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Prachanukool T, George N, Bowman J, Ito K, Ouchi K. Best Practices in End of Life and Palliative Care in the Emergency Department. Clin Geriatr Med 2023; 39:575-597. [PMID: 37798066 DOI: 10.1016/j.cger.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Three-quarters of patients over the age of 65 visit the emergency department (ED) in the last six months of their lives. Approximately 20% of hospice residents have ED visits. These patients must decide whether to receive emergency care that prioritizes life support, which may not achieve their desired outcomes and might even be futile. The patients in these end-of-life stages could benefit from early palliative care or hospice consultation before they present to the ED. Furthermore, early integration of palliative care at the time of ED visits is important in establishing the goals of the entire treatment.
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Affiliation(s)
- Thidathit Prachanukool
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand; Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA.
| | - Naomi George
- Division of Critical Care Medicine, Department of Emergency Medicine, University of New Mexico School of Medicine, 700 Camino de Salud, Albuquerque, NM 87131, USA
| | - Jason Bowman
- Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA; Department of Psychosocial Oncology and Palliative Medicine, Dana Farber Cancer Institute, 75 Francis Street, Neville House, Boston, MA 02115, USA
| | - Kaori Ito
- Department of Emergency Medicine, Division of Acute Care Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi-ku, Tokyo 173-8606, Japan
| | - Kei Ouchi
- Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA; Department of Psychosocial Oncology and Palliative Medicine, Dana Farber Cancer Institute, 75 Francis Street, Neville House, Boston, MA 02115, USA
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2
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Cook A, Swindall R, Spencer K, Wadle C, Cage SA, Mohiuddin M, Desai Y, Norwood S. Hospitalization and readmission after single-level fall: a population-based sample. Inj Epidemiol 2023; 10:49. [PMID: 37858271 PMCID: PMC10588028 DOI: 10.1186/s40621-023-00463-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/08/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Single-level falls (SLFs) in the older US population is a leading cause of hospital admission and rates are increasing. Unscheduled hospital readmission is regarded as a quality-of-care indication and a preventable burden on healthcare systems. We aimed to characterize the predictors of 30-day readmission following admission for SLF injuries among patients 65 years and older. METHODS We conducted a retrospective cohort study using the Nationwide Readmission Database from 2018 to 2019. Included patients were 65 and older, admitted emergently following a SLF with a primary injury diagnosis. Hierarchical logit regression was used to model factors associated with readmission within 30 days of discharge. RESULTS Of 1,338,905 trauma patients, 65 years or older, 61.3% had a single-level fall as the mechanism of injury. Among fallers, the average age was 81.1 years and 68.5% were female. SLF patients underwent more major therapeutic procedures (56.3% vs. 48.2%), spent over 2 million days in the hospital and incurred total charges of over $28 billion annually. Over 11% of SLF patients were readmitted within 30 days of discharge. Increasing income had a modest effect, where the highest zip code quartile was 9% less likely to be readmitted. Decreasing population density had a protective effect of readmission of 16%, comparing Non-Urban to Large Metropolitan. Transfer to short-term hospital, brain and vascular injuries were independent predictors of 30-day readmission in multivariable analysis (OR 2.50, 1.31, and 1.42, respectively). Palliative care consultation was protective (OR 0.41). The subsequent hospitalizations among those 30-day readmissions were primarily emergent (92.9%), consumed 260,876 hospital days and a total of $2.75 billion annually. CONCLUSIONS SLFs exact costs to patients, health systems, and society. Transfer to short-term hospitals at discharge, along with brain and vascular injuries were strong predictors of 30-day readmission and warrant mitigation strategy development with consideration of expanded palliative care consultation.
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Affiliation(s)
- Alan Cook
- Trauma Services, UT Health East Texas, 1020 E. Idel St., Tyler, TX, 75701, USA
| | - Rebecca Swindall
- Department of Epidemiology and Biostatistics, The University of Texas Health Science Center at Tyler, 11937 US Highway 271, Room H252, Tyler, TX, 75708, USA
| | - Katherine Spencer
- CHRISTUS Health-Texas A&M Spohn Emergency Medicine Residency, Texas A&M University-Corpus Christi, 600 Elizabeth Street, 9B, Corpus Christi, TX, 78404, USA
| | - Carly Wadle
- Department of Epidemiology and Biostatistics, The University of Texas Health Science Center at Tyler, 11937 US Highway 271, Room H252, Tyler, TX, 75708, USA
| | - S Andrew Cage
- Department of Sports Medicine, The University of Texas at Tyler, 3900 University Blvd., Tyler, TX, 75799, USA
| | - Musharaf Mohiuddin
- Department of Epidemiology and Biostatistics, The University of Texas Health Science Center at Tyler, 11937 US Highway 271, Room H252, Tyler, TX, 75708, USA.
| | - Yagnesh Desai
- Department of Emergency Medicine, UT Health East Texas, 1000 S. Beckham Ave., Tyler, TX, 75701, USA
| | - Scott Norwood
- Trauma Services, UT Health East Texas, 1020 E. Idel St., Tyler, TX, 75701, USA
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3
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Mitchell CJ, Althouse A, Feldman R, Arnold RM, Rosenzweig M, Smith K, Chu E, White D, Smith T, Schenker Y. Symptom Burden and Shared Care Planning in an Oncology Nurse-Led Primary Palliative Care Intervention (CONNECT) for Patients with Advanced Cancer. J Palliat Med 2023; 26:667-673. [PMID: 36472545 PMCID: PMC10150730 DOI: 10.1089/jpm.2022.0277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose: Primary palliative care (PPC) interventions are needed to address unmet symptom needs within standard oncology care. We designed an oncology nurse-led PPC intervention using shared care planning to facilitate patient engagement. This analysis examines the prevalence and severity of symptoms reported by patients and how symptoms were addressed on shared care plans (SCPs). Methods: Secondary analysis of a cluster randomized PPC intervention trial. Adult patients with metastatic solid tumors whose oncologist "would not be surprised if the patient died within a year" were included. Twenty-three oncology nurses received PPC training and conducted up to three monthly visits with patients. Symptom prevalence and severity were assessed before each visit using the Edmonton Symptom Assessment Scale (ESAS). Nurses collaboratively developed treatment strategies with patients, targeting the most bothersome symptoms for improvement. Results: Among 571 nurse-led PPC visits with 235 patients, the most prevalent and severe symptoms were tiredness (reported at 86% of visits; ESAS ≥4 in 55% of visits), low sense of wellbeing (78%; ESAS ≥4 in 38%), and poor appetite (69%; ESAS ≥4 in 42%). Moderately severe symptoms were addressed on SCPs ranging from 4% (drowsiness) to 35% (tiredness) of the time. Symptom management plans developed by PPC-trained oncology nurses primarily focused on nonpharmaceutical interventions (70%) compared with pharmaceutical interventions (30%). Conclusion: The symptoms that patients report most frequently and as most severe on SCPs were addressed less frequently than expected. Further research is needed to understand how PPC interventions can be designed to more effectively target and improve bothersome symptoms for patients with advanced cancer. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT02712229.
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Affiliation(s)
- Chandler J. Mitchell
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrew Althouse
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert Feldman
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M. Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Margaret Rosenzweig
- Palliative Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Kenneth Smith
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Edward Chu
- Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Doug White
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tom Smith
- Division of General Internal Medicine, Section of Palliative Medicine, Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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4
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Pennarola A, Yoshioka T, Shah D, Larson S. Primary Palliative Care Education for Graduate Medical Trainees: Impacts and Needs. Am J Hosp Palliat Care 2023; 40:387-395. [PMID: 35583487 DOI: 10.1177/10499091221102141] [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
As demand for palliative care (PC) services rise, there are insufficient numbers of PC specialists to provide PC for the US population. "Primary palliative care" refers to PC services that are administered by non-specialist PC providers. Educating trainees in graduate medical education (GME) programs is 1 strategy for expanding primary palliative care, though questions remain regarding the impact of PC education for GME trainees and where additional education is needed. This study is a multicenter, cross-sectional, web-based survey study of GME trainees assessing the needs for and impacts of primary palliative care education. The survey assessed the implementation of and participants' confidence with fundamental PC skills. The survey also asked about prior exposure to PC education and for participants' beliefs regarding areas that would be particularly helpful for future education. 170 residents and fellows from diverse training backgrounds participated in the survey out of 851 potential participants (response rate 19.98%). Exposure to PC education was associated with higher confidence and increased frequency of implementation of fundamental PC skills. Of the forms of education that were assessed, clinical/experiential education was associated most often with higher confidence and higher frequency of use of PC skills. Discussing goals of care, pain management for seriously ill patients, and communicating difficult information were those skills most frequently identified as important for additional training. This study demonstrates that by improving existing PC education or increasing access to PC education for GME trainees, it may be possible to improve primary palliative care.
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Affiliation(s)
- Adam Pennarola
- 23217Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Tammy Yoshioka
- 23217Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Dhruvi Shah
- 23217Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sharon Larson
- 20284Main Line Health Center for Population Health Research at Lankenau Institute for Medical Research (LIMR), Wynnewood, PA, USA
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Breaking New Ground in Palliative Care: Examining the Impact of Al Ain – Palliative Care Outreach Program on Patients With Advanced Cancer in the United Arab Emirates. Cureus 2023; 15:e36756. [PMID: 36992813 PMCID: PMC10042392 DOI: 10.7759/cureus.36756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/29/2023] Open
Abstract
Introduction This study aimed to evaluate the effectiveness of the Palliative Outreach Program in improving the quality of palliative care for patients with advanced cancer in a Tertiary Hospital in the Al Ain region of the United Arab Emirates (UAE). Methods & Material One hundred patients who met the inclusion criteria were included in the study and administered the patient version of the Consumer Quality (CQ) Index Palliative Care Instrument to assess their perception of the quality of care they received. The demographics, diagnosis, and questionnaire responses were analyzed to determine the effectiveness of the Palliative Outreach Program. Results A total of one hundred patients met the criteria for the study. Most patients were above 50, female, female, Non-Emiratis, and had high school certificates. The top three cancer diagnoses were breast (22%), lung (15%), and head & neck (13%). The patients reported high levels of support from their caregivers regarding physical, psychological, and spiritual well-being, as well as information and expertise. The mean scores for most variables were favorable, except for information (mean = 2.9540, SD= 0.25082) and general appreciation (mean = 6.7150, sd = 0.82344). Overall, the patients rated the care they received positively, with high mean scores for physical/psychological well-being (mean = 3.4950, SD = 0.28668), autonomy (mean = 3.7667, SD= 0.28623), privacy (mean = 3.6490, SD = 0.23159), and spiritual well-being (mean =3.7500, SD = 0.54356). The patients would recommend their caregivers to others in similar situations. Discussion The findings demonstrate that the Palliative Outreach Program effectively improves the quality of palliative care for patients with advanced cancer in the UAE. The CQ Index Palliative Care Instrument proved a novel method for assessing palliative care quality from patients' perspectives. However, there is room for improvement in providing more favorable information and general appreciation outcomes. Caregivers should focus on all areas to enhance their physical/psychological well-being, autonomy, privacy, spiritual well-being, expertise, and general appreciation of their patients. Conclusion In conclusion, the Palliative Outreach Program is an effective intervention to improve the quality of palliative care for patients with advanced cancer in the UAE. The patients reported high levels of support from their caregivers in all aspects of care, except for information and general appreciation. These findings provide valuable insights into the effectiveness of palliative care interventions and highlight the need for continued efforts to improve the quality of care for patients with advanced cancer.
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Mroz EL, McDarby M, Arnold RM, Bylund CL, Kutner JS, Pollak KI. Empathic Communication in Specialty Palliative Care Encounters: An Analysis of Opportunities and Responses. J Palliat Med 2022; 25:1622-1628. [PMID: 35426742 PMCID: PMC9836699 DOI: 10.1089/jpm.2021.0664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2022] [Indexed: 01/22/2023] Open
Abstract
Background: Although empathic responding is considered a core competency in specialty palliative care (PC), patterns of empathic communication in PC encounters are not well understood. Objectives: In this secondary analysis, we delineate types and frequency of empathic communication and examine relationships between patient empathic opportunities and clinician responses. Design: We used the Empathic Communication Coding System to analyze empathic opportunities across three types: emotion (i.e., negative affective state), progress (i.e., stated recent positive life event or development), and challenge (i.e., stated problem or recent, negative life-changing event) and clinician responses. Setting/Subjects: Transcripts from a pilot randomized trial of communication coaching in specialty PC encounters (N = 71) audio-recorded by 22 PC clinicians at two sites in the United States: an academic health system and a community-based hospice and PC organization. Results: Empathic opportunities were frequent across encounters; clinicians often responded empathically to those opportunities (e.g., confirming or acknowledging patients' emotions or experiences). Even though challenge empathic opportunities occurred most frequently, clinicians responded empathically more often to progress opportunities (i.e., 93% of the time) than challenge opportunities (i.e., 75% of the time). One in 12 opportunities was impeded by the patient or a family member changing the topic before the clinician could respond. Conclusions: PC patients frequently express emotions, share progress, or divulge challenges as empathic opportunities. Clinicians often convey empathy in response and can differentiate their empathic responses based on the type of empathic opportunity. PC communication research and training should explore which empathic responses promote desired patient outcomes.
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Affiliation(s)
- Emily L. Mroz
- Section of Geriatrics, Department of Internal Medicine, Yale University, New Haven, Connecticut, USA
| | - Meghan McDarby
- Department of Psychological and Brain Sciences, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Robert M. Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carma L. Bylund
- Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Jean S. Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kathryn I. Pollak
- Cancer Prevention and Control, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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Sullivan DR, Iyer AS, Enguidanos S, Cox CE, Farquhar M, Janssen DJA, Lindell KO, Mularski RA, Smallwood N, Turnbull AE, Wilkinson AM, Courtright KR, Maddocks M, McPherson ML, Thornton JD, Campbell ML, Fasolino TK, Fogelman PM, Gershon L, Gershon T, Hartog C, Luther J, Meier DE, Nelson JE, Rabinowitz E, Rushton CH, Sloan DH, Kross EK, Reinke LF. Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement. Am J Respir Crit Care Med 2022; 206:e44-e69. [PMID: 36112774 PMCID: PMC9799127 DOI: 10.1164/rccm.202207-1262st] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.
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Hahn W, Schütte K, Schultz K, Wolkenhauer O, Sedlmayr M, Schuler U, Eichler M, Bej S, Wolfien M. Contribution of Synthetic Data Generation towards an Improved Patient Stratification in Palliative Care. J Pers Med 2022; 12:1278. [PMID: 36013227 PMCID: PMC9409663 DOI: 10.3390/jpm12081278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 11/23/2022] Open
Abstract
AI model development for synthetic data generation to improve Machine Learning (ML) methodologies is an integral part of research in Computer Science and is currently being transferred to related medical fields, such as Systems Medicine and Medical Informatics. In general, the idea of personalized decision-making support based on patient data has driven the motivation of researchers in the medical domain for more than a decade, but the overall sparsity and scarcity of data are still major limitations. This is in contrast to currently applied technology that allows us to generate and analyze patient data in diverse forms, such as tabular data on health records, medical images, genomics data, or even audio and video. One solution arising to overcome these data limitations in relation to medical records is the synthetic generation of tabular data based on real world data. Consequently, ML-assisted decision-support can be interpreted more conveniently, using more relevant patient data at hand. At a methodological level, several state-of-the-art ML algorithms generate and derive decisions from such data. However, there remain key issues that hinder a broad practical implementation in real-life clinical settings. In this review, we will give for the first time insights towards current perspectives and potential impacts of using synthetic data generation in palliative care screening because it is a challenging prime example of highly individualized, sparsely available patient information. Taken together, the reader will obtain initial starting points and suitable solutions relevant for generating and using synthetic data for ML-based screenings in palliative care and beyond.
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Affiliation(s)
- Waldemar Hahn
- Institute for Medical Informatics and Biometry, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Katharina Schütte
- University Palliative Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Kristian Schultz
- Department of Systems Biology and Bioinformatics, University of Rostock, Universitätsplatz 1, 18051 Rostock, Germany
| | - Olaf Wolkenhauer
- Department of Systems Biology and Bioinformatics, University of Rostock, Universitätsplatz 1, 18051 Rostock, Germany
- Leibniz-Institute for Food Systems Biology, Technical University Munich, 85354 Freising, Germany
- Stellenbosch Institute of Advanced Study, Wallenberg Research Centre, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Martin Sedlmayr
- Institute for Medical Informatics and Biometry, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Ulrich Schuler
- University Palliative Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Martin Eichler
- National Center for Tumor Diseases Dresden (NCT/UCC), Fetscherstraße 74, 01307 Dresden, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Bautzner Landstraße 400, 01328 Dresden, Germany
| | - Saptarshi Bej
- Department of Systems Biology and Bioinformatics, University of Rostock, Universitätsplatz 1, 18051 Rostock, Germany
- Leibniz-Institute for Food Systems Biology, Technical University Munich, 85354 Freising, Germany
| | - Markus Wolfien
- Institute for Medical Informatics and Biometry, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
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Sigler LE, Althouse AD, Thomas TH, Arnold RM, White D, Smith TJ, Chu E, Rosenzweig M, Smith KJ, Schenker Y. Effects of an Oncology Nurse-Led, Primary Palliative Care Intervention (CONNECT) on Illness Expectations Among Patients With Advanced Cancer. JCO Oncol Pract 2022; 18:e504-e515. [PMID: 34767474 PMCID: PMC9014423 DOI: 10.1200/op.21.00573] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Patients with advanced cancer often have unrealistic expectations about prognosis and treatment. This study assessed the effect of an oncology nurse-led primary palliative care intervention on illness expectations among patients with advanced cancer. METHODS This study is a secondary analysis of a cluster-randomized trial of primary palliative care conducted at 17 oncology clinics. Adult patients with advanced solid tumors for whom the oncologist would not be surprised if died within 1 year were enrolled. Monthly visits were designed to foster realistic illness expectations by eliciting patient concerns and goals for their medical care and empowering patients and families to engage in discussions with oncologists about treatment options and preferences. Baseline and 3-month questionnaires included questions about life expectancy, treatment intent, and terminal illness acknowledgment. Odds of realistic illness expectations at 3 months were adjusted for baseline responses, patient demographic and clinical characteristics, and intervention dose. RESULTS Among 457 primarily White patients, there was little difference in realistic illness expectations at 3 months between intervention and standard care groups: 12.8% v 11.4% for life expectancy (adjusted odds ratio [aOR] = 1.15; 95% CI, 0.59 to 2.22; P = .684); 24.6% v 33.3% for treatment intent (aOR = 0.76; 95% CI, 0.44 to 1.27; P = .290); 53.6% v 44.7% for terminal illness acknowledgment (aOR = 1.28; 95% CI, 0.81 to 2.00; P = .288). Results did not differ when accounting for variation in clinic sites or intervention dose. CONCLUSION Illness expectations are difficult to change among patients with advanced cancer. Additional work is needed to identify approaches within oncology practices that foster realistic illness expectations to improve patient decision making.
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Affiliation(s)
- Lauren E. Sigler
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,Emory Palliative Care Center, Emory University School of Medicine, Atlanta, GA,Lauren E. Sigler, MD, Emory Palliative Care Center, Emory University School of Medicine, 1821 Clifton Road NE, Suite 1017 Atlanta, GA 30329; e-mail:
| | - Andrew D. Althouse
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
| | - Teresa H. Thomas
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,University of Pittsburgh School of Nursing, Pittsburgh, PA
| | - Robert M. Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
| | - Douglas White
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thomas J. Smith
- Division of General Internal Medicine, Section of Palliative Medicine, Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Edward Chu
- Albert Einstein Cancer Center, Albert Einstein College of Medicine, New York, NY
| | - Margaret Rosenzweig
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,University of Pittsburgh School of Nursing, Pittsburgh, PA
| | - Kenneth J. Smith
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA,Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
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Shibata T, Oishi S, Mizuno A, Ohmori T, Okamura T, Kashiwagi H, Sakashita A, Kishi T, Obara H, Kakuma T, Fukumoto Y. Evaluation of the effectiveness of the physician education program on primary palliative care in heart failure. PLoS One 2022; 17:e0263523. [PMID: 35120191 PMCID: PMC8815870 DOI: 10.1371/journal.pone.0263523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/20/2022] [Indexed: 11/18/2022] Open
Abstract
Major cardiology societies’ guidelines support integrating palliative care into heart failure (HF) care. This study aimed to identify the effectiveness of the HEart failure Palliative care Training program for comprehensive care providers (HEPT), a physician education program on primary palliative care in HF. We performed a pre- and post-test survey to evaluate HEPT outcomes. Physician-reported practices, difficulties and knowledge were evaluated using the Palliative Care Self-Reported Practices Scale in HF (PCPS-HF), Palliative Care Difficulties Scale in HF (PCDS-HF), and Palliative care knowledge Test in HF (PT-HF), respectively. Structural equation models (SEM) were used to estimate path coefficients for PCPS-HF, PCDS-HF, and PT-HF. A total of 207 physicians participated in the HEPT between February 2018 and July 2019, and 148 questionnaires were ultimately analyzed. The total PCPS-HF, PCDS-HF, and PT-HF scores were significantly improved 6 months after HEPT completion (61.1 vs 67.7, p<0.001, 54.9 vs 45.1, p<0.001, and 20.8 vs 25.7, p<0.001, respectively). SEM analysis showed that for pre-post difference (Dif) PCPS-HF, “clinical experience of more than 14 years” and pre-test score had significant negative effects (-2.31, p = 0.048, 0.52, p<0.001, respectively). For Dif PCDS-HF, ≥ “28 years old or older” had a significant positive direct effect (13.63, p<0.001), although the pre-test score had a negative direct effect (-0.56, p<0.001). For PT-HF, “involvement in more than 50 HF patients’ treatment in the past year” showed a positive direct effect (0.72, p = 0.046), although the pre-test score showed a negative effect (-0.78, p<0.001). Physicians who completed the HEPT showed significant improvements in practice, difficulty, and knowledge scales in HF palliative care.
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Affiliation(s)
- Tatsuhiro Shibata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Shogo Oishi
- Department of Cardiology, Himeji Cardiovascular Center, Hyogo, Japan
| | - Atsushi Mizuno
- Department of Cardiovascular Medicine, St. Luke’s International Hospital, Tokyo, Japan
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, PA, United States of America
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Takashi Ohmori
- Department of Transitional and Palliative Care, Iizuka Hospital, Fukuoka, Japan
| | - Tomonao Okamura
- Department of Transitional and Palliative Care, Iizuka Hospital, Fukuoka, Japan
| | - Hideyuki Kashiwagi
- Department of Transitional and Palliative Care, Iizuka Hospital, Fukuoka, Japan
| | - Akihiro Sakashita
- Department of Cardiology, Himeji Cardiovascular Center, Hyogo, Japan
- Department of Palliative Medicine, Kobe University School of Medicine, Hyogo, Japan
| | - Takuya Kishi
- Faculty of Health and Welfare Sciences in Fukuoka, International University of Health and Welfare, Fukuoka, Japan
| | - Hitoshi Obara
- Biostatistics Center, Kurume University School of Medicine, Kurume, Japan
| | - Tatsuyuki Kakuma
- Biostatistics Center, Kurume University School of Medicine, Kurume, Japan
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
- * E-mail:
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11
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Cox CE, Ashana DC, Haines KL, Casarett D, Olsen MK, Parish A, O’Keefe YA, Al-Hegelan M, Harrison RW, Naglee C, Katz JN, Frear A, Pratt EH, Gu J, Riley IL, Otis-Green S, Johnson KS, Docherty SL. Assessment of Clinical Palliative Care Trigger Status vs Actual Needs Among Critically Ill Patients and Their Family Members. JAMA Netw Open 2022; 5:e2144093. [PMID: 35050358 PMCID: PMC8777568 DOI: 10.1001/jamanetworkopen.2021.44093] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE Palliative care consultations in intensive care units (ICUs) are increasingly prompted by clinical characteristics associated with mortality or resource utilization. However, it is not known whether these triggers reflect actual palliative care needs. OBJECTIVE To compare unmet needs by clinical palliative care trigger status (present vs absent). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted in 6 adult medical and surgical ICUs in academic and community hospitals in North Carolina between January 2019 and September 2020. Participants were consecutive patients receiving mechanical ventilation and their family members. EXPOSURE Presence of any of 9 common clinical palliative care triggers. MAIN OUTCOMES AND MEASURES The primary outcome was the Needs at the End-of-Life Screening Tool (NEST) score (range, 0-130, with higher scores reflecting greater need), which was completed after 3 days of ICU care. Trigger status performance in identifying serious need (NEST score ≥30) was assessed using sensitivity, specificity, positive and negative likelihood ratios, and C statistics. RESULTS Surveys were completed by 257 of 360 family members of patients (71.4% of the potentially eligible patient-family member dyads approached) with a median age of 54.0 years (IQR, 44-62 years); 197 family members (76.7%) were female, and 83 (32.3%) were Black. The median age of patients was 58.0 years (IQR, 46-68 years); 126 patients (49.0%) were female, and 88 (33.5%) were Black. There was no difference in median NEST score between participants with a trigger present (45%) and those with a trigger absent (55%) (21.0; IQR, 12.0-37.0 vs 22.5; IQR, 12.0-39.0; P = .52). Trigger presence was associated with poor sensitivity (45%; 95% CI, 34%-55%), specificity (55%; 95% CI, 48%-63%), positive likelihood ratio (1.0; 95% CI, 0.7-1.3), negative likelihood ratio (1.0; 95% CI, 0.8-1.2), and C statistic (0.50; 95% CI, 0.44-0.57). CONCLUSIONS AND RELEVANCE In this cohort study, clinical palliative care trigger status was not associated with palliative care needs and no better than chance at identifying the most serious needs, which raises questions about an increasingly common clinical practice. Focusing care delivery on directly measured needs may represent a more person-centered alternative.
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Affiliation(s)
- Christopher E. Cox
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Deepshikha Charan Ashana
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Krista L. Haines
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - David Casarett
- Section of Palliative Care and Hospice Medicine, Duke University, Durham, North Carolina
| | - Maren K. Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | | | - Mashael Al-Hegelan
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Robert W. Harrison
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jason N. Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Allie Frear
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Elias H. Pratt
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Jessie Gu
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Isaretta L. Riley
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Kimberly S. Johnson
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
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12
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Bushunow V, Alamgir L, Arnold RM, Bell LF, Ivonye C, Johnson M, Kelsey R, Larbi D, Schenker Y. Palliative Care Attitudes and Experiences among Resident Physicians at Historically Black Colleges and Universities. J Pain Symptom Manage 2022; 63:106-111. [PMID: 34273523 DOI: 10.1016/j.jpainsymman.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/01/2021] [Accepted: 07/07/2021] [Indexed: 11/21/2022]
Abstract
CONTEXT Seriously ill Black patients receive lower quality palliative care than White patients. Equitable access requires palliative care skills training for all physicians. Historically Black Colleges and Universities (HBCUs) play a key role in educating Black physicians and have less access to palliative care resources. OBJECTIVE To investigate palliative care attitudes and experiences among primary care residents at HBCUs. METHODS Internal Medicine and Family Medicine residents at two HBCUs completed an online survey assessing attitudes towards palliative care and teaching and clinical experiences in palliative care. We performed a descriptive analysis of survey items. RESULTS Among 91 residents who completed the survey (response rate 48%), 65% were women and 68% Black. Most (96%) said that learning about palliative care was moderately/very important to their career; however, two-thirds of respondents considered care for dying patients to be depressing and half reported receiving negative messages about palliative care from other physicians. Residents reported receiving less teaching about providing palliative care (5.4 ± 2.3 on 10-point scale) than about managing sepsis (8.3 ± 1.8; P < 0.05). Fewer residents rated their palliative care education as "Excellent" or "Very Good" compared to their overall education (13% vs 70%; P < 0.05). CONCLUSION In the first survey exploring palliative care education at HBCUs, residents viewed palliative care as important but described the quality of their palliative care education as poor. This study highlights opportunities for improving palliative care education at HBCUs as a step toward addressing disparities in serious illness care.
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Affiliation(s)
- Vasilii Bushunow
- Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Laila Alamgir
- Department of Internal Medicine, Howard University College of Medicine, Washington, DC
| | - Robert M Arnold
- Department of Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA; Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
| | - Lindsay F Bell
- Department of Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA; Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
| | - Chinedu Ivonye
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA
| | - Mark Johnson
- Department of Community and Family Medicine, Howard University College of Medicine, Washington, DC
| | - Riba Kelsey
- Department of Family Medicine, Morehouse School of Medicine, Atlanta, GA
| | - Daniel Larbi
- Department of Internal Medicine, Howard University College of Medicine, Washington, DC
| | - Yael Schenker
- Department of Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA; Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
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13
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Ansari A, Baron A, Nelson-Becker H, Deamant C, Fitchett G, Fister E, O'Mahony S, Levine S. Practice Improvement Projects in an Interdisciplinary Palliative Care Training Program. Am J Hosp Palliat Care 2021; 39:831-837. [PMID: 34490785 DOI: 10.1177/10499091211044689] [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: 11/15/2022] Open
Abstract
CONTEXT Demand for palliative care (PC) continues to increase with an insufficient number of specialists to meet the need. This requires implementation of training curricula to expand the workforce of interdisciplinary clinicians who care for persons with serious illness. OBJECTIVES To evaluate the impact of utilizing individual practice improvement projects (PIP) as part of a longitudinal PC curriculum, the Coleman Palliative Medicine Training Program (CPMTP-2). METHODS Participants developed their PIPs based on their institutional needs and through a mentor, and participated in monthly meetings and bi-annual conferences, thereby allowing for continued process improvement and feedback. RESULTS Thirty-seven interdisciplinary participants implemented 30 PIPs encompassing 7 themes: (1) staff education; (2) care quality and processes; (3) access to care; (4) documentation of care delivered; (5) new program development; (6) assessing gaps in care/patient needs; and (7) patient/family education. The majority of projects did achieve completion, with 16 of 30 projects reportedly being sustained several months after conclusion of the required training period. Qualitative feedback regarding mentors' expertise and availability was uniformly positive. CONCLUSION The CPMTP-2 demonstrates the positive impact of PIPs in the development of skills for interdisciplinary learners as part of a longitudinal training program in primary PC. Participation in a PIP with administrative support may lead to operational improvement within PC teams.
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Affiliation(s)
- Aziz Ansari
- Division of Hospital Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Aliza Baron
- University of Chicago Medicine, Chicago, IL, USA
| | | | - Catherine Deamant
- Rosalind Franklin University of Medicine and Sciences, North Chicago, IL, USA
| | | | - Erik Fister
- Rush University Medical Center, Chicago, IL, USA
| | - Sean O'Mahony
- Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Stacie Levine
- Section of Geriatrics and Palliative Medicine, University of Chicago Medicine, Chicago, IL, USA
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14
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Berta P, Lovaglio PG, Verzillo S. How have casemix, cost and hospital stay of inpatients in the last year of life changed over the past decade? Evidence from Italy. Health Policy 2021; 125:1031-1039. [PMID: 34175137 PMCID: PMC8310922 DOI: 10.1016/j.healthpol.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 11/23/2022]
Abstract
Healthcare utilisation and expenditure are highly concentrated in hospital inpatient services, in particular in end-of-life care with the peak occurring in the very last year of life, regardless of patient age. Few scientific studies have investigated hospital costs and stays of patients at the end of life, and even fewer studies have analysed their evolution over time. In this paper, we exploit hospitalisation data for the Lombardy region of Italy with the aim of studying the evolution of hospital casemix, costs and stays of chronic patients, and compare the last year of life of two cohorts of patients who died in 2005 and 2014. Despite an overall three-year increase in the age at death, the results showed a significant decrease in hospital costs and use due to reduced interventions and length of hospital stays. However, this was not associated with an increase in quality of life/conditions (as indicated by clinical casemix as a proxy) for end-of-life patients; patients' casemix characteristics and clinical condition, as measured by the number of comorbidities, disease severity, prevalence of pulmonary disease and heart failure diagnosis, significantly worsened over the decade. This gives rise to important health policy concerns on how to identify effective policies and possible changes in healthcare system organisation to move from hospital-centred care to a community-centred approach whose value has been demonstrated during the COVID-19 pandemic.
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Affiliation(s)
- Paolo Berta
- CRISP - Interuniversity Research Centre on Public Services, University of Milano Bicocca, Milan, Italy; Department of Statistics and Quantitative Methods, University of Milano Bicocca, Milan, Italy
| | - Pietro Giorgio Lovaglio
- CRISP - Interuniversity Research Centre on Public Services, University of Milano Bicocca, Milan, Italy; Department of Statistics and Quantitative Methods, University of Milano Bicocca, Milan, Italy
| | - Stefano Verzillo
- CRISP - Interuniversity Research Centre on Public Services, University of Milano Bicocca, Milan, Italy; European Commission, Joint Research Centre (JRC), Ispra Italy.
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15
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Schenker Y, Ellington L, Bell L, Kross EK, Rosenberg AR, Kutner JS, Bickel KE, Ritchie C, Kavalieratos D, Bekelman DB, Mooney KB, Fischer SM. The National Postdoctoral Palliative Care Research Training Collaborative: History, Activities, Challenges, and Future Goals. J Palliat Med 2021; 24:545-553. [PMID: 32955969 PMCID: PMC8182655 DOI: 10.1089/jpm.2020.0411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Palliative care-related postdoctoral training opportunities are critical to increase the quantity and quality of palliative care research. Objective: To describe the history, activities, challenges, and future goals of the National Postdoctoral Palliative Care Research Training Collaborative. Design: National web-based survey of participating program leaders. Measurements: Information about participating programs, trainees, challenges faced, and future goals. Results: Nine participating programs at academic institutions across the United States focus on diverse aspects of palliative care research. The majority of 73 current and former fellows are female (75%) and white (84%). In total, 38% of fellows (n = 28) have MD backgrounds, of whom less than half (n = 12) completed hospice and palliative medicine fellowships. An additional 38% of fellows (n = 28) have nursing PhD backgrounds and 23% (n = 17) have other diverse types of PhD backgrounds. Key challenges relate to recruiting diverse trainees, fostering a shared identity, effectively advocating for trainees, and securing funding. Future goals include expanding efforts to engage clinician and nonclinician scientists, fostering the pipeline of palliative care researchers through expanded mentorship of predoctoral and clinical trainees, increasing the number of postdoctoral palliative care training programs, and expanding funding support for career development grants. Conclusion: The National Postdoctoral Palliative Care Research Training Collaborative fills an important role in creating a community for palliative care research trainees and developing strategies to address shared challenges.
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Affiliation(s)
- Yael Schenker
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Lindsay Bell
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Abby R. Rosenberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Palliative Care and Resilience Laboratory, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jean S. Kutner
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kathleen E. Bickel
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Medicine, Veterans Affairs Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Christine Ritchie
- Center for Palliative Care, Harvard Medical School, Boston, Massachusetts, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - David B. Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Medicine, Veterans Affairs Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | | | - Stacy M. Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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16
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O'Mahony S, Baron A, Ansari A, Deamant C, Nelson-Becker H, Fitchett G, Levine S. Expanding the Interdisciplinary Palliative Medicine Workforce: A Longitudinal Education and Mentoring Program for Practicing Clinicians. J Pain Symptom Manage 2020; 60:602-612. [PMID: 32276103 DOI: 10.1016/j.jpainsymman.2020.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/22/2020] [Accepted: 03/27/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT The disparity between gaps in workforce and availability of palliative care (PC) services is an increasing issue in health care. To meet the demand, team-based PC requires additional educational training for all clinicians caring for persons with serious illness. OBJECTIVES To describe the educational methodology and evaluation of an existing regional interdisciplinary PC training program that was expanded to include chaplain and social worker trainees. METHODS From 2015 to 2017, 26 social workers, chaplains, physicians, nurses, and advanced practice providers representing 22 health systems completed a two-year training program. The curriculum comprises biannual interdisciplinary conferences, individualized mentoring and clinical shadowing, self-directed e-learning, and profession-focused seminar series for social workers and chaplains. Site-specific practice improvement projects were developed to address gaps in PC at participating sites. RESULTS PC and program development skills were self-assessed before and after training. Among 12 skills common to all disciplines, trainees reported significant increases in confidence across all 12 skills and significant increases in frequency of performing 11 of 12 skills. Qualitative evaluation identified a myriad of program strengths and challenges regarding the educational format, mentoring, and networking across disciplines. CONCLUSION Teaching PC and program development knowledge and skills to an interdisciplinary regional cohort of practicing clinicians yielded improvements in clinical skills, implementation of practice change projects, and a sense of belonging to a supportive professional network.
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Affiliation(s)
- Sean O'Mahony
- Rush University Medical Center, Chicago, Illinois, USA.
| | - Aliza Baron
- University of Chicago Medical Center, Chicago, Illinois, USA
| | - Aziz Ansari
- Loyola University Medical Center, Maywood, Illinois, USA
| | - Catherine Deamant
- Chicago Medical School-Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Holly Nelson-Becker
- Loyola University Medical Center, Maywood, Illinois, USA; Brunel University, London, UK
| | | | - Stacie Levine
- University of Chicago Medical Center, Chicago, Illinois, USA
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17
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Kistler EA, Stevens E, Scott E, Philpotts LL, Greer JA, Greenwald JL. Triggered Palliative Care Consults: A Systematic Review of Interventions for Hospitalized and Emergency Department Patients. J Pain Symptom Manage 2020; 60:460-475. [PMID: 32061721 DOI: 10.1016/j.jpainsymman.2020.02.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 02/05/2023]
Abstract
CONTEXT Palliative care improves the quality of care and may reduce utilization, but delays or the absences of such services are common and costly in inpatient and emergency department settings. Triggered palliative care consults (PCCs) offer one way to identify patients who would benefit from palliative care and to connect them with services early in their course. Consensus reports recommend use of triggers to identify patients for PCC, but no standards exist to guide trigger design or implementation. OBJECTIVES To conduct a systematic review of published trigger tools for PCC. METHODS Studies included quality improvement and prospective analyses of triggers for PCC for adults in the emergency department and inpatient settings since 2008. Paired reviewers evaluated the studies for inclusion criteria and extracted data related to study demographics, trigger processes, trigger criteria, and study bias. RESULTS The search yielded 5773 citations. Twenty studies were included for final analysis with more than 17,000 patients represented. Trigger processes and composition were heterogeneous, although frequently used categories, such as cancer, dementia, and chronic comorbidities, were identified. Three-quarters of the studies were deemed to have moderate or high risk of bias. CONCLUSION We present a range of trigger tools spanning different hospital settings and patient populations. Common themes in implementation and content arose, but the limitations of these studies are notable, and further rigorous randomized comparisons are needed to generate standards of care. In addition, future studies should focus on developing triggers that identify patients requiring primary-level vs. specialty-level palliative care.
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Affiliation(s)
- Emmett A Kistler
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Erin Stevens
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erin Scott
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa L Philpotts
- Treadwell Library, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey L Greenwald
- Department of Medicine, Core Educator Faculty, Massachusetts General Hospital, Boston, Massachusetts, USA
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18
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Abstract
BACKGROUND The significance of palliative care consultation in psychiatry is unclear. ACTUAL CASE SERIES Analysis of the introduction of palliative care consultation in a large psychiatric hospital. POSSIBLE COURSES OF ACTION Continue without offering, survey the need for or offer palliative care consultation, and analyse its introduction. FORMULATION OF A PLAN Palliative care consultation was established and details including patient age, department, diagnosis, main problem, solution and discharge were analysed during the first 2 years. OUTCOME Two consultations in the first year and 18 consultations in the second year were requested (18 geriatric, 2 addiction, 0 general, clinical social and forensic psychiatry) involving two domains: delirium associated with dementia or another condition (75%) and mental illness (e.g. alcoholic psycho-syndrome, psychosis, suicidal tendency, schizophrenia, depression) and cancer (25%). Recommendations of consultations were realized in 95%. LESSONS FROM THE CASE SERIES Implementation of palliative care consultation in psychiatry is one possible method of how to introduce palliative care in a field of medicine with lack of palliative care. VIEW Future research should focus on reasons for reservations about palliative care in psychiatry, include more patients with severe persistent mental illness and assess the value of palliative care consultation in resolving this problem.
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Affiliation(s)
- Thorleif Etgen
- Klinik für Neurologie, Klinikum Traunstein - Kliniken Südostbayern, Traunstein, Germany.,Neurologische Klinik, kbo-Inn-Salzach-Klinikum, Wasserburg am Inn, Germany.,Klinik und Poliklinik für Psychiatrie und Psychotherapie, Technische Universität München, München, Germany
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19
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Sorensen A, Le LW, Swami N, Hannon B, Krzyzanowska MK, Wentlandt K, Rodin G, Zimmermann C. Readiness for delivering early palliative care: A survey of primary care and specialised physicians. Palliat Med 2020; 34:114-125. [PMID: 31849272 DOI: 10.1177/0269216319876915] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence supporting early palliative care is based on trials of specialised palliative care, but a more sustainable model might involve mainly primary providers. AIM The aim of this study was to compare the characteristics of physicians providing primary and specialised palliative care, their attitudes towards early palliative care and their perception of having sufficient resources for its provision. DESIGN Survey distributed by mail and e-mail. Specialised providers were defined as both receiving palliative care referrals from other physicians and not providing palliative care only for their own patients. SETTING/PARTICIPANTS A total of 531 physicians providing palliative care in Canada (71% participation) participated in the study. RESULTS Of the participants, 257 (48.4%) provided specialised and 274 (51.6%) primary care. Specialists were more likely to have palliative care training (71.8% vs 35.2%), work in urban areas (94.1% vs 75.6%), academic centres (47.8% vs 26.0%) and on teams (82.4% vs 16.8%), and to provide mainly cancer care (84.4% vs 65.1%) (all p < 0.001). Despite strongly favouring early palliative care, only half in each group agreed they had resources to deliver it; agreement was stronger among family physicians, those working on teams and those with greater availability of community and psychosocial support. Primary providers were more likely to agree that renaming the specialty 'supportive care' would increase patient comfort with early palliative care referral (47.4% vs 35.5%, p < 0.001). CONCLUSION Despite strongly favouring the concept, both specialists and primary providers lack resources to deliver early palliative care; its provision may be facilitated by team-based care with appropriate support. Opinions differ regarding the value of renaming palliative care.
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Affiliation(s)
- Anna Sorensen
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Lisa W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Nadia Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Monika K Krzyzanowska
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Kirsten Wentlandt
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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20
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Ufere NN, Donlan J, Waldman L, Dienstag JL, Friedman LS, Corey KE, Hashemi N, Carolan P, Mullen AC, Thiim M, Bhan I, Nipp R, Greer JA, Temel JS, Chung RT, El-Jawahri A. Barriers to Use of Palliative Care and Advance Care Planning Discussions for Patients With End-Stage Liver Disease. Clin Gastroenterol Hepatol 2019; 17:2592-2599. [PMID: 30885884 PMCID: PMC6745282 DOI: 10.1016/j.cgh.2019.03.022] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/28/2019] [Accepted: 03/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Despite evidence for the benefits of palliative care (PC) referrals and early advance care planning (ACP) discussions for patients with chronic diseases, patients with end-stage liver disease (ESLD) often do not receive such care. We sought to examine physicians' perceptions of the barriers to PC and timely ACP discussions for patients with ESLD. METHODS We conducted a cross-sectional survey of hepatologists and gastroenterologists who provide care to adult patients with ESLD, recruited from the American Association for the Study of Liver Diseases 2018 membership registry. Using a questionnaire adapted from prior studies, we assessed physicians' perceptions of barriers to PC use and timely ACP discussions; 396 of 1236 eligible physicians (32%) completed the questionnaire. RESULTS The most commonly cited barriers to PC use were cultural factors that affect perception of PC (by 95% of respondents), unrealistic expectations from patients about their prognosis (by 93% of respondents), and competing demands for clinicians' time (by 91% of respondents). Most respondents (81%) thought that ACP discussions with patients who have ESLD typically occur too late in the course of illness. The most commonly cited barriers to timely ACP discussions were insufficient communication between clinicians and families about goals of care (by 84% of respondents) and insufficient cultural competency training about end-of-life care (81%). CONCLUSION There are substantial barriers to use of PC and timely discussions about ACP-most hepatologists and gastroenterologists believe that ACP occurs too late for patients with ESLD. Strategies are needed to overcome barriers and increase delivery of high-quality palliative and end-of-life care to patients with ESLD.
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Affiliation(s)
- Nneka N. Ufere
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - John Donlan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Lauren Waldman
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jules L. Dienstag
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | | | - Kathleen E. Corey
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Nikroo Hashemi
- Division of Gastroenterology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
| | - Peter Carolan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Alan C. Mullen
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Michael Thiim
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Irun Bhan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Ryan Nipp
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Joseph A. Greer
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jennifer S. Temel
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond T. Chung
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Areej El-Jawahri
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
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21
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Artioli G, Bedini G, Bertocchi E, Ghirotto L, Cavuto S, Costantini M, Tanzi S. Palliative care training addressed to hospital healthcare professionals by palliative care specialists: a mixed-method evaluation. BMC Palliat Care 2019; 18:88. [PMID: 31655585 PMCID: PMC6815393 DOI: 10.1186/s12904-019-0476-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 12/17/2022] Open
Abstract
Background Despite the great advances in the concept of palliative care (PC) and its benefits, its application seems to be delayed, leaving unfulfilled the many needs of patients and family members. One way to overcome this difficulty could be to develop a new training programme by palliative care specialists to improve PC primary skills in healthcare professionals. The aim of this study was to evaluate the training’s impact on trainees within a hospital setting using Kirkpatrick’s and Moore’s models. Methods We adopted a mixed-method evaluation with concurrent triangulation. The evaluation followed the first three steps of Kirkpatrick’s and Moore’s models and included a pre- and post-training evaluation through self-administered questionnaires and focus groups. We used the McNemar statistical test. Results The results highlighted the significant amount of knowledge acquired by the hospital professionals after training, in terms of increasing their knowledge of palliative care and in terms of the change in meaning that they attributed to phenomena related to chronicity and incurability, which they encounter daily in their professional practice. In both quantitative and qualitative research, the results, in synthesis, highlight: (i) the development of a new concept of palliative care, centred on the response to the holistic needs of people; (ii) that palliative care can also be extended to non-oncological patients in advanced illness stages (our training was directed to Geriatrics and Nephrology/Dialysis professionals); (iii) the empowerment and the increase in self-esteem that healthcare professionals gained, from learning about the logistical and structural organization of palliative care, to activate and implement PC; (iv) the need to share personal aspects of their professional life (this result emerges only in qualitative research); (v) the appreciation of cooperation and the joining of multiple competences towards a synergistic approach and enhanced outcomes. Conclusion It is necessary to further develop rigorous research on training evaluation, at the most complex orders of the Kirkpatrick and Moore models, to measure primary PC skills in health care professionals. This will develop the effectiveness of the integration of I- and II-level palliative care competencies in hospitals and improve outcomes of patients’ and families’ quality of life.
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Affiliation(s)
- Giovanna Artioli
- Palliative Care Unit, Azienda USL-IRCCS di Reggio Emilia, Viale Umberto I, 50, 42123, Reggio Emilia, Italy.
| | - Gabriele Bedini
- Casa Madonna dell'Uliveto, Centro Residenziale Cure Palliative - Hospice di Reggio Emilia, Reggio Emilia, Italy
| | - Elisabetta Bertocchi
- Palliative Care Unit, Azienda USL-IRCCS di Reggio Emilia, Viale Umberto I, 50, 42123, Reggio Emilia, Italy
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Silvio Cavuto
- Clinical Trials and Statistics Unit, Infrastructure Research and Statistic, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Massimo Costantini
- Scientific Director, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Silvia Tanzi
- Palliative Care Unit, Azienda USL-IRCCS di Reggio Emilia, Viale Umberto I, 50, 42123, Reggio Emilia, Italy.,Clinical and Experimental Medicine, PhD program, University of Modena and Reggio Emilia, Modena, Italy
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22
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Affiliation(s)
- Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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23
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Monitoring the Italian Home Palliative Care Services. Healthcare (Basel) 2019; 7:healthcare7010004. [PMID: 30609722 PMCID: PMC6473487 DOI: 10.3390/healthcare7010004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/13/2018] [Accepted: 12/24/2018] [Indexed: 01/03/2023] Open
Abstract
Background: In Italy, there currently is a lack of reliable and consistent data on home palliative care provided to people near death. Objectives: Monitoring the activities of the Italian Home Palliative Care Services, according to the 2014 national data collection program entitled “Observatory of Best Practices in Palliative Care” and providing process/outcome measures on a subsample (Best Practice Panel), on regulatory standards and on complete/reliable activity data. Design: A data collection web portal using two voluntary internet-based questionnaires in order to retrospectively identify the main care activity data provided within the year 2013 by Home care units. In the Best Practice Panel and International best practices, eligibility and quality measures refer to the national standards of the NL 38/2010. Setting/Subject: Home Palliative Care Services (HPCSs) that provided care from January to December 2013. Results: 118 Home care units were monitored, globally accounting for 40,955 assisted patients within the year 2013 (38,384 cancer patients); 56 (47.5% of 118) were admitted in the Best Practice Panel. Non-cancer (5%) and pediatric (0.4%) patients represented negligible percentages of frail care patients, and a majority of patients died at home (respectively nearly 75% and 80% of cancer and non-cancer patients). Conclusion: The study demonstrated the feasibility of the collection of certified data from Home care services through a web-based system. Only 80% of the facilities met the requirements provided by the Italian NL 38/2010. Moreover, the extension of the palliative care services provided to frail non-cancer and pediatric patients, affected by complex and advanced chronic conditions, is still inadequate in Italy.
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24
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Carey EC, Paniagua M, Morrison LJ, Levine SK, Klick JC, Buckholz GT, Rotella J, Bruno J, Liao S, Arnold RM. Palliative Care Competencies and Readiness for Independent Practice: A Report on the American Academy of Hospice and Palliative Medicine Review of the U.S. Medical Licensing Step Examinations. J Pain Symptom Manage 2018; 56:371-378. [PMID: 29935969 DOI: 10.1016/j.jpainsymman.2018.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/05/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
Abstract
CONTEXT It is unknown whether the palliative care (PC) content tested in the U.S. Medical Licensing Examination (USMLE) step examinations reflects the consensus-developed PC competencies. OBJECTIVES To review the USMLE step examinations to determine whether they test the PC knowledge necessary for graduating medical students and residents applying for licensure. METHODS Eight PC physicians reviewed three complete examination forms and a focused 509-item bundle of multiple-choice questions (MCQs) identified by the USMLE content outline as potentially assessing PC content. Reviewers determined MCQs to be PC items if the patient was seriously ill and PC knowledge was required to answer correctly. PC items' competency domains were determined using reference domains from PC subspecialty consensus competencies. RESULTS Reviewers analyzed 1090 MCQs and identified 242 (22%) as PC items. PC items were identified in each step examination. Patients in PC items were mostly males (62.8%), older than 65 years (62%), and diagnosed with cancer (43.6%). Only 6.6% and 6.2%, respectively, had end-stage heart disease or multimorbid illness. Fifty-one percent of PC items addressed ethics (31%) or communication (19.8%), focusing on patient autonomy, surrogate decision makers, or conflict between decision makers. Pain and symptom management was assessed in 28.5% of PC items, and one-third of those addressed addiction or substance use disorder. CONCLUSION We identified PC content in each step examination. However, heart disease and multimorbidity were under-represented in PC items relative to their prevalence. In addition, there was heavy overlap with ethics, a focus on conflict in assessing communication skills, and emphasis on addiction when testing pain management. Our findings highlight opportunities to enhance testing of clinical PC skills essential for all licensed physicians practicing medicine.
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Affiliation(s)
- Elise C Carey
- Center for Palliative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA.
| | - Miguel Paniagua
- Test Materials and Development, National Board of Medical Examiners, Philadelphia, Pennsylvania, USA; Palliative Care Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laura J Morrison
- Department of Medicine, Yale Palliative Care Program, Yale School of Medicine, New Haven, Connecticut, USA
| | - Stacie K Levine
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jeffrey C Klick
- Pediatric Palliative Care Program, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Gary T Buckholz
- Doris Howell Palliative Care Service, University of California, San Diego, California, USA
| | - Joseph Rotella
- American Academy of Hospice and Palliative Medicine, Chicago, Illinois, USA
| | - Julie Bruno
- American Academy of Hospice and Palliative Medicine, Chicago, Illinois, USA
| | - Solomon Liao
- Department of Medicine, University of California Irvine Medical Center, Orange, California, USA
| | - Robert M Arnold
- Department of Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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25
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Creutzfeldt CJ, Kluger B, Kelly AG, Lemmon M, Hwang DY, Galifianakis NB, Carver A, Katz M, Curtis JR, Holloway RG. Neuropalliative care: Priorities to move the field forward. Neurology 2018; 91:217-226. [PMID: 29950434 DOI: 10.1212/wnl.0000000000005916] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/06/2018] [Indexed: 11/15/2022] Open
Abstract
Neuropalliative care is an emerging subspecialty in neurology and palliative care. On April 26, 2017, we convened a Neuropalliative Care Summit with national and international experts in the field to develop a clinical, educational, and research agenda to move the field forward. Clinical priorities included the need to develop and implement effective models to integrate palliative care into neurology and to develop and implement informative quality measures to evaluate and compare palliative approaches. Educational priorities included the need to improve the messaging of palliative care and to create standards for palliative care education for neurologists and neurology education for palliative specialists. Research priorities included the need to improve the evidence base across the entire research spectrum from early-stage interventional research to implementation science. Highest priority areas include focusing on outcomes important to patients and families, developing serious conversation triggers, and developing novel approaches to patient and family engagement, including improvements to decision quality. As we continue to make remarkable advances in the prevention, diagnosis, and treatment of neurologic illness, neurologists will face an increasing need to guide and support patients and families through complex choices involving immense uncertainty and intensely important outcomes of mind and body. This article outlines opportunities to improve the quality of care for all patients with neurologic illness and their families through a broad range of clinical, educational, and investigative efforts that include complex symptom management, communication skills, and models of care.
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Affiliation(s)
- Claire J Creutzfeldt
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle.
| | - Benzi Kluger
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Adam G Kelly
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Monica Lemmon
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - David Y Hwang
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Nicholas B Galifianakis
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Alan Carver
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Maya Katz
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - J Randall Curtis
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Robert G Holloway
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
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26
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Langberg KM, Kapo JM, Taddei TH. Palliative care in decompensated cirrhosis: A review. Liver Int 2018; 38:768-775. [PMID: 29112338 DOI: 10.1111/liv.13620] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 10/30/2017] [Indexed: 12/16/2022]
Abstract
Decompensated cirrhosis is an illness that causes tremendous suffering. The incidence of cirrhosis is increasing and rates of liver transplant, the only cure, remain stagnant. Palliative care is focused on improving quality of life for patients with serious illness by addressing advanced care planning, alleviating physical symptoms and providing emotional support to the patient and family. Palliative care is used infrequently in patients with decompensated cirrhosis. The allure of transplant as a potential treatment option for cirrhosis, misperceptions about the role of palliative care and difficulty predicting prognosis in liver disease are potential contributors to the underutilization of palliative care in this patient population. Studies have demonstrated some benefit of palliative care in patients with decompensated cirrhosis but the literature is limited to small observational studies. There is evidence that palliative care consultation in other patient populations lowers hospital costs and ICU utilization and improves symptom control and patient satisfaction. Prospective randomized control trials are needed to investigate the effects of palliative care on traditional- and patient-reported outcomes as well as cost of care in decompensated cirrhosis for transplant eligible and ineligible patient populations.
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Affiliation(s)
- Karl M Langberg
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer M Kapo
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tamar H Taddei
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
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27
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Khateeb R, Puelle MR, Firn J, Saul D, Chang R, Min L. Interprofessional Rounds Improve Timing of Appropriate Palliative Care Consultation on a Hospitalist Service. Am J Med Qual 2018; 33:569-575. [PMID: 29644871 PMCID: PMC9097960 DOI: 10.1177/1062860618768069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
Despite known benefits, palliative care (PC) consultation for hospitalized patients remains underutilized. The objective was to improve frequency and timeliness of appropriate inpatient PC consultation. On 2 of 11 hospitalist teams, a PC representative attended discharge rounds twice a week. Control teams' discharge rounds were unenhanced. Subjects were all patients admitted to a hospitalist service in a quaternary academic medical center. The primary outcome was change in provision of PC consultation over time; the secondary outcome was change in time-to-consult (days). Hospitalists were surveyed regarding the intervention. The unadjusted proportion of patients receiving PC consultation increased from 2.7% to 5.2% on the intervention teams. Compared to control teams over time and adjusting for multiple covariates, the intervention increased PC consultation (difference-in-difference [DID] = 1.0 percentage-point increase [95% CI = 0.3%-1.8%]) and decreased time to consult (DID = -5 days [95% CI = -11 to -1]) in patients admitted for noncancer diagnoses. Hospitalists thought the intervention facilitated effective patient care without increased burden.
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Affiliation(s)
| | | | | | | | | | - Lillian Min
- 1 University of Michigan, Ann Arbor, MI
- 4 VA Ann Arbor Healthcare System, Ann Arbor, MI
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28
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Interventionist training and intervention fidelity monitoring and maintenance for CONNECT, a nurse-led primary palliative care in oncology trial. Contemp Clin Trials Commun 2018; 10:57-61. [PMID: 29696159 PMCID: PMC5898502 DOI: 10.1016/j.conctc.2018.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 02/27/2018] [Accepted: 03/14/2018] [Indexed: 12/25/2022] Open
Abstract
Context Intervention fidelity is a critical component of behavioral research that has received inadequate attention in palliative care studies. With increasing focus on the need for palliative care models that can be widely disseminated and delivered by non-specialists, rigorous yet pragmatic strategies for training interventionists and maintaining intervention fidelity are needed. Objectives (1) Describe components of a plan for interventionist training and monitoring and maintaining intervention fidelity as part of a primary palliative care trial (CONNECT) and (2) present data about perceived training effectiveness and delivery of key intervention content. Methods Post-training evaluations, visit checklists, and visit audio-recordings. Results Data were collected from June, 2016 through April, 2017. We include procedures for (1) identification, training and certification of oncology nurses as CONNECT interventionists; (2) monitoring intervention delivery; and (3) maintaining intervention quality. All nurses (N = 14) felt prepared to deliver key competencies after a 3-day in-person training. As assessed via visit checklists, interventionists delivered an average of 94% (SD 13%) of key content for first intervention visits and 85% (SD 14%) for subsequent visits. As assessed via audio-recordings, interventionists delivered an average of 85% (SD 8%) of key content for initial visits and 85% (SD 12%) for subsequent visits. Conclusion We present a 3-part strategy for training interventionists and monitoring and maintaining intervention delivery in a primary palliative care trial. Training was effective in having nurses feel prepared to deliver primary palliative care skills. As assessed via nursing checklists and visit audio-recordings, intervention fidelity was high.
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Stajduhar K, Sawatzky R, Robin Cohen S, Heyland DK, Allan D, Bidgood D, Norgrove L, Gadermann AM. Bereaved family members' perceptions of the quality of end-of-life care across four types of inpatient care settings. BMC Palliat Care 2017; 16:59. [PMID: 29178901 PMCID: PMC5702136 DOI: 10.1186/s12904-017-0237-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 11/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aims of this study were to gain a better understanding of how bereaved family members perceive the quality of EOL care by comparing their satisfaction with quality of end-of-life care across four different settings and by additionally examining the extent to which demographic characteristics and psychological variables (resilience, optimism, grief) explain variation in satisfaction. METHODS A cross-sectional mail-out survey was conducted of bereaved family members of patients who had died in extended care units (n = 63), intensive care units (n = 30), medical care units (n = 140) and palliative care units (n = 155). 1254 death records were screened and 712 bereaved family caregivers were identified as eligible, of which 558 (who were initially contacted by mail and then followed up by phone) agreed to receive a questionnaire and 388 returned a completed questionnaire (response rate of 70%). Measures included satisfaction with end-of-life care (CANHELP- Canadian Health Care Evaluation Project - family caregiver bereavement version; scores range from 0 = not at all satisfied to 5 = completely satisfied), grief (Texas Revised Inventory of Grief (TRIG)), optimism (Life Orientation Test - Revised) and resilience (The Resilience Scale). ANCOVA and multivariate linear regression were used to analyze the data. RESULTS Family members experienced significantly lower satisfaction in MCU (mean = 3.69) relative to other settings (means of 3.90 [MCU], 4.14 [ICU], and 4.00 [PCU]; F (3371) = 8.30, p = .000). Statistically significant differences were also observed for CANHELP subscales of "doctor and nurse care", "illness management", "health services" and "communication". The regression model explained 18.9% of the variance in the CANHELP total scale, and between 11.8% and 27.8% of the variance in the subscales. Explained variance in the CANHELP total score was attributable to the setting of care and psychological characteristics of family members (44%), in particular resilience. CONCLUSION Findings suggest room for improvement across all settings of care, but improving quality in acute care and palliative care should be a priority. Resiliency appears to be an important psychological characteristic in influencing how family members appraise care quality and point to possible sites for targeted intervention.
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Affiliation(s)
- Kelli Stajduhar
- School of Nursing and Institute on Aging and Lifelong Health, University of Victoria, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2 Canada
| | - Richard Sawatzky
- School of Nursing, Trinity Western University, 7600 Glover Road, Langley, BC V2Y 1Y1 Canada
| | - S. Robin Cohen
- Oncology and Medicine, McGill University, Lady Davis Research Institute, Jewish General Hospital, 845 Sherbrooke Street West, Montreal, QC H3A 0G4 Canada
| | - Daren K. Heyland
- Critical Care Medicine, Queen’s University, 76 Stuart Street, Kingston, ON K7L 2V7 Canada
| | - Diane Allan
- College of Nursing, University of Saskatchewan, 104 Clinic Place, Saskatoon, SASK S7N 2Z4 Canada
| | - Darcee Bidgood
- Institute on Aging and Lifelong Health, University of Victoria, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2 Canada
| | - Leah Norgrove
- Palliative Care, Saanich Peninsula Hospital, Island Health, 2166 Mt. Newton X Road, Saanichton, BC V8M 2B2 Canada
| | - Anne M. Gadermann
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3 Canada
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Johnston EE, Alvarez E, Saynina O, Sanders L, Bhatia S, Chamberlain LJ. Disparities in the Intensity of End-of-Life Care for Children With Cancer. Pediatrics 2017; 140:peds.2017-0671. [PMID: 28963112 PMCID: PMC9923617 DOI: 10.1542/peds.2017-0671] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Many adult patients with cancer who know they are dying choose less intense care; additionally, high-intensity care is associated with worse caregiver outcomes. Little is known about intensity of end-of-life care in children with cancer. METHODS By using the California Office of Statewide Health Planning and Development administrative database, we performed a population-based analysis of patients with cancer aged 0 to 21 who died between 2000 and 2011. Rates of and sociodemographic and clinical factors associated with previously-defined end-of-life intensity indicators were determined. The intensity indicators included an intense medical intervention (cardiopulmonary resuscitation, intubation, ICU admission, or hemodialysis) within 30 days of death, intravenous chemotherapy within 14 days of death, and hospital death. RESULTS The 3732 patients were 34% non-Hispanic white, and 41% had hematologic malignancies. The most prevalent intensity indicators were hospital death (63%) and ICU admission (20%). Sixty-five percent had ≥1 intensity indicator, 23% ≥2, and 22% ≥1 intense medical intervention. There was a bimodal association between age and intensity: ages <5 years and 15 to 21 years was associated with intense care. Patients with hematologic malignancies were more likely to have high-intensity end-of-life care, as were patients from underrepresented minorities, those who lived closer to the hospital, those who received care at a nonspecialty center (neither Children's Oncology Group nor National Cancer Institute Designated Cancer Center), and those receiving care after 2008. CONCLUSIONS Nearly two-thirds of children who died of cancer experienced intense end-of-life care. Further research needs to determine if these rates and disparities are consistent with patient and/or family goals.
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Affiliation(s)
- Emily E. Johnston
- Divisions of Pediatric Hematology/Oncology and,Address correspondence to Emily E. Johnston, MD, Division of Pediatric Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Rd, Suite 300, Palo Alto, CA 94304. E-mail:
| | | | - Olga Saynina
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; and
| | - Lee Sanders
- General Pediatrics, Department of Pediatrics, School of Medicine, and,Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; and
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lisa J. Chamberlain
- General Pediatrics, Department of Pediatrics, School of Medicine, and,Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; and
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Wang Y, Spatz ES, Tariq M, Angraal S, Krumholz HM. Home Health Agency Performance in the United States: 2011-15. J Am Geriatr Soc 2017; 65:2572-2579. [PMID: 28960228 DOI: 10.1111/jgs.14987] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To evaluate home health agency quality performance. DESIGN Observational study. SETTING Home health agencies. PARTICIPANTS All Medicare-certified agencies with at least 6 months of data from 2011 to 2015. MEASUREMENTS Twenty-two quality indicators, five patient survey indicators, and their composite scores. RESULTS The study included 11,462 Medicare-certified home health agencies that served 92.4% of all ZIP codes nationwide, accounting for 315.2 million people. The mean composite scores were 409.1 ± 22.7 out of 500 with the patient survey indicators and 492.3 ± 21.7 out of 600 without the patient survey indicators. Home health agency performance on 27 quality indicators varied, with the coefficients of dispersion ranging from 4.9 to 62.8. Categorization of agencies into performance quartiles revealed that 3,179 (27.7%) were in the low-performing group (below 25th percentile) at least one time during the period from 2011-12 to 2014-15 and that 493 were in the low-performing group throughout the study period. Geographic variation in agency performance was observed. Agencies with longer Medicare-certified years were more likely to have high-performing scores; agencies providing partial services, with proprietary ownership, and those with long travel distances to reach patients had lower performance. Agencies serving low-income counties and counties with lower proportions of women and senior residences and greater proportions of Hispanic residents were more likely to attain lower performance scores. CONCLUSION Home health agency performance on several quality indicators varied, and many agencies were persistently in the lowest quartile of performance. Still, there is a need to improve the quality of care of all agencies. Many parts of the United States, particularly lower-income areas and areas with more Hispanic residents, are more likely to receive lower quality home health care.
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Affiliation(s)
- Yun Wang
- Department of Biostatistics, T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Erica S Spatz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Maliha Tariq
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Suveen Angraal
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.,Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.,Department of Health Policy and Management, School of Public Health, Yale University, New Haven, Connecticut
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Gelfman LP, Kavalieratos D, Teuteberg WG, Lala A, Goldstein NE. Primary palliative care for heart failure: what is it? How do we implement it? Heart Fail Rev 2017; 22:611-620. [PMID: 28281018 PMCID: PMC5591756 DOI: 10.1007/s10741-017-9604-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [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
Heart failure (HF) is a chronic and progressive illness, which affects a growing number of adults, and is associated with a high morbidity and mortality, as well as significant physical and psychological symptom burden on both patients with HF and their families. Palliative care is the multidisciplinary specialty focused on optimizing quality of life and reducing suffering for patients and families facing serious illness, regardless of prognosis. Palliative care can be delivered as (1) specialist palliative care in which a palliative care specialist with subspecialty palliative care training consults or co-manages patients to address palliative needs alongside clinicians who manage the underlying illness or (2) as primary palliative care in which the primary clinician (such as the internist, cardiologist, cardiology nurse, or HF specialist) caring for the patient with HF provides the essential palliative domains. In this paper, we describe the key domains of primary palliative care for patients with HF and offer some specific ways in which primary palliative care and specialist palliative care can be offered in this population. Although there is little research on HF primary palliative care, primary palliative care in HF offers a key opportunity to ensure that this population receives high-quality palliative care in spite of the growing numbers of patients with HF as well as the limited number of specialist palliative care providers.
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Affiliation(s)
- Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY, 10029, USA.
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA.
| | - Dio Kavalieratos
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Winifred G Teuteberg
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anuradha Lala
- Divisions of Cardiology and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY, 10029, USA
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
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Scaccabarozzi G, Lovaglio PG, Limonta F, Floriani M, Pellegrini G. Quality assessment of palliative home care in Italy. J Eval Clin Pract 2017; 23:725-733. [PMID: 28176419 DOI: 10.1111/jep.12704] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 12/16/2016] [Accepted: 12/16/2016] [Indexed: 11/28/2022]
Abstract
RATIONALE The complexity of end-of-life care, represented by a large number of units caring for dying patients, of different types of organizations motivates the importance of measure the quality of provided care. Despite the law 38/2010 promulgated to remove the barriers and provide affordable access to palliative care, measurement, and monitoring of processes of home care providers in Italy has not been attempted. AIMS AND OBJECTIVES Using data drawn by an institutional voluntary observatory established in Italy in 2013, collecting home palliative care units caring for people between January and December 2013, we assess the degree to which Italian home palliative care teams endorse a set of standards required by the 38/2010 law and best practices as emerged from the literature. METHODS The evaluation strategy is based on Rasch analysis, allowing to objectively measuring both performances of facilities and quality indicators' difficulty on the same metric, using 14 quality indicators identified by the observatory's steering committee. RESULTS Globally, 195 home care teams were registered in the observatory reporting globally 40 955 cured patients in 2013 representing 66% of the population of home palliative care units active in Italy in 2013. Rasch analysis identifies 5 indicators ("interview" with caregivers, continuous training provided to medical and nursing staff, provision of specialized multidisciplinary interventions, psychological support to the patient and family, and drug supply at home) easy to endorse by health care providers and 3 problematic indicators (presence of a formally established Local Network of Palliative care in the area of reference, provision of the care for most problematic patient requiring high intensity of the care, and the percentage of cancer patient dying at Home). CONCLUSIONS The lack of Local Network of Palliative care, required by law 38/2010, is, at the present, the main barrier to its application. However, the adopted methodology suggests that a clear roadmap for health facilities to afford future quality and normative challenges.
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Affiliation(s)
- Gianlorenzo Scaccabarozzi
- Department of Frailty, Local social health authority (ASST) Lecco, Local Network of Palliative care, Merate, Italy
| | - Pietro Giorgio Lovaglio
- Department of Statistics and Quantitative Methods, and CRISP, University of Milano-Bicocca, Milan, Italy
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Sevilla-Sánchez D, Molist-Brunet N, Amblàs-Novellas J, Espaulella-Panicot J, Codina-Jané C. Potentially inappropriate medication at hospital admission in patients with palliative care needs. Int J Clin Pharm 2017; 39:1018-1030. [PMID: 28744675 DOI: 10.1007/s11096-017-0518-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 07/21/2017] [Indexed: 01/23/2023]
Abstract
Background Potentially inappropriate medications (PIMs) are common in older patients with polypharmacy, and are related to negative clinical results. Little information is available on the characteristics and consequences of PIMs in patients with advanced chronic conditions and palliative care needs. Objective To evaluate, for this population: (i) the prevalence of PIMs; (ii) the possible risk factors associated with its onset; and (iii) the related clinical consequences. Setting Acute-hospital care Geriatric Unit (AGU) in County of Osona, Spain. Method Ten-month prospective cross-sectional study. Patients with palliative care needs were identified according to the NECPAL CCOMS-ICO® test. Upon hospital admission, a multidisciplinary team consisting of a pharmacist and two AGU physicians determined the PIMs of the routine chronic medication of the patients. Sociodemographic and pharmacological data were collected with the objective of determining possible risk factors related to the existence of PIMs. Main outcome measure Prevalence and type of PIMs according to STOPP version 2 and MAI criteria at the time of hospital admission. Furthermore, days of hospital admission, destination at hospital discharge and survival analysis at 12 months related to PIMs were evaluated. Results Two hundred thirty-five patients (mean age 86.80, SD 5.37; 65.50% women) were recruited. According to the STOPP criteria, 88.50% of patients had ≥1 criterion (mainly 'indication of medication', followed by those that affect the nervous system and psychotropic drugs and risk drugs in people suffering from falls), and according to the MAI tool, 97.40% of the patients had some criterion related to inappropriate medication (mainly, duration of therapy). The following conditions were identified as risk factors for the existence of PIMs: insomnia, anxiety-depressive disorder, falls, pain, excessive polypharmacy and therapeutic complexity. There were no differences among patients in days of hospital stay, discharge's destination or survival at 12 months, regardless of the tool used. Conclusion The presence of PIMs is high in patients requiring palliative care. Some potentially modifiable risk factors such as the pharmacological ones are associated with a greater presence of inappropriate medication. The presence of PIMs does not affect this population in terms of mortality.
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Affiliation(s)
- Daniel Sevilla-Sánchez
- Pharmacy Department, Hospital Universitari de Vic, Hospital Universitari de la Santa Creu de Vic, Vic, Barcelona, Spain.
| | - Núria Molist-Brunet
- Acute Geriatric Unit, Hospital Universitari de Vic, Hospital Universitari de la Santa Creu de Vic, Vic, Spain
| | - Jordi Amblàs-Novellas
- Acute Geriatric Unit, Hospital Universitari de Vic, Hospital Universitari de la Santa Creu de Vic, Vic, Spain
| | - Joan Espaulella-Panicot
- Acute Geriatric Unit, Hospital Universitari de Vic, Hospital Universitari de la Santa Creu de Vic, Vic, Spain
- Geriatric and Palliative Care Territorial Unit, Hospital Universitari de la Santa Creu de Vic, Vic, Spain
| | - Carles Codina-Jané
- Pharmacy Department, Hospital Universitari de Vic, Hospital Universitari de la Santa Creu de Vic, Vic, Barcelona, Spain
- Pharmacy Department, Hospital Clinic de Barcelona, Vic, Barcelona, Spain
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Rosansky SJ, Schell J, Shega J, Scherer J, Jacobs L, Couchoud C, Crews D, McNabney M. Treatment decisions for older adults with advanced chronic kidney disease. BMC Nephrol 2017; 18:200. [PMID: 28629462 PMCID: PMC5477347 DOI: 10.1186/s12882-017-0617-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 06/09/2017] [Indexed: 12/28/2022] Open
Abstract
Dialysis initiation rates among older adults, aged 75 years or greater, are increasing at a faster rate than for younger age groups. Older adults with advanced CKD (eGFR < 30 ml/min/1.73 m2) typically lose renal function slowly, often suffer from significant comorbidity and thus may die from associated comorbidities before they require dialysis.A patient's pattern of renal function loss over time in relation to their underlying comorbidities can serve as a guide to the probability of a future dialysis requirement. Most who start dialysis, initiate treatment "early", at an estimated glomerulofiltration rate (eGFR) >10 ml/min/1.73 m2 and many initiate dialysis in hospital, often in association with an episode of acute renal failure. In the US older adults start dialysis at a mean e GFR of 12.6 ml/min/1.73 m2 and 20.6% die within six months of dialysis initiation. In both the acute in hospital and outpatient settings, many older adults appear to be initiating dialysis for non-specific, non-life threatening symptoms and clinical contexts. Observational data suggests that dialysis does not provide a survival benefit for older adults with poor mobility and high levels of comorbidity. To optimize the care of this population, early and repeat shared decision making conversations by health care providers, patients, and their families should consider the risks, burdens, and benefits of dialysis versus conservative management, as well as the patient specific symptoms and clinical situations that could justify dialysis initiation. The potential advantages and disadvantages of dialysis therapy should be considered in conjunction with each patient's unique goals and priorities.In conclusion, when considering the morbidity and quality of life impact associated with dialysis, many older adults may prefer to delay dialysis until there is a definitive indication or may opt for conservative management without dialysis. This approach can incorporate all CKD treatments other than dialysis, provide psychosocial and spiritual support and active symptom management and may also incorporate a palliative care approach with less medical monitoring of lab parameters and more focus on the use of drug therapies directed to relief of a patient's symptoms.
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Affiliation(s)
| | - Jane Schell
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | | | - Jennifer Scherer
- Division of Palliative Care and Division of Nephrology, NYU School of Medicine, New York, NY, USA
| | - Laurie Jacobs
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, USA
| | - Cecile Couchoud
- REIN registry, Agence de la biomedicine, Saint Denis La Paine, France
| | - Deidra Crews
- Division of Nephrology, Department of Medicine, Welch Center for Prevention Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, USA
| | - Matthew McNabney
- Division of Geriatrics, Johns Hopkins University, Baltimore, MD, USA
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Haun MW, Estel S, Rücker G, Friederich H, Villalobos M, Thomas M, Hartmann M. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev 2017; 6:CD011129. [PMID: 28603881 PMCID: PMC6481832 DOI: 10.1002/14651858.cd011129.pub2] [Citation(s) in RCA: 248] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Incurable cancer, which often constitutes an enormous challenge for patients, their families, and medical professionals, profoundly affects the patient's physical and psychosocial well-being. In standard cancer care, palliative measures generally are initiated when it is evident that disease-modifying treatments have been unsuccessful, no treatments can be offered, or death is anticipated. In contrast, early palliative care is initiated much earlier in the disease trajectory and closer to the diagnosis of incurable cancer. OBJECTIVES To compare effects of early palliative care interventions versus treatment as usual/standard cancer care on health-related quality of life, depression, symptom intensity, and survival among adults with a diagnosis of advanced cancer. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, OpenGrey (a database for grey literature), and three clinical trial registers to October 2016. We checked reference lists, searched citations, and contacted study authors to identify additional studies. SELECTION CRITERIA Randomised controlled trials (RCTs) and cluster-randomised controlled trials (cRCTs) on professional palliative care services that provided or co-ordinated comprehensive care for adults at early advanced stages of cancer. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. We assessed risk of bias, extracted data, and collected information on adverse events. For quantitative synthesis, we combined respective results on our primary outcomes of health-related quality of life, survival (death hazard ratio), depression, and symptom intensity across studies in meta-analyses using an inverse variance random-effects model. We expressed pooled effects as standardised mean differences (SMDs, or Hedges' adjusted g). We assessed certainty of evidence at the outcome level using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) and created a 'Summary of findings' table. MAIN RESULTS We included seven randomised and cluster-randomised controlled trials that together recruited 1614 participants. Four studies evaluated interventions delivered by specialised palliative care teams, and the remaining studies assessed models of co-ordinated care. Overall, risk of bias at the study level was mostly low, apart from possible selection bias in three studies and attrition bias in one study, along with insufficient information on blinding of participants and outcome assessment in six studies.Compared with usual/standard cancer care alone, early palliative care significantly improved health-related quality of life at a small effect size (SMD 0.27, 95% confidence interval (CI) 0.15 to 0.38; participants analysed at post treatment = 1028; evidence of low certainty). As re-expressed in natural units (absolute change in Functional Assessment of Cancer Therapy-General (FACT-G) score), health-related quality of life scores increased on average by 4.59 (95% CI 2.55 to 6.46) points more among participants given early palliative care than among control participants. Data on survival, available from four studies enrolling a total of 800 participants, did not indicate differences in efficacy (death hazard ratio 0.85, 95% CI 0.56 to 1.28; evidence of very low certainty). Levels of depressive symptoms among those receiving early palliative care did not differ significantly from levels among those receiving usual/standard cancer care (five studies; SMD -0.11, 95% CI -0.26 to 0.03; participants analysed at post treatment = 762; evidence of very low certainty). Results from seven studies that analysed 1054 participants post treatment suggest a small effect for significantly lower symptom intensity in early palliative care compared with the control condition (SMD -0.23, 95% CI -0.35 to -0.10; evidence of low certainty). The type of model used to provide early palliative care did not affect study results. One RCT reported potential adverse events of early palliative care, such as a higher percentage of participants with severe scores for pain and poor appetite; the remaining six studies did not report adverse events in study publications. For these six studies, principal investigators stated upon request that they had not observed any adverse events. AUTHORS' CONCLUSIONS This systematic review of a small number of trials indicates that early palliative care interventions may have more beneficial effects on quality of life and symptom intensity among patients with advanced cancer than among those given usual/standard cancer care alone. Although we found only small effect sizes, these may be clinically relevant at an advanced disease stage with limited prognosis, at which time further decline in quality of life is very common. At this point, effects on mortality and depression are uncertain. We have to interpret current results with caution owing to very low to low certainty of current evidence and between-study differences regarding participant populations, interventions, and methods. Additional research now under way will present a clearer picture of the effect and specific indication of early palliative care. Upcoming results from several ongoing studies (N = 20) and studies awaiting assessment (N = 10) may increase the certainty of study results and may lead to improved decision making. In perspective, early palliative care is a newly emerging field, and well-conducted studies are needed to explicitly describe the components of early palliative care and control treatments, after blinding of participants and outcome assessors, and to report on possible adverse events.
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Affiliation(s)
- Markus W Haun
- Im Neuenheimer Feld 410, Heidelberg University HospitalDepartment of General Internal Medicine and PsychosomaticsHeidelbergGermanyD‐69120
| | - Stephanie Estel
- Im Neuenheimer Feld 410, Heidelberg University HospitalDepartment of General Internal Medicine and PsychosomaticsHeidelbergGermanyD‐69120
| | - Gerta Rücker
- Faculty of Medicine and Medical Center – University of FreiburgInstitute for Medical Biometry and StatisticsStefan‐Meier‐Str. 26FreiburgGermany79104
| | - Hans‐Christoph Friederich
- University Hospital DüsseldorfPsychosomatic Medicine and PsychotherapyMoorenstrasse 5DüsseldorfGermany40225
| | - Matthias Villalobos
- Thoraxklinik at Heidelberg University HospitalDepartment of Thoracic OncologyHeidelbergGermanyD‐69120
| | - Michael Thomas
- Thoraxklinik at Heidelberg University HospitalDepartment of Thoracic OncologyHeidelbergGermanyD‐69120
| | - Mechthild Hartmann
- Im Neuenheimer Feld 410, Heidelberg University HospitalDepartment of General Internal Medicine and PsychosomaticsHeidelbergGermanyD‐69120
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Allsop MJ, Kite S, McDermott S, Penn N, Millares-Martin P, Bennett MI. Electronic palliative care coordination systems: Devising and testing a methodology for evaluating documentation. Palliat Med 2017; 31:475-482. [PMID: 27507636 PMCID: PMC5405823 DOI: 10.1177/0269216316663881] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The need to improve coordination of care at end of life has driven electronic palliative care coordination systems implementation across the United Kingdom and internationally. No approaches for evaluating electronic palliative care coordination systems use in practice have been developed. AIM This study outlines and applies an evaluation framework for examining how and when electronic documentation of advance care planning is occurring in end of life care services. DESIGN A pragmatic, formative process evaluation approach was adopted. The evaluation drew on the Project Review and Objective Evaluation methodology to guide the evaluation framework design, focusing on clinical processes. SETTING/PARTICIPANTS Data were extracted from electronic palliative care coordination systems for 82 of 108 general practices across a large UK city. All deaths ( n = 1229) recorded on electronic palliative care coordination systems between April 2014 and March 2015 were included to determine the proportion of all deaths recorded, median number of days prior to death that key information was recorded and observations about routine data use. RESULTS The evaluation identified 26.8% of all deaths recorded on electronic palliative care coordination systems. The median number of days to death was calculated for initiation of an electronic palliative care coordination systems record (31 days), recording a patient's preferred place of death (8 days) and entry of Do Not Attempt Cardiopulmonary Resuscitation decisions (34 days). Where preferred and actual place of death was documented, these were matching for 75% of patients. Anomalies were identified in coding used during data entry on electronic palliative care coordination systems. CONCLUSION This study reports the first methodology for evaluating how and when electronic palliative care coordination systems documentation is occurring. It raises questions about what can be drawn from routine data collected through electronic palliative care coordination systems and outlines considerations for future evaluation. Future evaluations should consider work processes of health professionals using electronic palliative care coordination systems.
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Affiliation(s)
- Matthew J Allsop
- 1 Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | | | - Naomi Penn
- 4 Leeds South and East Clinical Commissioning Group, Leeds, UK
| | | | - Michael I Bennett
- 1 Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Groeneveld EI, Cassel JB, Bausewein C, Csikós Á, Krajnik M, Ryan K, Haugen DF, Eychmueller S, Gudat Keller H, Allan S, Hasselaar J, García-Baquero Merino T, Swetenham K, Piper K, Fürst CJ, Murtagh FE. Funding models in palliative care: Lessons from international experience. Palliat Med 2017; 31:296-305. [PMID: 28156188 PMCID: PMC5405831 DOI: 10.1177/0269216316689015] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Funding models influence provision and development of palliative care services. As palliative care integrates into mainstream health care provision, opportunities to develop funding mechanisms arise. However, little has been reported on what funding models exist or how we can learn from them. AIM To assess national models and methods for financing and reimbursing palliative care. DESIGN Initial literature scoping yielded limited evidence on the subject as national policy documents are difficult to identify, access and interpret. We undertook expert consultations to appraise national models of palliative care financing in England, Germany, Hungary, Republic of Ireland, New Zealand, The Netherlands, Norway, Poland, Spain, Sweden, Switzerland, the United States and Wales. These represent different levels of service development and a variety of funding mechanisms. RESULTS Funding mechanisms reflect country-specific context and local variations in care provision. Patterns emerging include the following: Provider payment is rarely linked to population need and often perpetuates existing inequitable patterns in service provision. Funding is frequently characterised as a mixed system of charitable, public and private payers. The basis on which providers are paid for services rarely reflects individual care input or patient needs. CONCLUSION Funding mechanisms need to be well understood and used with caution to ensure best practice and minimise perverse incentives. Before we can conduct cross-national comparisons of costs and impact of palliative care, we need to understand the funding and policy context for palliative care in each country of interest.
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Affiliation(s)
- E Iris Groeneveld
- 1 Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | - J Brian Cassel
- 2 School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Claudia Bausewein
- 3 Department of Palliative Medicine, Munich University Hospital, Ludwigs-Maximilians-University Munich, Munich, Germany
| | - Ágnes Csikós
- 4 PTE ÁOK Családorvostani Intézet, Hospice-Palliativ Tanszék, Pécs, Hungary
| | - Malgorzata Krajnik
- 5 Department of Palliative Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Karen Ryan
- 6 Saint Francis Hospice and Mater Hospital, Dublin, Ireland
| | - Dagny Faksvåg Haugen
- 7 Regional Centre of Excellence for Palliative Care, Haukeland University Hospital, Bergen, Norway.,8 Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
| | | | | | - Simon Allan
- 11 Arohanui Hospice, Palmerston North, New Zealand
| | - Jeroen Hasselaar
- 12 Department of Anesthesiology, Pain and Palliative Care, RadboudUMC, Nijmegen, The Netherlands
| | - Teresa García-Baquero Merino
- 13 Viceconsejería de Asistencia Sanitaria, Consejería de Sanidad de Madrid, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Kate Swetenham
- 14 Southern Adelaide Palliative Services, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Kym Piper
- 15 Finance & Corporate Services, South Australia Health, Adelaide, SA, Australia
| | - Carl Johan Fürst
- 16 Palliativa Utvecklingscentrum, Lund University and Region Skåne, Lund, Sweden
| | - Fliss Em Murtagh
- 1 Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
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Wang Y, Leifheit-Limson EC, Fine J, Pandolfi MM, Gao Y, Liu F, Eckenrode S, Lichtman JH. National Trends and Geographic Variation in Availability of Home Health Care: 2002-2015. J Am Geriatr Soc 2017; 65:1434-1440. [PMID: 28322441 DOI: 10.1111/jgs.14811] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate national trends and geographic variation in the availability of home health care from 2002 to 2015 and identify county-specific characteristics associated with home health care. DESIGN Observational study. SETTING All counties in the United States. PARTICIPANTS All Medicare-certified home health agencies included in the Centers for Medicare & Medicaid Services Home Health Compare system. MEASUREMENTS County-specific availability of home health care, defined as the number of available home health agencies that provided services to a given county per 100,000 population aged ≥18 years. RESULTS The study included 15,184 Medicare-certified home health agencies that served 97% of U.S. ZIP codes. Between 2002-2003 and 2014-2015, the county-specific number of available home health agencies per 100,000 population aged ≥18 years increased from 14.7 to 21.8 and the median (inter-quartile range) population that was serviced by at least one home health agency increased from 403,605 (890,329) to 455,488 (1,039,328). Considerable geographic variation in the availability of home health care was observed. The West, North East, and South Atlantic regions had lower home health care availability than the Central regions, and this pattern persisted over the study period. Counties with higher median income, a larger senior population, higher rates of households without a car and low access to stores, more obesity, greater inactivity, and higher proportions of non-Hispanic white, non-Hispanic black, and Hispanic populations were more likely to have higher availability of home health care. CONCLUSION The availability of home health care increased nationwide during the study period, but there was much geographic variation.
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Affiliation(s)
- Yun Wang
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Center for Outcomes Research and Evaluation, Yale University and Yale-New Haven Hospital, New Haven, Connecticut
| | - Erica C Leifheit-Limson
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Jonathan Fine
- Section of Pulmonary and Critical Care Medicine, Norwalk Hospital, Norwalk, Connecticut
| | | | - Yan Gao
- Department of Sociology, Graduate School, University of New Hampshire, Durham, New Hampshire
| | | | | | - Judith H Lichtman
- Center for Outcomes Research and Evaluation, Yale University and Yale-New Haven Hospital, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
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Coats H, Paganelli T, Starks H, Lindhorst T, Starks Acosta A, Mauksch L, Doorenbos A. A Community Needs Assessment for the Development of an Interprofessional Palliative Care Training Curriculum. J Palliat Med 2017; 20:235-240. [PMID: 27802069 PMCID: PMC5333526 DOI: 10.1089/jpm.2016.0321] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is a known shortage of trained palliative care professionals, and an even greater shortage of professionals who have been trained through interprofessional curricula. As part of an institutional Palliative Care Training Center grant, a core team of interprofessional palliative care academic faculty and staff completed a state-wide palliative care educational assessment to determine the needs for an interprofessional palliative care training program. OBJECTIVE The purpose of this article is to describe the process and results of our community needs assessment of interprofessional palliative care educational needs in Washington state. DESIGN We approached the needs assessment through a cross-sectional descriptive design by using mixed-method inquiry. SETTING/SUBJECTS Each phase incorporated a variety of settings and subjects. MEASUREMENTS The assessment incorporated multiple phases with diverse methodological approaches: a preparatory phase-identifying key informants; Phase I-key informant interviews; Phase II-survey; and Phase III-steering committee endorsement. RESULTS The multiple phases of the needs assessment helped create a conceptual framework for the Palliative Care Training Center and developed an interprofessional palliative care curriculum. The input from key informants at multiple phases also allowed us to define priority needs and to refine an interprofessional palliative care curriculum. CONCLUSIONS This curriculum will provide an interprofessional palliative care educational program that crosses disciplinary boundaries to integrate knowledge that is beneficial for all palliative care clinicians. The input from a range of palliative care clinicians and professionals at every phase of the needs assessment was critical for creating an interprofessional palliative care curriculum.
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Affiliation(s)
- Heather Coats
- UW/Cambia Palliative Care Center of Excellence NIH/NHLBI Post-Doctoral Fellow (T32), University of Washington, Seattle, Washington
| | - Tia Paganelli
- Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle, Washington
| | - Helene Starks
- Department of Bioethics & Humanities, University of Washington, Seattle, Washington
| | - Taryn Lindhorst
- School of Social Work, University of Washington, Seattle, Washington
| | | | - Larry Mauksch
- Department of Family Medicine, School of Medicine, University of Washington, Seattle, Washington
| | - Ardith Doorenbos
- Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle, Washington
- Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, Washington
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Becker CL, Arnold RM, Park SY, Rosenzweig M, Smith TJ, White DB, Smith KJ, Schenker Y. A cluster randomized trial of a primary palliative care intervention (CONNECT) for patients with advanced cancer: Protocol and key design considerations. Contemp Clin Trials 2017; 54:98-104. [PMID: 28104470 PMCID: PMC5331884 DOI: 10.1016/j.cct.2017.01.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND The addition of specialty palliative care to standard oncology care improves outcomes for patients with advanced cancer and their caregivers, but many lack access to specialty care services. Primary palliative care-meaning basic palliative care services provided by clinicians who are not palliative care specialists-is an alternative approach that has not been rigorously evaluated. METHODS A cluster randomized, controlled trial of the CONNECT (Care management by Oncology Nurses to address supportive care needs) intervention, an oncology nurse-led care management approach to providing primary palliative care for patients with advanced cancer and their family caregivers, is currently underway at 16 oncology practices in Western Pennsylvania. Existing oncology nurses are trained to provide symptom management and emotional support, engage patients and families in advance care planning, and coordinate appropriate care using evidence-based care management strategies. The trial will assess the impact of CONNECT versus standard oncology care on patient quality of life (primary outcome), symptom burden, and mood; caregiver burden and mood; and healthcare resource use. DISCUSSION This trial addresses the need for more accessible models of palliative care by evaluating an intervention led by oncology nurses that can be widely disseminated in community oncology settings. The design confronts potential biases in palliative care research by randomizing at the practice level to avoid contamination, enrolling patients prior to informing them of group allocation, and conducting blinded outcome assessments. By collecting patient, caregiver, and healthcare utilization outcomes, the trial will enable understanding of the full range of a primary palliative care intervention's impact.
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Affiliation(s)
| | - Robert M Arnold
- Division of General Internal Medicine, University of Pittsburgh, United States
| | - Seo Young Park
- Division of General Internal Medicine, University of Pittsburgh, United States
| | | | - Thomas J Smith
- Johns Hopkins Medical Institutions, Sidney Kimmel Comprehensive Cancer Center, United States
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh, United States
| | - Kenneth J Smith
- Division of General Internal Medicine, University of Pittsburgh, United States
| | - Yael Schenker
- Division of General Internal Medicine, University of Pittsburgh, United States.
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Gidwani R, Nevedal A, Patel M, Blayney DW, Timko C, Ramchandran K, Kelly PA, Asch SM. The Appropriate Provision of Primary versus Specialist Palliative Care to Cancer Patients: Oncologists' Perspectives. J Palliat Med 2016; 20:395-403. [PMID: 27997278 DOI: 10.1089/jpm.2016.0399] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Many cancer patients do not receive recommended palliative care (PC). Oncologists' perspectives about PC have not been adequately described qualitatively and may explain some of the gaps in the delivery of PC. OBJECTIVE To characterize U.S. oncologists' perceptions of: primary and specialist PC; experiences interacting with PC specialists; and the optimal interface of PC and oncology in providing PC. DESIGN In-depth interviews with practicing oncologists. SETTING/SUBJECTS Oncologists working in: the general community, academic medical centers (AMC), and Veterans Health Administration. MEASUREMENTS Semistructured telephone interviews with 31 oncologists analyzed using matrix and thematic approaches. RESULTS Seven major themes emerged: PC was perceived as appropriate throughout the disease trajectory but due to resource constraints was largely provided at end of life; oncologists had three schools of thought on primary versus specialist PC; there was an under-availability of outpatient PC; poor communication about prognosis and care plans created tension between providers; PC was perceived as a "team of outsiders"; PC had too narrow a focus of care; and AMC-based PC evidence did not generalize to community practices. Oncologists noted three ways to improve the interface between oncologists and PC providers: a clear division of responsibility, in-person collaboration, and sharing of nonphysician palliative team members. CONCLUSIONS Oncologists in our sample were supportive of PC, but they reported obstacles related to care coordination and inpatient PC. Inpatient PC posed some unique challenges with respect to conflicting prognoses and care practices that would be mitigated through the increased availability and use of outpatient PC.
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Affiliation(s)
- Risha Gidwani
- 1 Health Economics Resource Center (HERC) , VA Palo Alto Health Care System, Palo Alto, California.,2 Center for Innovation to Implementation (Ci2i) , VA Palo Alto Health Care System, Palo Alto, California.,3 Division of General Medical Disciplines, Stanford University , Stanford, California
| | - Andrea Nevedal
- 2 Center for Innovation to Implementation (Ci2i) , VA Palo Alto Health Care System, Palo Alto, California
| | - Manali Patel
- 4 Division of Medical Oncology, Stanford University , Stanford, California.,5 VA Palo Alto Health Care System , Palo Alto, California
| | - Douglas W Blayney
- 4 Division of Medical Oncology, Stanford University , Stanford, California
| | - Christine Timko
- 2 Center for Innovation to Implementation (Ci2i) , VA Palo Alto Health Care System, Palo Alto, California.,6 Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine , Stanford, California
| | | | - P Adam Kelly
- 7 Southeast Louisiana Veterans Health Care System , New Orleans, Louisiana.,8 Tulane University School of Medicine , New Orleans, Louisiana
| | - Steven M Asch
- 2 Center for Innovation to Implementation (Ci2i) , VA Palo Alto Health Care System, Palo Alto, California.,3 Division of General Medical Disciplines, Stanford University , Stanford, California
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Waldfogel JM, Battle DJ, Rosen M, Knight L, Saiki CB, Nesbit SA, Cooper RS, Browner IS, Hoofring LH, Billing LS, Dy SM. Team Leadership and Cancer End-of-Life Decision Making. J Oncol Pract 2016; 12:1135-1140. [PMID: 27601512 DOI: 10.1200/jop.2016.013862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
End-of-life decision making in cancer can be a complicated process. Patients and families encounter multiple providers throughout their cancer care. When the efforts of these providers are not well coordinated in teams, opportunities for high-quality, longitudinal goals of care discussions can be missed. This article reviews the case of a 55-year-old man with lung cancer, illustrating the barriers and missed opportunities for end-of-life decision making in his care through the lens of team leadership, a key principle in the science of teams. The challenges demonstrated in this case reflect the importance of the four functions of team leadership: information search and structuring, information use in problem solving, managing personnel resources, and managing material resources. Engaging in shared leadership of these four functions can help care providers improve their interactions with patients and families concerning end-of-life care decision making. This shared leadership can also produce a cohesive care plan that benefits from the expertise of the range of available providers while reflecting patient needs and preferences. Clinicians and researchers should consider the roles of team leadership functions and shared leadership in improving patient care when developing and studying models of cancer care delivery.
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Sevilla-Sanchez D, Molist-Brunet N, Amblàs-Novellas J, Roura-Poch P, Espaulella-Panicot J, Codina-Jané C. Adverse drug events in patients with advanced chronic conditions who have a prognosis of limited life expectancy at hospital admission. Eur J Clin Pharmacol 2016; 73:79-89. [DOI: 10.1007/s00228-016-2136-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/21/2016] [Indexed: 12/20/2022]
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Affiliation(s)
- Susan C Miller
- Department of Health Services, Policy, and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health , Providence, Rhode Island
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Miller SC, Lima JC, Intrator O, Martin E, Bull J, Hanson LC. Palliative Care Consultations in Nursing Homes and Reductions in Acute Care Use and Potentially Burdensome End-of-Life Transitions. J Am Geriatr Soc 2016; 64:2280-2287. [PMID: 27641157 DOI: 10.1111/jgs.14469] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate how receipt and timing of nursing home (NH) palliative care consultations (primarily by nurse practitioners with palliative care expertise) are associated with end-of-life care transitions and acute care use DESIGN: Propensity score-matched retrospective cohort study. SETTING Forty-six NHs in two states. PARTICIPANTS Nursing home residents who died from 2006 to 2010 stratified according to days between initial consultation and death (≤7, 8-30, 31-60, 61-180). Propensity score matching identified three controls (n = 1,174) according to strata for each consultation recipient (n = 477). MEASUREMENTS Outcomes were hospitalizations in the last 7, 30, and 60 days of life; emergency department (ED) visits in the last 30 and 60 days; and any potentially burdensome care transition, defined as hospitalization or hospice admission within 3 days of death or two or more hospitalizations or ED visits within 30 days. Weighted multivariate logistic regression analyses were used to evaluate outcomes. RESULTS Residents with consultations had lower rates of hospitalization than controls, with rates lowest when initial consultations were furthest from death. For instance, in residents with initial consultations 8 to 30 days before death, the adjusted hospitalization rate in the last 7 days of life was 11.1% (95% confidence interval (CI) = 9.8-12.4%), vs 22.0% (95% CI = 20.6-23.4%) in controls, although in those with initial consultations 61 to 180 days before death, rates were 6.9% (95% CI = 5.5-8.4%), vs 22.9% (95% CI = 20.5-25.4%). Potentially burdensome transition rates were lower when consultations were 61 to 180 days before death (16.2%, 95% CI = 13.7-18.6%), vs 28.2% (95% CI = 25.8-30.6%) for controls. CONCLUSION Palliative care consultations improve end-of-life NH care by reducing acute care use and potentially burdensome care transitions.
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Affiliation(s)
- Susan C Miller
- Department of Health Services, Policy, & Practice, Brown University, Providence, Rhode Island.,Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island
| | - Julie C Lima
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York.,Geriatrics and Extended Care Data and Analyses Center, Canandaigua Veterans Administration Medical Center, Canandaigua, New York
| | - Edward Martin
- Department of Medicine, Brown University, Providence, Rhode Island.,Hope Hospice & Palliative Care, Providence, Rhode Island
| | | | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill, North Carolina.,Center for Aging and Health, University of North Carolina, Chapel Hill, North Carolina.,Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina
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49
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Kavalieratos D, Rollman BL, Arnold RM. Homeward Bound, not hospital rebound: how transitional palliative care can reduce readmission. Heart 2016; 102:1079-80. [PMID: 27067361 DOI: 10.1136/heartjnl-2016-309385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA Department of Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bruce L Rollman
- Department of Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA Center for Behavioral Health and Smart Technology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA Department of Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Abstract
A decade ago, "Nutrition Support and The Troubling Trichotomy: A Call To Action" was published in this journal, identifying existing conflicts among technological, ethical, and legal aspects of nutrition support therapy, particularly in terminal or end-of-life situations. Over the past 10 years, the American Society for Parenteral and Enteral Nutrition and others have responded to the action call. A "state of the trichotomy" reveals that while much has been achieved, differences in all 3 aspects will continue to exist due to their dynamic and ever-changing states. The technology arena has made it possible to increase the delivery of nutrition support in alternative settings with the use of telemedicine and social media. Critical/crucial conversations and earlier declarations of individual wishes for care and treatment while having decision-making capacity have been enhanced with the focus on patient-centered and family-centered care. The definition of death as brain death has been challenged in at least one instance. Conflicts between the state's interests and the individual's interests have added to recent legal controversies. Notwithstanding the progress made over the past 10 years, several challenges remain. The future challenges presented by the Troubling Trichotomy can be best confronted if we ACT-Accountability, Communication, and Teamwork. The focus of teamwork should move from multidisciplinary and interdisciplinary teams to transdisciplinary teams, reflecting the shift to function rather than form presented by the new healthcare environment. The transdisciplinary team will be able address the opportunities of the Troubling Trichotomy in the next decade by incorporating the 12 Cs, as detailed in the article.
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