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Kaufman BG, Woolson S, Stanwyck C, Burns M, Dennis P, Ma J, Feder S, Thorpe JM, Hastings SN, Bekelman DB, Van Houtven CH. Veterans' use of inpatient and outpatient palliative care: The national landscape. J Am Geriatr Soc 2024. [PMID: 39180221 DOI: 10.1111/jgs.19141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 07/12/2024] [Accepted: 07/23/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Palliative care improves the quality of life for people with life-limiting conditions, which are common among older adults. Despite the Veterans Health Administration (VA) outpatient palliative care expansion, most research has focused on inpatient palliative care. This study aimed to compare veteran characteristics and hospice use for palliative care users across care settings (inpatient vs. outpatient) and dose (number of palliative care encounters). METHODS This national cohort included veterans with any VA palliative care encounters from 2014 through 2017. We used VA and Medicare administrative data (2010-2017) to describe veteran demographics, socioeconomic status, life-limiting conditions, frailty, and palliative care utilization. Specialty palliative care encounters were identified using clinic stop codes (353, 351) and current procedural terminology codes (99241-99245). RESULTS Of 120,249 unique veterans with specialty palliative care over 4 years, 67.8% had palliative care only in the inpatient setting (n = 81,523) and 32.2% had at least one palliative care encounter in the outpatient setting (n = 38,726), with or without an inpatient palliative care encounter. Outpatient versus inpatient palliative care users were more likely to have cancer and less likely to have high frailty, but sociodemographic factors including rurality and housing instability were similar. Duration of hospice use was similar between inpatient (median = 37 days; IQR = 11, 112) and outpatient (median = 44 days; IQR = 14, 118) palliative care users, and shorter among those with only one palliative care encounter (median = 18 days; IQR = 5, 64). CONCLUSIONS This national evaluation provides novel insights into the care setting and dose of VA specialty palliative care for veterans. Among veterans with palliative care use, one-third received at least some palliative care in the outpatient care setting. Differences between veterans with inpatient and outpatient use motivate the need for further research to understand how care settings and number of palliative care encounters impact outcomes for veterans and older adults.
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Affiliation(s)
- Brystana G Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sandra Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Catherine Stanwyck
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Madison Burns
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Paul Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jessica Ma
- Geriatric Research, Education, and Clinical Center, Durham VA Health System, Durham, North Carolina, USA
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shelli Feder
- Yale University School of Nursing, Orange, Connecticut, USA
- West Haven Department of Veterans Affairs, West Haven, Connecticut, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health System, Durham, North Carolina, USA
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - David B Bekelman
- Department of Veterans Affairs, Department of Medicine, Eastern Colorado Health Care System, Aurora, Colorado, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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Lee MW, Vallejo A, Furey KB, Woll SM, Klar M, Roman LD, Wright JD, Matsuo K. Racial and ethnic differences in early death among gynecologic malignancy. Am J Obstet Gynecol 2024; 231:231.e1-231.e11. [PMID: 38460831 DOI: 10.1016/j.ajog.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Racial and ethnic differences in early death after cancer diagnosis have not been well studied in gynecologic malignancy. OBJECTIVE This study aimed to assess population-level trends and characteristics of early death among patients with gynecologic malignancy based on race and ethnicity in the United States. STUDY DESIGN The National Cancer Institute's Surveillance, Epidemiology, and End Results Program was queried to examine 461,300 patients with gynecologic malignancies from 2000 to 2020, including uterine (n=242,709), tubo-ovarian (n=119,989), cervical (n=68,768), vulvar (n=22,991), and vaginal (n=6843) cancers. Early death, defined as a mortality event within 2 months of the index cancer diagnosis, was evaluated per race and ethnicity. RESULTS At the cohort level, early death occurred in 21,569 patients (4.7%), including 10.5%, 5.5%, 2.9%, 2.5%, and 2.4% for tubo-ovarian, vaginal, cervical, uterine, and vulvar cancers, respectively (P<.001). In a race- and ethnicity-specific analysis, non-Hispanic Black patients with tubo-ovarian cancer had the highest early death rate (14.5%). Early death racial and ethnic differences were the largest in tubo-ovarian cancer (6.4% for Asian vs 14.5% for non-Hispanic Black), followed by uterine (1.6% for Asian vs 4.9% for non-Hispanic Black) and cervical (1.8% for Hispanic vs 3.8% to non-Hispanic Black) cancers (all, P<.001). In tubo-ovarian cancer, the early death rate decreased over time by 33% in non-Hispanic Black patients from 17.4% to 11.8% (adjusted odds ratio, 0.67; 95% confidence interval, 0.53-0.85) and 23% in non-Hispanic White patients from 12.3% to 9.5% (adjusted odds ratio, 0.77; 95% confidence interval, 0.71-0.85), respectively. The early death between-group difference diminished only modestly (12.3% vs 17.4% for 2000-2002 [adjusted odds ratio for non-Hispanic White vs non-Hispanic Black, 0.54; 95% confidence interval, 0.45-0.65] and 9.5% vs 11.8% for 2018-2020 [adjusted odds ratio, 0.65; 95% confidence interval, 0.54-0.78]). CONCLUSION Overall, approximately 5% of patients with gynecologic malignancy died within the first 2 months from cancer diagnosis, and the early death rate exceeded 10% in non-Hispanic Black individuals with tubo-ovarian cancer. Although improving early death rates is encouraging, the difference among racial and ethnic groups remains significant, calling for further evaluation.
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Affiliation(s)
- Matthew W Lee
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Andrew Vallejo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Katelyn B Furey
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Sabrina M Woll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
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Volberg C, Schönfeld PN, Krönig L, Hertl M, Gschnell M. Palliativversorgung in der Dermatoonkologie – Aktuelle Praxis in deutschen zertifizierten Hautkrebszentren und dermatoonkologischen Schwerpunktpraxen. J Dtsch Dermatol Ges 2024; 22:1106-1114. [PMID: 39105230 DOI: 10.1111/ddg.15439_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 03/26/2024] [Indexed: 08/07/2024]
Abstract
ZusammenfassungHintergründeDermatoonkologische Patienten werden häufig in zertifizierten Hautkrebszentren oder dermatoonkologischen Schwerpunktpraxen betreut. Insbesondere in höheren Tumorstadien entwickeln Patienten krankheitsbedingt oder als Nebenwirkung der Therapien Symptome, die behandlungsbedürftig sind. Bei fortschreitender Erkrankung bedarf es trotz deutlich verbesserter Prognose seit Einführung der zielgerichteten und Immuntherapien einer vorausschauenden Vorsorgeplanung. Unklar ist, wie die Palliativversorgung von Hautkrebspatienten in der Dermatoonkologie aktuell organisiert wird.Patienten und MethodikIn einer deutschlandweiten Befragung wurden alle zertifizierten Hautkrebszentren und dermatoonkologischen Schwerpunktpraxen angeschrieben und um Teilnahme an der anonymisierten Befragung gebeten.ErgebnisseInsgesamt gingen 45 Antworten (42%) ein. Der Großteil (98%) der Befragten screent Patienten regelhaft auf belastende Symptome und alle Zentren haben auch eine Anbindung an eine palliativmedizinische Versorgungsstruktur. Es wurde angegeben, dass lediglich 5% der ärztlichen Mitarbeiter die Zusatzqualifikation „Palliativmedizin“ führen. Bei 68% der teilnehmenden Institutionen wird den Patienten die Möglichkeit einer Vorsorgeplanung angeboten. Für 89% ist Palliativmedizin relevant für die tägliche Arbeit, und 82% wünschen sich hierzu mehr Fortbildungsmöglichkeiten.SchlussfolgerungenMit der Erhebung kann dargestellt werden, dass die palliativmedizinische Versorgung einen wichtigen Stellenwert in der dermatoonkologischen Arbeit hat. Da jedoch nur ein geringer Anteil der Mitarbeitenden eine Weiterbildung in Palliativmedizin besitzt, wäre es für die umfassende Versorgung wünschenswert, wenn dieser Anteil größer würde.
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Affiliation(s)
- Christian Volberg
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg
- AG Ethik in der Medizin, Dekanat Humanmedizin, Philipps-Universität Marburg
| | - Philip Niklas Schönfeld
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Marburg, Philipps-Universität Marburg
| | - Lisa Krönig
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Marburg, Philipps-Universität Marburg
| | - Michael Hertl
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Marburg, Philipps-Universität Marburg
| | - Martin Gschnell
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Marburg, Philipps-Universität Marburg
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Volberg C, Schönfeld PN, Krönig L, Hertl M, Gschnell M. Palliative care in dermatooncology - Current practice in German dermatooncological centers and specialist offices. J Dtsch Dermatol Ges 2024; 22:1106-1113. [PMID: 38965657 DOI: 10.1111/ddg.15439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 03/26/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Dermato-oncology patients are often treated in certified skin cancer centers or dermato-oncological specialist offices. Especially in higher tumor stages, patients develop symptoms, either disease-related or due to therapy-related side effects, requiring treatment. Despite a markedly improved prognosis since the introduction of targeted therapies and immunotherapies, advance care planning is required in progressive disease. It is unclear how palliative care of skin cancer patients is currently organized in dermato-oncology. PATIENTS AND METHODS In a nationwide survey, all certified skin cancer centers and dermato-oncological specialist offices in Germany were contacted and asked to participate in this anonymized survey. RESULTS Overall, 45 responses (42%) were received. The majority (98%) of the respondents screen the patients on a regular basis for distressing symptoms, and all centers are connected to palliative medical care providers. Only 5% of the medical staff members have the additional qualification "palliative medicine". In 68% of the participating institutions, the opportunity for care planning is offered to patients. For 89%, palliative care is relevant for everyday work, and 82% desire more research opportunities on this topic. CONCLUSIONS This survey has shown that palliative care plays a major role in dermato-oncological work. Given that only a small proportion of the staff have received specialized training in palliative care, however, an increase of this proportion would be desirable for comprehensive care.
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Affiliation(s)
- Christian Volberg
- Department of Anesthesia and Critical Care, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
- Research Group Medical Ethics, Department of Human Medicine, Philipps University Marburg, Marburg, Germany
| | - Philip Niklas Schönfeld
- Department of Dermatology and Allergology, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
| | - Lisa Krönig
- Department of Dermatology and Allergology, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
| | - Martin Gschnell
- Department of Dermatology and Allergology, University Hospital Marburg, Philipps University Marburg, Marburg, Germany
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Boire A, Burke K, Cox TR, Guise T, Jamal-Hanjani M, Janowitz T, Kaplan R, Lee R, Swanton C, Vander Heiden MG, Sahai E. Why do patients with cancer die? Nat Rev Cancer 2024; 24:578-589. [PMID: 38898221 PMCID: PMC7616303 DOI: 10.1038/s41568-024-00708-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
Cancer is a major cause of global mortality, both in affluent countries and increasingly in developing nations. Many patients with cancer experience reduced life expectancy and have metastatic disease at the time of death. However, the more precise causes of mortality and patient deterioration before death remain poorly understood. This scarcity of information, particularly the lack of mechanistic insights, presents a challenge for the development of novel treatment strategies to improve the quality of, and potentially extend, life for patients with late-stage cancer. In addition, earlier deployment of existing strategies to prolong quality of life is highly desirable. In this Roadmap, we review the proximal causes of mortality in patients with cancer and discuss current knowledge about the interconnections between mechanisms that contribute to mortality, before finally proposing new and improved avenues for data collection, research and the development of treatment strategies that may improve quality of life for patients.
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Affiliation(s)
- Adrienne Boire
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katy Burke
- University College London Hospitals NHS Foundation Trust and Central and North West London NHS Foundation Trust Palliative Care Team, London, UK
| | - Thomas R Cox
- Cancer Ecosystems Program, The Garvan Institute of Medical Research and The Kinghorn Cancer Centre, Darlinghurst, New South Wales, Australia.
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, UNSW Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.
| | - Theresa Guise
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariam Jamal-Hanjani
- Cancer Metastasis Laboratory, University College London Cancer Institute, London, UK
- Department of Oncology, University College London Hospitals, London, UK
- Cancer Research UK Lung Centre of Excellence, University College London Cancer Institute, London, UK
| | - Tobias Janowitz
- Cold Spring Harbour Laboratory, Cold Spring Harbour, New York, NY, USA
- Northwell Health Cancer Institute, New York, NY, USA
| | - Rosandra Kaplan
- Paediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rebecca Lee
- Tumour Cell Biology Laboratory, The Francis Crick Institute, London, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Charles Swanton
- Department of Oncology, University College London Hospitals, London, UK
- Cancer Research UK Lung Centre of Excellence, University College London Cancer Institute, London, UK
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London, UK
| | - Matthew G Vander Heiden
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Erik Sahai
- Tumour Cell Biology Laboratory, The Francis Crick Institute, London, UK.
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Oswalt CJ, Nakatani MM, Troy J, Wolf S, Locke SC, LeBlanc TW. Timing of Palliative Care Consultation Impacts End of Life Care Outcomes in Metastatic Non-Small Cell Lung Cancer. J Pain Symptom Manage 2024:S0885-3924(24)00858-3. [PMID: 39002711 DOI: 10.1016/j.jpainsymman.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 07/15/2024]
Abstract
CONTEXT Early specialist palliative care (PC) involvement in metastatic non-small cell lung cancer (mNSCLC) is associated with improved quality of life, less aggressive end of life (EoL) care, and longer survival. As treatment paradigms for NSCLC have evolved, PC utilization remains low. OBJECTIVES This work examines how the timing and extent of PC involvement impacts outcomes and the patient experience in mNSCLC in the era of immunotherapy. METHODS This retrospective review analyzed patients with mNSCLC who initiated first-line treatment with chemotherapy, immunotherapy, or combined chemoimmunotherapy at Duke University between March 2015 and July 2019. PC consultation and outcomes data were abstracted through November 2022. EoL care variables were analyzed using descriptive statistics. RESULTS 152 patients were stratified based on whether PC was consulted during their disease course. 80 patients (53%) never saw PC, while the 72 patients (47%) who saw PC were further stratified by time to first PC encounter and total number of PC visits. 31% were seen within two months of diagnosis (early), 33% between two and six months (intermediate), and 36% after 6 months (late). Patients who received early PC had longer median time on hospice (35 days), had lower rates of aggressive EoL care (43%), and experienced less frequent in-hospital death (14%) compared to other groups. CONCLUSION This real-world study reveals that referrals to PC still occur late or not at all in mNSCLC despite demonstrated benefits of early PC integration. Early outpatient PC referrals resulted in longer time on hospice, lower frequency of aggressive EoL care, and lower rates of in-hospital death.
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Affiliation(s)
- Cameron J Oswalt
- Duke Cancer Institute (C.J.O., S.C.L., T.W.L.B.,), Durham, North Carolina, USA.
| | - Morgan M Nakatani
- Medicine-Psychiatry Resident (M.M.N.), Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jesse Troy
- Department of Biostatistics and Bioinformatics (J.T., S.W.), Division of Biostatistics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Steven Wolf
- Department of Biostatistics and Bioinformatics (J.T., S.W.), Division of Biostatistics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan C Locke
- Duke Cancer Institute (C.J.O., S.C.L., T.W.L.B.,), Durham, North Carolina, USA
| | - Thomas W LeBlanc
- Duke Cancer Institute (C.J.O., S.C.L., T.W.L.B.,), Durham, North Carolina, USA
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Yoon W, Chen S, Gao Y, Zhao Z, Dligach D, Bitterman DS, Afshar M, Miller T. LCD Benchmark: Long Clinical Document Benchmark on Mortality Prediction for Language Models. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.26.24304920. [PMID: 38585973 PMCID: PMC10996733 DOI: 10.1101/2024.03.26.24304920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Objective The application of Natural Language Processing (NLP) in the clinical domain is important due to the rich unstructured information in clinical documents, which often remains inaccessible in structured data. When applying NLP methods to a certain domain, the role of benchmark datasets is crucial as benchmark datasets not only guide the selection of best-performing models but also enable the assessment of the reliability of the generated outputs. Despite the recent availability of language models (LMs) capable of longer context, benchmark datasets targeting long clinical document classification tasks are absent. Materials and Methods To address this issue, we propose LCD benchmark, a benchmark for the task of predicting 30-day out-of-hospital mortality using discharge notes of MIMIC-IV and statewide death data. We evaluated this benchmark dataset using baseline models, from bag-of-words and CNN to instruction-tuned large language models. Additionally, we provide a comprehensive analysis of the model outputs, including manual review and visualization of model weights, to offer insights into their predictive capabilities and limitations. Results and Discussion Baseline models showed 28.9% for best-performing supervised models and 32.2% for GPT-4 in F1-metrics. Notes in our dataset have a median word count of 1687. Our analysis of the model outputs showed that our dataset is challenging for both models and human experts, but the models can find meaningful signals from the text. Conclusion We expect our LCD benchmark to be a resource for the development of advanced supervised models, or prompting methods, tailored for clinical text. The benchmark dataset is available at https://github.com/Machine-Learning-for-Medical-Language/long-clinical-doc.
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Patel MI, Agrawal M, Blayney DW, Bundorf MK, Milstein A. Long-Term Engagement of Patients With Advanced Cancer: Results From the EPAC Randomized Clinical Trial. JAMA Oncol 2024; 10:905-911. [PMID: 38814627 PMCID: PMC11140577 DOI: 10.1001/jamaoncol.2024.1221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/22/2023] [Indexed: 05/31/2024]
Abstract
Importance The long-term effect of interventions that assist patients with establishing their end-of-life care preferences among patients with cancer remain relatively unknown. Objective To evaluate the association of a long-term intervention of a lay health worker-led advance care planning intervention among patients with advanced stages of cancer with overall survival and end-of-life health care use and costs. Design, Setting, and Participants This follow-up study of the EPAC randomized clinical trial conducted between August 2013 and February 2015 used data from 9.4 years after the first patient was enrolled with a data cut-off date of February 1, 2023. Overall, 213 participants with stage 3 or 4 or recurrent cancer in the US Veterans Affairs Palo Alto Health Care System were included. Interventions A 6-month lay health worker-led education and support intervention to assist patients with establishing their end-of-life preferences vs usual care. Main Outcomes and Measures The outcomes of interest were overall survival, risk of death, restricted mean survival time, and palliative care, hospice, and acute care use in the final 30 days before death for participants who died. Results Among 213 participants randomized and included in the intention-to-treat analysis, the mean (SD) age was 69.3 (9.1) years; 211 (99.1%) were male, 2 (0.90%) were female. There were no demographic or clinical characteristic imbalances at enrollment. As of February 1, 2023, 188 had died. The intervention group had a 25% reduction in risk of death (hazard ratio, 0.75; 95% CI, 0.56-0.98); more palliative care (44 [50.0%] vs 35 [35.0%]) and hospice use (64 [72.7%] vs 53 [53.0%]); and lower emergency department use (20 [22.7%] vs 47 [47.0%]), hospitalizations (17 [19.3%] vs 46 [46.0%]), and median (IQR) total health care costs (median [IQR], $1637 [$383-$9026] vs $18 520 [$4790-$50 729]) than control group participants. Conclusions and Relevance The effects of the lay health worker-led intervention remain durable, with nearly complete follow-up, supporting integration into routine cancer care. Trial Registration ClinicalTrials.gov Identifier: NCT02966509.
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Affiliation(s)
- Manali I. Patel
- Department of Medicine, Stanford University School of Medicine, Stanford, California
- VA Palo Alto Health Care System, Palo Alto, California
| | | | - Douglas W. Blayney
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Arnold Milstein
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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Bernacki R, Periyakoil VS. Best Practices in Caring for Seriously Ill Patients. Ann Intern Med 2024; 177:ITC97-ITC112. [PMID: 38976884 DOI: 10.7326/aitc202407160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2024] Open
Abstract
Palliative care (PC) is the art and science of providing goal-concordant care, skillfully managing complex and refractory pain and nonpain symptoms, mitigating suffering, and augmenting quality of life for seriously ill patients throughout the course of the illness trajectory. The primary team should provide generalist PC for all seriously ill patients and know when to refer patients to specialist PC. Specialty-level PC services should be reserved for complex problems beyond the scope of primary PC. This article reviews principles and best practices to support patient-centered PC.
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Affiliation(s)
- Rachelle Bernacki
- Harvard Medical School and Dana-Farber Cancer Institute, Boston, Massachusetts (R.B.)
| | - Vyjeyanthi S Periyakoil
- Stanford University School of Medicine, Stanford, California, and VA Palo Alto Health Care System, Palo Alto, California (V.S.P.)
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10
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Wong AKY, Wang D, Gordon I, Alexander M, Siew B, Yap N, Le B, Philip J. Opioid initiation timing and palliative care referrals in advanced cancer: retrospective study. BMJ Support Palliat Care 2024:spcare-2024-005028. [PMID: 38918048 DOI: 10.1136/spcare-2024-005028] [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: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 06/27/2024]
Abstract
OBJECTIVES Early opioid initiation is recommended for advanced cancer pain, however the timing of opioid commencement in relation to diagnosis has not been described, and the role of palliative care prescribers is unclear. This study aims to determine the timing of opioid initiation by prescriber and cancer type in relation to key timepoints in the cancer illness course (diagnosis, palliative care referral and death). METHODS This retrospective cohort study included patients at a quaternary cancer centre with incurable advanced cancer of five different subtype groups. Demographics, clinical characteristics, health service use and details of first slow and immediate release opioid prescription are reported. RESULTS Among 200 patients, median time to first immediate release opioid prescription was 23 days (IQR 1-82) and to slow release opioid prescription was 47 days (IQR 14-155). Most patients (95%, (n=190) were referred to palliative care (median time to referral 54 days (IQR 18-190)). Non-palliative care prescribers initiated slow release opioids for half the cohort (49%, n=97) prior to referral. Patients with pancreatic cancer had the shortest time to slow/immediate release opioid prescription (median 10 days (IQR 0-39) and 26 days (IQR 1-43) respectively) and shortest survival (median 136 days (IQR 82-214)). CONCLUSIONS Median time to opioid commencement was approximately 3 weeks after diagnosis. Despite early palliative care involvement, opioid initiation by non-palliative care clinicians was common and remains important. Timely palliative care referral for those with pancreatic cancer may include consideration of earlier complex pain presentations and shorter prognosis.
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Affiliation(s)
- Aaron Kee Yee Wong
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Dorothy Wang
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ian Gordon
- Statistical Consulting Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Marliese Alexander
- Pharmacy Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Beverly Siew
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Natasha Yap
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Brian Le
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jennifer Philip
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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11
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Freeman JQ, Omoleye OJ, Zhao F, Huo D. Palliative Care Use Trends, Racial/Ethnic Disparities, and Overall Survival Differences Among Patients With Metastatic Breast Cancer. J Palliat Med 2024; 27:763-775. [PMID: 38301120 PMCID: PMC11301711 DOI: 10.1089/jpm.2023.0547] [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: 01/08/2024] [Indexed: 02/03/2024] Open
Abstract
Background: Palliative care improves cancer patients' quality of life. Limited research has investigated racial/ethnic disparities in palliative care utilization and its associated survival among metastatic breast cancer (MBC) patients. Objectives: To examine racial/ethnic palliative care use disparities and assess racial/ethnic overall survival differences in MBC patients stratified by palliative care use. Design: A retrospective study of MBC patients from the 2004-2020 National Cancer Database. Measurements: Palliative care was defined as noncurative cancer treatment, including surgery, radiotherapy, systemic therapy, and/or pain management; utilization was coded "yes/no." Racial/ethnic groups included Asian, American Indian or Alaska Native (AIAN), Black, Hawaiian or Other Pacific Islander (HPI), Hispanic, and White. Logistic regression was performed to assess palliative care use disparities. Overall survival was modeled using Cox regression. Results: Of 148,931 patients, the mean age was 62 years; 99% were female; 73% identified as White, 17% as Black, 6% as Hispanic, 3% as Asian, 0.3% as AIAN, and 0.3% as HPI; 42% and 39% had Medicare and private insurance, respectively. Overall, 21% used palliative care, with an increasing utilization rate from 2004 to 2020 (3.6% increase per year, p-trend <0.001). Black (adjusted odds ratio [aOR] = 0.89; 95% confidence interval [CI]: 0.84 to 0.94), Asian (aOR = 0.76; 95% CI: 0.68 to 0.86), and Hispanic (aOR = 0.68; 95% CI: 0.62 to 0.74) patients had a lower likelihood of palliative care utilization than White patients. Among palliative care users, compared with White patients, Black (adjusted hazard ratio [aHR] = 1.14, 95% CI: 1.07 to 1.21) patients had a greater mortality risk, while Asian (aHR = 0.83, 95% CI: 0.71 to 0.97) and Hispanic (aHR = 0.77, 95% CI: 0.69 to 0.87) patients had a lower mortality risk. Conclusions: Palliative care utilization among MBC patients significantly increased but remained suboptimal. Racial/ethnic minority patients were less likely to use palliative care, and Black patients had worse survival, than White patients, suggesting the need for improving palliative care access and ameliorating disparities in MBC patients.
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Affiliation(s)
- Jincong Q. Freeman
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois, USA
- Center for Health and the Social Sciences, The University of Chicago, Chicago, Illinois, USA
- Cancer Prevention and Control Research Program, UChicago Medicine Comprehensive Cancer Center, Chicago, Illinois, USA
| | - Olasubomi J. Omoleye
- Center for Clinical Cancer Genetics and Global Health, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Fangyuan Zhao
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois, USA
| | - Dezheng Huo
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois, USA
- Cancer Prevention and Control Research Program, UChicago Medicine Comprehensive Cancer Center, Chicago, Illinois, USA
- Center for Clinical Cancer Genetics and Global Health, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
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12
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Chen TC, Wang SH, Ho CM, Lin HC, Tung CL, Chang CC, Tsai CF, Chen TH, Fang YC, Lin WT, Lee YT, Chang YS, Lee MY. Effectiveness of early palliative care in patients with head and neck cancer in Taiwan. J Chin Med Assoc 2024; 87:643-652. [PMID: 38838200 DOI: 10.1097/jcma.0000000000001104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Early palliative care (EPC) benefits some cancers, but its clinical outcomes differ depending on patients' racial and ethnic disparities, and customs. To determine whether EPC improves symptoms, emotional distress, and quality of life among Taiwanese patients with early or advanced-stage head and neck cancer (HNC). METHODS Based on participants' pathological stages, they were categorized as having early and advanced-stage HNC. Those willing and unwilling to undergo EPC were assigned to the EPC and standard groups, respectively. Their daily cancer-related symptoms were assessed using the Distress Thermometer (DT) and MD Anderson Symptom Inventory (MDASI), whose scores' concurrent validity was evaluated using the European Organization for Research and Treatment of Core Quality of Life (EORTC-QLQ-C30) and Head and Neck 35 (EORTC-QLQ-H&N35) questionnaires. RESULTS Patients (n = 93) diagnosed with HNC at Taiwan's Chia-Yi Christian Hospital from November 2020 to October 2022 were recruited. The patients voluntarily split into two groups: EPC groups and standard groups (23 and 11 in early-stage; 46 and 13 in advanced-stage, respectively). DT assessment showed significant emotional distress improvements for all patients with HNC who received EPC. The EORTC-QLQ-C30 questionnaire indicated that, compared to standard interventions, EPC groups significantly improved the quality of life and some symptoms for both early and advanced-stage HNC patients. However, the EORTC-QLQ-H&N35 questionnaire found no significant difference between the two groups. Furthermore, advanced-stage patients' anticancer treatment completion rates with EPC and standard interventions were 95.35% and 75%, respectively. CONCLUSION EPC improves symptoms, emotional distress, quality of life, and treatment completion rates in Taiwanese patients with early or advanced-stage HNC. Nonetheless, further extensive clinical studies are required for validation.
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Affiliation(s)
- Tzu-Chun Chen
- Cancer Center, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
- Min-Hwei Junior College of Health Care Management, Tainan, Taiwan, ROC
| | - Shih-Hao Wang
- Department of Otolaryngology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
- Department of otolaryngology, St. Martin De Porres Hospital, Chiayi, Taiwan, ROC
| | - Cho-Ming Ho
- Department of Oral and Maxillofacial Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
| | - Hwan-Chung Lin
- Department of Oral and Maxillofacial Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
| | - Chun-Liang Tung
- Department of Oral and Maxillofacial Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
| | - Chih-Chia Chang
- Department of Radiation Therapy and Oncology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
| | - Ching-Fang Tsai
- Department of Medical Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
| | - Tsung-Hsien Chen
- Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
| | - Yi-Chun Fang
- Cancer Center, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
| | - Wei-Ting Lin
- Department of Oral and Maxillofacial Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
| | - Yu-Ting Lee
- Department of Internal Medicine, Division of Hemato-Oncology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
| | - Yu-Sung Chang
- Department of Otolaryngology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
| | - Ming-Yang Lee
- Min-Hwei Junior College of Health Care Management, Tainan, Taiwan, ROC
- Department of Internal Medicine, Division of Hemato-Oncology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan, ROC
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13
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Sullivan DR, Jones KF, Wachterman MW, Griffin HL, Kinder D, Smith D, Thorpe J, Feder SL, Ersek M, Kutney-Lee A. Opportunities to Improve End-of-Life Care Quality among Patients with Short Terminal Admissions. J Pain Symptom Manage 2024:S0885-3924(24)00789-9. [PMID: 38810950 DOI: 10.1016/j.jpainsymman.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Abstract
CONTEXT Little is known about Veterans who die during a short terminal admission, which renders them ineligible for the Department of Veterans Affairs (VA) Bereaved Family Survey. OBJECTIVES We sought to describe this population and identify opportunities to improve end-of-life (EOL) care quality. METHODS Retrospective, cohort analysis of Veteran decedents who died in a VA inpatient setting between October 2018-September 2019. Veterans were dichotomized by short (<24 hours) and long (≥24 hours) terminal admissions; sociodemographics, clinical characteristics, VA and non-VA healthcare use, and EOL care quality indicators were compared. RESULTS Among 17,033 inpatient decedents, 723 (4%) had short terminal admissions. Patients with short compared to long terminal admissions were less likely to have a VA hospitalization (38% vs. 54%) in the last 90 days of life and were more likely to die in an intensive care (49% vs 21%) or acute care (27% vs 18%) unit. Patients with a short compared to long admission were about half as likely to receive hospice (33% vs 64%) or palliative care (33% vs 69%). Most patients with short admissions (76%) had a life-limiting condition (e.g., cancer, chronic obstructive pulmonary disease) and those with cancer were more likely to receive palliative care compared to those with non-cancer conditions. CONCLUSION Veterans with short terminal admissions are less likely to receive hospice or palliative care compared to patients with long terminal admissions. Many patients with short terminal admissions, such as those with life-limiting conditions (especially cancer), receive aspects of high-quality EOL care, however, opportunities for improvement exist.
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Affiliation(s)
- Donald R Sullivan
- Department of Medicine (D.R.S.), Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland Oregon, USA; Center to Improve Veteran Involvement in Care (D.R.S.), Portland Veteran Affairs Healthcare System, Portland Oregon, USA.
| | - Katie F Jones
- New England Geriatric Research Education and Clinical Center (K.F.J.), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA; Department of Medicine (K.F.J.), Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa W Wachterman
- Section of General Internal Medicine (M.W.), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA; Division of General Internal Medicine (M.W.), Brigham and Women's Hospital, Boston MA, USA; Department of Psychosocial Oncology and Palliative Care (M.W.), Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Hilary L Griffin
- Veteran Experience Center (H.G., D.K., D.G., M.E., A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Daniel Kinder
- Veteran Experience Center (H.G., D.K., D.G., M.E., A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Dawn Smith
- Veteran Experience Center (H.G., D.K., D.G., M.E., A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua Thorpe
- Center for Health Equity Research and Promotion (J.M.T.), Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania, USA; University of North Carolina School of Pharmacy (J.M.T.), Chapel Hill, North Carolina, USA
| | - Shelli L Feder
- Yale University School of Nursing (S.L.F.), Orange, Connecticut, USA; West Haven Department of Veterans Affairs (S.L.F.), West Haven, Connecticut, USA
| | - Mary Ersek
- Veteran Experience Center (H.G., D.K., D.G., M.E., A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA; Leonard Davis Institute (M.E.), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ann Kutney-Lee
- Veteran Experience Center (H.G., D.K., D.G., M.E., A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA; Center for Health Equity and Research Promotion (A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania (A.K.L.), School of Nursing, Philadelphia, Pennsylvania, USA
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14
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Olafimihan A, Jackson I, Nwachukwu C, Ozogbo S, Oh Y, George L, Fawehinmi P, Abdullahi A, Mullane M. Trends, Sociodemographic and Hospital-Level Factors Associated with Palliative Care Utilization Among Metastatic Prostate Cancer Patients. Am J Hosp Palliat Care 2024:10499091241256627. [PMID: 38780478 DOI: 10.1177/10499091241256627] [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: 05/25/2024] Open
Abstract
Background: Several factors are reported to be associated with palliative care utilization among patients with various cancers, but literature is lacking on metastatic prostate cancer (MPC) specific factors. Early integration of palliative care in management of MPC patients could increase their quality of life and overall outcomes. Methods: Retrospective longitudinal analyses were conducted using the National Inpatient Sample (NIS) data (2010 - 2019). Prevalence trends in palliative care utilization were assessed, and sociodemographic and hospital-level factors associated with palliative care utilization in MPC patients were examined. Results: The overall prevalence of palliative care utilization was 13.1% with an increasing trend from 8490 to 15,231 per 100,000 MPC admissions (p-trend <.001). MPC patients aged 65 years and above had similar odds of receiving palliative care compared to younger patients. Relative to non-Hispanic Whites, other racial groups had similar likelihood to utilize palliative care services. Patients in higher median household national income quartiles had greater odds of utilizing palliative care relative to those in the first income quartile. Patients on Medicaid, private insurance and other insurance types had greater odds of palliative care use in comparison to those on Medicare. Other factors identified were hospital region, location and teaching status, patient disposition, admission type, length of stay, and number of comorbidities. Conclusion: Our findings underscore the significance of enhanced government policies and institutional support in improving palliative care use among hospitalized MPC patients. Health systems must be proactive in addressing barriers to optimization of palliative care utilization in this population.
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Affiliation(s)
- Ayobami Olafimihan
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Inimfon Jackson
- Department of Hematology Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chiamaka Nwachukwu
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Stanley Ozogbo
- Department of Internal Medicine, St Elizabeth Hospital, Youngstown, OH, USA
| | - Youjin Oh
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Lina George
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Praise Fawehinmi
- Department of Pharmaceutical Sciences, Southern Illinois University Edwardsville, IL, USA
| | - Abubakar Abdullahi
- Department of Internal Medicine, Federal Medical Centre, Bida, Niger, Nigeria
| | - Michael Mullane
- Department of Hematology and Oncology, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
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15
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Wang SE, Gozansky WS, Steiner C, Lee JS, Nguyen A, Shen E, Martel H, Mangels DB, Sterett AT, Zalavadia R, Hou N, Nguyen HQ. Association Between Intensity and Timing of Specialty Palliative Care and Hospice Exposure With Quality of End-of-Life Care. J Palliat Med 2024; 27:602-613. [PMID: 38483344 DOI: 10.1089/jpm.2023.0407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
Background: Gaps remain in our understanding of the intensity and timing of specialty palliative care (SPC) exposure on end-of-life (EOL) outcomes. Objective: Examine the association between intensity and timing of SPC and hospice (HO) exposure on EOL care outcomes. Design, Settings, Participants: Data for this cohort study were drawn from 2021 adult decedents from Kaiser Permanente Southern California and Colorado (n = 26,251). Caregivers of a decedent subgroup completed a postdeath care experience survey from July to August 2022 (n = 424). Measurements: SPC intensity (inpatient, outpatient, and home-based) and HO exposure in the five years before death were categorized as: (1) No SPC or HO; (2) SPC-only; (3) HO-only; and (4) SPC-HO. Timing of SPC exposure (<90 or 90+ days) before death was stratified by HO enrollment. Death in the hospital and potentially burdensome treatments in the last 14 days of life were extracted from electronic medical records (EMRs) and claims. EOL care experience was obtained from the caregiver survey. Results: Among the EMR cohort, exposure to SPC and HO were: No SPC or HO (38%), SPC-only (14%; of whom, 55% received inpatient SPC only), HO-only (20%), and SPC-HO (28%). For decedents who did not enroll in HO, exposure to SPC 90+ days versus <90 days before death was associated with lower risk of receiving potentially burdensome treatments (adjusted relative risk, aRR: 0.69 [95% confidence interval, CI: 0.62-0.76], p < 0.001) and 23% lower risk of dying in the hospital (aRR: 0.77 [95% CI: 0.73-0.81], p < 0.001). Caregivers of patients in the HO-only (aRR: 1.27 [95% CI: 0.98-1.63], p = 0.07) and SPC-HO cohorts (aRR: 1.19 [95% CI: 0.93-1.52], p = 0.18) tended to report more positive care experience compared to the no SPC or HO cohort. Conclusion: Earlier exposure to SPC was important in reducing potentially burdensome treatments and death in the hospital for decedents who did not enroll in HO. Increasing availability and access to community-based SPC is needed.
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Affiliation(s)
- Susan E Wang
- The Permanente Federation, Oakland, California, USA
| | - Wendolyn S Gozansky
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
- Colorado Permanente Medical Group, Denver, Colorado, USA
| | - Claudia Steiner
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
- Colorado Permanente Medical Group, Denver, Colorado, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Janet S Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - AnMarie Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Helene Martel
- Kaiser Permanente Care Management Institute, Oakland, California, USA
| | - Diana B Mangels
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
| | - Andrew T Sterett
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
| | - Ravi Zalavadia
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
| | - Nanjiang Hou
- Kaiser Permanente Care Management Institute, Oakland, California, USA
| | - Huong Q Nguyen
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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16
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Moghanaki D, Taylor J, Bryant AK, Vitzthum LK, Sebastian N, Gutman D, Burns A, Huang Z, Lewis JA, Spalluto LB, Williams CD, Sullivan DR, Slatore CG, Behera M, Stokes WA. Lung Cancer Survival Trends in the Veterans Health Administration. Clin Lung Cancer 2024; 25:225-232. [PMID: 38553325 PMCID: PMC11098707 DOI: 10.1016/j.cllc.2024.02.009] [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] [Received: 12/04/2023] [Revised: 02/14/2024] [Accepted: 02/29/2024] [Indexed: 04/09/2024]
Abstract
INTRODUCTION Lung cancer survival is improving in the United States. We investigated whether there was a similar trend within the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States. MATERIALS AND METHODS Data from the Veterans Affairs Central Cancer Registry were analyzed for temporal survival trends using Kaplan-Meier estimates and linear regression. RESULTS A total number of 54,922 Veterans were identified with lung cancer diagnosed from 2010 to 2017. Histologies were classified as non-small-cell lung cancer (NSCLC) (64.2%), small cell lung cancer (SCLC) (12.9%), and 'other' (22.9%). The proportion with stage I increased from 18.1% to 30.4%, while stage IV decreased from 38.9% to 34.6% (both P < .001). The 3-year overall survival (OS) improved for stage I (58.6% to 68.4%, P < .001), stage II (35.5% to 48.4%, P < .001), stage III (18.7% to 29.4%, P < .001), and stage IV (3.4% to 7.8%, P < .001). For NSCLC, the median OS increased from 12 to 21 months (P < .001), and the 3-year OS increased from 24.1% to 38.3% (P < .001). For SCLC, the median OS remained unchanged (8 to 9 months, P = .10), while the 3-year OS increased from 9.1% to 12.3% (P = .014). Compared to White Veterans, Black Veterans with NSCLC had similar OS (P = .81), and those with SCLC had higher OS (P = .003). CONCLUSION Lung cancer survival is improving within the VHA. Compared to White Veterans, Black Veterans had similar or higher survival rates. The observed racial equity in outcomes within a geographically and socioeconomically diverse population warrants further investigation to better understand and replicate this achievement in other healthcare systems.
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Affiliation(s)
- Drew Moghanaki
- Veterans Affairs Greater Los Angeles Healthcare System, Radiation Oncology Service, Los Angeles, CA; University of California Los Angeles Jonsson Comprehensive Cancer Center, Los Angeles, CA.
| | | | - Alex K Bryant
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University, Palo Alto, CA; Office of Research and Development, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Nikhil Sebastian
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - David Gutman
- Department of Psychiatry, Atlanta Veterans Affairs Health Care System, Decatur, GA; Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Abigail Burns
- Foundation for Atlanta Veterans Education and Research, Decatur, GA
| | - Zhonglu Huang
- Winship Cancer Institute of Emory University, Atlanta, GA
| | - Jennifer A Lewis
- Education and Clinical Center (GRECC) and Medicine Service, Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Nashville, TN; Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Lucy B Spalluto
- Vanderbilt-Ingram Cancer Center, Nashville, TN; Education and Clinical Center (GRECC), Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Nashville, TN; Department of Radiology, Vanderbilt University Medical Center, Nashville, TN
| | - Christina D Williams
- Cooperative Studies Program Epidemiology Center, Durham VA Health Care System, Durham, NC; Department of Medicine, Duke University, Durham, NC; Duke Cancer Institute, Duke University, Durham, NC
| | - Donald R Sullivan
- Division of Pulmonary, Oregon Health and Science University, Allergy and Critical Care Medicine, Portland, OR; Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR; Cancer Prevention and Control Program, Oregon Health and Science University Knight Cancer Institute, Portland, OR
| | - Christopher G Slatore
- Division of Pulmonary, Oregon Health and Science University, Allergy and Critical Care Medicine, Portland, OR; Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR; Section of Pulmonary and Critical Care Medicine, VA Portland Health Care System, Portland, OR; Department of Radiation Medicine, Oregon Health and Science University Knight Cancer Institute, Portland, OR
| | | | - William A Stokes
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
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Reinke LF, Tartaglione EV, Ruedebusch S, Smith PH, Sullivan DR. Nurse-Led, Telephone-Based Primary Palliative Care Intervention for Patients With Lung Cancer: Domains of Quality Care. J Hosp Palliat Nurs 2024; 26:104-111. [PMID: 38096450 DOI: 10.1097/njh.0000000000001005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
Palliative care is traditionally delivered by specialty-trained palliative care teams. Because of a national workforce shortage of palliative care specialists, there is an urgent need to explore alternative models of palliative care delivery to meet the needs of patients living with serious illness. As part of a multisite randomized controlled trial, 2 registered nurses without previous palliative care experience were trained to deliver a primary palliative care intervention to patients with newly diagnosed lung cancer. The intervention focused on assessing and managing symptoms, psychosocial needs, education, and initiating goals-of-care discussions. The primary outcome, improved symptom burden and quality of life, was not statistically significant. Despite this finding, nurses addressed 5 of the 8 National Consensus Project Guidelines domains of quality palliative care: structure and processes of care; physical, psychological, and social aspects of care; and ethical and legal aspects. Patients' engagement in goals-of-care discussions, a measure of high-quality palliative care, increased. Clinical recommendations offered by the nurses to the patients' clinicians were addressed and accepted on a timely basis. Most patients rated satisfaction with the intervention as "very or extremely" satisfied. These findings may inform future nurse-led palliative care interventions on the specific quality domains of palliative care.
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18
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Freeman JQ, Scott AW, Akhiwu TO. Rural-urban disparities and trends in utilization of palliative care services among US patients with metastatic breast cancer. J Rural Health 2024:10.1111/jrh.12826. [PMID: 38375950 PMCID: PMC11333727 DOI: 10.1111/jrh.12826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/25/2024] [Accepted: 02/05/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE To assess trends and rural-urban disparities in palliative care utilization among patients with metastatic breast cancer. METHODS We analyzed data from the 2004-2019 National Cancer Database. Palliative care services, including surgery, radiotherapy, systemic therapy, and/or other pain management, were provided to control pain or alleviate symptoms; utilization was dichotomized as "yes/no." Rural-urban residence, defined by the US Department of Agriculture Economic Research Service's Rural-Urban Continuum Codes, was categorized as "rural/urban/metropolitan." Multivariable logistic regression was used to examine rural-urban differences in palliative care use. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated. FINDINGS Of 133,500 patients (mean age 62.4 [SD = 14.2] years), 86.7%, 11.7%, and 1.6% resided in metropolitan, urban, and rural areas, respectively; 72.5% were White, 17.0% Black, 5.8% Hispanic, and 2.7% Asian. Overall, 20.3% used palliative care, with a significant increase from 15.6% in 2004-2005 to 24.5% in 2008-2019 (7.0% increase per year; p-value for trend <0.001). In urban areas, 23.3% received palliative care, compared to 21.0% in rural and 19.9% in metropolitan areas (p < 0.001). After covariate adjustment, patients residing in rural (AOR = 0.84; 95% CI: 0.73-0.98) or metropolitan (AOR = 0.85, 95% CI: 0.80-0.89) areas had lower odds of having used palliative care than those in urban areas. CONCLUSIONS In this national, racially diverse sample of patients with metastatic breast cancer, the utilization of palliative care services increased over time, though remained suboptimal. Further, our findings highlight rural-urban disparities in palliative care use and suggest the potential need to promote these services while addressing geographic access inequities for this patient population.
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Affiliation(s)
- Jincong Q Freeman
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
- Cancer Prevention and Control Program, UChicago Medicine Comprehensive Cancer Center, Chicago, Illinois, USA
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois, USA
| | - Adam W Scott
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Ted O Akhiwu
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
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19
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Cerullo G, Figueiredo T, Coelho C, Campos CS, Videira-Silva A, Carrilho J, Midão L, Costa E. Palliative Care in the Ageing European Population: A Cross-Country Comparison. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:113. [PMID: 38276807 PMCID: PMC10815293 DOI: 10.3390/ijerph21010113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
With Europe's ageing population and rising demand for palliative care, it is crucial to examine the use of palliative care among older adults during their last years of life and understand the factors influencing their access and end-of-life circumstances. This study employed a cohort of SHARE participants aged 65 years or older who had passed away between Wave 6 (2015) and Wave 7 (2017). Information on death circumstances, palliative care utilization, and associated variables were analysed. The study revealed that nearly 13.0% of individuals across these countries died under palliative care, with Slovenia having the lowest rate (0.3%) and France the highest (30.4%). Palliative care utilization in the last 30 days before death was observed in over 24.0% of participants, with the Czech Republic having the lowest rate (5.0%) and Greece the highest (48.8%). A higher risk of using or dying in palliative care was significantly associated with cognitive impairment (low verbal fluency), physical inactivity, and good to excellent self-perceived health. This work highlights the urgent need for enhanced global access to palliative care and advocates for the cross-country comparison of effective practices within Europe, tailored to the unique healthcare needs of older adults.
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Affiliation(s)
- Giovanni Cerullo
- Palliative Care, Centro Hospitalar Universitário do Algarve, 8000-386 Algarve, Portugal;
- Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | - Teodora Figueiredo
- CINTESIS@RISE, Biochemistry Lab, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal; (T.F.); (C.C.); (C.S.C.); (J.C.); (L.M.)
- Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Porto4Ageing—Competences Centre on Active and Healthy Ageing, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
| | - Constantino Coelho
- CINTESIS@RISE, Biochemistry Lab, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal; (T.F.); (C.C.); (C.S.C.); (J.C.); (L.M.)
- Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Porto4Ageing—Competences Centre on Active and Healthy Ageing, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
| | - Cláudia Silva Campos
- CINTESIS@RISE, Biochemistry Lab, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal; (T.F.); (C.C.); (C.S.C.); (J.C.); (L.M.)
- Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Porto4Ageing—Competences Centre on Active and Healthy Ageing, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
| | - António Videira-Silva
- Pediatric University Clinic, Faculty of Medicine, University of Lisbon, 1649-028 Lisbon, Portugal;
- Research Centre in Physical Activity, Health and Leisure, Faculty of Sport, University of Porto, 4200-450 Porto, Portugal
- Centro de Investigação em Desporto, Educação Física, Exercício e Saúde (CIDEFES), Universidade Lusófona, 1749-024 Lisbon, Portugal
| | - Joana Carrilho
- CINTESIS@RISE, Biochemistry Lab, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal; (T.F.); (C.C.); (C.S.C.); (J.C.); (L.M.)
- Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Porto4Ageing—Competences Centre on Active and Healthy Ageing, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
| | - Luís Midão
- CINTESIS@RISE, Biochemistry Lab, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal; (T.F.); (C.C.); (C.S.C.); (J.C.); (L.M.)
- Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Porto4Ageing—Competences Centre on Active and Healthy Ageing, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
| | - Elísio Costa
- CINTESIS@RISE, Biochemistry Lab, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal; (T.F.); (C.C.); (C.S.C.); (J.C.); (L.M.)
- Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Porto4Ageing—Competences Centre on Active and Healthy Ageing, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
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Seiça Cardoso C, Prazeres F, Oliveiros B, Nunes C, Simões P, Aires C, Rita P, Penetra J, Lopes P, Alcobia S, Baptista S, Venâncio C, Gomes B. Feasibility and effectiveness of a two-tiered intervention involving training and a new consultation model for patients with palliative care needs in primary care: A before-after study. Palliat Med 2024:2692163231219682. [PMID: 38226491 DOI: 10.1177/02692163231219682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
BACKGROUND Evidence suggests that involving General Practitioners in the care of patients with palliative care needs may improve patient outcomes. AIM To evaluate whether a two-tiered intervention involving training in palliative care and a new consultation model in primary care for patients with palliative care needs is feasible and could reduce patients' symptom burden. DESIGN Before-after study including an internal pilot. SETTING/PARTICIPANTS Nine general practitioners working in a health region in Portugal and 53 patients with palliative care needs from their patient lists were recruited. General Practitioners received training in palliative care and used a new primary palliative care consultation model, with medical consultations every 3 weeks for 12 weeks. The primary outcome was physical symptom burden, self-reported using the Integrated Palliative care Outcome Scale (IPOS) patient version (min.0-max.1000). Secondary outcomes included emotional symptoms (min.0-max.400) and communication/practical issues (min.0-max.300). RESULTS Of the 35/53 patients completed the 12-week intervention (mean age 72.53 years, SD = 13.45; 54.7% female). All had advanced disease: one third had cancer (n = 13), one third had congestive heart failure (n = 12); others had chronic kidney disease and chronic obstructive pulmonary disease. After the 12 weeks of intervention, there was a reduction in physical symptom burden [mean difference from baseline of 71.42 (95%CI 37.01-105.85) with a medium-large effect size (0.71], and in emotional symptom burden [mean difference 42.86 (95%CI 16.14-69.58), with a medium effect size (0.55)]. No difference was found for communication/practical issues. CONCLUSIONS Our intervention can be effective in reducing patients' physical and emotional symptoms. TRIAL REGISTRATION ClinicalTrials.gov ID - NCT05244590. Registration: 14th February 2022.
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Affiliation(s)
- Carlos Seiça Cardoso
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Filipe Prazeres
- CINTESIS@RISE, MEDCIDS, Faculty of Medicine of the University of Porto, Porto, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
- USF Beira Ria, Gafanha da Nazaré, Portugal
| | - Bárbara Oliveiros
- Laboratory of Biostatistics and Medical Informatics (LBIM), Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Cátia Nunes
- Family Health Unit Penacova, Coimbra, Portugal
| | - Pedro Simões
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
- Personalized Health Care Unit Fundão, Fundão, Portugal
| | - Carolina Aires
- Family Health Unit São Martinho de Pombal, Pombal, Portugal
| | - Patrícia Rita
- Personalized Health Care Unit Castanheira de Pera, Coimbra, Portugal
| | | | - Paulo Lopes
- Family Health Unit Rainha Santa Isabel, Torres Novas, Santarém, Portugal
| | - Sara Alcobia
- Family Health Unit As Gandras, Cantanhede, Coimbra, Portugal
| | - Sara Baptista
- Personalized Health Care Unit Figueira-da-Foz Norte, Coimbra, Portugal
| | | | - Barbara Gomes
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Volberg C, Urhahn F, Pedrosa Carrasco AJ, Morin A, Gschnell M, Huber J, Flegar L, Heers H. End-of-Life Care Preferences of Patients with Advanced Urological Malignancies: An Explorative Survey Study at a Tertiary Referral Center. Curr Oncol 2024; 31:462-471. [PMID: 38248116 PMCID: PMC10814887 DOI: 10.3390/curroncol31010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/30/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024] Open
Abstract
Background: Many people want to die at home, but it is often not possible because they do not share their wishes with family members. This study was conducted to find out the extent to which patients with advanced urological malignancies had wishes regarding their final stage of life, made arrangements accordingly, and communicated their wishes to relatives and health care professionals. Methods: We conducted a survey among advanced urological tumor patients during their clinic visit at a German university hospital using a 31-item questionnaire. Inclusion criteria were metastatic or irresectable prostate cancer, urothelial carcinoma, or renal cell carcinoma. Results: In total, 88 patients (76 male, 12 female) completed the questionnaire, and 62 of those respondents (70%) had received their tumor diagnosis within the past 5 years. Symptoms were reported by 80%, and 18% described five or more symptoms. The majority (88%) stated that they had thought about their preferred place of death but 58% had not informed anyone about it. The preference for a hospice as the place of death correlated statistically significantly with the absence of a domestic partnership (p = 0.001) or marriage (p < 0.001) and with a high number of symptoms (≥5; p = 0.009). However, 73% had not talked with their urological oncologist about care options in case their health deteriorated though 36% of those were interested in having a conversation about it. Conclusions: Our results showed that 9 out of 10 patients reflected on their preferred place of death but only a few discussed it with anyone. Based on this finding, physicians and healthcare staff should initiate discussions about early care planning so that patients in incurable situations can express their wishes regarding their preferred place of death.
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Affiliation(s)
- Christian Volberg
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University Marburg, Baldingerstraße, 35033 Marburg, Germany
- Research Group Medical Ethics, Faculty of Medicine, Philipps University Marburg, Baldingerstraße, 35033 Marburg, Germany
| | - Fabian Urhahn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University Marburg, Baldingerstraße, 35033 Marburg, Germany
| | | | - Astrid Morin
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University Marburg, Baldingerstraße, 35033 Marburg, Germany
| | - Martin Gschnell
- Department of Dermatology and Allergology, Skin Tumor Center, University Hospital Marburg, Philipps University Marburg, Baldingerstraß, 35033 Marburg, Germany
| | - Johannes Huber
- Department of Urology, University Hospital Marburg, Philipps University Marburg, Baldingerstraß, 35033 Marburg, Germany
| | - Luka Flegar
- Department of Urology, University Hospital Marburg, Philipps University Marburg, Baldingerstraß, 35033 Marburg, Germany
| | - Hendrik Heers
- Department of Urology, University Hospital Marburg, Philipps University Marburg, Baldingerstraß, 35033 Marburg, Germany
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Harrison RA, Tang M, Shih KK, Khan M, Pham L, De Moraes AR, O'Brien BJ, Bassett R, Bruera E. Characterization of patients with brain metastases referred to palliative care. BMC Palliat Care 2024; 23:13. [PMID: 38212765 PMCID: PMC10782691 DOI: 10.1186/s12904-023-01320-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 12/04/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE In this study, we aimed to assess the clinical characteristics, reasons for referral, and outcomes of patients with brain metastases (BM) referred to the supportive care center. METHODS Equal numbers of patients with melanoma, breast cancer, and lung cancer with (N = 90) and without (N = 90) BM were retrospectively identified from the supportive care database for study. Descriptive statistics were used to analyze demographic, disease, and clinical data. Kaplan Meier method was used to evaluate survival outcomes. RESULTS While physical symptom management was the most common reason for referral to supportive care for both patients with and without BM, patients with BM had significantly lower pain scores on ESAS at time of referral (p = 0.002). They had greater interaction with acute care in the last weeks of life, with higher rates of ICU admission, emergency room visits, and hospitalizations after initial supportive care (SC) visit. The median survival time from referral to Supportive Care Center (SCC) was 0.90 years (95% CI 0.73, 1.40) for the brain metastasis group and 1.29 years (95% CI 0.91, 2.29) for the group without BM. CONCLUSIONS Patients with BM have shorter survival and greater interaction with acute care in the last weeks of life. This population also has distinct symptom burdens from patients without BM. Strategies to optimize integration of SC for patients with BM warrant ongoing study.
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Affiliation(s)
- Rebecca A Harrison
- Division of Neurology, BC Cancer, The University of British Columbia, Vancouver, BC, Canada.
| | - Michael Tang
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kaoswi Karina Shih
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria Khan
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lily Pham
- Department of Neurology, University of Maryland School or Medicine, Baltimore, MD, USA
| | - Aline Rozman De Moraes
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbara J O'Brien
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roland Bassett
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Rice E, Scott MM, Webber C, Seow H, Sivapathasundaram B, Tanuseputro P. Characterizing the Palliative Care Physician Workforce: A Retrospective Cross-Sectional Study With Population-Based Data in Ontario, Canada. J Am Med Dir Assoc 2023; 24:1849-1854.e1. [PMID: 37460087 DOI: 10.1016/j.jamda.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVES Because of an increasing need to build capacity for end-of-life care, improving access to palliative care is a priority. Where a physician practices (eg, hospital, outpatient clinic, home) directly relates to the type of service and the stage of illness at which care is provided. In this study, we describe the physician palliative care specialist workforce and the settings of care within which they practice. DESIGN A retrospective cohort. SETTING AND PARTICIPANTS All physicians with palliative care billing codes who were practicing between April 1, 2018, and March 31, 2019, in Ontario, Canada. METHODS Descriptive statistics of physician billing location and frequency using linked population-based health administrative data. RESULTS We identified 8883 physicians who provided palliative care during the study period. Of those, 723 (8.1%) were classified as palliative care specialists (>10% of their billings encounters were palliative care). The majority (57.4%) of palliative care specialists worked in 1 setting more than 90% of their time, across home visits (27.1%), indirect care (22.4%), and office (7.9%). There were 61 palliative care specialists practicing in mixed locations who provided home visits, meaning 310 (42.9%) of the palliative care specialists delivered some home-based care. CONCLUSIONS AND IMPLICATIONS This research provides a comprehensive description of the current palliative care specialist physician workforce that can support efforts to build capacity for high-quality end-of-life care.
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Affiliation(s)
- Emily Rice
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - Hsien Seow
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; ICES, Hamilton, Ontario, Canada
| | | | - Peter Tanuseputro
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada.
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24
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Bansal VV, Kim D, Reddy B, Witmer HDD, Dhiman A, Godley FA, Ong CT, Clark S, Ulrich L, Polite B, Shergill A, Malec M, Eng OS, Tun S, Turaga KK. Early Integrated Palliative Care Within a Surgical Oncology Clinic. JAMA Netw Open 2023; 6:e2341928. [PMID: 37934497 PMCID: PMC10630898 DOI: 10.1001/jamanetworkopen.2023.41928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/18/2023] [Indexed: 11/08/2023] Open
Abstract
Importance Advance directive (AD) designation is an important component of advance care planning (ACP) that helps align care with patient goals. However, it is underutilized in high-risk surgical patients with cancer, and multiple barriers contribute to the low AD designation rates in this population. Objective To assess the association of early palliative care integration with changes in AD designation among patients with cancer who underwent surgery. Design, Setting, and Participants This cohort study was a retrospective analysis of a prospectively maintained registry of adult patients who underwent elective surgery for advanced abdominal and soft tissue malignant tumors at a surgical oncology clinic in a comprehensive cancer center with expertise in regional therapeutics between June 2016 and May 2022, with a median (IQR) postoperative follow-up duration of 27 (15-43) months. Data analysis was conducted from December 2022 to April 2023. Exposure Integration of ACP recommendations and early palliative care consultations into the surgical workflow in 2020 using electronic health records (EHR), preoperative checklists, and resident education. Main Outcomes and Measures The primary outcomes were AD designation and documentation. Multivariable logistic regression was performed to assess factors associated with AD designation and documentation. Results Among the 326 patients (median [IQR] age 59 [51-67] years; 189 female patients [58.0%]; 243 non-Hispanic White patients [77.9%]) who underwent surgery, 254 patients (77.9%) designated ADs. The designation rate increased from 72.0% (131 of 182 patients) before workflow integration to 85.4% (123 of 144 patients) after workflow integration in 2020 (P = .004). The AD documentation rate did not increase significantly after workflow integration in 2020 (48.9% [89 of 182] ADs documented vs 56.3% [81 of 144] ADs documented; P = .19). AD designation was associated with palliative care consultation (odds ratio [OR], 41.48; 95% CI, 9.59-179.43; P < .001), palliative-intent treatment (OR, 5.12; 95% CI, 1.32-19.89; P = .02), highest age quartile (OR, 3.79; 95% CI, 1.32-10.89; P = .01), and workflow integration (OR, 2.05; 95% CI, 1.01-4.18; P = .048). Patients who self-identified as a race or ethnicity other than non-Hispanic White were less likely to have designated ADs (OR, 0.36; 95% CI, 0.17-0.76; P = .008). AD documentation was associated with palliative care consulation (OR, 4.17; 95% CI, 2.57- 6.77; P < .001) and the highest age quartile (OR, 2.41; 95% CI, 1.21-4.79; P = .01). Conclusions and Relevance An integrated ACP initiative was associated with increased AD designation rates among patients with advanced cancer who underwent surgery. These findings demonstrate the feasibility and importance of modifying clinical pathways, integrating EHR-based interventions, and cohabiting palliative care physicians in the surgical workflow for patients with advanced care.
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Affiliation(s)
- Varun V. Bansal
- Division of Surgical Oncology, Yale School of Medicine, New Haven, Connecticut
| | - Daniel Kim
- Pritzker School of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Biren Reddy
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Hunter D. D. Witmer
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Ankit Dhiman
- Department of Surgery, Medical College of Georgia, Augusta
| | - Frederick A. Godley
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Cecilia T. Ong
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Sandra Clark
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Leah Ulrich
- Department of Surgery, Division of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Blase Polite
- Department of Medicine, Section of Hematology and Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Ardaman Shergill
- Department of Medicine, Section of Hematology and Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Monica Malec
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Oliver S. Eng
- Department of Surgery, Division of Surgical Oncology, University of California, Irvine
| | - Sandy Tun
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Kiran K. Turaga
- Division of Surgical Oncology, Yale School of Medicine, New Haven, Connecticut
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Hooker ER, Chapa J, Vranas KC, Niederhausen M, Goodlin SJ, Slatore CG, Sullivan DR. Intersection of Palliative Care and Hospice Use Among Patients With Advanced Lung Cancer. J Palliat Med 2023; 26:1474-1481. [PMID: 37262128 PMCID: PMC10658737 DOI: 10.1089/jpm.2023.0040] [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: 04/27/2023] [Indexed: 06/03/2023] Open
Abstract
Background: Hospice and palliative care (PC) are important components of lung cancer care and independently provide benefits to patients and their families. Objective: To better understand the relationship between hospice and PC and factors that influence this relationship. Methods: A retrospective cohort study of patients diagnosed with advanced lung cancer (stage IIIB/IV) within the U.S. Veterans Health Administration (VA) from 2007 to 2013 with follow-up through 2017 (n = 22,907). Mixed logistic regression models with a random effect for site, adjustment for patient variables, and propensity score weighting were used to examine whether the association between PC and hospice use varied by U.S. region and PC team characteristics. Results: Overall, 57% of patients with lung cancer received PC, 69% received hospice, and 16% received neither. Of those who received hospice, 60% were already enrolled in PC. Patients who received PC had higher odds of hospice enrollment than patients who did not receive PC (adjusted odds ratio = 3.25, 95% confidence interval: 2.43-4.36). There were regional differences among patients who received PC; the predicted probability of hospice enrollment was 85% and 73% in the Southeast and Northeast, respectively. PC team and facility characteristics influenced hospice use in addition to PC; teams with the shortest duration of existence, with formal team training, and at lower hospital complexity were more likely to use hospice (all p < 0.05). Conclusions: Among patients with advanced lung cancer, PC was associated with hospice enrollment. However, this relationship varied by geographic region, and PC team and facility characteristics. Our findings suggest that regional PC resource availability may contribute to substitution effects between PC and hospice for end-of-life care.
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Affiliation(s)
- Elizabeth R. Hooker
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
| | - Joaquin Chapa
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Portland Veterans Affairs Medical Center, Divisions of Pulmonary Critical Care Medicine, Portland, Oregon, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Oregon Health and Science University—Portland State University School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Sarah J. Goodlin
- Geriatrics Section, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Donald R. Sullivan
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
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26
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Lee A, DeGroote NP, Brock KE. Early Versus Late Outpatient Pediatric Palliative Care Consultation and Its Association With End-of-Life Outcomes in Children With Cancer. J Palliat Med 2023; 26:1466-1473. [PMID: 37222727 DOI: 10.1089/jpm.2023.0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Background: There is no consensus on what constitutes "early" pediatric palliative care (PPC) referral within pediatric oncology. Few studies report outcomes based on PPC timing. Objectives: Investigate associations between early (<12 weeks) or late (≥12 weeks from diagnosis) outpatient PPC consultation with demographics, advance care planning (ACP), and end-of-life (EOL) outcomes. Design: Retrospective chart and database review of demographic, disease, visit data, and PPC/EOL outcomes. Setting/Subjects: Deceased pediatric patients with cancer 0-27 years of age seen at an embedded consultative PPC clinic. Measurements: Patient demographics, disease characteristics, PPC/EOL outcomes: timing/receipt of ACP, hospice enrollment, do-not-resuscitate (DNR) documentation, hospital days in last 90 days of life, concordance between actual and preferred location of death, receipt of cardiopulmonary resuscitation (CPR) at EOL, and death in the intensive care unit. Results: Thirty-two patients received early and 118 received late PPC. Early outpatient PPC was associated with cancer type (p < 0.01). Early PPC (p = 0.04) and ACP documentation (p = 0.04) were associated with documentation of preferred location of death. Early PPC was associated with a preference for home death (p = 0.02). Timing of outpatient PPC was not associated with ACP documentation or other EOL outcomes. In the entire cohort, 73% of PPC patients received hospice, 74% had a DNR order, 87% did not receive CPR at EOL, and 90% died in their preferred location. Conclusions: When using a cutoff of 12 weeks from diagnosis, outpatient PPC timing was only associated with location of death metrics, likely due to high-quality PPC and EOL care among all patients.
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Affiliation(s)
- Annika Lee
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nicholas P DeGroote
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Katharine E Brock
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Department of Pediatrics, Divisions of Pediatric Hematology/Oncology and Palliative Care, Emory University, Atlanta, Georgia, USA
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Katano A, Tongyu G, Minamitani M, Ohira S, Yamashita H. Thirty-day Mortality in Palliative Radiotherapy: A Retrospective Cohort Analysis in a Single Center. CANCER DIAGNOSIS & PROGNOSIS 2023; 3:721-725. [PMID: 37927804 PMCID: PMC10619574 DOI: 10.21873/cdp.10277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/21/2023] [Indexed: 11/07/2023]
Abstract
Background/Aim Palliative radiotherapy is a critical component of cancer care aimed at symptom management and enhancing the quality of life of patients with advanced cancer. Balancing symptom relief and potential risks is pivotal in clinical decision-making. This study explored the 30-day mortality (30-DM) rate after palliative radiotherapy in a single-center setting to shed light on potential prognostic factors and safety considerations. Patients and Methods This retrospective cohort study included patients who underwent palliative radiotherapy for various indications between March 2020 and February 2023. Data were retrieved from electronic medical records and analyzed according to ethical guidelines. The primary outcome measure was 30-DM rate, and multivariate logistic regression analysis was conducted to identify the independent predictors of 30-DM. Results A total of 931 palliative radiotherapy sessions were administered to 601 patients, with a median of one session per patient. The cohort had a median age of 70 years, predominantly men (58%), and featured diverse primary cancer types, with lung cancer being the most prevalent (15.8%). The 30-DM rate was 12.9%. Multivariate analysis identified Karnofsky Performance Status (KPS) as the sole independent prognostic factor significantly associated with 30-DM. Conclusion This study provides valuable insights into 30-DM rates following palliative radiotherapy. Future research should focus on prospective multicenter investigations with larger cohorts and comprehensive data collection, ultimately leading to improved risk prediction models for personalized treatment decisions in palliative radiotherapy.
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Affiliation(s)
- Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Gao Tongyu
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Masanari Minamitani
- Department of Comprehensive radiation oncology, The University of Tokyo, Tokyo, Japan
| | - Shingo Ohira
- Department of Comprehensive radiation oncology, The University of Tokyo, Tokyo, Japan
| | - Hideomi Yamashita
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
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Chen M, Yu H, Yang L, Yang H, Cao H, Lei L, Ma L, Liu S, Tian L, Wang S. Combined early palliative care for non-small-cell lung cancer patients: a randomized controlled trial in Chongqing, China. Front Oncol 2023; 13:1184961. [PMID: 37781179 PMCID: PMC10539600 DOI: 10.3389/fonc.2023.1184961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/23/2023] [Indexed: 10/03/2023] Open
Abstract
Purpose More effective approaches are needed to improve the prognosis of non-small-cell lung cancer (NSCLC) patients. Thus, we used the E-warm model to assess how early integration of interdisciplinary palliative care was related to the quality of life (QoL), psychological functioning, pain management, and nutrition factors of NSCLC patients. Methods This randomized controlled trial enrolled 280 newly diagnosed NSCLC patients, which were randomly divided (1:1) into combined early palliative care (CEPC) and standard oncological care (SC) groups. At baseline and after 24 weeks, the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale, Hospital Anxiety and Depression Scale (HADS), and the Patient Health Questionnaire-9 (PHQ-9) were used to assess QoL and psychological function, respectively. The Numerical Rating Scale (NRS) and Patient-Generated Subjective Global Assessment (PG-SGA) were used to assess cancer patients' pain and nutrition levels. The primary outcome was overall survival (OS). Secondary outcomes comprised changes in the QoL, psychological functioning, pain, and nutrition state. The intention-to-treat method was applied for analysis. This study was registered at www.chictr.org.cn (ChiCTR2200062617). Results Of the 140 patients enrolled in the CEPC and SC groups, 102 and 82 completed the research. The CEPC group presented higher QoL than the SC group (p < 0.05). Additionally, fewer patients presented depressive symptoms in the CEPC group than in the SC group (p < 0.05), as well as better nutritional status (p = 0.007) and pain management (p = 0.003). Compared to the SC group, CEPC patients had significantly longer OS (20.4 vs. 24.6 months, p = 0.042; HR: 0.19; 95% CI: 0.04-0.85, p = 0.029). Conclusion With combined early palliative care, NSCLC patients lived longer, had better QoL, were psychologically stable, were in less pain, and were more nutritionally satisfied.
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Affiliation(s)
- Mengting Chen
- Department of Clinical Nutrition, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Huiqing Yu
- Department of Clinical Nutrition, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
- Department of Geriatric Oncology and Department of Palliative Care, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Liejun Yang
- Department of Geriatric Oncology and Department of Palliative Care, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Hong Yang
- Department of Geriatric Oncology and Department of Palliative Care, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Haoyang Cao
- Department of Clinical Nutrition, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Lei Lei
- Department of Geriatric Oncology and Department of Palliative Care, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Liling Ma
- Department of Geriatric Oncology and Department of Palliative Care, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Shihong Liu
- Department of Geriatric Oncology and Department of Palliative Care, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Ling Tian
- Department of Geriatric Oncology and Department of Palliative Care, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Sixiong Wang
- Department of Geriatric Oncology and Department of Palliative Care, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
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Sausman J, Arif A, Young A, MacArtney J, Bailey C, Rajani J, Burt R. Healthcare professionals' perspectives of the management of people with palliative care needs in the emergency department of a UK hospital. BMC Palliat Care 2023; 22:129. [PMID: 37670312 PMCID: PMC10481573 DOI: 10.1186/s12904-023-01248-8] [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] [Received: 06/12/2023] [Accepted: 08/22/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND The Emergency Department (ED) is not always the optimal place for people with palliative care needs but is the most common route for treatment when urgent care is sought. The aim of this study,''REasons for PalLIative Care Admissions (REPLICA)' was to explore the perspectives of ED healthcare professionals of hospital admission or discharge via ED for palliative care patients. METHODS This is a sequential mixed methods study comprising (i) quantitative descriptive analysis of Hospital Episode Statistics (HES) of palliative care patients (code Z51.5) who were admitted through ED in a West Midlands Hospital and for the rest of England; (ii) in-depth semi-structured interviews with 17 ED staff which were analysed using thematic content analysis. RESULTS Over the four years (2013-2017), 430,116 people admitted through ED were identified with a Z51.5 diagnosis code, 0.6% (n = 2736) of whom were from the West Midlands Hospital. The most common reasons for palliative care patients' admission to hospitals across England were for care of chronic kidney disease, cancers and urinary tract infections. Five themes were elicited from the qualitative analysis: (1) Providing palliative care in ED is challenging, due to factors including lack of training in palliative care and the unsuitable environment. (2) Patients go to ED due to challenges in community management such as inappropriate referrals and no care plan in place. (3) Health system influences admission and discharge decisions, including bed availability and being unable to set up community services out-of-hours. (4) Discussion with patient about treatment and end of life care needs to be outside of ED whilst the patient is still well enough to express their wishes. (5) Improving services for patients with palliative care needs. Recommendations include short training sessions for ED staff and accessing palliative care professionals 24/7. CONCLUSIONS A large number of palliative care patients visit ED and are admitted to hospital for care; there is an urgent need to prevent patients attending the hospital through the establishment of a coordinated and dedicated service to support palliative care patients in the community.
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Affiliation(s)
- Jane Sausman
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Azra Arif
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Annie Young
- University Hospitals Coventry and Warwickshire, Coventry, UK.
- Warwick Medical School, University of Warwick, Coventry, UK.
| | - John MacArtney
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Cara Bailey
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Jaimini Rajani
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Rebecca Burt
- University Hospitals Coventry and Warwickshire, Coventry, UK
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Yoong SQ, Porock D, Whitty D, Tam WWS, Zhang H. Performance of the Palliative Prognostic Index for cancer patients: A systematic review and meta-analysis. Palliat Med 2023; 37:1144-1167. [PMID: 37310019 DOI: 10.1177/02692163231180657] [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] [Indexed: 06/14/2023]
Abstract
BACKGROUND Clinician predicted survival for cancer patients is often inaccurate, and prognostic tools may be helpful, such as the Palliative Prognostic Index (PPI). The PPI development study reported that when PPI score is greater than 6, it predicted survival of less than 3 weeks with a sensitivity of 83% and specificity of 85%. When PPI score is greater than 4, it predicts survival of less than 6 weeks with a sensitivity of 79% and specificity of 77%. However, subsequent PPI validation studies have evaluated various thresholds and survival durations, and it is unclear which is most appropriate for use in clinical practice. With the development of numerous prognostic tools, it is also unclear which is most accurate and feasible for use in multiple care settings. AIM We evaluated PPI model performance in predicting survival of adult cancer patients based on different thresholds and survival durations and compared it to other prognostic tools. DESIGN This systematic review and meta-analysis was registered in PROSPERO (CRD42022302679). We calculated the pooled sensitivity and specificity of each threshold using bivariate random-effects meta-analysis and pooled diagnostic odds ratio of each survival duration using hierarchical summary receiver operating characteristic model. Meta-regression and subgroup analysis were used to compare PPI performance with clinician predicted survival and other prognostic tools. Findings which could not be included in meta-analyses were summarised narratively. DATA SOURCES PubMed, ScienceDirect, Web of Science, CINAHL, ProQuest and Google Scholar were searched for articles published from inception till 7 January 2022. Both retrospective and prospective observational studies evaluating PPI performance in predicting survival of adult cancer patients in any setting were included. The Prediction Model Risk of Bias Assessment Tool was used for quality appraisal. RESULTS Thirty-nine studies evaluating PPI performance in predicting survival of adult cancer patients were included (n = 19,714 patients). Across meta-analyses of 12 PPI score thresholds and survival durations, we found that PPI was most accurate for predicting survival of <3 weeks and <6 weeks. Survival prediction of <3 weeks was most accurate when PPI score>6 (pooled sensitivity = 0.68, 95% CI 0.60-0.75, specificity = 0.80, 95% CI 0.75-0.85). Survival prediction of <6 weeks was most accurate when PPI score>4 (pooled sensitivity = 0.72, 95% CI 0.65-0.78, specificity = 0.74, 95% CI 0.66-0.80). Comparative meta-analyses found that PPI performed similarly to Delirium-Palliative Prognostic Score and Palliative Prognostic Score in predicting <3-week survival, but less accurately in <30-day survival prediction. However, Delirium-Palliative Prognostic Score and Palliative Prognostic Score only provide <30-day survival probabilities, and it is uncertain how this would be helpful for patients and clinicians. PPI also performed similarly to clinician predicted survival in predicting <30-day survival. However, these findings should be interpreted with caution as limited studies were available for comparative meta-analyses. Risk of bias was high for all studies, mainly due to poor reporting of statistical analyses. while there were low applicability concerns for most (38/39) studies. CONCLUSIONS PPI score>6 should be used for <3-week survival prediction, and PPI score>4 for <6-week survival. PPI is easily scored and does not require invasive tests, and thus would be easily implemented in multiple care settings. Given the acceptable accuracy of PPI in predicting <3- and <6-week survival and its objective nature, it could be used to cross-check clinician predicted survival especially when clinicians have doubts about their own judgement, or when clinician estimates seem to be less reliable. Future studies should adhere to the reporting guidelines and provide comprehensive analyses of PPI model performance.
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Affiliation(s)
- Si Qi Yoong
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Davina Porock
- School of Nursing and Midwifery, Edith Cowan University, Perth, WA, Australia
| | - Dee Whitty
- School of Nursing and Midwifery, Edith Cowan University, Perth, WA, Australia
| | - Wilson Wai San Tam
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hui Zhang
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- St. Andrew's Community Hospital, Singapore
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Amaral AF, Colares PDFB, Kairalla RA. Idiopathic pulmonary fibrosis: current diagnosis and treatment. J Bras Pneumol 2023; 49:e20230085. [PMID: 37556670 PMCID: PMC10578906 DOI: 10.36416/1806-3756/e20230085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/20/2023] [Indexed: 08/11/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a devastating chronic lung disease without a clear recognizable cause. IPF has been at the forefront of new diagnostic algorithms and treatment developments that led to a shift in patients' care in the past decade, indeed influencing the management of fibrotic interstitial lung diseases other than IPF itself. Clinical presentation, pathophysiology, and diagnostic criteria are briefly addressed in this review article. Additionally, evidence regarding the use of antifibrotics beyond the settings of clinical trials, impact of comorbidities, and therapeutic approaches other than pharmacological treatments are discussed in further detail.
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Affiliation(s)
- Alexandre Franco Amaral
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Philippe de Figueiredo Braga Colares
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Ronaldo Adib Kairalla
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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Kim KM, Muench U, Maki JE, Yefimova M, Oh A, Jopling JK, Rinaldo F, Shah NR, Giannitrapani KF, Williams MY, Lorenz KA. Racial disparities in inpatient palliative care consultation among frail older patients undergoing high-risk elective surgical procedures in the United States: a cross-sectional study of the national inpatient sample. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad026. [PMID: 38756238 PMCID: PMC10986263 DOI: 10.1093/haschl/qxad026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/21/2023] [Accepted: 07/11/2023] [Indexed: 05/18/2024]
Abstract
Surgical interventions are common among seriously ill older patients, with nearly one-third of older Americans facing surgery in their last year of life. Despite the potential benefits of palliative care among older surgical patients undergoing high-risk surgical procedures, palliative care in this population is underutilized and little is known about potential disparities by race/ethnicity and how frailty my affect such disparities. The aim of this study was to examine disparities in palliative care consultations by race/ethnicity and assess whether patients' frailty moderated this association. Drawing on a retrospective cross-sectional study of inpatient surgical episodes using the National Inpatient Sample of the Healthcare Cost and Utilization Project from 2005 to 2019, we found that frail Black patients received palliative care consultations least often, with the largest between-group adjusted difference represented by Black-Asian/Pacific Islander frail patients of 1.6 percentage points, controlling for sociodemographic, comorbidities, hospital characteristics, procedure type, and year. No racial/ethnic difference in the receipt of palliative care consultations was observed among nonfrail patients. These findings suggest that, in order to improve racial/ethnic disparities in frail older patients undergoing high-risk surgical procedures, palliative care consultations should be included as the standard of care in clinical care guidelines.
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Affiliation(s)
- Kyung Mi Kim
- Office of Research Patient Care Services, Stanford Health Care,Menlo Park, CA 94025, United States
- Clinical Excellence Research Center, School of Medicine, Stanford University,Palo Alto, CA 94304, United States
- Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, CA 94143, United States
| | - Ulrike Muench
- Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, CA 94143, United States
- Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco, San Francisco, CA 94143, United States
| | - John E Maki
- Saint Francis Memorial Hospital, San Francisco, CA 94109, United States
| | - Maria Yefimova
- Center for Nursing Excellence and Innovation, UCSF Health,San Francisco, CA 94143, United States
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, San Francisco, CA 94143, United States
| | - Anna Oh
- Office of Research Patient Care Services, Stanford Health Care,Menlo Park, CA 94025, United States
| | - Jeffrey K Jopling
- Clinical Excellence Research Center, School of Medicine, Stanford University,Palo Alto, CA 94304, United States
- Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, United States
| | - Francesca Rinaldo
- Clinical Excellence Research Center, School of Medicine, Stanford University,Palo Alto, CA 94304, United States
| | - Nirav R Shah
- Clinical Excellence Research Center, School of Medicine, Stanford University,Palo Alto, CA 94304, United States
| | - Karleen Frances Giannitrapani
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs,Palo Alto, CA 94304, United States
- Quality Improvement Resource Center for Palliative Care, Stanford University,Stanford, CA 94305, United States
- Primary Care and Population Health, School of Medicine, Stanford University,Stanford, CA 94305, United States
| | - Michelle Y Williams
- Office of Research Patient Care Services, Stanford Health Care,Menlo Park, CA 94025, United States
- Primary Care and Population Health, School of Medicine, Stanford University,Stanford, CA 94305, United States
| | - Karl A Lorenz
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs,Palo Alto, CA 94304, United States
- Quality Improvement Resource Center for Palliative Care, Stanford University,Stanford, CA 94305, United States
- Primary Care and Population Health, School of Medicine, Stanford University,Stanford, CA 94305, United States
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Abstract
Global palliative medicine is a priority for global health. The aging world population lives with multiple chronic diseases and malignancies that often lead to debility, morbidity, mortality, and decreased quality of life. In the United States, 68% of adults aged older than 65 years live with 2 or more chronic conditions. Endeavors to improve access to palliative care for seniors are ongoing within "age-friendly health systems." This review article aims to provide an overview of the present state of global geriatric palliative care and to identify potential areas for future improvement.
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Affiliation(s)
- Nafiisah B M H Rajabalee
- Johns Hopkins School of Medicine, 600 North Wolfe Street, Blalock 359, Baltimore, MD 21287, USA.
| | - Augustin Joseph
- Section of Palliative Medicine, Department of Medicine, Johns Hopkins Medical Institutions, 600 North Wolfe Street, Blalock 359, Baltimore, MD 21287, USA
| | - Corey X Tapper
- Section of Palliative Medicine, Department of Medicine, Johns Hopkins Medical Institutions, 600 North Wolfe Street, Blalock 359, Baltimore, MD 21287, USA
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Han X, Shi KS, Zhao J, Nogueira L, Parikh RB, Kamal AH, Jemal A, Yabroff KR. Medicaid Expansion Associated With Increase In Palliative Care For People With Advanced-Stage Cancers. Health Aff (Millwood) 2023; 42:956-965. [PMID: 37406229 DOI: 10.1377/hlthaff.2023.00035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Clinical guidelines have endorsed early palliative care for patients with advanced malignancies, but receipt remains low in the US. This study examined the association between Medicaid expansion under the Affordable Care Act and receipt of palliative care among patients newly diagnosed with advanced-stage cancers. Using the National Cancer Database, we found that the percentage of eligible patients who received palliative care as part of first-course treatment increased from 17.0 percent preexpansion to 18.9 percent postexpansion in Medicaid expansion states and from 15.7 percent to 16.7 percent, respectively, in nonexpansion states, resulting in a net increase of 1.3 percentage points in expansion states in adjusted analyses. Increases in receipt of palliative care associated with Medicaid expansion were largest for patients with advanced pancreatic, colorectal, lung, and oral cavity and pharynx cancers and non-Hodgkin lymphoma. Our findings suggest that increasing Medicaid coverage facilitates access to guideline-based palliative care for advanced cancer, and they provide additional evidence of benefit in cancer care from states' expansion of income eligibility for Medicaid.
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Affiliation(s)
- Xuesong Han
- Xuesong Han , American Cancer Society, Kennesaw, Georgia
| | | | | | | | - Ravi B Parikh
- Ravi B. Parikh, University of Pennsylvania, Philadelphia, Pennsylvania
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Waldman LP, Centracchio JA, Jacobs JM, Petrillo LA, El-Jawahri AR, Temel JS, Greer JA. Study protocol for a randomized trial of a supportive care mobile application to improve symptoms, coping, and quality of life in patients with advanced non-small cell lung cancer. Front Psychol 2023; 14:1184482. [PMID: 37425161 PMCID: PMC10325829 DOI: 10.3389/fpsyg.2023.1184482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Patients with advanced non-small cell lung cancer (NSCLC) often experience burdensome symptoms, emotional distress, and poor quality of life (QOL). While national guidelines recommend early palliative care to address these supportive care needs, most patients with advanced NSCLC lack access to such comprehensive care. Our aim in the current study is to test a novel model of palliative care delivery and use of innovative technology to evaluate the feasibility, acceptability, and preliminary efficacy of a supportive care mobile application (app) for improving symptom management and adaptive coping in patients with advanced NSCLC. We will enroll 120 patients with unresectable Stage III or IV NSCLC diagnosed within the past 12 weeks receiving care with palliative intent at a major academic comprehensive cancer center and its community affiliates. The study will take place in two phases, the first of which will be dedicated to adapting an evidence-based, early palliative care treatment guide and prior supportive care mobile app intervention to address the specific symptom management and coping needs of patients with advanced NSCLC. The second phase of the study will be a two-group, randomized controlled trial. Study patients will complete baseline self-report measures of symptoms, mood, coping skills, and QOL, after which they will be randomized to receive either the mobile app intervention combined with usual oncology care or usual oncology care alone. Intervention patients will use a tablet computer to self-administer the mobile app, which consists of six modules that teach evidence-based skills for managing burdensome symptoms and coping effectively with advanced cancer and its treatment. At 12 weeks follow up, patients in both groups will repeat the same self-report measures. We will use descriptive statistics to determine feasibility metrics of enrollment and retention rates. For secondary self-report measures, we will use linear regression controlling for baseline values. The results of the present study will contribute to a growing body of evidence regarding the supportive care needs of patients with advanced cancer and will have implications for how best to use innovative technology to widely disseminate comprehensive supportive care services to all patients who may benefit. Clinical Trial Registration: [www.ClinicalTrials.gov], identifier[NCT04629300].
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Shlobin NA, Bernstein M. Letter to the Editor Regarding: "Palliative Care Effects on Survival in Glioblastoma: Who Receives Palliative Care?". World Neurosurg 2023; 173:294-295. [PMID: 37189315 DOI: 10.1016/j.wneu.2023.01.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada; Temmy Latner Center for Palliative Care, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Meyers DE, Pasternak M, Dolter S, Grosjean HA, Lim CA, Stukalin I, Goutam S, Navani V, Heng DY, Cheung WY, Morris DG, Pabani A. Impact of Performance Status on Survival Outcomes and Health Care Utilization in Patients With Advanced NSCLC Treated With Immune Checkpoint Inhibitors. JTO Clin Res Rep 2023; 4:100482. [PMID: 37090101 PMCID: PMC10120368 DOI: 10.1016/j.jtocrr.2023.100482] [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: 11/07/2022] [Revised: 01/24/2023] [Accepted: 02/16/2023] [Indexed: 04/25/2023] Open
Abstract
Introduction Landmark trials testing immune checkpoint inhibitors (ICIs) in advanced NSCLC are difficult to extrapolate to real-world practice given the exclusion of patients with poor (i.e., ≥2) Eastern Cooperative Oncology Group performance status (ECOG PS). We sought to evaluate the impact of ECOG PS on clinical outcomes and health care utilization in patients with NSCLC treated with ICIs in real-world practice. Methods Patients with advanced NSCLC who received at least one dose of pembrolizumab or nivolumab were retrospectively identified from the Alberta Immunotherapy Database. The primary outcome was median overall survival, as stratified by ECOG PS. Secondary outcomes included median time-to-treatment failure and metrics of health care utilization, including emergency department visits, hospitalizations, and death in hospital. Results A total of 790 patients were included, with 29.2% having poor ECOG PS at initiation of ICI. These patients had significantly lower median overall survival (3.3 versus 13.4 mo) and median time-to-treatment failure (1.4 versus 4.9 mo) compared with those with favorable ECOG PS (p < 0.0001 for both outcomes). Patients with poor ECOG PS were also more likely to present to the emergency department, be admitted to the hospital, and die in the hospital during their first admission (risk ratio = 1.6, 2.3-2.7, p < 0.001). Conclusions Patients with NSCLC with poor ECOG PS treated with ICI had significantly worse survival outcomes and were significantly more likely to use health care services than those with favorable ECOG PS. The large proportion of patients with poor ECOG PS further justifies the urgent need for randomized trials evaluating the efficacy of ICI in this high-risk population.
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Affiliation(s)
- Daniel E. Meyers
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Corresponding author. Address for correspondence: Daniel E. Meyers, MD, MSc, Department of Oncology, University of Calgary, 1331 29th Street Northwest, Calgary, AB T2N 4N2, Canada.
| | - Meghann Pasternak
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Samantha Dolter
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | | | - Chloe A. Lim
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Igor Stukalin
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Siddhartha Goutam
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Vishal Navani
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Daniel Y.C. Heng
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Winson Y. Cheung
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Don G. Morris
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Aliyah Pabani
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
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Brugel M, Dupont M, Carlier C, Botsen D, Essi DE, Sanchez V, Slimano F, Perrier M, Bouché O. Association of palliative care management and survival after chemotherapy discontinuation in patients with advanced pancreatic adenocarcinoma: A retrospective single-centre observational study. Pancreatology 2023:S1424-3903(23)00069-8. [PMID: 37037682 DOI: 10.1016/j.pan.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 02/20/2023] [Accepted: 03/16/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Palliative care (PC) is integrated into standard oncology care. However, its clinical impact at the end of life remains unclear in pancreatic adenocarcinoma (PA). We aimed to describe the end-of-life care pathway and to assess whether PC referral influences survival after chemotherapy discontinuation (CD) among advanced PA patients. METHODS This retrospective single-centre observational study was conducted among deceased patients with advanced PA who had received chemotherapy between January 1, 2016, and December 31, 2021. Baseline characteristics, the timing of PC referral and events after CD were collected. The primary outcome was time from CD to death. RESULTS Among the 148 included patients, 53.4% (n = 79) received PC, mostly late after the CD (n = 133, 89.9%), 16.9% (n = 25) received chemotherapy in the last 14 days of life and 75.6% died at the hospital. None received PC in the 8 weeks following the diagnosis. PC referral significantly increased PC department admissions (p < 0.001) and decreased medical unit admissions (p < 0.001). The median survival after the CD was 35 days (IQR: 19-64.5). PC referral was associated with increased survival after CD (HR: 0.65 [0.47-0.90], p = 0.010, Cox) and after adjusting (HR: 0.65 [0.42-0.99], p = 0.045, Cox). CONCLUSION The study suggests that PC may be associated with longer survival after CD in advanced PA patients. However, PC is underused, and patients are referred late in their care pathway.
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Affiliation(s)
- M Brugel
- Université de Reims Champagne-Ardenne, Department of Ambulatory Oncology Care Unit, CHU Reims, Reims, France.
| | - M Dupont
- Department of Medical Oncology, Institut Jean Godinot, Reims, France
| | - C Carlier
- Université de Reims Champagne-Ardenne, Department of Ambulatory Oncology Care Unit, CHU Reims, Reims, France; Department of Medical Oncology, Institut Jean Godinot, Reims, France
| | - D Botsen
- Université de Reims Champagne-Ardenne, Department of Ambulatory Oncology Care Unit, CHU Reims, Reims, France; Department of Medical Oncology, Institut Jean Godinot, Reims, France
| | - D Edoh Essi
- Department of Medical Oncology, Institut Jean Godinot, Reims, France
| | - V Sanchez
- Department of Palliative Care, CHU Reims, Reims, France
| | - F Slimano
- Université de Reims Champagne-Ardenne, Department of Pharmacy, CHU Reims, Reims, France
| | - M Perrier
- Université de Reims Champagne-Ardenne, Department of Ambulatory Oncology Care Unit, CHU Reims, Reims, France
| | - O Bouché
- Université de Reims Champagne-Ardenne, Department of Ambulatory Oncology Care Unit, CHU Reims, Reims, France
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Pain and Interventions in Stage IV Non-Small Cell Lung Cancer: A Province-Wide Analysis. Curr Oncol 2023; 30:3461-3472. [PMID: 36975475 PMCID: PMC10047317 DOI: 10.3390/curroncol30030262] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/25/2023] [Accepted: 03/15/2023] [Indexed: 03/22/2023] Open
Abstract
Pain is a common symptom in stage IV non-small cell lung cancer (NSCLC). The objective of the study was to examine the use of interventions and factors associated with interventions for pain. A population-based cohort study in Ontario, Canada was conducted with patients diagnosed with stage IV NSCLC from January 2007 to September 2018. An Edmonton Symptom Assessment System (ESAS) score of ≥4 defined moderate-to-severe pain following diagnosis. The study cohort included 13,159 patients, of which 68.5% reported at least one moderate-to-severe pain score. Most patients were assessed by a palliative care team (85.4%), and the majority received radiation therapy (73.2%). The use of nerve block was rare (0.8%). For patients ≥65 years of age who had drug coverage, 59.6% received an opiate prescription. Patients with moderate-to-severe pain were more likely to receive palliative assessment or radiation therapy compared to patients with none or mild pain. Patients aged ≥70 years and with a greater comorbidity burden were associated with less likelihood to receive radiation therapy. Patients from rural/non-major urban residence and with a greater comorbidity burden were also less likely to receive palliative care assessment. Factors associated with interventions for pain are described to inform future symptom management in this population.
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Jogerst K, Zhang C, Chang YH, Abujbarah S, Ali-Mucheru M, Pockaj B, Stucky CC, Cronin P, Wasif N. Socioeconomic and racial disparities in survival for patients with stage IV cancer. Am J Surg 2023:S0002-9610(23)00099-5. [PMID: 36922322 DOI: 10.1016/j.amjsurg.2023.03.003] [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: 12/21/2022] [Revised: 02/20/2023] [Accepted: 03/03/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Disparities in cancer outcomes for minoritized people and groups experiencing disadvantages with Stage IV cancer is largely unknown. METHODS Patients with Stage IV pancreatic, colorectal, lung, breast, and prostate cancer were identified from 2004 to 2015 in the National Cancer Database. Cox proportional hazard models were used to quantify how demographics and treatments received were associated with overall survival. RESULTS 903,151 patients were included. Patients who were younger, non-Hispanic White, had private insurance, higher income, or received care at an academic center were more likely to receive surgery, chemotherapy, and/or radiation therapy (p < 0.001). Black patients, those with Medicare, Medicaid, no insurance, and lower income had lower survival rates across all five cancer types (p < 0.001). On multivariable analysis, receipt of surgery, radiation, and chemotherapy attenuated but did not eliminate this worse survival (p < 0.001). CONCLUSIONS Survival for patients with Stage IV cancer differs by socioeconomic and self-reported racial classifications.
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Affiliation(s)
- Kristen Jogerst
- Department of Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Chi Zhang
- Department of Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First St. SW, Harwick Building, 2nd Floor, Rochester, MN, 55905, USA
| | - Yu-Hui Chang
- Mayo Foundation for Medical Education and Research, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Sami Abujbarah
- Mayo Clinic Alix School of Medicine, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Mariam Ali-Mucheru
- Department of Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Barbara Pockaj
- Department of Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Chee-Chee Stucky
- Department of Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Patricia Cronin
- Department of Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Nabil Wasif
- Department of Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA.
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Recent Developments in the Evaluation and Management of Cardiorenal Syndrome: A Comprehensive Review. Curr Probl Cardiol 2023; 48:101509. [PMID: 36402213 DOI: 10.1016/j.cpcardiol.2022.101509] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
Cardiorenal syndrome (CRS) is an increasingly recognized diagnostic entity associated with high morbidity and mortality among acutely ill heart failure (HF) patients with acute and/ or chronic kidney diseases (CKD). While traditionally viewed as a state of decline in glomerular filtration rate (GFR) due to decreased renal perfusion, mainly due to therapeutic interventions to relieve congestive in HF, recent insights into the underlying pathophysiologic mechanisms of CRS led to a broader definition and further classification of CRS into 5 distinct types. In this comprehensive review, we discuss the classification of CRS, highlighting the underlying common pathogenetic pathways of heart failure and kidney injury, including increased congestion, neurohormonal dysregulation, oxidative stress as well as inflammation, and cytokine storm that are particularly evident in COVID-19 patients with multiorgan failure and also in those with other disorders including sepsis, systemic lupus erythematosus and amyloidosis. In this review we also present the recent advances in the diagnostic strategies of CRS including cardiac and renal biomarkers as well as advanced cardiac and renal imaging techniques that are available to aid in the diagnosis as well as in the prognostication of this disorder. Finally, we discuss the various therapeutic options available to-date, including fluid optimization, hemofiltration, renal replacement therapy as well as the role of SGLT2 inhibitors in light of recent data from RCTs. It is important to note that, CRS population are either excluded or underrepresented, at best, in major RCTs and therefore, therapeutic recommendations are largely extrapolated from HF and CKD clinical trials.
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Natesan D, Carpenter DJ, Giles W, Oyekunle T, Niedzwiecki D, Reitman ZJ, Kirkpatrick JP, Floyd SR. Clinical Factors Associated with 30-Day Mortality Among Patients Undergoing Brain Metastases Radiotherapy. Adv Radiat Oncol 2023; 8:101211. [PMID: 37152484 PMCID: PMC10157109 DOI: 10.1016/j.adro.2023.101211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 02/24/2023] [Indexed: 03/11/2023] Open
Abstract
Purpose Existing brain metastasis prognostic models do not identify patients at risk of very poor survival after radiation therapy (RT). Identifying patient and disease risk factors for 30-day mortality (30-DM) after RT may help identify patients who would not benefit from RT. Methods and Materials All patients who received stereotactic radiosurgery (SRS) or whole-brain RT (WBRT) for brain metastases from January 1, 2017, to September 30, 2020, at a single tertiary care center were included. Variables regarding demographics, systemic and intracranial disease characteristics, symptoms, RT, palliative care, and death were recorded. Thirty-day mortality was defined as death within 30 days of RT completion. The Kaplan-Meier method was used to estimate median overall survival. Univariate and multivariable logistic regression models were used to assess associations between demographic, tumor, and treatment factors and 30-DM. Results A total of 636 patients with brain metastases were treated with either WBRT (n = 117) or SRS (n = 519). The most common primary disease types were non-small cell lung (46.7%) and breast (19.8%) cancer. Median survival time was 6 months (95% CI, 5-7 months). Of the 636 patients, 75 (11.7%) died within 30 days of RT. On multivariable analysis, progressive intrathoracic disease (hazard ratio [HR], 4.67; 95% CI, 2.06-10.60; P = .002), progressive liver and/or adrenal metastases (HR, 2.20; 95% CI, 1.16-3.68; P = .02), and inpatient status (HR, 4.51; 95% CI, 1.78-11.42; P = .002) were associated with dying within 30 days of RT. A higher Karnofsky Performance Status (KPS) score (HR, 0.95; 95% CI, 0.93-0.97; P < .001), synchronous brain metastases at time of initial diagnosis (HR, 0.45; 95% CI, 0.21-0.96; P = .04), and outpatient palliative care utilization (HR, 0.45; 95% CI, 0.20-1.00; P = .05) were associated with surviving more than 30 days after RT. Conclusions Multiple factors including a lower KPS, progressive intrathoracic disease, progressive liver and/or adrenal metastases, and inpatient status were associated with 30-DM after RT. A higher KPS, brain metastases at initial diagnosis, and outpatient palliative care utilization were associated with survival beyond 30 days. These data may aid in identifying which patients may benefit from brain metastasis-directed RT.
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Affiliation(s)
| | | | | | - Taofik Oyekunle
- Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Donna Niedzwiecki
- Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | | | | | - Scott R. Floyd
- Departments of Radiation Oncology
- Corresponding author: Scott R. Floyd, MD, PhD
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Shieh LT, Ho CH, Guo HR, Ho YC, Ho SY. Comparison of healthcare utilization and life-sustaining interventions between patients with glioblastoma receiving palliative care or not: A population-based study. Palliat Med 2023; 37:824-833. [PMID: 36789966 DOI: 10.1177/02692163231152526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Palliative care has historically been under-utilized in patients with glioblastoma. Furthermore, literature on the utilization of healthcare and life-sustaining interventions during the late-stage of glioblastoma has been limited. AIM To identify and compare healthcare utilization and life-sustaining interventions between patients with glioblastoma who received palliative care and who did not based on patients identified retrospectively from Taiwan Cancer Registry between January 2007 and December 2017. DESIGN In this study, palliative care was defined on the basis of claims submitted to the National Health Insurance, which has a specific code for it. Variables included demographic characteristics, the utilization of healthcare services, and invasive life-sustaining interventions. SETTING/PARTICIPANTS Of the 1994 patients with glioblastoma identified, 1784 fulfilled the inclusion criteria, 613 (34%) of whom received palliative care. RESULTS The survival of patients with glioblastoma under palliative care was significantly longer than that of those without palliative care. Those without palliative care had significantly more frequent intensive care unit admissions and a longer cumulative length of intensive care unit stay. Regarding cardiopulmonary or respiratory treatments, patients without palliative care had significantly more invasive interventions than those with palliative care. Patients receiving palliative care had significantly lower odds than those without life-sustaining interventions. CONCLUSIONS Our retrospective analysis reveals that glioblastoma patients without palliative care had greater odds of receiving life-sustaining treatments within 1 year before their death, although no gains in survival as compared to those that received palliative care. These findings highlight the urgent need for palliative care in caring for patients with glioblastoma.
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Affiliation(s)
- Li-Tsun Shieh
- Department of Radiation Oncology, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan.,Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - How-Ran Guo
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yi-Chia Ho
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Sheng-Yow Ho
- Department of Radiation Oncology, Chi Mei Medical Center, Liouying, Tainan, Taiwan.,Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan, Taiwan
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Blum TG, Morgan RL, Durieux V, Chorostowska-Wynimko J, Baldwin DR, Boyd J, Faivre-Finn C, Galateau-Salle F, Gamarra F, Grigoriu B, Hardavella G, Hauptmann M, Jakobsen E, Jovanovic D, Knaut P, Massard G, McPhelim J, Meert AP, Milroy R, Muhr R, Mutti L, Paesmans M, Powell P, Putora PM, Rawlinson J, Rich AL, Rigau D, de Ruysscher D, Sculier JP, Schepereel A, Subotic D, Van Schil P, Tonia T, Williams C, Berghmans T. European Respiratory Society guideline on various aspects of quality in lung cancer care. Eur Respir J 2023; 61:13993003.03201-2021. [PMID: 36396145 DOI: 10.1183/13993003.03201-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.
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Affiliation(s)
- Torsten Gerriet Blum
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Joanna Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - David R Baldwin
- Department of Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
| | | | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | | | | | - Bogdan Grigoriu
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Georgia Hardavella
- Department of Respiratory Medicine, King's College Hospital London, London, UK
- Department of Respiratory Medicine and Allergy, King's College London, London, UK
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Neuruppin, Germany
| | - Erik Jakobsen
- Department of Thoracic Surgery, Odense University Hospital, Odense, Denmark
| | | | - Paul Knaut
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Gilbert Massard
- Faculty of Science, Technology and Medicine, University of Luxembourg and Department of Thoracic Surgery, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | - John McPhelim
- Lung Cancer Nurse Specialist, Hairmyres Hospital, NHS Lanarkshire, East Kilbride, UK
| | - Anne-Pascale Meert
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Robert Milroy
- Scottish Lung Cancer Forum, Glasgow Royal Infirmary, Glasgow, UK
| | - Riccardo Muhr
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Luciano Mutti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- SHRO/Temple University, Philadelphia, PA, USA
| | - Marianne Paesmans
- Data Centre, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Paul Martin Putora
- Departments of Radiation Oncology, Kantonsspital St Gallen, St Gallen and University of Bern, Bern, Switzerland
| | | | - Anna L Rich
- Department of Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
| | - David Rigau
- Iberoamerican Cochrane Center, Barcelona, Spain
| | - Dirk de Ruysscher
- Maastricht University Medical Center, Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
- Erasmus Medical Center, Department of Radiation Oncology, Rotterdam, The Netherlands
| | - Jean-Paul Sculier
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Arnaud Schepereel
- Pulmonary and Thoracic Oncology, Université de Lille, Inserm, CHU Lille, Lille, France
| | - Dragan Subotic
- Clinic for Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Thierry Berghmans
- Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
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Navani V, Meyers DE, Ruan Y, Boyne DJ, O'Sullivan DE, Dolter S, Grosjean HA, Stukalin I, Heng DYC, Morris DG, Brenner DR, Sangha R, Cheung WY, Pabani A. Lung Immune Therapy Evaluation (LITE) Risk, a Novel Prognostic Model for Patients With Advanced Non-Small Cell Lung Cancer Treated With Immune Checkpoint Blockade. Clin Lung Cancer 2023; 24:e152-e159. [PMID: 36774234 DOI: 10.1016/j.cllc.2022.12.014] [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: 07/28/2022] [Revised: 10/28/2022] [Accepted: 12/26/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION/BACKGROUND Immune checkpoint inhibitors (ICI) have revolutionized non-small cell lung cancer (NSCLC). We aimed to identify baseline characteristics, that are prognostic factors for overall survival (OS) in patients with NSCLC treated with ICI monotherapy, in order to derive the Lung Immune Therapy Evaluation (LITE) risk, a prognostic model. MATERIALS AND METHODS Multi-center observational cohort study of patients with advanced NSCLC that received ≥1 dose of ICI monotherapy. The training set (n=342) consisted of patients with NSCLC who received first line ICI. The test set (n=153) used for external validation was a discrete cohort of patients who received second line ICI. 20 candidate prognostic factors were examined. Penalized Cox regression was used for variable selection. Multiple imputation was used to address missingness. RESULTS Three baseline characteristics populated the final model: ECOG (0, 1 or ≥2), lactate dehydrogenase>upper limit of normal, and derived neutrophil to lymphocyte ratio ≥3. Patients were parsed into 3 risk groups; favorable (n=146, risk score 0-1), intermediate (n=101, risk score 2) and poor (n=95, risk score ≥3). The c-statistic of the training cohort was 0.702 and 0.694 after bootstrapping. The test cohort c-statistic was 0.664. The median OS for favorable, intermediate and poor LITE risk were; 28.3 months, 9.1 months and 2.1 months respectively. Improving LITE risk group was associated with improved OS, intermediate vs favorable HR 2.08 (95%CI 1.46-2.97, P < .001); poor vs favorable HR 5.21 (95%CI 3.69-7.34, P < .001). CONCLUSION A simple prognostic model, utilizing accessible clinical data, can discriminate survival outcomes in patients with advanced NSCLC.
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Affiliation(s)
- Vishal Navani
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada; Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Daniel E Meyers
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Yibing Ruan
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, Alberta, Canada; Forzani & MacPhail Colon Cancer Screening Centre, University of Calgary, Calgary, Alberta, Canada
| | - Devon J Boyne
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, Alberta, Canada
| | - Dylan E O'Sullivan
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, Alberta, Canada; Forzani & MacPhail Colon Cancer Screening Centre, University of Calgary, Calgary, Alberta, Canada
| | - Samantha Dolter
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Heidi Ai Grosjean
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Igor Stukalin
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Daniel Y C Heng
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada; Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Don G Morris
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada; Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darren R Brenner
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, Alberta, Canada
| | - Randeep Sangha
- Department of Medical Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Winson Y Cheung
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada; Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Aliyah Pabani
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada; Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Lycan TW, Buckenheimer A, Ruiz J, Russell G, Dothard AS, Ahmed T, Grant S, Grey C, Petty WJ. Team-Based Hospice Referrals: A Potential Quality Metric for Lung Cancer in the Immunotherapy Era. Am J Hosp Palliat Care 2023; 40:10-17. [PMID: 35512681 PMCID: PMC9815203 DOI: 10.1177/10499091221091745] [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: 01/11/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) can lead to durable responses in patients with lung cancer but may delay transitions to hospice at the end of life (EOL). We aimed to test the association of continuity of care with EOL outcomes in the ICI era. METHODS We collected retrospective data on all patients with lung cancer who started ICI treatment at a single comprehensive cancer center in the United States (1/1/14-5/1/18) and subsequently died. We defined a hospice referral as having continuity of care if placed by a provider from the patient's multidisciplinary cancer team (e.g., a medical oncologist, palliative care specialist, intensivist, and hospitalist). RESULTS In this cohort of 143 patients, 58% had a team-based hospice referral which was associated with a lower risk of death in the hospital. The most common reason patients declined hospice at EOL was an unwillingness to discontinue cancer-directed therapy. As compared to a similar historical cohort of patients treated with chemotherapy alone (2008-2010), there was a similar rate of hospice referral (68% vs 74%) but higher rates of new systemic therapy initiated within 30 days of death (17% vs 6%, p .001) and last dose within 14 days of death (13% vs 5%, p .005). CONCLUSIONS Future studies should test the continuity of care at EOL as a new quality metric for advanced NSCLC.
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Affiliation(s)
- Thomas W. Lycan
- Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Alyssa Buckenheimer
- Hospice abd Palliative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jimmy Ruiz
- Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gregory Russell
- Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Andy Shipe Dothard
- Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Tamjeed Ahmed
- Hematology and Oncology, Tennessee Oncology, Gallatin, TN, USA
| | - Stefan Grant
- Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Carl Grey
- Hospice abd Palliative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - William J. Petty
- Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Sullivan DR, Vranas KC, Delorit M, Golden SE, Slatore CG, Ganzini L, Hansen L. Relationships among clinicians are crucial to successful palliative care integration: a qualitative study in lung cancer. Future Oncol 2023; 19:245-257. [PMID: 36974605 PMCID: PMC10119814 DOI: 10.2217/fon-2022-0958] [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] [Received: 09/27/2022] [Accepted: 01/19/2023] [Indexed: 03/29/2023] Open
Abstract
Aims: Palliative care integration improves quality of life among patients with lung cancer and their families. Despite these benefits, significant barriers persist and patients do not receive timely integration. This study sought to identify facilitators of and barriers to integration in lung cancer care. Materials & methods: Semistructured qualitative interviews were conducted with palliative care and lung cancer clinicians and analyzed using traditional content analysis. 23 clinicians were interviewed from geographically dispersed hospitals within a national healthcare system. Results: Palliative care integration improved over time, enhanced by several facilitators stratified at four levels (patient/clinician/hospital/organization). Most important among these was multidisciplinary care delivered in outpatient settings, fostering trust and relationships among clinicians which were pivotal to successful integration. Workforce shortages and limited use of primary palliative care among lung cancer clinicians need to be addressed for continued growth in the field. Conclusion: Relationships among clinicians are crucial to successful palliative care integration in lung cancer care.
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Affiliation(s)
- Donald R Sullivan
- Division of Pulmonary & Critical Care Medicine, Oregon Health & Science University OHSU, Portland, OR 97239, USA
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System (VAPORHCS), Portland, OR 97239, USA
- Cancer Prevention & Control Program, Knight Cancer Institute, OHSU, Portland, OR 97239, USA
| | - Kelly C Vranas
- Division of Pulmonary & Critical Care Medicine, Oregon Health & Science University OHSU, Portland, OR 97239, USA
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System (VAPORHCS), Portland, OR 97239, USA
- Section of Pulmonary & Critical Care Medicine, VAPORHCS, Portand, OR 97239, USA
- Department of Medicine, Palliative & Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Molly Delorit
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System (VAPORHCS), Portland, OR 97239, USA
| | - Sara E Golden
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System (VAPORHCS), Portland, OR 97239, USA
| | - Christopher G Slatore
- Division of Pulmonary & Critical Care Medicine, Oregon Health & Science University OHSU, Portland, OR 97239, USA
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System (VAPORHCS), Portland, OR 97239, USA
- Cancer Prevention & Control Program, Knight Cancer Institute, OHSU, Portland, OR 97239, USA
- Section of Pulmonary & Critical Care Medicine, VAPORHCS, Portand, OR 97239, USA
| | - Linda Ganzini
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System (VAPORHCS), Portland, OR 97239, USA
- Department of Psychiatry, Division of Geriatric Psychiatry, OHSU, Portland, OR 97239, USA
| | - Lissi Hansen
- Cancer Prevention & Control Program, Knight Cancer Institute, OHSU, Portland, OR 97239, USA
- School of Nursing, OHSU, Portland, OR 97239, USA
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Schweiger L, Vranas KC, Furuno JP, Hansen L, Slatore CG, Sullivan DR. Association of Patient-Centered Elements of Care and Palliative Care Among Patients With Advanced Lung Cancer. Am J Hosp Palliat Care 2023; 40:18-26. [PMID: 36191296 PMCID: PMC9772174 DOI: 10.1177/10499091221130944] [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: 12/24/2022] Open
Abstract
CONTEXT Palliative care (PC) is associated with improved quality of life, survival, and decreased healthcare use at the end of life among lung cancer patients. However, the specific elements of palliative care that may contribute to these benefits are unclear. OBJECTIVES To evaluate the associations of PC and its setting of delivery with prescriptions of symptom management medications, advance care planning (ACP), hospice enrollment, and home health care (HHC) receipt. METHODS Retrospective, cohort study of patients with advanced stage (IIIB/IV) lung cancer in the Veterans Health Administration (VA) diagnosed from 2007-2013; with follow-up through 2017. Propensity score methods were used with inverse probability of treatment weighting and logistic regression modeling, adjusting for patient and tumor characteristics. RESULTS Among 23 142 patients, 57% received PC. Compared to non-receipt of PC, PC in any setting (inpatient or outpatient) was associated with increased prescriptions of pain medications (Adjusted Odds Ratio (aOR) = 1.63, 95% CI: 1.45-1.83), constipation regimen with pain medications (aOR = 2.04, 95% CI: 1.63-2.54), and antidepressants (aOR = 1.78, 95% CI: 1.52-2.09). PC was also associated with increased ACP (aOR = 1.52, 95% CI: 1.37-1.67) and hospice enrollment (aOR = 1.39, 95% CI:1.31-1.47), and decreased HHC (aOR = 0.79, 95% CI: 0.70-.90) compared to non-receipt of PC. Receipt of PC in outpatient settings was associated with increased prescriptions of pain medications (aOR = 2.54, 95% CI: 2.13-3.04) and antidepressants (aOR = 1.76, 95% CI: 1.46-2.12), and hospice enrollment (aOR = 2.09, 95% CI: 1.90-2.31) compared to receipt of PC in inpatient settings. CONCLUSIONS PC is associated with increased use of symptom management medications, ACP, and hospice enrollment, especially when delivered in outpatient settings. These elements of care elucidate potential mechanisms for improved outcomes associated with PC and provide a framework for a primary palliative care approach among non-palliative care clinicians.
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Affiliation(s)
- Liana Schweiger
- Center to Improve Veteran Involvement in Care, Health Services Research & Development, VA Portland Health Care System; Portland, OR
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University; Portland, OR
- Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System; Portland, OR
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in Care, Health Services Research & Development, VA Portland Health Care System; Portland, OR
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University; Portland, OR
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania; Philadelphia, PA
- Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System; Portland, OR
| | - Jon P Furuno
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, OR
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in Care, Health Services Research & Development, VA Portland Health Care System; Portland, OR
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University; Portland, OR
- Knight Cancer Institute, Oregon Health & Science University; Portland, OR
- Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System; Portland, OR
| | - Donald R. Sullivan
- Center to Improve Veteran Involvement in Care, Health Services Research & Development, VA Portland Health Care System; Portland, OR
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University; Portland, OR
- Knight Cancer Institute, Oregon Health & Science University; Portland, OR
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49
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Islam JY, Braithwaite D, Zhang D, Guo Y, Tailor TD, Akinyemiju T. Racial and ethnic inequities of palliative care use among advanced
Non‐Small
cell lung cancer patients in the
US. Cancer Med 2022; 12:8567-8580. [PMID: 36533434 PMCID: PMC10134338 DOI: 10.1002/cam4.5538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/03/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND With early intervention, palliative care (PC) can improve quality of life and increase survival among advanced-stage non-small cell lung cancer (aNCSLC) patients. However, PC is often offered late in the cancer treatment course and is underused. We characterized racial/ethnic inequities and the role of healthcare access in PC use among patients with aNSCLC. METHODS We used data from the 2004-2016 National Cancer Database, including adults aged 18-90 years with aNSCLC (stage 3 or 4 at diagnosis; n = 803,618). Based on the NCCN guidelines, PC includes non-curative surgery, radiation, chemotherapy, pain management, or any combination of non-curative care. We examined PC use by sociodemographic and health care-level characteristics. To evaluate the independent associations of race/ethnicity and health care access characteristics with PC, we estimated adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). Covariate adjustment sets varied by exposure determined using directed acyclic graphs. RESULTS Our population was 55% male and 77% non-Hispanic/Latinx (NH)-White, with a mean age of 68 years. Overall, 19% of patients with aNSCLC used PC. Compared to NH-White patients, NH-Black (aOR:0.91,95% CI:0.89-0.93) and Hispanic/Latinx (aOR:0.80,95% CI:0.77-0.83) patients were less likely to use PC, whereas Indigenous (AI/AN) (aOR:1.18,95% CI:1.06-1.31) and Native Hawaiian/Pacific Islander (aOR:2.08,95% CI:1.83-2.36) patients were more likely. Overall, compared to the privately-insured, uninsured (aOR:1.19,95% CI:1.11-1.28) and Medicaid-insured patients (aOR:1.19,95% CI:1.14-1.25) were more likely to use PC. CONCLUSION PC is underutilized among NH-Black and Hispanic/Latinx patients with aNSCLC. Insurance type may play a role in PC use among patients with aNSCLC.
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Affiliation(s)
- Jessica Y. Islam
- Center for Immunization and Infections in Cancer, Cancer Epidemiology Program, H. Lee Moffitt Cancer Center Tampa Florida USA
- Department of Population Health Sciences Duke University School of Medicine Durham North Carolina USA
| | - Dejana Braithwaite
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine University of Florida Gainesville Florida USA
| | - Dongyu Zhang
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine University of Florida Gainesville Florida USA
| | - Yi Guo
- Department of Health Outcomes and Biomedical Informatics, College of Medicine University of Florida Gainesville Florida USA
| | - Tina D. Tailor
- Department of Radiology Duke University School of Medicine Durham North Carolina USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences Duke University School of Medicine Durham North Carolina USA
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50
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Billiot AA, Danos DM, Stevens J, Vance KM, Raven MC, Lyons JM. Palliative care reduces emergency room visits and total hospital days among patients with metastatic HPB and GI cancers. Sci Rep 2022; 12:21068. [PMID: 36473913 PMCID: PMC9727158 DOI: 10.1038/s41598-022-23928-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
Palliative care services (PCS) have improved quality of life for patients across various cancer subtypes. Minimal data exists regarding PCSfor metastatic hepatopancreaticobiliary (HPB) and gastrointestinal (GI) cancers. We assessed the impact of PCS on emergency department visits, hospital admissions, and survival among these patients. Patients with metastatic HPB and GI cancer referred to outpatient PCS between 2014 and 2018 at a single institution were included. We compared the demographics, outcomes, and end-of-life indicators between those who did and did not receive PCS. The study included 183 patients, with 118 (64.5%) having received PCS. There were no significant differences in age, gender, race, marital status, or insurance. Those receiving PCS were more likely to have colorectal cancer (p = 0.0082) and receive chemotherapy (p = 0.0098). On multivariate analysis, PCS was associated with fewer ED visits (p = 0.0319), hospital admissions (p = 0.0002), and total inpatient hospital days (p < 0.0001) per 30 days of life. Overall survival was greater among patients receiving PCS (HR: 0.65 (0.46-0.92)). Outpatient PCS for patients with metastatic HPB and GI cancer is associated with fewer emergency department visits, hospital admissions, and inpatient hospital days, and improved overall survival.
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Affiliation(s)
- Angelle A. Billiot
- grid.279863.10000 0000 8954 1233LSUHSC Department of Surgery, New Orleans, LA USA
| | - Denise M. Danos
- grid.279863.10000 0000 8954 1233LSUHSC School of Public Health, New Orleans, LA USA
| | - Jenny Stevens
- grid.279863.10000 0000 8954 1233LSUHSC Department of Surgery, New Orleans, LA USA
| | - Katie M. Vance
- Our Lady of the Lake-Division of Academic Affairs, Baton Rouge, LA USA
| | - Mary C. Raven
- Our Lady of the Lake Cancer Institute, 7777 Hennessy Blvd, Baton Rouge, LA 70808 USA
| | - John M. Lyons
- grid.279863.10000 0000 8954 1233LSUHSC Department of Surgery, New Orleans, LA USA ,Our Lady of the Lake Cancer Institute, 7777 Hennessy Blvd, Baton Rouge, LA 70808 USA
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