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Marshall C, Virdun C, Phillips JL. Patient and family perspectives on rural palliative care models: A systematic review and meta-synthesis. Palliat Med 2024:2692163241269796. [PMID: 39254116 DOI: 10.1177/02692163241269796] [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: 09/11/2024]
Abstract
BACKGROUND Almost half the world's population lives in rural areas. How best to provide palliative care to rural populations is unclear. Privileging rural patient and family voices about their experiences of receiving care delivered via rural palliative care models is necessary. AIM To identify the key palliative care elements that rural patients with palliative care needs and their families perceive to be critical to receiving the care and support they need to live well. DESIGN AND DATA SOURCES A systematic review and meta-synthesis registered with Prospero (CRD42020154273). Three databases were searched in June 2024. Raw qualitative data were extracted and analysed using Thomas and Harden's three-stage thematic synthesis methodology. Findings reported according to the PRISMA statement. RESULTS Of the 10,834 identified papers, 11 met the inclusion criteria. Meta-synthesis of extracted, raw quotes (n = 209) revealed three major themes: (1) Honouring the patient's existing relationship with their General Practitioner (GP); (2) strategically timed access to specialist services, clinicians and equipment is critical; and (3) a need to feel safe, prepared and supported. CONCLUSION The strategic inclusion of specialists alongside primary care providers is integral to optimising rural palliative care models. General Practioners are central to these models, through being embedded in their communities and as the conduit to specialist palliative care services. Rural palliative care patients and families value responsive care, trajectory signposting, effective communication, 24/7 support and recognise the value of virtual health. Globally, positive public policy and funding is critical to ensuring access to GP-led, specialist-supported, rural palliative care models.
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Affiliation(s)
- Claire Marshall
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, NSW, Australia
| | - Claudia Virdun
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, NSW, Australia
- Flinders Research Centre for Palliative Care, Death, and Dying, College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
- Faculty of Health, Cancer and Palliative Care Outcomes Centre, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - Jane L Phillips
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, NSW, Australia
- Faculty of Health, Queensland University of Technology, Kelvin Grove, QLD, Australia
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Cerni J, Hosseinzadeh H, Mullan J, Westley-Wise V, Chantrill L, Barclay G, Rhee J. Does Geography Play a Role in the Receipt of End-of-Life Care for Advanced Cancer Patients? Evidence from an Australian Local Health District Population-Based Study. J Palliat Med 2023; 26:1453-1465. [PMID: 37252775 PMCID: PMC10658736 DOI: 10.1089/jpm.2022.0555] [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] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives: To assess the influence of geographic remoteness on health care utilization at end of life (EOL) by people with advanced cancer in a geographically diverse Australian local health district, using two objective measures of rurality and travel-time estimations to health care facilities. Methods: This retrospective cohort study examined the association between rurality (using the Modified Monash Model) and travel-time estimation, and demographic and clinical factors, with the receipt of >1 inpatient and outpatient health service in the last year of life in multivariate models. The study cohort comprised of 3546 patients with cancer, aged ≥18 years, who died in a public hospital between 2015 and 2019. Results: Compared with decedents from metropolitan areas, decedents from some rural areas had higher rates of emergency department visits (small rural towns: aRR 1.29, 95% CI: 1.07-1.57) and ICU admissions (large rural towns: aRR 1.32, 95% CI: 1.03-1.69), but lower rates of acute hospital admissions (large rural towns: aRR 0.83, 95% CI: 0.76-0.90), inpatient palliative care (PC) (regional centers: aRR 0.85, 95% CI: 0.75-0.97), and inpatient radiotherapy (lowest in small rural towns: aRR 0.07, 95% CI: 0.03-0.18). Decedents from rural and regional centers had lower rates of outpatient chemotherapy and radiotherapy use, yet higher rates of outpatient cancer service utilization (p < 0.05). Shorter travel times (10-<30 minutes) were associated with higher rates of inpatient specialist PC (aRR 1.48, 95% CI: 1.09-1.98). Conclusions: Reporting on a series of inpatient and outpatient services used in the last year of life, measures of rurality and travel-time estimates can be useful tools to estimate geographic variation in EOL cancer care provision, with significant gaps uncovered in inpatient PC and outpatient service utilization in rural areas. Policies aimed at redistributing EOL resources in rural and regional communities to reduce travel times to health care facilities could help to reduce regional disparities and ensure equitable access to EOL care services.
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Affiliation(s)
- Jessica Cerni
- Faculty of Arts, Social Sciences, and Humanities, School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
| | - Hassan Hosseinzadeh
- Faculty of Arts, Social Sciences, and Humanities, School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
| | - Judy Mullan
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Victoria Westley-Wise
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), Illawarra Shoalhaven Local Health District (ISLHD), University of Wollongong, Wollongong, New South Wales, Australia
| | - Lorraine Chantrill
- Department of Medical Oncology and Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Greg Barclay
- Department of Palliative Care, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Joel Rhee
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
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Marshall C, Virdun C, Phillips JL. Evidence-based models of rural palliative care: A systematic review. Palliat Med 2023; 37:1129-1143. [PMID: 37537971 DOI: 10.1177/02692163231183994] [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: 08/05/2023]
Abstract
BACKGROUND Forty-five percent of the world's population lives in rural areas, yet their access to palliative care is quite limited. Identifying the care elements rural populations with palliative care needs require is critical to improving care outcomes. AIM To identify the key care elements that optimise palliative care for people in rural communities. DESIGN AND DATA SOURCES A systematic review of articles studying the impact of novel rural model of care interventions was undertaken in May 2022. This study is reported using the PRISMA Statement and was registered with Prospero (CRD42020154273). Three databases were searched, and the data analysed according to Popay's narrative synthesis, and elements classified using the WHO Innovative Care for Chronic Conditions (ICCC) Framework. RESULTS Of the 9508 identified papers, 15 met the inclusion criteria, reporting on 14 studies involving 1820 rural patients. Care received spanned 12/18 of the WHO ICCC Framework elements, with wide variability in how these elements were operationalised. The five elements that signal improved outcomes were: (1) Promote continuity and coordination; (2) Prepared, informed and motivated health care teams; (3) Prepared, informed and motivated patients and families; (4) Organise and equip health care teams and (5) Promote consistent financing. CONCLUSIONS A well-coordinated multidisciplinary team approach, led by clinicians with specialist palliative care expertise, integrated across local health care settings, using information systems and care planning, is critical to optimising rural palliative care patient outcomes. Rural patients and their families require timely input from specialist palliative care clinicians and information to address their needs.Prospero registration ID: CRD42020154273 https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=154273.
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Affiliation(s)
- Claire Marshall
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, NSW, Australia
| | - Claudia Virdun
- Faculty of Health, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - Jane L Phillips
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology Sydney, Sydney, NSW, Australia
- Faculty of Health, Queensland University of Technology, Kelvin Grove, QLD, Australia
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Svynarenko R, Cozad MJ, Keim-Malpass J, Lindley LC. Incremental cost analysis of pediatric hospice care in rural and urban Appalachia. J Rural Health 2023; 39:551-556. [PMID: 36127766 PMCID: PMC10025168 DOI: 10.1111/jrh.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Considering growing disparities in health outcomes between rural and urban areas of Appalachia, this study compared the incremental Medicaid costs of pediatric concurrent care (implemented by the Patient Protection and Affordable Care Act) versus standard hospice care. METHODS Data on 1,788 pediatric hospice patients, from the Appalachian region, collected between 2011 and 2013, were obtained from the Centers for Medicare and Medicaid Services. Incremental per-patient-per-month (PPM) costs of enrollment in concurrent versus standard hospice care were analyzed using multilevel generalized linear models. Increments for analysis were hospice length of stay (LOS). RESULTS For rural children enrolled in concurrent hospice care, the mean Medicaid cost of hospice care was $3,954 PPPM (95% CI: $3,223-$4,684) versus $1,933 PPPM (95% CI: $1,357-$2,509) for urban. For rural children enrolled in standard hospice care, the mean Medicaid cost was $2,889 PPPM (95% CI: $2,639-$3,139) versus $1,122 PPPM (95% CI: $980-$1,264) for urban. There were no statistically significant differences in Medicaid costs for LOS of 1 day. However, for LOS between 2 and 14 days, concurrent enrollment decreased total costs for urban children (IC = $-236.9 PPPM, 95% CI: $-421-$-53). For LOS of 15 days or more, concurrent care had higher costs compared to standard care, for both rural (IC = $1,399 PPPM, 95% CI: $92-$2,706) and urban children (IC = $1,867 PPPM, 95% CI: $1,172-$2,363). CONCLUSIONS The findings revealed that Medicaid costs for concurrent hospice care were highest among children in rural Appalachia. Future research on factors of high costs of rural care is needed.
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Affiliation(s)
| | - Melanie J. Cozad
- Department of Health Services Research and Administration, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Lisa C. Lindley
- College of Nursing, University of Tennessee, Knoxville, Tennessee
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Cornell PY, Halladay CW, Montano AR, Celardo C, Chmelka G, Silva JW, Rudolph JL. Social Work Staffing and Use of Palliative Care Among Recently Hospitalized Veterans. JAMA Netw Open 2023; 6:e2249731. [PMID: 36598783 PMCID: PMC9856777 DOI: 10.1001/jamanetworkopen.2022.49731] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Palliative care improves quality of life for patients and families but may be underused. OBJECTIVE To assess the association of an intervention to increase social work staffing in Veterans Health Administration primary care teams with use of palliative care among veterans with a recent hospitalization. DESIGN, SETTING, AND PARTICIPANTS This cohort study used differences-in-differences analyses of the change in palliative care use associated with implementation of the Social Work Patient Aligned Care Team (PACT) staffing program, conducted from October 1, 2016, to September 30, 2019. The study included 71 VA primary care sites serving rural veterans. Participants were adult veterans who received primary care services from a site enrolled in the program and who received inpatient hospital care. Data were analyzed from January 2020 to August 2022. EXPOSURES The PACT staffing program was a clinic-level intervention that provided 3-year seed funding to Veterans Health Administration medical centers to hire 1 or more additional social workers in primary care teams. Staggered timing of the intervention enabled comparison of mean outcomes across sites before and after the intervention. MAIN OUTCOMES AND MEASURES The primary outcome was the number of individuals per 1000 veterans who had any palliative care use in 30 days after an inpatient hospital stay. RESULTS The analytic sample included 43 200 veterans (mean [SD] age, 65.34 [13.95] years; 37 259 [86.25%] men) and a total of 91 675 episodes of inpatient hospital care. Among the total cohort, 8611 veterans (9.39%) were Black, 77 069 veterans (84.07%) were White, and 2679 veterans (2.92%) were another race (including American Indian or Alaskan Native, Asian, and Native Hawaiian or other Pacific Islander). A mean of 14.5 individuals per 1000 veterans (1329 individuals in all) used palliative care after a hospital stay. After the intervention, there was an increase of 15.6 (95% CI, 9.2-22.3) individuals per 1000 veterans using palliative or hospice care after a hospital stay, controlling for national time trends and veteran characteristics-a 2-fold difference relative to the mean. CONCLUSIONS AND RELEVANCE This cohort study found significant increases in use of palliative care for recently hospitalized veterans whose primary care team had additional social work staffing. These findings suggest that social workers may increase access to and/or use of palliative care. Future work should assess the mechanism for this association and whether the increase in palliative care is associated with other health or health care outcomes.
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Affiliation(s)
- Portia Y. Cornell
- Center of Innovation for Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island
- Brown University School of Public Health, Providence, Rhode Island
| | - Christopher W. Halladay
- Center of Innovation for Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | | | - Caitlin Celardo
- National Social Work Program, Care Management and Social Work Services, Patient Care Services, Department of Veterans Affairs, Washington, District of Columbia
- Northport VA Medical Center, Northport, New York
| | - Gina Chmelka
- National Social Work Program, Care Management and Social Work Services, Patient Care Services, Department of Veterans Affairs, Washington, District of Columbia
- Tomah VA Medical Center, Tomah, Wisconsin
| | - Jennifer W. Silva
- National Social Work Program, Care Management and Social Work Services, Patient Care Services, Department of Veterans Affairs, Washington, District of Columbia
- VA Tennessee Valley Healthcare System, Nashville
| | - James L. Rudolph
- Center of Innovation for Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island
- Brown University School of Public Health, Providence, Rhode Island
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Allen E, Stanek J, Lundorf J. Early Palliative Care Initiation: Role of the Primary Care Clinician. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Tsai Y, Lindley MC, Zhou F, Stokley S. Urban-Rural Disparities in Vaccination Service Use Among Low-Income Adolescents. J Adolesc Health 2021; 69:114-120. [PMID: 33288460 PMCID: PMC8175462 DOI: 10.1016/j.jadohealth.2020.10.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To access urban-rural disparities in vaccination service use among Medicaid-enrolled adolescents and examine its association with residence county characteristics. STUDY DESIGN We used the 2016 Medicaid T-MSIS Analytic File to estimate adolescents' use of vaccination services, defined as the proportion of adolescents aged 11-18 years with ≥ 1 vaccination visit in a county. We used linear regression and the Oaxaca-Blinder decomposition method to examine the association between county characteristics and urban-rural disparities in vaccination service use. RESULTS The analysis included 2,473 counties located in 38 states. The mean proportion of adolescents making ≥ 1 vaccination visit at the county level was low (36.09%) and was lower in rural than in urban counties (31.99% vs. 36.85%, p < .01). The number of primary care physicians (PCPs) was positively associated with vaccination service use in rural counties; in urban counties, % of households without a vehicle was negatively associated with vaccination service use. The decomposition results showed that 66.78% (3.24 percentage points) of the urban-rural disparities in vaccination service use could be attributed to urban-rural differences in the county characteristics included in the study. Characteristics measuring access to care (number of PCPs), social and economic factors (% adults with at least a bachelor's degree and % children in poverty), quality of care (influenza vaccination rates and preventable hospital stays), and demographics (% non-Hispanic black, % Hispanic, and % females) played a role in urban-rural disparities. CONCLUSIONS Differences in county characteristics could partly explain the observed urban-rural disparities in vaccination service use among low-income adolescents.
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Affiliation(s)
- Yuping Tsai
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
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Murday P, Downing K, Gaab E, Misasi J, Michelson KN. A Qualitative Study Describing Pediatric Palliative Care in Non-Metropolitan Areas of Illinois. Am J Hosp Palliat Care 2021; 39:18-26. [PMID: 33764190 DOI: 10.1177/10499091211005700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is little information about providing pediatric palliative care (PPC) in non-metropolitan areas. OBJECTIVE Describe the strengths of and challenges to delivering PPC in non-metropolitan communities and identify opportunities to improve care delivery. DESIGN A qualitative study involving focus groups (FGs) with PPC stakeholders. SETTING/PARTICIPANTS From 4 non-metropolitan areas in Illinois, we recruited 3 stakeholder groups: healthcare providers (HPs); bereaved parents; and parents caring for a seriously ill child (SIC). MEASUREMENTS At each site, we held an FG with people of the same stakeholder group and then an FG involving all stakeholders. Discussion topics included: availability and strengths of local PPC services, barriers to local PPC, opportunities for improving local PPC access and quality, and clinician educational needs. We analyzed data using phenomenology and directed content analysis. RESULTS Thirty people, 12 parents and 18 HPs, participated in FGs. Identified themes related to: PPC perceptions; availability and use of local resources; and challenges associated with travel, care coordination, and finances. Participants described benefits of and limits to local PPC including pediatric-specific issues such as attending to siblings, creating child peer-support activities, providing school guidance, and financing for PPC. Recommendations included suggestions to enhance care coordination, use existing resources, improve community and provider education, develop community networks, and minimize financial challenges. CONCLUSION Unique PPC challenges exist in non-metropolitan areas. PPC in non-metropolitan areas would benefit from enhancing local resource utilization and quality. Future work should address the challenges to providing PPC in non-metropolitan areas with a focus on pediatric-specific issues.
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Affiliation(s)
- Patrick Murday
- 12244Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kimberly Downing
- 442693Greater Illinois Pediatric Palliative Care Coalition, Evanston, IL, USA
| | - Erin Gaab
- 33244University of California, Merced, CA, USA
| | - Jennifer Misasi
- 442693Greater Illinois Pediatric Palliative Care Coalition, Evanston, IL, USA
| | - Kelly N Michelson
- 12244Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Rosted E, Aabom B, Hølge-Hazelton B, Raunkiær M. Comparing two models of outpatient specialised palliative care. BMC Palliat Care 2021; 20:33. [PMID: 33602200 PMCID: PMC7893925 DOI: 10.1186/s12904-021-00727-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/10/2021] [Indexed: 11/26/2022] Open
Abstract
Background Ideally, patients with life-threatening illness who are suffering from multiple symptoms and reduced quality of life should receive palliative care that addresses their specific needs. The many well-defined clinical pathways may not always leave room for a person-centred and individual approach with respect to symptom control, psychosocial and spiritual support, and practical issues. In deciding how to organize outpatient specialist palliative care (SPC), it is relevant to include the perspectives of both patients and families. Thus, the aim of this study was to compare two models for outpatient SPC: first contact between patient, next-of-kin and doctor/nurse in the form of a home visit; and first visit in the hospital setting. Method The study was a comparative mixed methods study with follow-up at one and 3 months. It started with a quantitative strand in the form of a 38-item questionnaire. Data were analysed using linear mixed effects models, with maximum likelihood estimation for each outcome variable. The repeated measurements on patient level were modelled by including random intercepts of patients in the mixed model. Results In total, 190 participants were enrolled, of whom 102 answered the first questionnaire. No differences were found between the two SPC interventions when development in satisfaction with care, communication or overall quality of life were compared. At baseline, a significantly higher score for satisfaction was found, in favour of first visit taking place in the hospital setting (65.91 vs. 55.83; p = 0.03) measured by FAMCARE-P16, and more patients were satisfied with availability of nurses and their abilities to listen and communicate than of doctors. Conclusion Specialist palliative care is in request for many patients in the late phase of their disease. We found no significant differences in satisfaction with care, communication with health professionals or in overall quality of life between the two models. This may imply that access to SPC is more important than the model that is applied, and that a person-centred approach together with time available may matter more than the context. These two factors should be considered when implementing SPC.
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Affiliation(s)
- Elizabeth Rosted
- Department of Oncology and Palliative Care, Zealand University Hospital, Sygehusvej 10, 4000, Roskilde, Denmark. .,Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000, Odense C, Denmark.
| | - Birgit Aabom
- Department of Oncology and Palliative Care, Zealand University Hospital, Sygehusvej 10, 4000, Roskilde, Denmark
| | - Bibi Hølge-Hazelton
- Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000, Odense C, Denmark.,Department of Research Support, Zealand University Hospital, Munkesøvej 14, 4000, Roskilde, Denmark
| | - Mette Raunkiær
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital and University of Southern Denmark, Nyborg, Denmark
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Osakwe ZT, Arora BK, Peterson ML, Obioha CU, Fleur-Calixte RS. Factors Associated With Home-Hospice Utilization. Home Healthc Now 2021; 39:39-47. [PMID: 33417361 DOI: 10.1097/nhh.0000000000000937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Utilization of hospice for end-of-life care is known to be lower among racial and ethnic minority groups than among White populations when controlling for other socioeconomic factors. Certain patient, provider, and community characteristics may influence home-hospice use. We sought to identify patient, provider, and community factors associated with home-hospice use. Our final analytic sample included 1,208,700 hospice patients who received home-hospice from 2,148 Medicare-certified hospice providers in 2016. We found that an increase in the proportion of hospice patients with a primary diagnosis of dementia decreased the odds that home-hospice was provided (OR = 1.42, 95% CI = 1.36-1.48). Patients who received hospice care from a provider with a higher proportion of dually enrolled patients were less likely to receive home-hospice (OR = 1.42, 95% CI = 1.36-1.48) and hospices located in ZIP-codes with higher proportion of Hispanic resident were less likely to provide home-hospice (OR = 1.00, 95% CI = 0.99-0.99). Additional research is needed to clarify the mechanisms underlying these associations.
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Cromwell CA, Edwards B, March AL. Improving Access to Palliative Care at a VHA Hospital. Am J Hosp Palliat Care 2020; 38:320-325. [PMID: 33030019 DOI: 10.1177/1049909120963079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Explore veteran-specific factors impacting the acceptance of palliative care services at a Veterans Health Administration hospital. METHODS Prospective, focused one-on-one interviews were conducted with 18 inpatient veterans with an initial consult to receive palliative care services. Domains impacting reception of outpatient palliative care management were evaluated including knowledge deficit, emotional barriers, physical barriers, psychosocial barriers, and physical support. Themes and trends from interview responses were analyzed using a qualitative directed content analysis approach. RESULTS The following themes were discovered to influence veteran participation in outpatient palliative care: Knowledge Deficit, Environmental Factors, Positive Patient Satisfaction, Openness to Technology, and Resiliency. Characteristics of veterans interviewed included an average age of 71 with an average distance from the hospital of 59 miles. CONCLUSION The identification of factors impacting veteran access to palliative care will be used to guide interventions and improve receipt of services. Care of seriously ill veterans may be substantially improved by facilitating access to palliative care.
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Affiliation(s)
| | | | - Alice L March
- 20120Central Texas Veterans Health Care System, Temple, TX, USA
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Johnson LA, Melendez C, Larson K, Moye J, Schreier AM, Ellis C. Using Demographics to Predict Palliative Care Access in Inpatient Facilities in Rural North Carolina. J Rural Health 2020; 37:412-416. [PMID: 32808716 DOI: 10.1111/jrh.12507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE For individuals with cancer, palliative care improves quality of life, mood, and survival. Rural residents experience limited access to palliative care. In eastern North Carolina, a rural area, little is known about access to inpatient cancer-related palliative care. This study describes access to inpatient palliative care and developed a predictive model of who was most likely to be admitted to an inpatient facility without a palliative care provider. METHODS A descriptive, exploratory design was used to examine demographics, clinical variables, and inpatient admissions from 2017 and 2018, in a major regional teaching hospital system that included 8 hospitals (7 rural hospitals). Descriptive statistics and a binary logistic regression were used to analyze data. FINDINGS The mean age was 62.2 years (N = 2,161, range: 18-88, SD = 15.52): 49.4% were female, 54% lived in a rural county, and 44.4% were black. The outlying rural hospitals, with no palliative care providers on staff, had 388 admissions (18%). Only gender (P = .0128), county (P < .0001), and age (P < .05) contributed to the logistic model. The predicted probability of being admitted to an inpatient facility with a palliative care provider is higher for younger males living in urban counties. That probability decreases with age regardless of the gender or type of county. CONCLUSIONS These findings highlight the limited availability of inpatient palliative care for those with cancer. Women, older adults, and rural residents are more likely to be admitted to 1 of the 7 rural hospitals with no palliative care provider on staff.
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Affiliation(s)
- Lee Ann Johnson
- School of Nursing, University of Virginia, Charlottesville, Virginia
| | - Carlos Melendez
- Nursing Science Department, College of Nursing, East Carolina University, Greenville, North Carolina
| | - Kim Larson
- Nursing Science Department, College of Nursing, East Carolina University, Greenville, North Carolina
| | - Janet Moye
- Vidant Health, Greenville, North Carolina
| | - Ann M Schreier
- Nursing Science Department, College of Nursing, East Carolina University, Greenville, North Carolina
| | - Charles Ellis
- Center for Health Disparities, East Carolina University, Greenville, North Carolina
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Cerni J, Rhee J, Hosseinzadeh H. End-of-Life Cancer Care Resource Utilisation in Rural Versus Urban Settings: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17144955. [PMID: 32660146 PMCID: PMC7400508 DOI: 10.3390/ijerph17144955] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/30/2020] [Accepted: 07/03/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Despite the advances in End-of-life (EOL) cancer care, disparities remain in the accessibility and utilisation of EOL cancer care resources. Often explained by socio-demographic factors, geographic variation exists in the availability and provision of EOL cancer care services among EOL cancer decedents across urban versus rural settings. This systematic review aims to synthesise mortality follow-back studies on the patterns of EOL cancer care resource use for adults (>18 years) during end-of-life cancer care. METHODS Five databases were searched and data analysed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria involved; a) original research; b) quantitative studies; c) English language; d) palliative care related service use in adults (>18 years) with any malignancy excluding non-melanoma skin cancers; e) exclusive end of life focus; f) urban-rural focus. Narrative reviews and discussions were excluded. RESULTS 24 studies met the inclusion criteria. End-of-life cancer care service utilisation patterns varied by rurality and treatment intent. Rurality was strongly associated with higher rates of Emergency Department (ED) visits and hospitalisations and lower rates of hospice care. The largest inequities between urban and rural health service utilisation patterns were explained by individual level factors including age, gender, proximity to service and survival time from cancer diagnosis. CONCLUSIONS Rurality is an important predictor for poorer outcomes in end-of-life cancer care. Findings suggest that addressing the disparities in the urban-rural continuum is critical for efficient and equitable palliative cancer care. Further research is needed to understand barriers to service access and usage to achieve optimal EOL care for all cancer patient populations.
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Affiliation(s)
- Jessica Cerni
- School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, NSW 2522, Australia;
- Correspondence:
| | - Joel Rhee
- General Practice Academic Unit, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW 2522, Australia;
- Illawarra Southern Practice Based Research Network (ISPRN), University of Wollongong, Wollongong, NSW 2522, Australia
- Centre for Positive Ageing + Care, HammondCare, Hammondville, NSW 2170, Australia
| | - Hassan Hosseinzadeh
- School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, NSW 2522, Australia;
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14
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Pilewski H. Introduction to Hospice and Palliative Medicine. PHYSICIAN ASSISTANT CLINICS 2020. [DOI: 10.1016/j.cpha.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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Crimmins RM, Elliott L, Absher DT. Palliative Care in a Death-Denying Culture: Exploring Barriers to Timely Palliative Efforts for Heart Failure Patients in the Primary Care Setting. Am J Hosp Palliat Care 2020; 38:77-83. [PMID: 32319317 DOI: 10.1177/1049909120920545] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT Heart failure (HF) is a complex, life-limiting disease that is prevalent and burdensome. All major cardiology societies and international clinical practice guidelines recommend the integration of palliative care (PC) interventions alongside usual HF management. OBJECTIVES The purpose of this review of the literature was to evaluate the various barriers to the early initiation of PC for HF patients in the primary care setting. METHODS An integrative literature review was conducted in order to assess and incorporate the diverse sources of literature available. An EBSCO search identified relevant articles in the following databases: Medline complete, Academic Search Premier, CINAHL, PsycINFO, Cochrane Library, and SocINDEX. The search was limited to full text, peer reviewed, English only, and published between 2010 and 2019. RESULTS Barriers to the integration of PC for HF patients include poor communication between provider/patient and interdisciplinary providers, the misperception and miseducation of what PC is and how it can be incorporated into patient care, the unpredictable disease trajectory of HF, and the limited time allowed for patient care in the primary care setting. CONCLUSION The results of this review highlight a lack of communication, time, and knowledge as barriers to delivering PC. Primary care providers caring for patients with HF need to establish an Annual Heart Failure Review to meticulously evaluate symptoms and allow the time for communication involving prognosis, utilize a PC referral screening tool such as the Needs Assessment Tool: Progressive Disease-Heart Failure, and thoroughly understand the benefits and appropriate integration of PC.
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Affiliation(s)
| | - Lydia Elliott
- MS(N) Program, 2739Western Carolina University, Cullowhee, NC, USA
| | - Darren T Absher
- MS(N) Program, 2739Western Carolina University, Cullowhee, NC, USA
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16
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Spence W, Ghosh S, Palen M, Liska A, Ha V, Wong R, Huang F. Symptom burden among Northern Alberta radiotherapy patients with advanced cancer: mapping needs and gaps. Support Care Cancer 2020; 28:4963-4969. [PMID: 32034512 DOI: 10.1007/s00520-020-05330-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 01/28/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Patients with advanced cancer often experience symptoms including pain, nausea, anorexia, fatigue, and depression. High symptom burden can be alleviated by multidisciplinary palliative care (PC) teams practicing symptom-directed management. Patients who are unable to access such services may be at higher risk of increased symptoms and poor outcomes. METHODS A sequential exploratory mixed methods study was performed to explore the burden of symptoms experienced by Northern Alberta patients with advanced cancer. The symptom burden among patients from rural and remote communities was characterized in a retrospective review capturing basic demographic and clinicopathologic information, in addition to patient-reported outcomes. Symptom prevalence was evaluated against the nature and range of supportive care services available. Service accessibility was assessed at community level by surveying health care providers (HCPs) and performing thematic analysis on their responses. RESULTS From January 1 to December 31, 2017, 607 outpatients were seen in consultation in an integrated palliative radiotherapy clinic in Edmonton, Alberta. A total of 166 (27.3%) patients resided in Alberta communities designated as rural or remote. Patient-reported symptom prevalence and intensity of scores did not differ significantly between rural/remote and urban populations. Unmet practical needs were flagged significantly more often by patients from rural communities (p = 0.05). HCPs from rural community health centers in Northern Alberta were knowledgeable regarding PC services availability and referral processes within their communities. CONCLUSION Although the symptom burden experienced by patients living with advanced cancer in rural and remote areas of Northern Alberta does not differ significantly from their urban counterparts, and community HCPs are knowledgeable regarding PC services, unmet needs within these communities remain. Continuing support for PC services in rural communities, as well as establishing care pathways for patients from rural populations traveling to urban centers to receive treatment, will help to minimize the unmet needs these patients experience.
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Affiliation(s)
- Winter Spence
- Cross Cancer Institute, 11560 University Ave, Edmonton, Alberta, Canada.
| | - Sunita Ghosh
- Cross Cancer Institute, 11560 University Ave, Edmonton, Alberta, Canada.,University of Alberta, 8440 112 St NW, Edmonton, Alberta, Canada
| | - Megan Palen
- Cross Cancer Institute, 11560 University Ave, Edmonton, Alberta, Canada
| | - Alex Liska
- Cross Cancer Institute, 11560 University Ave, Edmonton, Alberta, Canada
| | - Vincent Ha
- Cross Cancer Institute, 11560 University Ave, Edmonton, Alberta, Canada
| | - Rebecca Wong
- Princess Margaret Cancer Centre, 610 University Ave, Toronto, Ontario, Canada.,University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada
| | - Fleur Huang
- Cross Cancer Institute, 11560 University Ave, Edmonton, Alberta, Canada.,University of Alberta, 8440 112 St NW, Edmonton, Alberta, Canada
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17
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Rocque GB, Williams CP, Miller HD, Azuero A, Wheeler SB, Pisu M, Hull O, Rocconi RP, Kenzik KM. Impact of Travel Time on Health Care Costs and Resource Use by Phase of Care for Older Patients With Cancer. J Clin Oncol 2019; 37:1935-1945. [PMID: 31184952 DOI: 10.1200/jco.19.00175] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Many community cancer clinics closed between 2008 and 2016, with additional closings potentially expected. Limited data exist on the impact of travel time on health care costs and resource use. METHODS This retrospective cohort study (2012 to 2015) evaluated travel time to cancer care site for Medicare beneficiaries age 65 years or older in the southeastern United States. The primary outcome was Medicare spending by phase of care (ie, initial, survivorship, end of life). Secondary outcomes included patient cost responsibility and resource use measured by hospitalization rates, intensive care unit admissions, and chemotherapy-related hospitalization rates. Hierarchical linear models with patients clustered within cancer care site (CCS) were used to determine the effects of travel time on average monthly phase-specific Medicare spending and patient cost responsibility. RESULTS Median travel time was 32 (interquartile range, 18-59) minutes for the 23,382 included Medicare beneficiaries, with 24% of patients traveling longer than 1 hour to their CCS. During the initial phase of care, Medicare spending was 14% higher and patient cost responsibility was 10% higher for patients traveling longer than 1 hour than those traveling 30 minutes or less. Hospitalization rates were 4% to 13% higher for patients traveling longer than 1 hour versus 30 minutes or less in the initial (61 v 54), survivorship (27 v 26), and end-of-life (310 v 286) phases of care (all P < .05). Most patients traveling longer than 1 hour were hospitalized at a local hospital rather than at their CCS, whereas the converse was true for patients traveling 30 minutes or less. CONCLUSION As health care locations close, patients living farther from treatment sites may experience more limited access to care, and health care spending could increase for patients and Medicare.
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Affiliation(s)
| | | | - Harold D Miller
- 2Center for Healthcare Quality and Payment Reform, Pittsburgh, PA
| | - Andres Azuero
- 1University of Alabama at Birmingham, Birmingham, AL
| | | | - Maria Pisu
- 1University of Alabama at Birmingham, Birmingham, AL
| | - Olivia Hull
- 1University of Alabama at Birmingham, Birmingham, AL
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Conlon MSC, Caswell JM, Santi SA, Ballantyne B, Meigs ML, Knight A, Earle CC, Hartman M. Access to Palliative Care for Cancer Patients Living in a Northern and Rural Environment in Ontario, Canada: The Effects of Geographic Region and Rurality on End-of-Life Care in a Population-Based Decedent Cancer Cohort. Clin Med Insights Oncol 2019; 13:1179554919829500. [PMID: 30799969 PMCID: PMC6378418 DOI: 10.1177/1179554919829500] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/18/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Access to palliative care has been associated with improving quality of life and reducing the use of potentially aggressive end-of-life care. However, many challenges and barriers exist in providing palliative care to residents in northern and rural settings in Ontario, Canada. AIM The purpose of this study was to examine access to palliative care and associations with the use of end-of-life care in a decedent cohort of northern and southern, rural and urban, residents. DESIGN Using linked administrative databases, residents were classified into geographic and rural categories. Regression methods were used to define use and associations of palliative and end-of-life care and death in acute care hospital. SETTING/PARTICIPANTS A decedent cancer cohort of Ontario residents (2007-2012). RESULTS Northern rural residents were less likely to receive palliative care (adjusted odds ratio [OR] = 0.90, 95% confidence interval [CI]: 0.83-0.97). Those not receiving palliative care were more likely to receive potentially aggressive end-of-life care and die in an acute care hospital (adjusted OR = 1.20, 95% CI: 1.02-1.41). CONCLUSIONS Palliative care was significantly associated with reduced use of aggressive end-of-life care; however, disparities exist in rural locations, especially those in the north. Higher usage of emergency department (ED) and hospital resources at end of life in rural locations also reflects differing roles of rural community hospitals compared with urban hospitals. Improving access to palliative care in rural and northern locations is an important care issue and may reduce use of potentially aggressive end-of-life care.
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Affiliation(s)
- Michael SC Conlon
- Epidemiology, Outcomes & Evaluation Research, Health Sciences North Research Institute (HSNRI), Sudbury, ON, Canada
- ICES North Satellite Site, Health Sciences North Research Institute (HSNRI), Sudbury, ON, Canada
- Laurentian University, Sudbury, ON, Canada
- Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Joseph M Caswell
- Epidemiology, Outcomes & Evaluation Research, Health Sciences North Research Institute (HSNRI), Sudbury, ON, Canada
- ICES North Satellite Site, Health Sciences North Research Institute (HSNRI), Sudbury, ON, Canada
| | - Stacey A Santi
- Epidemiology, Outcomes & Evaluation Research, Health Sciences North Research Institute (HSNRI), Sudbury, ON, Canada
| | - Barbara Ballantyne
- Systemic Therapy Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON, Canada
- Northeast Cancer Centre, Health Sciences North Research Institute, Sudbury, ON, Canada
- The Ontario Palliative Care Network, Toronto, ON, Canada
| | - Margaret L Meigs
- Epidemiology, Outcomes & Evaluation Research, Health Sciences North Research Institute (HSNRI), Sudbury, ON, Canada
| | - Andrew Knight
- Northern Ontario School of Medicine, Sudbury, ON, Canada
- Systemic Therapy Program, Northeast Cancer Centre, Health Sciences North, Sudbury, ON, Canada
- Northeast Cancer Centre, Health Sciences North Research Institute, Sudbury, ON, Canada
- The Ontario Palliative Care Network, Toronto, ON, Canada
- Cancer Care Ontario, Toronto, ON, Canada
| | - Craig C Earle
- Canadian Partnership Against Cancer, Toronto, ON, Canada
| | - Mark Hartman
- Northeast Cancer Centre, Health Sciences North Research Institute, Sudbury, ON, Canada
- Cancer Care Ontario, Toronto, ON, Canada
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Dionne-Odom JN, Taylor R, Rocque G, Chambless C, Ramsey T, Azuero A, Ivankova N, Martin MY, Bakitas MA. Adapting an Early Palliative Care Intervention to Family Caregivers of Persons With Advanced Cancer in the Rural Deep South: A Qualitative Formative Evaluation. J Pain Symptom Manage 2018; 55:1519-1530. [PMID: 29474939 PMCID: PMC5951755 DOI: 10.1016/j.jpainsymman.2018.02.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/12/2018] [Accepted: 02/13/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT There is a scarcity of early palliative care interventions to support family caregivers of persons with advanced cancer living in the rural Southern U.S. OBJECTIVE The objective of this study was to adapt the content, format, and delivery of a six session, palliative care, telehealth intervention with monthly follow-up for rural family caregivers to enhance their own self-care and caregiving skills. METHODS Qualitative formative evaluation consisting of one-on-one, semistructured interviews with rural-dwelling persons with metastatic cancer (n = 18), their primary family caregiver (n = 20), and lay patient navigators (n = 26) were conducted to elicit feedback on a family caregiver intervention outline based on published evidence-based interventions. Transcribed interviews were analyzed using a thematic analysis approach. Coinvestigators reviewed and refined preliminary themes. RESULTS Participants recommended that intervention topical content be flexible and has an adaptable format based on continuous needs assessment. Sessions should be 20 minutes long at minimum, and additional sessions should be offered if requested. Faith and spirituality is essential to address but should not be an overarching intervention theme. Content needs to be communicated in simple language. Intervention delivery via telephone is acceptable, but face-to-face contact is desired to establish relationships. Other Internet-based technologies (e.g., video-conferencing) could be helpful, but many rural dwellers may not be technology savvy or have Internet access. Most lay navigators believed they could lead the intervention with additional training, protocols for professional referral, and supervision by specialty-trained palliative care clinicians. CONCLUSIONS A potentially scalable palliative care intervention is being adapted for family caregivers of rural-dwelling persons with advanced cancer and will undergo piloting in a small-scale randomized controlled trial.
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Affiliation(s)
- J Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA; Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, UAB Center for Palliative and Supportive Care, Birmingham, Alabama, USA.
| | - Richard Taylor
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Gabrielle Rocque
- Division of Hematology and Oncology, Department of Medicine, UAB, Birmingham, Alabama
| | | | - Thomas Ramsey
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Nataliya Ivankova
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA; Department of Health Services Administration, UAB, Birmingham, Alabama, USA
| | - Michelle Y Martin
- Department of Preventive Medicine, Center for Innovation in Health Equity Research, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA; Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, UAB Center for Palliative and Supportive Care, Birmingham, Alabama, USA
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