251
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Penrod JD, Garrido MM, McKendrick K, May P, Aldridge MD, Meier DE, Ornstein KA, Morrison RS. Characteristics of Hospitalized Cancer Patients Referred for Inpatient Palliative Care Consultation. J Palliat Med 2017. [PMID: 28628352 DOI: 10.1089/jpm.2017.0111] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Palliative care is associated with improved patient and family outcomes and lower cost of care, but studies estimate that <50% of hospitalized adults in the United States who are appropriate for palliative care receive it. Few studies have addressed demographic and clinical factors associated with receipt of palliative care. OBJECTIVE Our aim was to identify characteristics of hospitalized advanced cancer patients that are associated with referral to an interdisciplinary hospital-based palliative care team. METHODS The data are from a prospective observational study of hospitalized advanced cancer patients in five hospitals. We used multivariable logistic regression to estimate the relationship between patient characteristics and palliative care referral. RESULTS The sample includes 3096 patients; 81% received usual care and 19% were referred to palliative care. Advanced cancer patients were twice as likely to receive palliative care referral if, at admission, they needed assistance with transfer from bed (p = 0.002) and about 1.5 times as likely if they were taking medication for pain (p = 0.002), nausea (p = 0.04), or constipation (p = 0.04). Patients with more comorbidities (p = 0.001) and higher symptom burden (p = 0.001) were more likely to be referred. CONCLUSION Advanced cancer patients were more likely to be referred to the palliative care consultation team if they had high symptom burden at hospital admission. Overall a minority of advanced cancer patients were referred. Standardized screening for palliative care may be needed to ensure that advanced cancer patients receive the highest quality of evidence based care.
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Affiliation(s)
- Joan D Penrod
- 1 James J. Peters Veterans Affairs Medical Center , Bronx, New York.,2 Icahn School of Medicine at Mount Sinai , New York, New York
| | - Melissa M Garrido
- 1 James J. Peters Veterans Affairs Medical Center , Bronx, New York.,2 Icahn School of Medicine at Mount Sinai , New York, New York
| | | | - Peter May
- 3 Centre for Health Policy and Management, Trinity College , Dublin, Ireland
| | | | - Diane E Meier
- 2 Icahn School of Medicine at Mount Sinai , New York, New York
| | | | - R Sean Morrison
- 1 James J. Peters Veterans Affairs Medical Center , Bronx, New York.,2 Icahn School of Medicine at Mount Sinai , New York, New York
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252
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Ahluwalia SC, Harris BJ, Lewis VA, Colla CH. End-of-Life Care Planning in Accountable Care Organizations: Associations with Organizational Characteristics and Capabilities. Health Serv Res 2017; 53:1662-1681. [PMID: 28560783 DOI: 10.1111/1475-6773.12720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To measure the extent to which accountable care organizations (ACOs) have adopted end-of-life (EOL) care planning processes and characterize those ACOs that have established processes related to EOL. DATA SOURCES This study uses data from three waves (2012-2015) of the National Survey of ACOs. Respondents were 397 ACOs participating in Medicare, Medicaid, and commercial ACO contracts. STUDY DESIGN This is a cross-sectional survey study using multivariate ordered logit regression models. We measured the extent to which the ACO had adopted EOL care planning processes as well as organizational characteristics, including care management, utilization management, health informatics, and shared decision-making capabilities, palliative care, and patient-centered medical home experience. PRINCIPAL FINDINGS Twenty-one percent of ACOs had few or no EOL care planning processes, 60 percent had some processes, and 19.6 percent had advanced processes. ACOs with a hospital in their system (OR: 3.07; p = .01), and ACOs with advanced care management (OR: 1.43; p = .02), utilization management (OR: 1.58, p = .00), and shared decision-making capabilities (OR: 16.3, p = .000) were more likely to have EOL care planning processes than those with no hospital or few to no capabilities. CONCLUSIONS There remains considerable room for today's ACOs to increase uptake of EOL care planning, possibly by leveraging existing care management, utilization management, and shared decision-making processes.
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Affiliation(s)
- Sangeeta C Ahluwalia
- RAND Corporation, Santa Monica, CA.,UCLA Fielding School of Public Health, Los Angeles, CA
| | | | - Valerie A Lewis
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Carrie H Colla
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
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253
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Improving ICU-Based Palliative Care Delivery: A Multicenter, Multidisciplinary Survey of Critical Care Clinician Attitudes and Beliefs. Crit Care Med 2017; 45:e372-e378. [PMID: 27618270 DOI: 10.1097/ccm.0000000000002099] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Addressing the quality gap in ICU-based palliative care is limited by uncertainty about acceptable models of collaborative specialist and generalist care. Therefore, we characterized the attitudes of physicians and nurses about palliative care delivery in an ICU environment. DESIGN Mixed-methods study. SETTING Medical and surgical ICUs at three large academic hospitals. PARTICIPANTS Three hundred three nurses, intensivists, and advanced practice providers. MEASUREMENTS AND MAIN RESULTS Clinicians completed written surveys that assessed attitudes about specialist palliative care presence and integration into the ICU setting, as well as acceptability of 23 published palliative care prompts (triggers) for specialist consultation. Most (n = 225; 75%) reported that palliative care consultation was underutilized. Prompting consideration of eligibility for specialist consultation by electronic health record searches for triggers was most preferred (n = 123; 41%); only 17 of them (6%) felt current processes were adequate. The most acceptable specialist triggers were metastatic malignancy, unrealistic goals of care, end of life decision making, and persistent organ failure. Advanced age, length of stay, and duration of life support were the least acceptable. Screening led by either specialists or ICU teams was equally preferred. Central themes derived from qualitative analysis of 65 written responses to open-ended items included concerns about the roles of physicians and nurses, implementation, and impact on ICU team-family relationships. CONCLUSIONS Integration of palliative care specialists in the ICU is broadly acceptable and desired. However, the most commonly used current triggers for prompting specialist consultation were among the least well accepted, while more favorable triggers are difficult to abstract from electronic health record systems. There is also disagreement about the role of ICU nurses in palliative care delivery. These findings provide important guidance to the development of collaborative care models for the ICU setting.
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254
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Psotka MA, McKee KY, Liu AY, Elia G, De Marco T. Palliative Care in Heart Failure: What Triggers Specialist Consultation? Prog Cardiovasc Dis 2017; 60:215-225. [PMID: 28483606 DOI: 10.1016/j.pcad.2017.05.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/03/2017] [Indexed: 12/19/2022]
Abstract
Heart failure (HF) continues to cause substantial death and suffering despite the availability of numerous medical, surgical, and technological therapeutic advancements. As a patient-centered holistic discipline focused on improving quality of life and decreasing anguish, palliative care (PC) has a crucial role in the care of HF patients that has been acknowledged by multiple international guidelines. PC can be provided by all members of the HF care team, including but not limited to practitioners with specialty PC training. Unfortunately, despite recommendations to routinely include PC techniques and providers in the care of HF patients, use of general PC strategies as well as expert PC consultation is limited by a dearth of evidence-based interventions in the HF population and knowledge as to when to initiate these interventions, uncertainty regarding patient desires, prognosis, and the respective roles of each member of the care team, and a general shortage of specialist PC providers. This review seeks to provide guidance as to when to employ the limited resource of specialist PC practitioners, in combination with services from other members of the care team, to best tend to HF patients as their disease progresses and eventually overcomes.
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Affiliation(s)
- Mitchell A Psotka
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - Kanako Y McKee
- Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Albert Y Liu
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Giovanni Elia
- Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Teresa De Marco
- Division of Cardiology, University of California San Francisco, San Francisco, CA.
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255
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Carpenter JG, McDarby M, Smith D, Johnson M, Thorpe J, Ersek M. Associations between Timing of Palliative Care Consults and Family Evaluation of Care for Veterans Who Die in a Hospice/Palliative Care Unit. J Palliat Med 2017; 20:745-751. [PMID: 28471732 DOI: 10.1089/jpm.2016.0477] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Palliative care consultations (PCC) improve end-of-life (EOL) care, although they may occur too late in an illness to effect the best outcomes. Evidence about the optimal timing of PCC is limited. OBJECTIVE To examine the associations between PCC timing and bereaved families' evaluation of care. METHODS A retrospective, cross-sectional analysis of data collected between October 2011 and September 2014 was conducted with 5,592 patients who died in a Veterans Affairs inpatient hospice/palliative care unit. The independent measure was the date of first documented PCC within 180 days of death. Outcomes came from the validated Bereaved Family Survey (BFS) and included one global and three subscale scores characterizing EOL care in the last month of life. RESULTS After adjustment for patient and facility characteristics, family members of veterans whose first PCC occurred 91-180 days before death were more likely to rate overall care as "excellent" compared with those whose PCC occurred 0-7 days before death, 67.9% versus 62.1%, respectively (adjusted odds ratio = 1.37; confidence interval [95% CI] 1.08-1.73). Mean scores on two of the three subscales also were significantly higher for veterans receiving PCC 31-90 days before the veteran's death compared with those who had their first PCC 0-7 days before death: Respectful Care and Communication, 13.6 versus 13.4, respectively (β = 0.26; 95% CI 0.11-0.41), and Emotional and Spiritual Support, 7.6 versus 7.4, respectively (β = 0.22; 95% CI 0.03-0.41). CONCLUSIONS Earlier PCC is associated with greater family satisfaction with care. Strategies that are aimed at conducting PCC earlier in life-limiting illness are needed.
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Affiliation(s)
- Joan G Carpenter
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center , Philadelphia, Pennsylvania
| | - Meghan McDarby
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center , Philadelphia, Pennsylvania
| | - Dawn Smith
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center , Philadelphia, Pennsylvania
| | - Megan Johnson
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center , Philadelphia, Pennsylvania
| | - Joshua Thorpe
- 2 Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center , Pittsburgh, Pennsylvania.,3 Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy , Pittsburgh, Pennsylvania
| | - Mary Ersek
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center , Philadelphia, Pennsylvania.,4 University of Pennsylvania School of Nursing , Philadelphia, Pennsylvania
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256
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Kamal AH, Kaufmann T. Making the Right Thing Easier to Do: Standardized Integration of Oncology and Palliative Care. J Oncol Pract 2017; 13:291-292. [DOI: 10.1200/jop.2017.021717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Arif H. Kamal
- Duke University School of Medicine, Fuqua School of Business, and Duke Cancer Institute, Durham, NC; and University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Tara Kaufmann
- Duke University School of Medicine, Fuqua School of Business, and Duke Cancer Institute, Durham, NC; and University of Pennsylvania School of Medicine, Philadelphia, PA
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257
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Building a palliative radiation oncology program: From bedside to B.E.D. Pract Radiat Oncol 2017; 7:203-208. [DOI: 10.1016/j.prro.2016.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/29/2016] [Accepted: 09/08/2016] [Indexed: 11/23/2022]
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258
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Carpenter JG, Berry PH, Ersek M. Nursing home care trajectories for older adults following in-hospital palliative care consultation. Geriatr Nurs 2017; 38:531-536. [PMID: 28457493 DOI: 10.1016/j.gerinurse.2017.03.016] [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] [Received: 01/05/2017] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 12/18/2022]
Abstract
Palliative care consultation (PCC) during hospitalization is increasingly common for older adults with life-limiting illness discharged to nursing homes. The objective of this qualitative descriptive study was to describe the care trajectories and experiences of older adults admitted to a nursing home following a PCC during hospitalization. Twelve English-speaking adults, mean age 80 years, who received a hospital PCC and discharge to a nursing home without hospice. Data were collected from medical records at five time points from hospital discharge to 100 days after nursing home admission and care trajectories were mapped. Interviews (n = 15) with participants and surrogates were combined with each participant's medical record data. Content analysis was employed on the combined dataset. All PCC referrals were for goals of care conversations during which the PCC team discussed poor prognosis. All participants were admitted to a nursing home under the Medicare skilled nursing facility benefit. Seven were rehospitalized; six of the 12 died within 6 weeks of initial nursing home admission. The two care trajectories were Focus on Rehabilitative Care and Comfort Care Continuity. There was a heavy emphasis on recovering functional status through rehabilitation and skilled nursing care, despite considerable symptom burden and poor prognosis. Regardless of PCC with recommendations for palliative interventions, frail older adults with limited life expectancy and their family caregivers often perceive that rehabilitation will improve physical function. This perception may contribute to inappropriate, ineffective care. More emphasis is needed to coordinate care between PCC recommendations and post-acute care.
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Affiliation(s)
- Joan G Carpenter
- University of Utah College of Nursing, 10 South 2000 East, Salt Lake City, UT 84112, USA; Corporal Michael J. Crescenz VA Medical Center - Philadelphia, 3900 Woodland Avenue, Annex Suite 203, Philadelphia, PA 19104, USA.
| | - Patricia H Berry
- Hartford Center of Gerontological Nursing Excellence at OHSU, Oregon Health and Science, University School of Nursing, Mail Code: SN-6S, 3455 SW US Veterans Hospital Road, Portland, OR 97239, USA
| | - Mary Ersek
- Corporal Michael J. Crescenz VA Medical Center - Philadelphia, 3900 Woodland Avenue, Annex Suite 203, Philadelphia, PA 19104, USA; University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA
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259
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Abstract
NPs care for patients with chronic diseases such as heart failure, chronic obstructive pulmonary disease, cancer, and dementia. As the disease progresses or patients age, disease-related symptoms may become increasingly burdensome, and these patients may benefit from hospice or palliative care. NPs can guide individuals in this process to optimize care and support at the end of life.
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Affiliation(s)
- Kathleen Broglio
- Kathleen Broglio is an NP in the section of palliative care at Dartmouth-Hitchcock Medical Center, Lebanon, N.H. Anne Walsh is an NP at Visiting Nurse Service of New York Hospice and Palliative Care, New York, N.Y
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260
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Wang SY, Aldridge MD, Gross CP, Canavan M, Cherlin E, Bradley E. End-of-Life Care Transition Patterns of Medicare Beneficiaries. J Am Geriatr Soc 2017; 65:1406-1413. [PMID: 28369785 DOI: 10.1111/jgs.14891] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To characterize the patterns of transitions in care and factors associated with multiple transitions in the last 6 months of life of U.S. decedents (N = 660,132). DESIGN Retrospective study. SETTING United States. PARTICIPANTS Medicare beneficiaries aged 66 and older who died from July to December 2011. MEASUREMENTS Transitions between healthcare settings (e.g., hospital, skilled nursing facility, inpatient hospice, home hospice, home without hospice) in the last 6 months of life. A count variable for number of transitions was summarized, and Sankey diagrams were produced to illustrate the sequences of healthcare transitions. Multivariable analyses were used to identify factors associated with likelihood of having four or more transitions. RESULTS More than 80% decedents (n = 556,437) had at least one transition within the last 6 months of life; 218,731 had four or more transitions within the last 6 months of life. The most-frequent transition pattern (19.3% of all decedents; n = 127,435) was home to hospital, back to home or skilled nursing facility, to hospital again, and then to settings other than hospital, ending with four or more transitions. The average number of transitions in the last 6 months of life varied substantially across states, ranging from 1.8 in Alaska to 3.1 in New Jersey. Transitions became more intensive for decedents approaching death. In multivariable analyses, women, blacks, individuals younger than 85, and individuals without dementia were more likely to have four or more transitions (all P < .05). CONCLUSION Approximately one-third of the Medicare beneficiaries who died in 2011 had four or more transitions within their last 6 months of life. Identifying interventions that can facilitate care transitions consistent with beneficiaries' preferences is warranted.
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Affiliation(s)
- Shi-Yi Wang
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale Cancer Center and School of Medicine, Yale University, New Haven, Connecticut
| | - Melissa D Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York.,James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale Cancer Center and School of Medicine, Yale University, New Haven, Connecticut.,Section of General Internal Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Maureen Canavan
- Department of Health Policy and Management, School of Public Health, Yale University, New Haven, Connecticut
| | - Emily Cherlin
- Department of Health Policy and Management, School of Public Health, Yale University, New Haven, Connecticut
| | - Elizabeth Bradley
- Department of Health Policy and Management, School of Public Health, Yale University, New Haven, Connecticut
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261
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Kluger BM, Fox S, Timmons S, Katz M, Galifianakis NB, Subramanian I, Carter JH, Johnson MJ, Richfield EW, Bekelman D, Kutner JS, Miyasaki J. Palliative care and Parkinson's disease: Meeting summary and recommendations for clinical research. Parkinsonism Relat Disord 2017; 37:19-26. [DOI: 10.1016/j.parkreldis.2017.01.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 12/01/2016] [Accepted: 01/10/2017] [Indexed: 12/25/2022]
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262
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A Survey of Hospice and Palliative Nurses Association Nurse Educators’ Teaching Practices and Attitudes Toward Driving Safety in Hospice and Palliative Care Patients. J Hosp Palliat Nurs 2017. [DOI: 10.1097/njh.0000000000000323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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263
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Dalal S, Bruera E. End-of-Life Care Matters: Palliative Cancer Care Results in Better Care and Lower Costs. Oncologist 2017; 22:361-368. [PMID: 28314840 PMCID: PMC5388382 DOI: 10.1634/theoncologist.2016-0277] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 01/13/2017] [Indexed: 12/25/2022] Open
Abstract
This article reviews the current state of end‐of‐life care, analyzes the clinical and financial impact of palliative care, and proposes areas of future research and development.
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Affiliation(s)
- Shalini Dalal
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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264
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Ornstein KA, Schulz R, Meier DE. Families Caring for an Aging America Need Palliative Care. J Am Geriatr Soc 2017; 65:877-878. [PMID: 28221667 DOI: 10.1111/jgs.14785] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine, Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Richard Schulz
- Department of Psychiatry, University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Diane E Meier
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Center to Advance Palliative Care, New York, New York
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265
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Abstract
Despite significant advances in understanding the benefits of early integration of palliative care with disease management, many people living with a chronic life-threatening illness either do not receive any palliative care service or receive services only in the last phase of their illness. In this article, I explore some of the reasons for failure to provide palliative care services and recommend some strategies to overcome these barriers, emphasizing the importance of describing palliative care accurately. I provide language which I hope will help health care professionals of all disciplines explain what palliative care has to offer and ensure wider access to palliative care, early in the course of their illness.
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Affiliation(s)
- Pippa Hawley
- Pain & Symptom Management/Palliative Care Program, BC Cancer Agency, Vancouver, BC, Canada
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266
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Effects of hospital palliative care on health, length of stay, and in-hospital mortality across intensive and non-intensive-care units: A systematic review and metaanalysis. Palliat Support Care 2017; 15:741-752. [PMID: 28196551 DOI: 10.1017/s1478951516001164] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Hospital palliative care has been shown to improve quality of life and optimize hospital utilization for seriously ill patients who need intensive care. The present review examined whether hospital palliative care in intensive care (ICU) and non-ICU settings will influence hospital length of stay and in-hospital mortality. METHOD A systematic search of CINAHL/EBSCO, the Cochrane Library, Google Scholar, MEDLINE/Ovid, PubMed, and the Web of Science through 12 October 2016 identified 16 studies that examined the effects of hospital palliative care and reported on hospital length of stay and in-hospital death. Random-effects pooled odds ratios and mean differences with corresponding 95% confidence intervals were estimated. Heterogeneity was measured by the I 2 test. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was utilized to assess the overall quality of the evidence. RESULTS Of the reviewed 932 articles found in our search, we reviewed the full text of 76 eligible articles and excluded 60 of those, which resulted in a final total of 16 studies for analysis. Five studies were duplicated with regard to outcomes. A total of 18,330 and 9,452 patients were analyzed for hospital length of stay and in-hospital mortality from 11 and 10 studies, respectively. Hospital palliative care increased mean hospital length of stay by 0.19 days (pooled mean difference = 0.19; 95% confidence interval [CI 95%] = -2.22-2.61 days; p = 0.87; I 2 = 95.88%) and reduced in-hospital mortality by 34% (pooled odds ratio = 0.66; CI 95% = 0.52-0.84; p < 0.01; I 2 = 48.82%). The overall quality of evidence for both hospital length of stay and in-hospital mortality was rated as very low and low, respectively. SIGNIFICANCE OF RESULTS Hospital palliative care was associated with a 34% reduction of in-hospital mortality but had no correlation with hospital length of stay.
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267
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Edwards A, Nam S. Palliative Care Exposure in Internal Medicine Residency Education: A Survey of ACGME Internal Medicine Program Directors. Am J Hosp Palliat Care 2017; 35:41-44. [DOI: 10.1177/1049909116687986] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
As the baby boomer generation ages, the need for palliative care services will be paramount and yet training for palliative care physicians is currently inadequate to meet the current palliative care needs. Nonspecialty-trained physicians will need to supplement the gap between supply and demand. Yet, no uniform guidelines exist for the training of internal medicine residents in palliative care. To our knowledge, no systematic study has been performed to evaluate how internal medicine residencies currently integrate palliative care into their training. In this study, we surveyed 338 Accreditation Council for Graduate Medical Education–accredited internal medicine program directors. We queried how palliative care was integrated into their training programs. The vast majority of respondents felt that palliative care training was “very important” (87.5%) and 75.9% of respondents offered some kind of palliative care rotation, often with a multidisciplinary approach. Moving forward, we are hopeful that the data provided from our survey will act as a launching point for more formal investigations into palliative care education for internal medicine residents. Concurrently, policy makers should aid in palliative care instruction by formalizing required palliative care training for internal medicine residents.
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Affiliation(s)
- Asher Edwards
- Internal Medicine Department, Kaiser Permanente, Baldwin Park, CA, USA
| | - Samuel Nam
- Division of General Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
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268
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Carpenter JG. Hospital Palliative Care Teams and Post-Acute Care in Nursing Facilities: An Integrative Review. Res Gerontol Nurs 2017; 10:25-34. [PMID: 28112355 DOI: 10.3928/19404921-20161209-02] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 10/24/2016] [Indexed: 11/20/2022]
Abstract
Although palliative care consultation teams are common in U.S. hospitals, follow up and outcomes of consultations for frail older adults discharged to nursing facilities are unclear. To summarize and critique research on the care of patients discharged to nursing facilities following a hospital-based palliative care consult, a systematic search of PubMed, CINAHL, Ageline, and PsycINFO was conducted in February 2016. Data from the articles (N = 12) were abstracted and analyzed. The results of 12 articles reflecting research conducted in five countries are presented in narrative form. Two studies focused on nurse perceptions only, three described patient/family/caregiver experiences and needs, and seven described patient-focused outcomes. Collectively, these articles demonstrate that disruption in palliative care service on hospital discharge and nursing facility admission may result in high symptom burden, poor communication, and inadequate coordination of care. High mortality was also noted. [Res Gerontol Nurs. 2017; 10(1):25-34.].
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269
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Pruskowski J, Arnold R, Skledar SJ. Development of a health-system palliative care clinical pharmacist. Am J Health Syst Pharm 2016; 74:e6-e8. [PMID: 28007715 DOI: 10.2146/ajhp160055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jennifer Pruskowski
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburgh,
| | - Robert Arnold
- Section of Palliative Care and Medical EthicsDivision of General Internal MedicineUniversity of Pittsburgh School of MedicinePittsburgh, PA
| | - Susan J Skledar
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburgh, PA.,University of Pittsburgh Medical CenterPittsburgh, PA
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270
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Mun E, Umbarger L, Ceria-Ulep C, Nakatsuka C. Palliative Care Processes Embedded in the ICU Workflow May Reserve Palliative Care Teams for Refractory Cases. Am J Hosp Palliat Care 2016; 35:60-65. [PMID: 28273756 DOI: 10.1177/1049909116684821] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
CONTEXT Palliative Care Teams have been shown to be instrumental in the early identification of multiple aspects of advanced care planning. Despite an increased number of services to meet the rising consultation demand, it is conceivable that the numbers of palliative care consultations generated from an ICU alone could become overwhelming for an existing palliative care team. OBJECTIVE Improve end-of-life care in the ICU by incorporating basic palliative care processes into the daily routine ICU workflow, thereby reserving the palliative care team for refractory situations. METHODS A structured, palliative care, quality-improvement program was implemented and evaluated in the ICU at Kaiser Permanente Medical Center in Hawaii. This included selecting trigger criteria, a care model, forming guidelines, and developing evaluation criteria. MAIN OUTCOME MEASURES These included the early identification of the multiple features of advanced care planning, numbers of proactive ICU and palliative care family meetings, and changes in code status and treatment upon completion of either meeting. RESULTS Early identification of Goals-of-Care, advance directives, and code status by the ICU staff led to a proactive ICU family meeting with resultant increases in changes in code status and treatment. The numbers of palliative care consultations also rose, but not significantly. CONCLUSIONS Palliative care processes could be incorporated into a daily ICU workflow allowing for integration of aspects of advanced care planning to be identified in a systematic and proactive manner. This reserved the palliative care team for situations when palliative care efforts performed by the ICU staff were ineffective.
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Affiliation(s)
- Eluned Mun
- 1 Department of Physician Services, The Rehabilitation Hospital of the Pacific, Honolulu, HI, USA
| | - Lillian Umbarger
- 2 Department of Intensive Care Unit, Kaiser Permanente Medical Center, Honolulu, HI, USA
| | - Clementina Ceria-Ulep
- 3 Department of School of Nursing and Dental Hygiene, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Craig Nakatsuka
- 4 Department of Palliative Care, Kaiser Permanente Medical Center, Honolulu, HI, USA
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271
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Kamal AH. "Who Does What?" Ensuring High-Quality and Coordinated Palliative Care With Our Oncology Colleagues. J Pain Symptom Manage 2016; 52:e1-e2. [PMID: 27686601 DOI: 10.1016/j.jpainsymman.2016.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 08/21/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Arif H Kamal
- Division of Medical Oncology and Duke Palliative Care, Duke Cancer Institute, Duke School of Medicine, Durham, North Carolina, USA.
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272
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Thygeson NM, Wang M, O'Riordan D, Pantilat SZ. Self-Reported California Hospital Palliative Care Program Composition, Certification, and Staffing Level Are Associated with Lower End-of-Life Medicare Utilization. J Palliat Med 2016; 19:1281-1287. [DOI: 10.1089/jpm.2016.0176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- N. Marcus Thygeson
- Department of Healthcare Quality and Affordability, Blue Shield of California, San Francisco, California
| | - Meinong Wang
- School of Public Health, Yale University, New Haven, Connecticut
| | - David O'Riordan
- Department of Medicine, University of California, San Francisco, California
| | - Steven Z. Pantilat
- Department of Hospital Medicine, University of California, San Francisco, California
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273
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Kavalieratos D, Corbelli J, Zhang D, Dionne-Odom JN, Ernecoff NC, Hanmer J, Hoydich ZP, Ikejiani DZ, Klein-Fedyshin M, Zimmermann C, Morton SC, Arnold RM, Heller L, Schenker Y. Association Between Palliative Care and Patient and Caregiver Outcomes: A Systematic Review and Meta-analysis. JAMA 2016; 316:2104-2114. [PMID: 27893131 PMCID: PMC5226373 DOI: 10.1001/jama.2016.16840] [Citation(s) in RCA: 705] [Impact Index Per Article: 88.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE The use of palliative care programs and the number of trials assessing their effectiveness have increased. OBJECTIVE To determine the association of palliative care with quality of life (QOL), symptom burden, survival, and other outcomes for people with life-limiting illness and for their caregivers. DATA SOURCES MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL to July 2016. STUDY SELECTION Randomized clinical trials of palliative care interventions in adults with life-limiting illness. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data. Narrative synthesis was conducted for all trials. Quality of life, symptom burden, and survival were analyzed using random-effects meta-analysis, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-palliative care scale (FACIT-Pal) instrument (range, 0-184 [worst-best]; minimal clinically important difference [MCID], 9 points); and symptom burden translated to the Edmonton Symptom Assessment Scale (ESAS) (range, 0-90 [best-worst]; MCID, 5.7 points). MAIN OUTCOMES AND MEASURES Quality of life, symptom burden, survival, mood, advance care planning, site of death, health care satisfaction, resource utilization, and health care expenditures. RESULTS Forty-three RCTs provided data on 12 731 patients (mean age, 67 years) and 2479 caregivers. Thirty-five trials used usual care as the control, and 14 took place in the ambulatory setting. In the meta-analysis, palliative care was associated with statistically and clinically significant improvements in patient QOL at the 1- to 3-month follow-up (standardized mean difference, 0.46; 95% CI, 0.08 to 0.83; FACIT-Pal mean difference, 11.36] and symptom burden at the 1- to 3-month follow-up (standardized mean difference, -0.66; 95% CI, -1.25 to -0.07; ESAS mean difference, -10.30). When analyses were limited to trials at low risk of bias (n = 5), the association between palliative care and QOL was attenuated but remained statistically significant (standardized mean difference, 0.20; 95% CI, 0.06 to 0.34; FACIT-Pal mean difference, 4.94), whereas the association with symptom burden was not statistically significant (standardized mean difference, -0.21; 95% CI, -0.42 to 0.00; ESAS mean difference, -3.28). There was no association between palliative care and survival (hazard ratio, 0.90; 95% CI, 0.69 to 1.17). Palliative care was associated consistently with improvements in advance care planning, patient and caregiver satisfaction, and lower health care utilization. Evidence of associations with other outcomes was mixed. CONCLUSIONS AND RELEVANCE In this meta-analysis, palliative care interventions were associated with improvements in patient QOL and symptom burden. Findings for caregiver outcomes were inconsistent. However, many associations were no longer significant when limited to trials at low risk of bias, and there was no significant association between palliative care and survival.
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Affiliation(s)
- Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania2Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania3Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Jennifer Corbelli
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Di Zhang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Natalie C Ernecoff
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Janel Hanmer
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Zachariah P Hoydich
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dara Z Ikejiani
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Camilla Zimmermann
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada8Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania2Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lucas Heller
- Division of Endocrinology, Department of Medicine, University of Pittsburgh, Pittsburgh
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania2Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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274
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Wordingham SE, McIlvennan CK, Dionne-Odom JN, Swetz KM. Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life. Curr Heart Fail Rep 2016; 13:20-9. [PMID: 26829929 DOI: 10.1007/s11897-016-0282-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few.
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Affiliation(s)
- Sara E Wordingham
- Department of Medicine, Division of Hematology/Oncology, Palliative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - Colleen K McIlvennan
- Section of Advanced Heart Failure and Transplantation, Division of Cardiology, University of Colorado School of Medicine, Aurora and Colorado Cardiovascular Outcomes Research Consortium, Denver, CO, USA.
| | | | - Keith M Swetz
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center; Birmingham VA Medical Center; and Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA.
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275
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276
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Ferrell B, Malloy P, Mazanec P, Virani R. CARES: AACN's New Competencies and Recommendations for Educating Undergraduate Nursing Students to Improve Palliative Care. J Prof Nurs 2016; 32:327-33. [DOI: 10.1016/j.profnurs.2016.07.002] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Indexed: 11/29/2022]
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277
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Spetz J, Dudley N, Trupin L, Rogers M, Meier DE, Dumanovsky T. Few Hospital Palliative Care Programs Meet National Staffing Recommendations. Health Aff (Millwood) 2016; 35:1690-7. [DOI: 10.1377/hlthaff.2016.0113] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Joanne Spetz
- Joanne Spetz ( ) is a professor of economics at the Philip R. Lee Institute for Health Policy Studies and the Healthforce Center at the University of California, San Francisco (UCSF)
| | - Nancy Dudley
- Nancy Dudley is a VA Quality Scholars fellow with the UCSF Department of Geriatrics and the San Francisco Veterans Affairs Medical Center
| | - Laura Trupin
- Laura Trupin is an epidemiologist in the Philip R. Lee Institute for Health Policy Studies at UCSF
| | - Maggie Rogers
- Maggie Rogers is senior research associate at the Center to Advance Palliative Care, in New York City
| | - Diane E. Meier
- Diane E. Meier is the director of the Center to Advance Palliative Care and a professor in the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, in New York City
| | - Tamara Dumanovsky
- Tamara Dumanovsky is a vice president for research and analytics at the Center to Advance Palliative Care
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278
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Affiliation(s)
- R Sean Morrison
- Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Diane E Meier
- Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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279
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Petrillo LA, Dzeng E, Smith AK. California's End of Life Option Act: Opportunities and Challenges Ahead. J Gen Intern Med 2016; 31:828-9. [PMID: 27114358 PMCID: PMC4945570 DOI: 10.1007/s11606-016-3713-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/22/2016] [Accepted: 04/08/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Laura A Petrillo
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA. .,San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Elizabeth Dzeng
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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280
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Riggs A, Breuer B, Dhingra L, Chen J, Hiney B, McCarthy M, Portenoy RK, Knotkova H. Hospice Enrollment After Referral to Community-Based, Specialist-Level Palliative Care: Incidence, Timing, and Predictors. J Pain Symptom Manage 2016; 52:170-7. [PMID: 27208866 DOI: 10.1016/j.jpainsymman.2016.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 02/11/2016] [Accepted: 02/29/2016] [Indexed: 11/29/2022]
Abstract
CONTEXT Referral to community-based palliative care may increase the likelihood of hospice enrollment. OBJECTIVES This retrospective cohort study evaluated the incidence, timing, and predictors of hospice enrollment after referral to a community-based palliative care program. METHODS Data from 1505 homebound patients referred to community-based palliative care during 2010-2013 were analyzed using multivariate linear and logistic regression. RESULTS Mean (SD) age was 70.4 (16.7) years; 58.8% were women, and race/ethnicity was diverse (white 32.9%, black 29.8%, Hispanic 28.6%, Asian 5.4%). Patients received palliative care services for a mean (SD) of 10.2 (10.2) months (median 6.9; range 0.03-52.2 months). A total of 362 patients (24.1%) were enrolled in hospice after receiving palliative care services for a mean (SD) of 4.8 (6.8) months (median 7.9; range 0.09-25.7 months). The median hospice length of stay was approximately twice as long as other patients enrolled in hospice during the same period. The probability of hospice enrollment increased with shorter duration of palliative care, cancer diagnosis, poorer performance status, and a lower likelihood of poverty. Similarly, significant predictors of a shorter duration of palliative care services before hospice enrollment included both sociodemographic and clinical factors. CONCLUSION Almost one-quarter of patients were enrolled in hospice while receiving community-based palliative care, and hospice length of stay was relatively long for those who did. Both sociodemographic and clinical characteristics were associated with hospice-related outcomes. Studies are needed to further explore predictors and outcomes of hospice enrollment from palliative care.
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Affiliation(s)
- Alexa Riggs
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Brenda Breuer
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Bronx, New York, USA
| | - Jack Chen
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Barbara Hiney
- MJHS Hospice and Palliative Care, New York, New York, USA
| | - Maureen McCarthy
- The Center for Hospice & Palliative Care, New York, New York, USA
| | - Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Bronx, New York, USA; Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Helena Knotkova
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Bronx, New York, USA.
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281
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Harrison KL, Connor SR. First Medicare Demonstration of Concurrent Provision of Curative and Hospice Services for End-of-Life Care. Am J Public Health 2016; 106:1405-8. [PMID: 27310352 DOI: 10.2105/ajph.2016.303238] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Hospice developed in the United States in the 1970s as a way to address unmet needs for end-of-life care: support for pain and symptom management provided in the location and manner that the patient and family prefer. In Europe and Australia, hospice is available from the time of diagnosis of an advanced life-limiting illness onward, but in the United States, the Medicare hospice benefit restricts eligibility for these services to patients who no longer receive curative treatment. We provide background and analysis of the first Medicare hospice demonstration in 35 years that will test the concurrent provision of curative and hospice services for terminally ill individuals with a life expectancy of six months or less. This demonstration is a harbinger of potential policy changes to hospice and palliative care in the United States that could reduce barriers to end-of-life care that aligns with patient and family preferences as the demand for care increases with an aging population.
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Affiliation(s)
- Krista L Harrison
- Krista L. Harrison is with the Division of Geriatrics at University of California, San Francisco. Stephen R. Connor is with Worldwide Hospice Palliative Care Alliance, Fairfax Station, VA
| | - Stephen R Connor
- Krista L. Harrison is with the Division of Geriatrics at University of California, San Francisco. Stephen R. Connor is with Worldwide Hospice Palliative Care Alliance, Fairfax Station, VA
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282
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Marks S. Clinician as Medical Story Teller. J Palliat Med 2016; 19:1228-1229. [PMID: 27267209 DOI: 10.1089/jpm.2016.0193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sean Marks
- Department of Medicine, Section of Palliative Medicine, Medical College of Wisconsin , Milwaukee, Wisconsin
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283
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Bowman J, George N, Barrett N, Anderson K, Dove-Maguire K, Baird J. Acceptability and Reliability of a Novel Palliative Care Screening Tool Among Emergency Department Providers. Acad Emerg Med 2016; 23:694-702. [PMID: 26990541 DOI: 10.1111/acem.12963] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/03/2016] [Accepted: 03/05/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND The Palliative Care and Rapid Emergency Screening (P-CaRES) Project is an initiative intended to improve access to palliative care (PC) among emergency department (ED) patients with life-limiting illness by facilitating early referral for inpatient PC consultations. In the previous two phases of this project, we derived and validated a novel PC screening tool. This paper reports on the third and final preimplementation phase. OBJECTIVES Examine the acceptability of the P-CaRES tool among PC and ED providers as well as test its reliability on case vignettes. Compare variations in reliability and acceptability of the tool based on ED providers' roles (attendings, residents, and nurses) and lengths of experience. METHODS A two-part electronic survey was distributed to ED providers at multiple sites across the United States. We tested the reliability of the tool in the first part of the survey, through a series of case vignettes. A criterion standard of correct responses was first defined by consensus input from expert PC physicians' interpretations of the vignettes. The experts' input was validated using the Gwet's AC1 coefficient for inter-rater reliability. ED providers were then presented with the case vignettes and asked to use the P-CaRES tool to correctly identify which patients had unmet PC needs. ED provider responses were compared both against the criterion standard and against different subsets of respondents (divided both by role and by level of experience). The second part of the survey assessed acceptability of the P-CaRES tool among ED providers using responses to questions from a modified Ottawa Acceptability of Decision Rules Instrument, based on a 1-5 Likert rating scale. Descriptive statistics were used to report all outcomes. RESULTS In total, 213 ED providers employed in three different regions across the country responded to the survey (39.4%) and 185 (86.9%) of those completed it. The majority of providers felt that the tool would be useful in their practice (80.5%), agreed that the tool was clear and unambiguous (87.1%), thought that use of the tool would likely benefit patients (87.5%), and thought that it would result in improved use of resources to help severely ill patients (83.6%). Over three-quarters of ED providers (78.5%) also self-reported that they refer patients with unmet PC needs less than 10% of the time, and only 10.8% of respondents believed that they are already utilizing an effective strategy to screen or refer patients to PC. Applying our P-CaRES tool to case vignettes, ED providers generated PC referrals in concordance with PC experts over 88.7% of the time (95% confidence interval = 86.4% to 90.6%), with an overall sensitivity of more than 90%. These results varied minimally regardless of the respondent's role in the ED or their level of experience. CONCLUSION Screening by emergency medicine providers for unmet PC needs using a brief, novel, content-validated screening tool is acceptable and is also reliable when applied to case vignettes-regardless of provider role or experience. Clinical trial and further study are warranted and are currently under way.
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Affiliation(s)
- Jason Bowman
- Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
| | - Naomi George
- Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
| | | | | | - Kalie Dove-Maguire
- Department of Emergency Medicine; University of California at San Francisco; San Francisco CA
| | - Janette Baird
- Department of Emergency Medicine; Alpert Medical School; Brown University; Providence RI
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284
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Horton JR, Morrison RS, Capezuti E, Hill J, Lee EJ, Kelley AS. Impact of Inpatient Palliative Care on Treatment Intensity for Patients with Serious Illness. J Palliat Med 2016; 19:936-42. [PMID: 27248056 DOI: 10.1089/jpm.2015.0240] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Palliative care is associated with decreased treatment intensity and improved quality for individual patients at the end of life, but little is known about how hospital-wide outcomes are affected by the diffusion of palliative care principles. OBJECTIVE We examined the relationship between presence of palliative care programs and hospitals' average treatment intensity, as indicated by mean intensive care unit (ICU) length of stay (LOS) and days under Medicare hospice coverage, in the last six months of life among Medicare beneficiaries aged 67 and over with serious chronic illness. METHODS We linked hospital-level data from the American Hospital Association Annual Survey, National Palliative Care Registry, and Dartmouth Atlas of Health Care to examine hospital-level treatment intensity for chronically ill Medicare beneficiaries who died in 2010. We used propensity score-adjusted linear regression to estimate the relationship between palliative care programs and hospitals' mean ICU LOS and hospice length of enrollment. RESULTS Among 974 hospitals meeting inclusion criteria, we compared 295 hospitals with palliative care programs to 679 hospitals without. Hospitals with palliative care programs were higher volume, more likely to be teaching hospitals, and have oncology services and less likely to be located in rural areas. In propensity score weighted analyses, the mean ICU LOS in hospitals with palliative care was shorter by 0.23 days (standard error [SE] = 0.26), but this was not statistically significant (p = 0.76). In addition, the mean length of hospice enrollment among beneficiaries served by hospitals with palliative care was longer by 0.22 days (SE = 0.61), but also was not statistically significant (p = 0.76). CONCLUSIONS Hospital-based palliative care programs alone may not be sufficient to impact ICU LOS or hospice length of enrollment for all chronically ill older adults admitted to hospitals. Future work should measure hospital-wide palliative care outcomes and effects of core palliative knowledge and skills provided by nonpalliative care specialists.
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Affiliation(s)
- Jay R Horton
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - R Sean Morrison
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Elizabeth Capezuti
- 2 City University of New York , Hunter College School of Nursing, New York, New York
| | | | - Eric J Lee
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Amy S Kelley
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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285
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Kamal AH, Anderson WG, Boss RD, Brody AA, Campbell TC, Creutzfeldt CJ, Hurd CJ, Kinderman AL, Lindenberger EC, Reinke LF. The Cambia Sojourns Scholars Leadership Program: Project Summaries from the Inaugural Scholar Cohort. J Palliat Med 2016; 19:591-600. [DOI: 10.1089/jpm.2016.0086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Renee D. Boss
- Johns Hopkins School of Medicine, Baltimore, Maryland
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Centeno C, Lynch T, Garralda E, Carrasco JM, Guillen-Grima F, Clark D. Coverage and development of specialist palliative care services across the World Health Organization European Region (2005-2012): Results from a European Association for Palliative Care Task Force survey of 53 Countries. Palliat Med 2016; 30:351-62. [PMID: 26231421 PMCID: PMC4800456 DOI: 10.1177/0269216315598671] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The evolution of the provision of palliative care specialised services is important for planning and evaluation. AIM To examine the development between 2005 and 2012 of three specialised palliative care services across the World Health Organization European Region - home care teams, hospital support teams and inpatient palliative care services. DESIGN AND SETTING Data were extracted and analysed from two editions of the European Association for Palliative Care Atlas of Palliative Care in Europe. Significant development of each type of services was demonstrated by adjusted residual analysis, ratio of services per population and 2012 coverage (relationship between provision of available services and demand services estimated to meet the palliative care needs of a population). For the measurement of palliative care coverage, we used European Association for Palliative Care White Paper recommendations: one home care team per 100,000 inhabitants, one hospital support team per 200,000 inhabitants and one inpatient palliative care service per 200,000 inhabitants. To estimate evolution at the supranational level, mean comparison between years and European sub-regions is presented. RESULTS Of 53 countries, 46 (87%) provided data. Europe has developed significant home care team, inpatient palliative care service and hospital support team in 2005-2012. The improvement was statistically significant for Western European countries, but not for Central and Eastern countries. Significant development in at least a type of services was in 21 of 46 (46%) countries. The estimations of 2012 coverage for inpatient palliative care service, home care team and hospital support team are 62%, 52% and 31% for Western European and 20%, 14% and 3% for Central and Eastern, respectively. CONCLUSION Although there has been a positive development in overall palliative care coverage in Europe between 2005 and 2012, the services available in most countries are still insufficient to meet the palliative care needs of the population.
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Affiliation(s)
- Carlos Centeno
- ATLANTES Research Program, Institute for Culture and Society (ICS), University of Navarra, Pamplona, Spain Palliative Medicine Group, Area of Oncology and Haematology, Navarra's Health Research Institute (IDISNA), Pamplona, Spain European Association for Palliative Care (EAPC) Task Force on the Development of Palliative Care in Europe, Milan, Italy
| | - Thomas Lynch
- European Association for Palliative Care (EAPC) Task Force on the Development of Palliative Care in Europe, Milan, Italy Department of Anesthesiology and Critical Care Medicine and Palliative Care Program, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Eduardo Garralda
- ATLANTES Research Program, Institute for Culture and Society (ICS), University of Navarra, Pamplona, Spain Palliative Medicine Group, Area of Oncology and Haematology, Navarra's Health Research Institute (IDISNA), Pamplona, Spain
| | - José Miguel Carrasco
- ATLANTES Research Program, Institute for Culture and Society (ICS), University of Navarra, Pamplona, Spain Palliative Medicine Group, Area of Oncology and Haematology, Navarra's Health Research Institute (IDISNA), Pamplona, Spain
| | - Francisco Guillen-Grima
- Department of Health Sciences, Public University of Navarra, Pamplona, Spain Clinical Epidemiology Group, Epidemiology and Public Health Area, Navarra's Health Research Institute (IDISNA), Pamplona, Spain
| | - David Clark
- European Association for Palliative Care (EAPC) Task Force on the Development of Palliative Care in Europe, Milan, Italy School of Interdisciplinary Studies, University of Glasgow, Dumfries Campus, Dumfries, UK Wellcome Trust, London, UK University of Navarra, Pamplona, Spain
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287
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Abstract
OBJECTIVES To generate ideas and explore the future possibilities of patient-centered, transdisciplinary care delivery for individuals with cancer. DATA SOURCES Journal articles, cancer-related professional resources, and web-based resources. CONCLUSION As health care access increases, new strategies for transdisciplinary care need to evolve through education, research, and clinical practice. Application and utilization of palliative care models, survivorship plans, technological advances and other resources will be important components to improve quality of life and the cancer experience. IMPLICATION FOR NURSING PRACTICE Oncology nurse clinicians (at all levels), educators, researchers, and administrators involved in inpatient and outpatient settings should lead and participate in changes that will drive a more robust approach to transdisciplinary cancer care delivery.
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288
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May P, Garrido MM, Cassel JB, Kelley AS, Meier DE, Normand C, Stefanis L, Smith TJ, Morrison RS. Palliative Care Teams' Cost-Saving Effect Is Larger For Cancer Patients With Higher Numbers Of Comorbidities. Health Aff (Millwood) 2016; 35:44-53. [PMID: 26733700 PMCID: PMC4849270 DOI: 10.1377/hlthaff.2015.0752] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Patients with multiple serious conditions account for a high proportion of health care spending. Such spending is projected to continue to grow substantially as a result of increased insurance eligibility, the ever-rising cost of care, the continued use of nonbeneficial high-intensity treatments at the end of life, and demographic changes. We evaluated the impact of palliative care consultation on hospital costs for adults with advanced cancer, excluding those with dementia. We found that compared to usual care, the receipt of a palliative care consultation within two days of admission was associated with 22 percent lower costs for patients with a comorbidity score of 2-3 and with 32 percent lower costs for those with a score of 4 or higher. Earlier consultation was also found to be systematically associated with a larger cost-saving effect for all subsamples defined by multimorbidity. Given ongoing workforce shortages, targeting early specialist palliative care to hospitalized patients with advanced cancer and higher numbers of serious concurrent conditions could improve care while complementing strategies to curb the growth of health spending.
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Affiliation(s)
- Peter May
- Peter May is a health economics research fellow at the Centre for Health Policy and Management at Trinity College Dublin, in Ireland, and a visiting research fellow in geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai, in New York City
| | - Melissa M Garrido
- Melissa M. Garrido is a health services researcher at the James J. Peters Veterans Affairs (VA) Medical Center, in the Bronx, New York, and an assistant professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai
| | - J Brian Cassel
- J. Brian Cassel is an assistant professor of hematology, oncology, and palliative care at Virginia Commonwealth University, in Richmond
| | - Amy S Kelley
- Amy S. Kelley is an associate professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai
| | - Diane E Meier
- Diane E. Meier is director of the Center to Advance Palliative Care and a professor of geriatrics and palliative medicine, both at the Icahn School of Medicine at Mount Sinai
| | - Charles Normand
- Charles Normand is the Edward Kennedy Chair in Health Policy and Management at Trinity College Dublin
| | - Lee Stefanis
- Lee Stefanis is a statistician at the James J. Peters VA Medical Center
| | - Thomas J Smith
- Thomas J. Smith is director of palliative medicine at the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, in Baltimore, Maryland
| | - R Sean Morrison
- R. Sean Morrison is director of the National Palliative Care Research Center and a professor of geriatrics and palliative medicine, both at the Icahn School of Medicine at Mount Sinai
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289
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Dumanovsky T, Rogers M, Spragens LH, Morrison RS, Meier DE. Impact of Staffing on Access to Palliative Care in U.S. Hospitals. J Palliat Med 2015; 18:998-9. [PMID: 26556657 DOI: 10.1089/jpm.2015.0436] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Over the past decade over two-thirds of U.S. hospitals have established palliative care programs. National data on palliative care program staffing and its association with operational outcomes are limited. OBJECTIVE The objective of this report is to examine the impact of palliative care program staffing on access to palliative care in U.S. hospitals. METHODS Data from the National Palliative Care Registry™ for 2014 were used to calculate staffing levels, palliative care service penetration, and time to initial palliative care consultation for 398 palliative care programs operating across 482 U.S. hospitals. RESULTS Hospital-based palliative care programs reported an average service penetration of 4.4%. Higher staffing levels were associated with higher service penetration; higher service penetration was associated with shorter time to initial palliative care consultation. DISCUSSION This report demonstrates that operational effectiveness, as measured by staffing and palliative care service penetration, is associated with shorter time to palliative care consultation.
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Affiliation(s)
| | - Maggie Rogers
- 1 Center to Advance Palliative Care , New York, New York
| | | | - R Sean Morrison
- 3 Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,4 National Palliative Care Research Center, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Diane E Meier
- 1 Center to Advance Palliative Care , New York, New York
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