
- 1 Division of Hematology and Oncology, University of North Carolina , Chapel Hill, North Carolina
| | - Richard F Riedel
- 2 Duke Cancer Institute, Duke University Medical Center , Durham, North Carolina
| | - Thomas W LeBlanc
- 2 Duke Cancer Institute, Duke University Medical Center , Durham, North Carolina.,3 Palliative Medicine, Duke University Medical Center , Durham, North Carolina
| | - Christel N Rushing
- 2 Duke Cancer Institute, Duke University Medical Center , Durham, North Carolina.,4 Biostatistics Shared Resource, Duke University Medical Center , Duke Cancer Institute, Durham, North Carolina
| | - Anthony N Galanos
- 2 Duke Cancer Institute, Duke University Medical Center , Durham, North Carolina.,3 Palliative Medicine, Duke University Medical Center , Durham, North Carolina
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Tham K, Kenner DJ, William L. Inpatients With Advanced Lung Cancer: Palliative Care Service Referral Rates, Symptom Profile, and Outcomes in a Teaching Hospital Network-An Exploratory Study. J Palliat Care 2018; 34:245-247. [PMID: 30381989 DOI: 10.1177/0825859718810720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kathryn Tham
- Palliative Care Service, Austin Health, Heidelberg, Melbourne, Victoria, Australia
| | - David J Kenner
- Specialist Palliative Care Service North, Launceston, Tasmania, Australia
| | - Leeroy William
- Eastern Health, Melbourne, Australia.,Monash University, Melbourne, Australia
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80
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Balboni TA, Hui KKP, Kamal AH. Supportive Care in Lung Cancer: Improving Value in the Era of Modern Therapies. Am Soc Clin Oncol Educ Book 2018; 38:716-725. [PMID: 30231310 DOI: 10.1200/edbk_201369] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Driven by a discipline-wide imperative to maximize patient centeredness and value, supportive care services have experienced remarkable growth and acceptance in oncology care. Two such services with a growing evidence base and examples of routine integration into usual oncology care are palliative care and integrative medicine. Both focus on the patient experience with cancer during and after cancer-directed treatments occur, from diagnosis through survivorship or end-of-life care. With a frame of increasing value for all in the oncology care ecosystem, we highlight the evidence for how these two disciplines can improve the experience of patients with cancer and their loved ones. We further highlight how additional focus in palliative care and integrative medicine can continue to build toward a shared vision of high-value, high-quality cancer care.
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Affiliation(s)
- Tracy A Balboni
- From the Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Medicine, David Geffen School of Medicine, UCLA Center for East West Medicine, University of California, Los Angeles, CA; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC
| | - Ka-Kit P Hui
- From the Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Medicine, David Geffen School of Medicine, UCLA Center for East West Medicine, University of California, Los Angeles, CA; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC
| | - Arif H Kamal
- From the Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Medicine, David Geffen School of Medicine, UCLA Center for East West Medicine, University of California, Los Angeles, CA; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC
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81
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Ferrer RA, Orehek E, Padgett LS. Goal conflict when making decisions for others. JOURNAL OF EXPERIMENTAL SOCIAL PSYCHOLOGY 2018. [DOI: 10.1016/j.jesp.2018.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Chang S, Sigel K, Goldstein NE, Wisnivesky J, Dharmarajan KV. Trends of Earlier Palliative Care Consultation in Advanced Cancer Patients Receiving Palliative Radiation Therapy. J Pain Symptom Manage 2018; 56:379-384. [PMID: 29885456 DOI: 10.1016/j.jpainsymman.2018.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/25/2018] [Accepted: 05/30/2018] [Indexed: 12/19/2022]
Abstract
CONTEXT The American Society of Clinical Oncology recommends that all patients with metastatic disease receive dedicated palliative care (PC) services early in their illness, ideally via interdisciplinary care teams. OBJECTIVES We investigated the time trends of specialty palliative care consultations from the date of metastatic cancer diagnosis among patients receiving palliative radiation therapy (PRT). A shorter time interval between metastatic diagnosis and first PC consultation suggests earlier involvement of palliative care in a patient's life with metastatic cancer. METHODS In this IRB-approved retrospective analysis, patients treated with PRT for solid tumors (bone and brain) at a single tertiary care hospital between 2010 and 2016 were included. Cohorts were arbitrarily established by metastatic diagnosis within approximately two-year intervals: 1) 1/1/2010-3/27/2012, 2) 3/28/2012-5/21/2014, and 3) 5/22/2014-12/31/2016. Cox proportional hazards regression modeling was used to compare trends of PC consultation among cohorts. RESULTS Of 284 patients identified, 184 patients received PC consultation, whereas 15 patients died before receiving a PC consult. Median follow-up time until an event or censor was 257 days (range: 1900). Patients in the most recent cohort had a shorter median time to first PC consult (57 days) compared to those in the first (374 days) and second (186 days) cohorts. On multivariable analysis, patients in the third cohort were more likely to undergo a PC consultation earlier in their metastatic illness (hazard ratio: 1.8, 95% CI: 1.2-2.8). CONCLUSION Over a six-year period, palliative care consultation occurred earlier for metastatic patients treated with PRT at our institution.
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Affiliation(s)
- Sanders Chang
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Keith Sigel
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Department of Internal Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Nathan E Goldstein
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Juan Wisnivesky
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Department of Internal Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Kavita V Dharmarajan
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital, New York, New York, USA; Department of Radiation Oncology, Mount Sinai Hospital, New York, New York, USA.
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83
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Callaway C, Cunningham C, Grover S, Steele KR, McGlynn A, Sribanditmongkol V. Patient Handoff Processes: Implementation and Effects of Bedside Handoffs, the Teach-Back Method, and Discharge Bundles on an Inpatient Oncology Unit. Clin J Oncol Nurs 2018; 22:421-428. [PMID: 30035777 DOI: 10.1188/18.cjon.421-428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Bedside handoffs, the teach-back method, and discharge bundles have been shown to contribute to empowering patients to actively engage in their treatment. OBJECTIVES The objectives were to identify patient activation scores, patient readmission rates, and nursing staff satisfaction before and after implementing bedside handoffs, the teach-back method, and discharge bundles on an inpatient oncology unit at a large military treatment facility. METHODS A series of three cycles using the Plan-Do-Study-Act framework guided implementation of the multifaceted approach. Patient activation scores, readmission rates, staff satisfaction, and anecdotal feedback from patients and nursing staff were collected prior to and following implementation. FINDINGS The sample of patients with cancer had high patient activation scores. After implementation of the multifaceted approach, readmission rates decreased from 32% to 25%, and staff satisfaction improved.
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Affiliation(s)
| | | | - Shawna Grover
- Uniformed Services University of the Health Sciences
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84
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Treece J, Ghouse M, Rashid S, Arikapudi S, Sankhyan P, Kohli V, O’Neill L, Addo-Yobo E, Bhattad V, Baumrucker SJ. The Effect of Hospice on Hospital Admission and Readmission Rates: A Review. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2018. [DOI: 10.1177/1084822318761105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Symptom control may become challenging for terminally ill patients as they near the end of life. Patients often seek hospital admission to address symptoms, such as pain, nausea, vomiting, and restlessness. Alternatively, palliative medicine focuses on the control and mitigation of symptoms, while allowing patients to maintain their quality of life, whether in an outpatient or inpatient setting. Hospice care provides, in addition to inpatient care at a hospice facility or in a hospital, the option for patients to receive symptom management at home. This option for symptom control in the outpatient setting is essential to preventing repeated and expensive hospital readmissions. This article discusses the impact of hospice care on hospital readmission rates.
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Affiliation(s)
| | | | - Saima Rashid
- East Tennessee State University, Johnson City, TN, USA
| | | | | | - Varun Kohli
- East Tennessee State University, Johnson City, TN, USA
| | - Luke O’Neill
- East Tennessee State University, Johnson City, TN, USA
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85
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Collins A, Sundararajan V, Burchell J, Millar J, McLachlan SA, Krishnasamy M, Le BH, Mileshkin L, Hudson P, Philip J. Transition Points for the Routine Integration of Palliative Care in Patients With Advanced Cancer. J Pain Symptom Manage 2018; 56:185-194. [PMID: 29608934 DOI: 10.1016/j.jpainsymman.2018.03.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 03/26/2018] [Accepted: 03/27/2018] [Indexed: 10/17/2022]
Abstract
CONTEXT Increasing emphases are being placed on early integration of palliative care for patients with advanced cancers, yet barriers to implementation in clinical practice remain. Criteria to standardize referral have been endorsed, but their application is yet to be tested at the population level. OBJECTIVES This study sought to establish the need for standardized referral by examining current end-of-life care outcomes of decedents with cancer and define transition points within a cancer illness course, which are associated with poor prognosis, whereby palliative care should be routinely introduced to augment clinician-based decision making. METHODS Population cohort study of admitted patients with advanced cancer diagnosed with non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), prostate or breast cancer between 2000 and 2010 in Victoria, Australia, identified from routinely collected, linked, hospital discharge, emergency department, and death registration data. Descriptive statistics described quality indicators for end-of-life care outcomes for decedents. Kaplan-Meier analyses were used to test the predefined transition point that mostly accurately predicted survival of six months or lesser. RESULTS About 46,700 cases (56% females) were admitted with metastatic NSCLC (n = 14,759; 31.6%), SCLC (n = 2932; 6%), prostate (n = 9445; 20.2%), and breast cancer (n = 19,564; 41.9%). Of the 29,680 decedents, most (80%) died in hospital, had suboptimal end-of-life care outcomes (83%), and 59% received a palliative approach to care, a median of 27 days before death. Transition points in the cancer illness course of all cases were identified as first admission with any metastatic disease (NSCLC: 3.8 months [interquartile range {IQR} 1.1, 16.0]; n = 14,666; and SCLC: 4.2 months [IQR 1.0, 10.6]; n = 2914); first multiday admission with any metastatic disease (prostate: 6.0 months [IQR 1.3, 26.4]; n = 7174); and first multiday admission with at least one visceral metastatic site (breast: 6.0 months [IQR 1.2, 29.8]; n = 7120). CONCLUSION Despite calls for integrated palliative care, this occurs late or not at all for many patients with cancer. Our findings demonstrate the application of targeted cancer-specific transition points to trigger integration of palliative care as a standard part of quality oncological care and augment clinician-based referral in routine clinical practice.
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Affiliation(s)
- Anna Collins
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; VCCC Palliative Medicine Research Group, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.
| | - Vijaya Sundararajan
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jodie Burchell
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jeremy Millar
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Sue-Anne McLachlan
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Medical Oncology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Meinir Krishnasamy
- Department of Nursing, University of Melbourne, Melbourne, Victoria, Australia
| | - Brian H Le
- Palliative Care Service, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Linda Mileshkin
- Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Peter Hudson
- Centre for Palliative Care, St Vincent's Hospital Melbourne & University of Melbourne, Melbourne, Victoria, Australia; Vrije University, Brussel, Belgium
| | - Jennifer Philip
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; VCCC Palliative Medicine Research Group, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
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86
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Early Palliative Care for Patients with Hematologic Malignancies: Is It Really so Difficult to Achieve? Curr Hematol Malig Rep 2018. [PMID: 28639084 DOI: 10.1007/s11899-017-0392-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Evidence points to many benefits of "early palliative care," the provision of specialist palliative care services upstream from the end of life, to improve patients' quality of life while living with a serious illness. Yet most trials of early palliative care have not included patients with hematologic malignancies. Unfortunately, patients with hematologic malignancies are also known to have substantial illness burden, poor quality of life, and aggressive care at the end of life, including a greater likelihood of dying in the hospital, receiving chemotherapy at the end of life, and low hospice utilization, compared to patients with solid tumors. Given these unmet needs, one must wonder, why is palliative care so underutilized in this population? In this article, we discuss barriers to palliative care integration in hematology, highlight several reports of successful integration, and suggest specific indications for involving palliative care in the management of hematologic malignancy patients.
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87
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Chang S, May P, Goldstein NE, Wisnivesky J, Ricks D, Fuld D, Aldridge M, Rosenzweig K, Morrison RS, Dharmarajan KV. A Palliative Radiation Oncology Consult Service Reduces Total Costs During Hospitalization. J Pain Symptom Manage 2018. [PMID: 29526611 PMCID: PMC5972676 DOI: 10.1016/j.jpainsymman.2018.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT Palliative radiation therapy (PRT) is a highly effective treatment in alleviating symptoms from bone metastases; however, currently used standard fractionation schedules can lead to costly care, especially when patients are treated in an inpatient setting. The Palliative Radiation Oncology Consult (PROC) service was developed in 2013 to improve appropriateness, timeliness, and care value from PRT. OBJECTIVES Our primary objective was to compare total costs among two cohorts of inpatients with bone metastases treated with PRT before, or after, PROC establishment. Secondarily, we evaluated drivers of cost savings including hospital length of stay, utilization of specialty-care palliative services, and PRT schedules. METHODS Patients were included in our observational cohort study if they received PRT for bone metastases at a single tertiary care hospital from 2010 to 2016. We compared total costs and length of stay using propensity score-adjusted analyses. Palliative care utilization and PRT schedules were compared by χ2 and Mann-Whitney U tests. RESULTS We identified 181 inpatients, 76 treated before and 105 treated after PROC. Median total hospitalization cost was $76,792 (range $6380-$346,296) for patients treated before PROC and $50,582 (range $7585-$620,943) for patients treated after PROC. This amounted to an average savings of $20,719 in total hospitalization costs (95% CI [$3687, $37,750]). In addition, PROC was associated with shorter PRT schedules, increased palliative care utilization, and an 8.5 days reduction in hospital stay (95% CI [3.2,14]). CONCLUSION The PROC service, a radiation oncology model integrating palliative care practice, was associated with cost-savings, shorter treatment courses and hospitalizations, and increased palliative care.
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Affiliation(s)
- Sanders Chang
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Peter May
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Centre for Health Policy and Management, Trinity College, Dublin, Ireland
| | - Nathan E Goldstein
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Juan Wisnivesky
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Department of Internal Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Doran Ricks
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Department of Strategic Planning, Mount Sinai Health System, New York, New York, USA
| | - David Fuld
- Department of Finance, Mount Sinai Health System, New York, New York, USA
| | - Melissa Aldridge
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Kenneth Rosenzweig
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Department of Radiation Oncology, Mount Sinai Hospital, New York, New York, USA
| | - Rolfe Sean Morrison
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Kavita V Dharmarajan
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital, New York, New York, USA; Department of Radiation Oncology, Mount Sinai Hospital, New York, New York, USA.
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Watson GA, Saunders J, Coate L. Evaluating the Time to Palliative Care Referrals in Patients With Small-Cell Lung Cancer: A Single-Centre Retrospective Review. Am J Hosp Palliat Care 2018; 35:1426-1432. [PMID: 29739231 DOI: 10.1177/1049909118775066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Lung cancer is a leading cause of morbidity and mortality worldwide. Patients with lung cancer may experience a plethora of symptoms, which can be debilitating and affect their quality of life. Palliative care input to manage their physical and psychological well-being is a crucial component of their oncological care. The benefit of early palliative care input has been shown in patients with non-small cell lung cancer; however, data pertaining to patients with small-cell lung cancer are scarce. Nevertheless, early palliative care input is recommended by several national and international guidelines. Thus, we aimed to assess the time to palliative care referrals in patients diagnosed with small-cell lung cancer in an Irish tertiary hospital and to determine what impact this had on overall survival. METHODS We performed a retrospective, single-center audit of all patients diagnosed with extensive stage small-cell lung cancer over a 6-year period in an Irish tertiary hospital. RESULTS Overall, 91 patients were identified. Median age at diagnosis was 66 years (range: 38-83 years). The median Eastern Cooperative Oncology Group Performance Status at diagnosis was 1 (range: 0-3); 24 (26%) patients had multiple sites of distant metastasis at diagnosis; 45 (49.5%) patients were alive at 6 months, and 15 (16.5%) patients were alive at 12 months. One hundred percent of patients received palliative care input in our center over the course of their care. In the patients alive at 6 months after diagnosis, there was no survival advantage in those receiving palliative care within 1 month ( P = .002, odd ratio: 0.23, 95% confidence interval: 0.09-0.59). CONCLUSION Palliative care treatment is a critical aspect in the oncological treatment of all patients diagnosed with advanced cancer, and this study highlights good compliance with existing national guidelines. Further research focusing on quality-of-life issues with the use of questionnaires to assess physical and psychological symptoms should be performed to further understand the impact of palliative care in these patients.
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Affiliation(s)
- Geoffrey Alan Watson
- 1 Department of Medical Oncology, University Hospital Limerick, Limerick, Ireland
| | - Jean Saunders
- 2 Department of Mathematics and Statistics, University of Limerick, Limerick, Ireland
| | - Linda Coate
- 1 Department of Medical Oncology, University Hospital Limerick, Limerick, Ireland
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Handley NR, Schuchter LM, Bekelman JE. Best Practices for Reducing Unplanned Acute Care for Patients With Cancer. J Oncol Pract 2018; 14:306-313. [PMID: 29664697 DOI: 10.1200/jop.17.00081] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Variation and cost in oncology care represent a large and growing burden for the US health care system, and acute hospital care is one of the single largest drivers. Reduction of unplanned acute care is a major priority for clinical transformation in oncology; proposed changes to Medicare reimbursement for patients with cancer who suffer unplanned admissions while receiving chemotherapy heighten the need. We conducted a review of best practices to reduce unplanned acute care for patients with cancer. We searched PubMed for articles published between 2000 and 2017 and reviewed guidelines published by professional organizations. We identified five strategies to reduce unplanned acute care for patients with cancer: (1) identify patients at high risk for unplanned acute care; (2) enhance access and care coordination; (3) standardize clinical pathways for symptom management; (4) develop new loci for urgent cancer care; and (5) use early palliative care. We assessed each strategy on the basis of specific outcomes: reduction in emergency department visits, reduction in hospitalizations, and reduction in rehospitalizations within 30 days. For each, we define gaps in knowledge and identify areas for future effort. These five strategies can be implemented separately or, with possibly more success, as an integrated program to reduce unplanned acute care for patients with cancer. Because of the large investment required and the limited data on effectiveness, there should be further research and evaluation to identify the optimal strategies to reduce emergency department visits, hospitalizations, and rehospitalizations. Proposed reimbursement changes amplify the need for cancer programs to focus on this issue.
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Gani F, Enumah ZO, Conca-Cheng AM, Canner JK, Johnston FM. Palliative Care Utilization among Patients Admitted for Gastrointestinal and Thoracic Cancers. J Palliat Med 2018; 21:428-437. [PMID: 29100002 PMCID: PMC6016727 DOI: 10.1089/jpm.2017.0295] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Although a growing body of literature recommends the early initiation of palliative care (PC), the use of PC remains variable. OBJECTIVE The current study sought to describe the use of PC and to identify factors associated with the use of inpatient PC. DESIGN Retrospective, cross-sectional analysis of data from the National Inpatient Sample. SETTING AND SUBJECTS Patients admitted with a primary diagnosis of gastrointestinal and/or thoracic cancer from 2012 to 2013. MEASUREMENTS In-hospital length of stay (LOS), morbidity, mortality, and total charges. RESULTS A total of 282,899 patients were identified who met inclusion criteria of whom, 24,100 (8.5%) patients received a PC consultation during their inpatient admission. Patients who received PC were more likely to have a longer LOS (LOS >14 days: 5.4% vs. 9.4%) and were more likely to develop a postoperative complication (28.3% vs. 45.9%, both p < 0.001). Inpatient mortality was significantly higher among patients who had received PC than those who did not (5.4% vs. 44.1%, p < 0.001). On multivariable analysis, patient age (age ≥75 years: Odds Ratio [OR] = 2.54, 95% CI: 2.33-2.78), comorbidity (CCI >6: OR = 2.60, 95% CI: 2.48-2.74), and admission to larger hospitals (reference small: OR = 1.20, 95% CI: 1.14-1.25) were associated with greater odds of receiving PC (all p < 0.05). Patients who underwent a major operation during their inpatient admission demonstrated 79% lower odds of receiving PC (OR = 0.21, 95% CI: 0.20-0.22, p < 0.001). CONCLUSIONS Among patients admitted for cancer, PC services were used in 8.5% of patients during their inpatient admission with surgical patients being 79% less likely to receive a PC consultation. Further research is required to delineate the barriers to the use of PC so as to promote the use of PC among high-risk patients.
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Affiliation(s)
- Faiz Gani
- Department of Surgery, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Zachary O Enumah
- Department of Surgery, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Alison M Conca-Cheng
- Department of Surgery, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine , Baltimore, Maryland
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91
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Khang PS, Wang SE, Liu ILA, Watson HL, Koyama SY, Huynh DN, Lee JS, Nguyen HQ. Impact of Inpatient Palliative Care on Quality of End-of-Life Care and Downstream Acute and Postacute Care Utilization. J Palliat Med 2018; 21:913-923. [PMID: 29649400 DOI: 10.1089/jpm.2017.0275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Additional evidence is needed regarding the impact of inpatient palliative care (IPC) on the quality of end-of-life care and downstream utilization. AIM Examine the effects of IPC on quality of end-of-life care and acute and postacute care use in a large integrated system. DESIGN Retrospective cohort design. SETTING/PARTICIPANTS Adult decedents from January 1, 2012, to December 31, 2014, who had at least one hospitalization at 11 Kaiser Permanente Southern California medical centers in the 12 months before death and not hospitalized for a trauma-related condition or receiving home-based PC or hospice were included in the cohort. MATERIALS AND METHODS Inverse probability of treatment weighting of propensity scores was used to compare outcomes between patients exposed to IPC (n = 3742) and controls (n = 12,755) who never received IPC before death. RESULTS Patients who received IPC were more likely to enroll in home-based PC or hospice (69% vs. 43%) and were less likely to die in a hospital (15% vs. 29%) or intensive care (2% vs. 9%) compared with controls (all, p < 0.001). IPC exposure was associated with higher risk for rehospitalization (HR: 1.18, 95% CI 1.11-1.25) and more frequent emergency department visits (RR: 1.16, 95% CI 1.07-1.26) with no increase in postacute care use compared with controls. Stratified analyses showed that IPC effects on acute care utilization were dependent on code status. CONCLUSION IPC exposure was associated with higher enrollment in home-based PC/hospice and more deaths at home. The increased acute care utilization by the IPC group may reflect persistent confounding by indication.
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Affiliation(s)
- Peter S Khang
- 1 Geriatric Palliative Care, Kaiser Permanente Southern California, Los Angeles Medical Center , Los Angeles, California
| | - Susan E Wang
- 2 Geriatric Palliative Care, Kaiser Permanente Southern California, West Los Angeles Medical Center , Los Angeles, California
| | - In-Lu Amy Liu
- 3 Department of Research and Evaluation, Kaiser Permanente Southern California , Pasadena, California
| | - Heather L Watson
- 4 Complete Care Programs, Kaiser Permanente Southern California , Pasadena, California
| | - Sandra Y Koyama
- 5 Internal Medicine, Kaiser Permanente Southern California , Baldwin Park, California
| | - Dan N Huynh
- 6 Hospital Medicine, Home Care Services, Kaiser Permanente Southern California , Pasadena, California
| | - Janet S Lee
- 3 Department of Research and Evaluation, Kaiser Permanente Southern California , Pasadena, California
| | - Huong Q Nguyen
- 3 Department of Research and Evaluation, Kaiser Permanente Southern California , Pasadena, California
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Abstract
As the shift to value-based payment accelerates, hospitals are under increasing pressure to deliver high-quality, efficient services. Palliative care approaches improve quality of life and family well-being, and in doing so, reduce resource utilization and costs. Hospitalists frequently provide palliative care interventions to their patients, including pain and symptom management and engaging in conversations with patients and families about the realities of their illness and treatment plans that align with their priorities. Hospitalists are ideally positioned to identify patients who could most benefit from palliative care approaches and often refer the most complex cases to specialty palliative care teams. Though hospitalists are frequently called upon to provide palliative care, most lack formal training in these skills, which have not typically been included in medical education. Additional training in communication, safe and effective symptom management, and other palliative care knowledge and skills are available in both in-person and online formats.
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Affiliation(s)
- Robin E Fail
- Center to Advance Palliative Care, New York, New York, USA.
| | - Diane E Meier
- Center to Advance Palliative Care, New York, New York, USA
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Mitchell SA. Palliative care during and following allogeneic hematopoietic stem cell transplantation. Curr Opin Support Palliat Care 2018; 12:58-64. [PMID: 29303840 PMCID: PMC5803752 DOI: 10.1097/spc.0000000000000327] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to synthesize recent literature regarding the provision of palliative care to patients during and following allogeneic hematopoietic stem cell transplantation (HSCT), highlighting factors which mediate impairments in health-related quality of life in this patient population, and the intervention approaches and models of care delivery that clinicians can consider to address unmet needs for palliative care and to strengthen patient and family resiliency. RECENT FINDINGS Provision of palliative care simultaneous with the delivery of treatment directed at the underlying malignancy has emerged as a recommended practice for patients with advanced cancer and high-symptom burden, and a recent randomized trial demonstrates the effectiveness of early palliative care in reducing some of the symptom burden and mood disturbances associated with HSCT. Although more research is needed, there is an expanding body of research-tested interventions to ameliorate the physical and psychological morbidity of HSCT across the transplant trajectory. SUMMARY Palliative care interventions delivered by an interdisciplinary team that includes transplant clinicians and palliative care across the HSCT trajectory can alleviate physical and psychological morbidity, thereby improving the patient and family experience of HSCT.
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Affiliation(s)
- Sandra A Mitchell
- Division of Cancer Control and Population Sciences, Outcomes Research Branch, National Cancer Institute, Rockville, Maryland, USA
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94
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Cotogni P, Saini A, De Luca A. In-Hospital Palliative Care: Should We Need to Reconsider What Role Hospitals Should Have in Patients with End-Stage Disease or Advanced Cancer? J Clin Med 2018; 7:jcm7020018. [PMID: 29385757 PMCID: PMC5852434 DOI: 10.3390/jcm7020018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 01/08/2018] [Accepted: 01/13/2018] [Indexed: 12/25/2022] Open
Abstract
Traditionally, palliative care (PC) systems focused on the needs of advanced cancer patients, but most patients needing PC have end-stage organ diseases. Similarly, PC models focus on the needs of patients in hospices or at home; however, in most cases PC is provided in acute hospitals. Indeed, the symptom burden that these patients experience in the last year of life frequently forces them to seek care in emergency departments. The majority of them are admitted to the hospital and many die. This issue poses important concerns. Despite the efforts of attending healthcare professionals, in-hospital patients do not receive optimal care near the end-of-life. Also, evidence is emerging that delay in identifying patients needing PC have a detrimental impact on their quality of life (QoL). Therefore, there is an urgent need to identify, early and properly, these patients among those hospitalized. Several trials reported the efficacy of PC in improving the QoL in these patients. Each hospital should ensure that a multidisciplinary PC team is available to support attending physicians to achieve the best QoL for both PC patients and their families. This review discusses the role and the impact of in-hospital PC in patients with end-stage disease or advanced cancer.
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Affiliation(s)
- Paolo Cotogni
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
| | - Andrea Saini
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
| | - Anna De Luca
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
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95
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Hashemi H, Endicott-Yazdani TR, Oguayo C, Harmon DM, Tran T, Tsai-Nguyen G, Benavides R, Spak CW, Nguyen HL. Bartonella endocarditis with glomerulonephritis in a patient with complete transposition of the great arteries. Proc (Bayl Univ Med Cent) 2018; 31:102-104. [PMID: 29686571 DOI: 10.1080/08998280.2017.1400296] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
We describe a patient with history of dextro-transposition of the great vessels, ventricular septal defect, and pulmonary valve replacement who presented with fatigue, prolonged fever, and leg edema. He was found to have kidney injury, pancytopenia, and liver congestion. Echocardiogram revealed thickened leaflets with prolapsing vegetation on the pulmonary valve. Given the negative blood cultures, high Bartonella henselae immunogobulin G titer (≥1:1024) and positive immunoglobulin M titer (≥1:20), he was diagnosed with Bartonella endocarditis complicated with glomerulonephritis.
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Affiliation(s)
- Helen Hashemi
- Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | | | - Christopher Oguayo
- Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | | | - Tuan Tran
- Department of Pathology, Baylor University Medical Center, Dallas, Texas
| | - Ginger Tsai-Nguyen
- Department of Pulmonary and Critical Care, Baylor University Medical Center, Dallas, Texas
| | - Raul Benavides
- Department of Pathology, Baylor University Medical Center, Dallas, Texas
| | - Cedric W Spak
- Division of Infectious Diseases, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas
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96
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Chang S, May P, Goldstein NE, Wisnivesky J, Rosenzweig K, Morrison RS, Dharmarajan KV. A Palliative Radiation Oncology Consult Service's Impact on Care of Advanced Cancer Patients. J Palliat Med 2017; 21:438-444. [PMID: 29189093 DOI: 10.1089/jpm.2017.0372] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Palliative radiation therapy (PRT) is a commonly utilized intervention for symptom palliation among patients with metastatic cancer, yet it is under-recognized as a distinct area of subspecialty within radiation oncology. OBJECTIVE We developed a multidisciplinary service model within radiation oncology called the Palliative Radiation Oncology Consult (PROC) service to improve the quality of cancer care for advanced cancer patients. We assessed the service's impact on patient-related and healthcare utilization outcomes. DESIGN Patients were included in this observational cohort study if they received PRT at a single tertiary care hospital between 2009 and 2017. We compared outcomes of patients treated after (post-intervention group) to those treated before (control group) PROC's establishment using unadjusted and propensity score adjusted analyses. RESULTS Of the 450 patients in the cohort, 154 receive PRT pre- and 296 after PROC's establishment. In comparison to patients treated pre-PROC, post-PROC patients were more likely to undergo single-fraction radiation (RR: 7.74, 95% CI: 3.84-15.57) and hypofraction (2-5 fraction) radiation (RR: 10.74, 95% CI: 5.82-19.83), require shorter hospital stays (21 vs. 26.5 median days, p = 0.01), and receive more timely specialty-level palliative care (OR: 2.65, 95% CI: 1.56-4.49). Despite shortened treatments, symptom relief was similar (OR: 1.35, 95% CI: 0.80-2.28). CONCLUSION The PROC service was associated with more efficient radiation courses, substantially reduced hospital length of stays, and more timely palliative care consultation, without compromising symptom improvements. These results suggest that a multidisciplinary care delivery model can lead to enhanced quality of care for advanced cancer patients.
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Affiliation(s)
- Sanders Chang
- 1 Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital , New York, New York
| | - Peter May
- 1 Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital , New York, New York.,2 Centre for Health Policy and Management, Trinity College , Dublin, Ireland
| | - Nathan E Goldstein
- 1 Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital , New York, New York.,3 Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital , New York, New York
| | - Juan Wisnivesky
- 1 Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital , New York, New York.,4 Department of Internal Medicine, Mount Sinai Hospital , New York, New York
| | - Kenneth Rosenzweig
- 1 Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital , New York, New York.,5 Department of Radiation Oncology, Mount Sinai Hospital , New York, New York
| | - R Sean Morrison
- 1 Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital , New York, New York.,3 Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital , New York, New York
| | - Kavita V Dharmarajan
- 1 Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital , New York, New York.,3 Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital , New York, New York.,5 Department of Radiation Oncology, Mount Sinai Hospital , New York, New York
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97
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Rosenfeld EB, Chan JK, Gardner AB, Curry N, Delic L, Kapp DS. Disparities Associated With Inpatient Palliative Care Utilization by Patients With Metastatic Gynecologic Cancers: A Study of 3337 Women. Am J Hosp Palliat Care 2017; 35:697-703. [DOI: 10.1177/1049909117736750] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Emily B. Rosenfeld
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
- Division of Gynecologic Oncology, New York Medical College, Valhalla, NY, USA
| | - John K. Chan
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
| | - Austin B. Gardner
- Division of Gynecologic Oncology, Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
- Division of Gynecologic Oncology, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Natasha Curry
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
| | - Lejla Delic
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
| | - Daniel S. Kapp
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
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Mullen MM, Divine LM, Porcelli BP, Wilkinson-Ryan I, Dans MC, Powell MA, Mutch DG, Hagemann AR, Thaker PH. The effect of a multidisciplinary palliative care initiative on end of life care in gynecologic oncology patients. Gynecol Oncol 2017; 147:460-464. [DOI: 10.1016/j.ygyno.2017.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/23/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
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100
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Saiki C, Ferrell B, Longo-Schoeberlein D, Chung V, Smith TJ. Goals-of-care discussions. ACTA ACUST UNITED AC 2017; 15:e190-e194. [PMID: 30148185 DOI: 10.12788/jcso.0355] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Goals-of-care conversations led by the oncologist are key to advancing the prognostic awareness of the patient and family, but too frequently do not occur or are ineffective in leading to advance care planning and appropriate planning for end-of-life care. At our institution, a phase 3 trial of palliative care added to usual care of phase 1 clinical trial patients gave us the opportunity to develop an electronic medical record-based goals-of-care template for discussions. We can complete all or parts of the form with patients, use it to ensure full coverage of important tasks such as planning for transition to hospice and legacy work, and make sure all the providers are "on the same page" about treatment plans. We have this within our EMR as a SmartPhrase that can be brought up for completion, and have found that it helps to clarify patient understanding. The form can also be used to document advance care planning for both clinical care and billing. Although this tool has not been formally tested, we have found that it is effective in day-to-day practice as well as in research, and we share it here.
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Affiliation(s)
- Catherine Saiki
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - Thomas J Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
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