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Simberloff T, Godinez L, Chen T, Jiang L, Wu WC, Stafford J, Rudolph JL, Wice M. Concurrent Care and use of Advanced Cardiac Therapies for Hospitalized Veterans with Heart Failure. J Pain Symptom Manage 2024:S0885-3924(24)00959-X. [PMID: 39173897 DOI: 10.1016/j.jpainsymman.2024.08.026] [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: 05/13/2024] [Revised: 08/11/2024] [Accepted: 08/12/2024] [Indexed: 08/24/2024]
Abstract
CONTEXT Concurrent care allows patients to receive hospice while continuing disease-directed therapies. This treatment model is available in the Veterans Administration (VA) medical system, but its use in Veterans with heart failure (HF) is unexplored. OBJECTIVE To compare use of advanced HF therapies 30 days post-hospitalization in Veterans on hospice versus not on hospice following admission for HF exacerbation. METHODS We evaluated Veterans admitted for HF exacerbation to VA hospitals between Jan 2011 and June 2019 who received advanced HF therapies, hospice services, or both post-discharge. Concurrent care was defined as receiving both hospice services and advanced HF therapies. Demographics, comorbidities, and prior healthcare utilization were compared. Secondary outcomes included burdensome transitions and mortality. RESULTS Among 317,967 HF Veterans, 18,350 (5.8%) chose hospice post-hospitalization. Only 58 hospice-enrolled Veterans (0.3%) received advanced HF therapies (i.e. concurrent care) within 30 days post-discharge. Of 299,617 Veterans not on hospice, 6,083 (2.0%) received advanced HF therapies (0.3% vs 2.0%; p<0.001). Veterans receiving concurrent care had higher six-month mortality than those receiving advanced HF therapies alone (77.6% vs. 14.9%, SMD 1.61). Hazard of burdensome transitions was similar (adjusted HR 1.44, 95% CI 0.95-2.17). CONCLUSION Veterans with HF receiving concurrent care were few and experienced higher mortality. Rate of burdensome transitions was similar between Veterans receiving concurrent care and those not on hospice. Further research may explore why Veterans infrequently utilize concurrent care at the end of life.
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Affiliation(s)
- Tander Simberloff
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Laura Godinez
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Tiffany Chen
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Lan Jiang
- Center of Innovation in Long Term Services and Supports, Providence VA Healthcare System, Providence, Rhode Island, USA
| | - Wen-Chih Wu
- Center of Innovation in Long Term Services and Supports, Providence VA Healthcare System, Providence, Rhode Island, USA; Department of Medicine, Providence VA Healthcare System, Providence, Rhode Island, USA
| | - Jensy Stafford
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - James L Rudolph
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Medicine, Providence VA Healthcare System, Providence, Rhode Island, USA
| | - Mitchell Wice
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Medicine, Providence VA Healthcare System, Providence, Rhode Island, USA
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Hemrajani A, Lo S, Vahlkamp A, Silva A, Limaye S. Concurrent Hospice Healthcare Utilization in the Hematology/Oncology Veteran's Affairs Patient Population. Am J Hosp Palliat Care 2024; 41:906-910. [PMID: 37846638 DOI: 10.1177/10499091231206561] [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: 10/18/2023] Open
Abstract
Objectives: Concurrent care is a unique care delivery system that allows patients to receive disease modifying treatments and other supportive interventions while also receiving the traditional benefits of hospice care. The objectives of our observational study were to examine health care utilization, use of cancer-directed therapies and palliative interventions, and location of death in patients enrolled in concurrent care. Methods: 72 hematology-oncology patients at the Hines Veteran's Affairs Medical Center (VAMC) who enrolled in concurrent care from 12/2018-4/2021 were reviewed. Data were summarized with descriptive statistics including medians and percentages. Results: A minority of patients received cytotoxic chemotherapy (27.8%), immunotherapy (20.8%), palliative radiation (20.9%), blood products (11.1%), or invasive pain procedures (4.2%). Patients also used fewer cancer-directed treatments as they approached end of life (24.4% within 30 days of death compared to 13.3% within 14 days of death). Most patients died at home (62.9%) or in inpatient hospice (12.9%) as opposed to the hospital (2.9%). Conclusions: A minority of concurrent care patients received cancer-directed therapies or additional types of health care interventions despite the option to do so. Cancer-directed treatment utilization also decreased as patients approached end of life. Patients enrolled in concurrent care were able to appreciate its benefits for longer, as the average length of stay on concurrent care was nearly 3 months.
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Affiliation(s)
- Anshu Hemrajani
- Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | - Shelly Lo
- Loyola University Medical Center, Maywood, IL, USA
| | | | - Abigail Silva
- Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL. USA
| | - Seema Limaye
- Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
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Varilek BM, Da Rosa P. Analysis of Palliative Care Knowledge and Symptom Burden Among Female Veterans With Serious Illness: A Cross-Sectional Study. Am J Hosp Palliat Care 2024; 41:641-650. [PMID: 37385594 DOI: 10.1177/10499091231187341] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
Background: The female Veteran population is rapidly growing, as is their use of Veterans Affairs (VA) medical centers (VAMCs). Additionally, 90% of female Veterans are under 65 years old, meaning healthcare providers at VAMCs must be ready to manage the complex serious illnesses that affect female Veterans as they age. These serious illnesses require proper medical management, which can include palliative care. However, little palliative care research includes female Veterans. Aims: The aims of this cross-sectional study were to examine palliative care knowledge and symptom burden among female Veterans' and examine factors associated a symptom burden scale. Methods: Consenting participants completed online questionnaires, including the Palliative Care Knowledge Scale (PaCKS), Condensed Memorial Symptom Assessment Scale (CMSAS), and demographics. Descriptive statistics characterized the sample, bivariate association were carried out with a Chi-square and t test. A generalized linear model explored associations between CMSAS and its subscales with sociodemographic, number of serious illnesses, and facility type (VAMC vs civilian facility). Results: 152 female Veterans completed the survey. PaCKS scores were consistent across our sample. Physical symptoms were rated higher for those receiving care at VAMCs compared to civilian facilities (P = .02) in the bivariate analysis. The factors associated with CMSAS were age, employment status and number of serious illnesses (all P < .05). Conclusions: Palliative care can assist female Veterans with serious illness. More research is needed to further explore variables associated with symptom burden among female Veterans such as age, employment status, and number of serious illnesses.
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Affiliation(s)
- Brandon M Varilek
- College of Nursing, South Dakota State University, Sioux Falls, SD, USA
| | - Patricia Da Rosa
- Office of Nursing Research, College of Nursing, South Dakota State University, Brookings, SD, USA
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Tung HJ, Yeh MC. Use of Advance Directives in US Veterans and Non-Veterans: Findings from the Decedents of the Health and Retirement Study 1992-2014. Healthcare (Basel) 2023; 11:1824. [PMID: 37444658 DOI: 10.3390/healthcare11131824] [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: 05/16/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Evidence shows that older patients with advance directives such as a living will, or durable power of attorney for healthcare, are more likely to receive care consistent with their preferences at the end of life. Less is known about the use of advance directives between veteran and non-veteran older Americans. Using data from the decedents of a longitudinal survey, we explore whether there is a difference in having an established advance directive between the veteran and non-veteran decedents. Data were taken from the Harmonized End of Life data sets, a linked collection of variables derived from the Health and Retirement Study (HRS) Exit Interview. Only male decedents were included in the current analysis (N = 4828). The dependent variable, having an established advance directive, was measured by asking the proxy, "whether the deceased respondent ever provided written instructions about the treatment or care he/she wanted to receive during the final days of his/her life" and "whether the deceased respondent had a Durable Power of Attorney for healthcare?" A "yes" to either of the two items was counted as having an advance directive. The independent variable, veteran status, was determined by asking participants, "Have you ever served in the active military of the United States?" at their first HRS core interview. Logistic regression was used to predict the likelihood of having an established advance directive. While there was no difference in having an advance directive between male veteran and non-veteran decedents during the earlier follow-up period (from 1992 to 2003), male veterans who died during the second half of the study period (from 2004 to 2014) were more likely to have an established advance directive than their non-veteran counterparts (OR = 1.24, p < 0.05). Other factors positively associated with having an established advance directive include dying at older ages, higher educational attainment, needing assistance in activities of daily living and being bedridden three months before death, while Black decedents and those who were married were less likely to have an advance directive in place. Our findings suggest male veterans were more likely to have an established advance directive, an indicator for better end-of-life care, than their non-veteran counterparts. This observed difference coincides with a time when the Veterans Health Administration (VHA) increased its investment in end-of-life care. More studies are needed to confirm if this higher utilization of advance directives and care planning among veterans can be attributed to the improved access and quality of end-of-life care in the VHA system.
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Affiliation(s)
- Ho-Jui Tung
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, P.O. Box 8015, Statesboro, GA 30460-8015, USA
| | - Ming-Chin Yeh
- Nutrition Program, Hunter College, City University of New York, New York, NY 10065, USA
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Svynarenko R, Cozad MJ, Mack JW, Keim-Malpass J, Hinds PS, Lindley LC. Application of Instrumental Variable Analysis in Pediatric End-of-Life Research: A Case Study. West J Nurs Res 2023; 45:571-580. [PMID: 36964702 PMCID: PMC10559266 DOI: 10.1177/01939459231163441] [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: 03/26/2023]
Abstract
Instrumental variable analysis (IVA) has been widely used in many fields, including health care, to determine the comparative effectiveness of a treatment, intervention, or policy. However, its application in pediatric end-of-life care research has been limited. This article provides a brief overview of IVA and its assumptions. It illustrates the use of IVA by investigating the comparative effectiveness of concurrent versus standard hospice care for reducing 1-day hospice enrollments. Concurrent hospice care is a relatively recent type of care enabled by the Affordable Care Act in 2010 for children enrolled in the Medicaid program and allows for receiving life-prolonging medical treatment concurrently with hospice care. The IVA was conducted using observational data from 18,152 pediatric patients enrolled in hospice between 2011 and 2013. The results indicated that enrollment in concurrent hospice care reduced 1-day enrollment by 19.3%.
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Affiliation(s)
| | - Melanie J Cozad
- Department of Health Services Research and Administration, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jennifer W Mack
- Department of Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, MA, USA
| | | | - Pamela S Hinds
- Department of Nursing Science, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University, Washington, DC, USA
| | - Lisa C Lindley
- College of Nursing, University of Tennessee, Knoxville, TN, USA
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Davidoff AJ, Canavan ME, Prsic E, Saphire M, Wang SY, Presley CJ. End-of-life care trajectories among older adults with lung cancer. J Geriatr Oncol 2023; 14:101381. [PMID: 36202695 PMCID: PMC9974538 DOI: 10.1016/j.jgo.2022.09.010] [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: 05/05/2022] [Accepted: 09/22/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Medicare decedents with cancer often receive intensive care during the last month of life; however, little information exists on longer end-of-life care trajectories. MATERIALS AND METHODS Using SEER-Medicare data, we selected older adults diagnosed with lung cancer between 2008 and 2013 who survived at least six months and died between 2008 and 2014. Each month we assessed claims to assign care categories ordered by intensity as follows: full-month inpatient/skilled nursing facility > cancer-directed therapy (CDT) only > concurrent CDT and symptom management and supportive care services (SMSCS) > SMSCS only > full-month hospice. We assigned each decedent to one of six trajectories: stable hospice, stable SMSCS, stable CDT with or without concurrent SMSCS, decreasing intensity, increasing intensity, and mixed. Multinomial logistic regression estimated associations between socio-demographics, calendar year, and area hospice use rates with end-of-life trajectory. RESULTS The sample (N = 24,342) was predominantly aged ≥75 years (59.4%) and non-Hispanic White (80.5%); 19.1% lived in healthcare referral regions where ≤50% of cancer decedents received hospice care. Overall, 6.5% were continuously hospice enrolled, 25.6% received SMSCS only, and 29.4% experienced decreasing intensity; 3.9% received CDT or concurrent care, while 8.7% experienced an increase in intensity. Higher healthcare referral region hospice rates were associated with decreasing end-of-life intensity; Black, non-Hispanic decedents had a higher risk of increasing intensity and mixed patterns. DISCUSSION Among older decedents with lung cancer, 62% had six-month end-of-life trajectories indicating low or decreasing intensity, but few received persistent CDT. Demographic characteristics, including race/ethnicity, and contextual measures, including area hospice use patterns, were associated with end-of-life trajectory.
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Affiliation(s)
- Amy J Davidoff
- Yale School of Public Health, New Haven, CT, United States of America; Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, United States of America; Yale Cancer Center, New Haven, CT, United States of America.
| | - Maureen E Canavan
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, United States of America
| | - Elizabeth Prsic
- Yale-Smilow Cancer Hospital, New Haven, CT, United States of America
| | - Maureen Saphire
- The Ohio State University Comprehensive Cancer Center, Department of Pharmacy, Columbus, OH, United States of America
| | - Shi-Yi Wang
- Yale School of Public Health, New Haven, CT, United States of America; Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, United States of America; Yale Cancer Center, New Haven, CT, United States of America
| | - Carolyn J Presley
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, United States of America; The Ohio State University Comprehensive Cancer Center, Department of Internal Medicine, Division of Medical Oncology, Columbus, OH, United States of America
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7
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Fornehed MLC, Svynarenko R, Lindley LC. Impact of Concurrent Hospice Care on Primary Care Visits Among Children in Rural Southern Appalachia. J Pediatr Health Care 2022; 36:438-442. [PMID: 35654707 PMCID: PMC9398974 DOI: 10.1016/j.pedhc.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/05/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The purpose of the study was to test the effect of receiving pediatric concurrent hospice care on primary care visits. METHOD This retrospective study was limited to pediatric decedents younger than 21 years with a hospice service claim from 2011 to 2013. Our outcome of interest concerned whether concurrent hospice care impacted primary care visits. RESULTS Of the 460 pediatric decedents in rural Southern Appalachia, 42% continued to visit their primary care provider during hospice enrollment, whereas 51% received concurrent hospice care. Concurrent hospice care was significantly related to pediatric primary care visits (β = 2.31; p < .001). DISCUSSION Findings revealed that receipt of concurrent hospice care impacted primary care. Children in concurrent care were twice as likely to continue to receive care from their primary care provider. This finding is consistent with our hypothesis; however, the magnitude of the finding was unexpected given their residence in medically underserved areas.
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Kaiser U, Vehling-Kaiser U, Hoffmann A, Kaiser F. Inpatient Hospices in Germany: Medical Care Situation and Use of Supportive Oncological Therapies for Symptom Control in Tumor Patients. Palliat Med Rep 2022; 3:169-180. [PMID: 36059908 PMCID: PMC9438444 DOI: 10.1089/pmr.2022.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/18/2022] Open
Abstract
Background: More than 80% of the residents in German hospices suffer from tumor disease. But the administration of supportive-oncological therapies in hospices for symptom control is controversially discussed. Objectives: This study aims to investigate the care situation of tumor patients in German hospices with regard to medical care and the use of supportive-oncological therapies. Methods: In February 2019, all hospices in Germany were offered the opportunity to participate in an anonymous online survey on medical and drug care for their tumor patients. The survey was conducted using the online platform SoSci Survey and ended in April 2019. The analysis was descriptive. Results: Of 202 hospices, 112 responded to the questionnaire. The hospices were distributed nationwide. Most have 8 to 10 places. More than 80% of hospice residents are tumor patients, and the length of stay is usually three to four weeks. Medical care is primarily provided by primary care physicians. While specialized outpatient palliative care is increasingly involved in care, hematologists/oncologists are rarely represented. Supportive-oncological therapies are rarely prescribed, whereas medication for other chronic conditions is often continued. The percentage of supportive-oncological therapies prescribed is higher in hospices with oncology co-care. Conclusions: Although most hospice residents suffer from malignant disease, co-care by a hematologist/oncologist is rare. Supportive-oncology therapies, particularly for symptom relief, may therefore be rarely used. However, since a small select group of hospice residents may benefit from these therapies, further investigation in this direction should be undertaken.
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Affiliation(s)
- Ulrich Kaiser
- Clinic and Polyclinic for Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | | | | | - Florian Kaiser
- Oncology/Palliative Care Network Landshut, Landshut, Germany
- Department of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
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Thomas T, Patel B, Mitchell J, Whitmer A, Knoche E, Gupta P. Treating advanced lung cancer in older veterans with comorbid conditions and frailty. Semin Oncol 2022; 49:S0093-7754(22)00044-6. [PMID: 35853764 DOI: 10.1053/j.seminoncol.2022.06.004] [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: 06/07/2022] [Revised: 06/07/2022] [Accepted: 06/11/2022] [Indexed: 11/11/2022]
Abstract
Advanced lung cancer is a deadly malignancy that is a common cause of death among Veterans. Significant advancements in lung cancer therapeutics have been made over the past decade and survival outcomes have improved. The Veteran population is older, has more medical comorbidities and frailty compared to the general population. These factors must be accounted for when evaluating patients for treatment and selecting treatment options. This article explores the impact of these important issues in the management of advanced lung cancer. Recent clinical trials leading to the approval of modern therapies will be outlined and treatment outcomes specific to older patients discussed. The impact of key comorbidities that are common in Veterans and their impact on lung cancer treatment will be reviewed. There is no gold standard frailty index for assessment of frailty in patients with advanced lung cancer and the ability to predict tolerability and benefit from systemic therapies. Currently available systemic therapies are associated with higher risk of adverse events and lower potential for clinically meaningful improvement in outcomes. Future research needs to focus on designing better frailty indices and developing novel therapies that are safer and more effective therapies for frail patients, who constitute a considerable proportion of individuals diagnosed with lung cancer.
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Affiliation(s)
- Theodore Thomas
- Medicine Service, Saint Louis Veterans Health Administration Medical Center, St. Louis, Missouri; Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri.
| | - Bindiya Patel
- Medicine Service, Saint Louis Veterans Health Administration Medical Center, St. Louis, Missouri; Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Joshua Mitchell
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Alison Whitmer
- Medicine Service, Saint Louis Veterans Health Administration Medical Center, St. Louis, Missouri
| | - Eric Knoche
- Medicine Service, Saint Louis Veterans Health Administration Medical Center, St. Louis, Missouri; Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Pankaj Gupta
- Medicine Service, VA Long Beach Healthcare System, Long Beach, California; Department of medicine, University of California Irvine, Irvine, California
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Presley CJ, Kaur K, Han L, Soulos PR, Zhu W, Corneau E, O'Leary JR, Chao H, Shamas T, Rose MG, Lorenz KA, Levy CR, Mor V, Gross CP. Aggressive End-of-Life Care in the Veterans Health Administration versus Fee-for-Service Medicare among Patients with Advanced Lung Cancer. J Palliat Med 2022; 25:932-939. [PMID: 35363053 PMCID: PMC9360181 DOI: 10.1089/jpm.2021.0436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Unlike fee-for-service Medicare, the Veterans Health Administration (VHA) allows for the provision of concurrent care, incorporating cancer treatment while in hospice. Methods: We compared trends of aggressive care at end of life between Medicare and VHA decedents with advanced nonsmall cell lung cancer from 2006 to 2012, and the relation between regional level end-of-life care between Medicare and VHA beneficiaries. Results: Among 18,371 Veterans and 25,283 Medicare beneficiaries, aggressive care at end of life decreased 15% in VHA and 4% in SEER (Surveillance, Epidemiology, and End Results)-Medicare (p < 0.001). Hospice use significantly increased within both cohorts (VHA 28%-41%; SM 60%-73%, p < 0.001). Veterans receiving care in regions with higher hospice admissions among Medicare beneficiaries were significantly less likely to receive aggressive care at end of life (adjusted odds ratio: 0.13, 95% confidence interval: 0.08-0.23, p < 0.001). Conclusions: Patients receiving lung cancer care in the VHA had a greater decline in aggressive care at end of life, perhaps due to increasing concurrent care availability.
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Affiliation(s)
- Carolyn J. Presley
- Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
- Address correspondence to: Carolyn J. Presley, MD, Division of Medical Oncology, The Ohio State University, 1800 Cannon Drive, 13th Floor, Columbus, OH 43210, USA
| | - Kiranveer Kaur
- Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Ling Han
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Pamela R. Soulos
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Weiwei Zhu
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Emily Corneau
- Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, Rhode Island, USA
| | - John R. O'Leary
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Herta Chao
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Connecticut Veterans Health Administration, West Haven, Connecticut, USA
| | - Tracy Shamas
- Connecticut Veterans Health Administration, West Haven, Connecticut, USA
| | - Michal G. Rose
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Connecticut Veterans Health Administration, West Haven, Connecticut, USA
| | - Karl A. Lorenz
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California, USA
- School of Medicine, Stanford University, Stanford, California, USA
| | - Cari R. Levy
- Eastern Colorado VA Healthcare System, Aurora, Colorado, USA
| | - Vincent Mor
- Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Cary P. Gross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut, USA
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Mooney-Doyle K, Keim-Malpass J, Svynarenko R, Lindley LC. A Comparison of Young Adults With and Without Cancer in Concurrent Hospice Care: Implications for Transitioning to Adult Health Care. J Adolesc Young Adult Oncol 2022; 11:35-40. [PMID: 33877907 PMCID: PMC8864426 DOI: 10.1089/jayao.2021.0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Purpose: Concurrent hospice care provides important end-of-life care for youth under 21 years. Those nearing 21 years must decide whether to shift to adult hospice or leave hospice for life-prolonging care. This decision may be challenging for young adults with cancer, given the intensity of oncology care. Yet, little is known about their needs. We compared young adults with and without cancer in concurrent hospice care. Methods: Retrospective comparative design used data from 2011 to 2013 U.S. Medicaid data files. Decedents were included if they were 20 years of age, enrolled in Medicaid hospice care, and used nonhospice medical services on the same day as hospice care based on their Medicaid claims activity dates. Results: Among 226 decedents, 21% had cancer; more than half were female (60.6%), Caucasian (53.5%), non-Hispanic (77.4%), urban dwelling (58%), and had mental/behavioral disorder (53%). Young adults with cancer were more often non-Caucasian (68.7% vs. 40.4%), technology dependent (47.9% vs. 24.2%), had comorbidities (83.3% vs. 30.3%), and lived in rural (58.3% vs. 37.6%), southern (41.7% vs. 20.8%) areas versus peers without cancer. Those with cancer had significantly fewer live discharges from hospice (5.7 vs. 17.3) and sought treatment for symptoms more often from nonhospice providers (35.4% vs. 14.0%). Conclusions: Young adults in concurrent hospice experience medical complexity, even at end-of-life. Understanding care accessed at 20 years helps providers guide young adults and families considering options in adult-focused care. Clinical and demographic differences among those with and without cancer in concurrent care highlight needs for research exploring racial and geographic equity.
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Affiliation(s)
- Kim Mooney-Doyle
- School of Nursing, University of Maryland, Baltimore, Maryland, USA.,Address correspondence to: Kim Mooney-Doyle, PhD, RN, CPNP-AC, School of Nursing, University of Maryland, 655 West Lombard Street, Baltimore, MD 21201, USA
| | | | - Radion Svynarenko
- College of Nursing, University of Tennessee, Knoxville, Knoxville, Tennessee, USA
| | - Lisa C. Lindley
- College of Nursing, University of Tennessee, Knoxville, Knoxville, Tennessee, USA
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12
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Lindley LC, Keim-Malpass J, Cozad MJ, Mack JW, Svynarenko R, Fornehed MLC, Stone W, Qualls K, Hinds PS. A National Study to Compare Effective Management of Constipation in Children Receiving Concurrent Versus Standard Hospice Care. J Hosp Palliat Nurs 2022; 24:70-77. [PMID: 34840283 PMCID: PMC8720064 DOI: 10.1097/njh.0000000000000810] [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: 02/03/2023]
Abstract
Constipation is a distressing and uncomfortable symptom children experience at end of life. There is a gap in knowledge about how different approaches to hospice care delivery might improve pediatric symptom management of constipation. The purpose of this study was to evaluate the effectiveness of pediatric concurrent hospice versus standard hospice care to manage constipation. Medicaid data (2011-2013) were analyzed. Children who were younger than 21 years enrolled in hospice care and had a hospice enrollment between January 1, 2011, and December 31, 2013, were included. Instrumental variable analysis was used to test the effectiveness of concurrent versus standard hospice care. Among the 18 152 children, approximately 14% of participants were diagnosed or treated for constipation from a nonhospice provider during hospice enrollment. A higher proportion of children received nonhospice care for constipation in concurrent hospice care, compared with standard hospice (19.5% vs 13.2%), although this was not significant (β = .22, P < .05) after adjusting for covariates. The findings demonstrated that concurrent care was no more effective than standard hospice care in managing pediatric constipation. Hospice and nonhospice providers may be doing a sufficient job ordering bowel regimens before constipation becomes a serious problem for children at end of life.
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Svynarenko R, Lindley LC, Mooney-Doyle K, Mendola A, Naumann WC, Mack JW. Patterns of Healthcare Services Among Children With Advanced Cancer in Concurrent Hospice Care. Cancer Nurs 2022; 45:E843-E848. [PMID: 35175949 PMCID: PMC9378760 DOI: 10.1097/ncc.0000000000001067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Children with advanced cancer have access to comprehensive cancer care and hospice care if they enroll in concurrent hospice care. However, little is known about the patterns of nonhospice healthcare services used by these children. OBJECTIVE The aim of this study was to examine the patterns of nonhospice healthcare services among children with cancer in concurrent hospice care. METHODS This study was a retrospective cohort analysis of 2011-2013 Medicaid claims data from 862 pediatric cancer patients. Data were analyzed using descriptive statistics and latent class analysis (LCA). RESULTS Children used 120 388 healthcare services, including inpatient and outpatient hospital services, laboratories and x-rays, durable medical equipment, medications, and others. These services clustered into 2 classes with moderate-intensity (57.49%) and high-intensity (42.50%) healthcare service use. Children in the high-intensity cluster were more likely to reside in the South with comorbidities, mental/behavioral health conditions, and technology dependence and were less likely to have solid tumors, compared with the moderate-intensity group. CONCLUSIONS Nonhospice healthcare services clustered together in 2 distinct classes, providing critical insight into the complexity of the healthcare use among children with cancer in concurrent hospice care. IMPLICATIONS FOR PRACTICE Understanding that pediatric patients in concurrent care may have different healthcare service patterns may assist oncology nurses caring for children with advanced cancer. These findings also have policy implications.
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14
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Lindley LC, Cozad MJ, Mack JW, Keim-Malpass J, Svynarenko R, Hinds PS. Effectiveness of Pediatric Concurrent Hospice Care to Improve Continuity of Care. Am J Hosp Palliat Care 2021; 39:1129-1136. [PMID: 34866426 DOI: 10.1177/10499091211056039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The 2010 Patient Protection and Affordable Care Act (ACA) mandated landmark hospice care legislation for children at end of life. Little is known about the impact of pediatric concurrent hospice care. OBJECTIVE The purpose of this study was to examine the effect of pediatric concurrent vs standard hospice care on end-of-life care continuity among Medicaid beneficiaries. METHODS Using national Medicaid data, we conducted a quasi-experimental designed study to estimate the effect of concurrent vs standard hospice care to improve end-of-life care continuity for children. Care continuity (i.e., hospice length of stay, hospice disenrollment, emergency room transition, and inpatient transition) was measured via claims data. Exposures were concurrent hospice vs standard hospice care. Using instrumental variable analysis, the effectiveness of exposures on care continuity was compared. RESULTS Concurrent hospice care affected care continuity. It resulted in longer lengths of stays in hospice (β = 2.76, P < .001) and reduced hospice live discharges (β = -2.80, P < .05), compared to standard hospice care. Concurrent care was not effective at reducing emergency room (β = 2.09, P < .001) or inpatient care (β = .007, P < .05) transitions during hospice enrollment. CONCLUSION Our study provides critical insight into the quality of care delivered for children at end of life. These findings have policy implications.
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Affiliation(s)
- Lisa C Lindley
- College of Nursing, University of Tennessee, Knoxville, TN, USA
| | - Melanie J Cozad
- Department of Health Services Policy and Management, 2629University of South Carolina, Columbia, SC, USA
| | - Jennifer W Mack
- Department of Pediatric Oncology and Division of Population Sciences, 1862Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, MA, USA
| | | | | | - Pamela S Hinds
- Department of Nursing Science, 8404Children's National Hospital, Washington, DC, USA.,Department of Pediatrics, 8367The George Washington University, Washington, DC, USA
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15
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Lindley LC, Svynarenko R, Mooney-Doyle K, Mendola A, Naumann WC, Fortney CA. End-of-Life Healthcare Service Needs Among Children With Neurological Conditions: A Latent Class Analysis. J Neurosci Nurs 2021; 53:238-243. [PMID: 34593722 PMCID: PMC8578283 DOI: 10.1097/jnn.0000000000000615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: At the end of life, children with neurological conditions have complex healthcare needs that can be met by providing care of their life-limiting conditions concurrently with hospice care (ie, concurrent care). Given the limited literature on concurrent care for children with neurologic conditions, this investigation aimed to identify patterns of nonhospice, healthcare service needs and to assess characteristics of children within each group. METHODS: A nationally representative sample children with neurological conditions enrolled in concurrent hospice care was used. Latent class analysis and descriptive statistics were calculated to identify patterns of healthcare needs and characteristics of children within the groups. A subgroup analysis of infants was conducted. RESULTS: Among the 1601 children, the most common types of services were inpatient hospitals, durable medical equipment, and home health. Two classes of service needs were identified: moderate intensity (58%) and high intensity (42%). Children in the moderate-intensity group were predominantly between 1 and 5 years old, male, White, and non-Hispanic. The most common neurological condition was central nervous system degeneration. They also had significant comorbidities, mental/behavioral health conditions, and technology dependence. They commonly resided in urban areas in the South. Children in the high-intensity group had a wide range of neurological conditions and high acuity. The subgroup analysis of infants indicated a different neurological profile. CONCLUSIONS: Two distinct classes of nonhospice, healthcare service needs emerged among children with neurological conditions at the end of life. The groups had unique demographic profiles.
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Martin JL, Azizoddin DR, Rynar LZ, Weber J, Oliver T, Weldon CB, Hauser JM. Comprehensive and Equitable Care for Vulnerable Veterans With Integrated Palliative, Psychology, and Oncology Care. Fed Pract 2021; 38:S28-S35. [PMID: 34733093 DOI: 10.12788/fp.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective Veterans who live with cancer need comprehensive care. The National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer guidelines recommend evaluating distress and providing appropriate follow-up to all patients with cancer. Methods We created patient-centered, collaborative clinics to screen for and address cancer-related distress. Medical oncologists received education about available supportive services and instructions on how to make referrals. Participants completed the Coleman Supportive Oncology Collaborative screening questions. Results Patients in this outpatient US Department of Veterans Affairs medical oncology clinic were primarily older, African American men. Most veterans screened positive for ≥ 1 type of cancer-related distress. Patients screened for high levels of distress received in-person clinical follow-up for further evaluation and to make immediate referrals to supportive care services. Conclusions We evaluated patients' needs, made referrals as needed, and helped bring care directly into the oncology clinic. Using a screening tool for cancer-related distress and managing distress with integrated psychosocial providers could improve care coordination and enhance patient-centered supportive oncology care, especially for high-risk patients. A full-time social worker was integrated into the medical oncology clinics based on our program's success.
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Affiliation(s)
- Joanna L Martin
- and are Palliative Care Physicians; is a Palliative Care Nurse Practitioner; and is a Palliative Care and Hematology Oncology Clinical Social Worker; all at Jesse Brown VA Medical Center in Chicago, Illinois. is Adjunct Faculty in Hematology and Oncology; Joanna Martin is a Health System Clinician; and Joshua Hauser is a Palliative Care Physician; all at Northwestern Feinberg School of Medicine in Illinois. Christine Weldon is Director at the Center for Business Models in Healthcare in Illinois. is a Research Scientist at Brigham and Women's Hospital and Affiliate Research Faculty, Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, and Harvard Medical School, in Massachusetts. is an Assistant Professor, Supportive Oncology at Rush University Medical Center in Chicago
| | - Desiree R Azizoddin
- and are Palliative Care Physicians; is a Palliative Care Nurse Practitioner; and is a Palliative Care and Hematology Oncology Clinical Social Worker; all at Jesse Brown VA Medical Center in Chicago, Illinois. is Adjunct Faculty in Hematology and Oncology; Joanna Martin is a Health System Clinician; and Joshua Hauser is a Palliative Care Physician; all at Northwestern Feinberg School of Medicine in Illinois. Christine Weldon is Director at the Center for Business Models in Healthcare in Illinois. is a Research Scientist at Brigham and Women's Hospital and Affiliate Research Faculty, Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, and Harvard Medical School, in Massachusetts. is an Assistant Professor, Supportive Oncology at Rush University Medical Center in Chicago
| | - Lauren Z Rynar
- and are Palliative Care Physicians; is a Palliative Care Nurse Practitioner; and is a Palliative Care and Hematology Oncology Clinical Social Worker; all at Jesse Brown VA Medical Center in Chicago, Illinois. is Adjunct Faculty in Hematology and Oncology; Joanna Martin is a Health System Clinician; and Joshua Hauser is a Palliative Care Physician; all at Northwestern Feinberg School of Medicine in Illinois. Christine Weldon is Director at the Center for Business Models in Healthcare in Illinois. is a Research Scientist at Brigham and Women's Hospital and Affiliate Research Faculty, Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, and Harvard Medical School, in Massachusetts. is an Assistant Professor, Supportive Oncology at Rush University Medical Center in Chicago
| | - Jane Weber
- and are Palliative Care Physicians; is a Palliative Care Nurse Practitioner; and is a Palliative Care and Hematology Oncology Clinical Social Worker; all at Jesse Brown VA Medical Center in Chicago, Illinois. is Adjunct Faculty in Hematology and Oncology; Joanna Martin is a Health System Clinician; and Joshua Hauser is a Palliative Care Physician; all at Northwestern Feinberg School of Medicine in Illinois. Christine Weldon is Director at the Center for Business Models in Healthcare in Illinois. is a Research Scientist at Brigham and Women's Hospital and Affiliate Research Faculty, Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, and Harvard Medical School, in Massachusetts. is an Assistant Professor, Supportive Oncology at Rush University Medical Center in Chicago
| | - Tyra Oliver
- and are Palliative Care Physicians; is a Palliative Care Nurse Practitioner; and is a Palliative Care and Hematology Oncology Clinical Social Worker; all at Jesse Brown VA Medical Center in Chicago, Illinois. is Adjunct Faculty in Hematology and Oncology; Joanna Martin is a Health System Clinician; and Joshua Hauser is a Palliative Care Physician; all at Northwestern Feinberg School of Medicine in Illinois. Christine Weldon is Director at the Center for Business Models in Healthcare in Illinois. is a Research Scientist at Brigham and Women's Hospital and Affiliate Research Faculty, Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, and Harvard Medical School, in Massachusetts. is an Assistant Professor, Supportive Oncology at Rush University Medical Center in Chicago
| | - Christine B Weldon
- and are Palliative Care Physicians; is a Palliative Care Nurse Practitioner; and is a Palliative Care and Hematology Oncology Clinical Social Worker; all at Jesse Brown VA Medical Center in Chicago, Illinois. is Adjunct Faculty in Hematology and Oncology; Joanna Martin is a Health System Clinician; and Joshua Hauser is a Palliative Care Physician; all at Northwestern Feinberg School of Medicine in Illinois. Christine Weldon is Director at the Center for Business Models in Healthcare in Illinois. is a Research Scientist at Brigham and Women's Hospital and Affiliate Research Faculty, Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, and Harvard Medical School, in Massachusetts. is an Assistant Professor, Supportive Oncology at Rush University Medical Center in Chicago
| | - Joshua M Hauser
- and are Palliative Care Physicians; is a Palliative Care Nurse Practitioner; and is a Palliative Care and Hematology Oncology Clinical Social Worker; all at Jesse Brown VA Medical Center in Chicago, Illinois. is Adjunct Faculty in Hematology and Oncology; Joanna Martin is a Health System Clinician; and Joshua Hauser is a Palliative Care Physician; all at Northwestern Feinberg School of Medicine in Illinois. Christine Weldon is Director at the Center for Business Models in Healthcare in Illinois. is a Research Scientist at Brigham and Women's Hospital and Affiliate Research Faculty, Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, and Harvard Medical School, in Massachusetts. is an Assistant Professor, Supportive Oncology at Rush University Medical Center in Chicago
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Sullivan DR, Teno JM, Reinke LF. Evolution of Palliative Care in the Department of Veterans Affairs: Lessons from an Integrated Health Care Model. J Palliat Med 2021; 25:15-20. [PMID: 34665652 DOI: 10.1089/jpm.2021.0246] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Palliative care (PC) is beneficial, however, in many settings it is under-resourced and unable to consistently meet the needs of patients and their families. A lack of national health policy support for PC contributes to underutilization and the low value care experienced by many patients with serious illness at the end of life. Through a series of transformative health care structure and process improvements including developing robust initiatives and promoting institutional culture change, the Department of Veterans Affairs (VA) has significantly improved the quality of PC among veterans. VA's strategic simultaneous top-down and bottom-up approach to develop programs, policies, and initiatives provides important perspectives and deserves attention toward advancing PC in the broader U.S. health care system. Although opportunities for improvement exist, the comprehensive framework within VA should help inform the future of program development and serve as a model for integrated and accountable care organizations to emulate.
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Affiliation(s)
- Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA.,Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon, USA
| | - Joan M Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, OHSU, Portland, Oregon, USA
| | - Lynn F Reinke
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington, USA.,Department of Biobehavioral Nursing and Health Systems, University of Washington, School of Medicine, Seattle, Washington, USA
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18
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Keim-Malpass J, Cozad MJ, Svynarenko R, Mack JW, Lindley LC. Medical complexity and concurrent hospice care: A national study of Medicaid children from 2011 to 2013. J SPEC PEDIATR NURS 2021; 26:e12333. [PMID: 33811725 PMCID: PMC8547133 DOI: 10.1111/jspn.12333] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE Pediatric hospice is a comprehensive model of care for medically complex children at end of life. The Affordable Care Act changed regulatory requirements for pediatric Medicaid enrollees to allow for enrollment into hospice services while still receiving life-prolonging therapy. There are gaps in understanding factors associated with pediatric concurrent hospice care use. The objectives were to examine the prevalence of concurrent hospice care overtime and investigated the relationship between medical complexity and concurrent hospice care among Medicaid children. DESIGN AND METHODS We used national Medicaid data and included children less than 21 years with an admission to hospice care. Medical complexity was defined with four criteria (i.e., chronic conditions, functional limitations, high health care use and substantial needs). Using multivariate logistic regression, we evaluated the influence of medical complexity on concurrent hospice care use, while controlling for demographic, hospice, and community characteristics. RESULTS Thirty-four percent of the study sample used concurrent hospice care. Medical complexity was unrelated to concurrent hospice care. However, the four individual criteria were associated. A complex chronic condition was negatively related to concurrent hospice care, whereas technology dependence, multiple complex chronic conditions, and mental/behavioral disorders were positively associated to concurrent care use. PRACTICE IMPLICATIONS These findings suggest that concurrent hospice care may be important for a subset of medically complex children with functional limitations, high health utilization, and substantial needs at end of life.
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Affiliation(s)
- Jessica Keim-Malpass
- Department of Acute and Specialty Care, School of Nursing, University of Virginia, Charlottesville, Virginia, USA
| | - Melanie J Cozad
- Department of Health Services Policy and Management, University of South Carolina, Columbia, South Carolina, USA
| | - Radion Svynarenko
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
| | - Jennifer W Mack
- Division of Population Sciences, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lisa C Lindley
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
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19
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Lindley LC, Svynarenko R, Mooney-Doyle K, Mendola A, Naumann WC, Keim-Malpass J. Patterns of Health Care Services During Pediatric Concurrent Hospice Care: A National Study. Am J Hosp Palliat Care 2021; 39:282-288. [PMID: 34032124 DOI: 10.1177/10499091211018661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Children at end of life have unique and complex care needs. Although there is increasing evidence about pediatric concurrent hospice care, the health care services received while in hospice have not received sufficient attention. OBJECTIVES To examine the health care services, unique clusters of health care services, and characteristics of the children in the clusters. METHODS Multiple data sources were used including national Medicaid claims data. Children under 21years in pediatric concurrent hospice care were included. Using Medicaid categories assigned to claims, health care services were distributed across 20 categories. Latent class analysis was used to identify clusters of health care services. Demographic profiles of the clusters were created. RESULTS The 6,243 children in the study generated approximately 500,0000 non-hospice, health care service claims while enrolled in hospice care. We identified 3 unique classes of health care services use: low (61.1%), moderate (18.1%), and high (20.8%) intensity. The children in the 3 classes exhibited unique demographic profiles. CONCLUSIONS Health care services cluster together in unique fashion with distinct patterns among children in concurrent hospice care. The findings suggest that concurrent hospice care is not a 1-size-fit all solution for children. Concurrent hospice care may be customized and require attention to care coordination to ensure high-quality care.
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Affiliation(s)
- Lisa C Lindley
- College of Nursing, University of Tennessee, Knoxville, TN, USA
| | | | | | - Annette Mendola
- Department of Medicine, University of Tennessee Medical Center, Knoxville, TN, USA
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20
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Kutney-Lee A, Smith D, Griffin H, Kinder D, Carpenter J, Thorpe J, Murray A, Shreve S, Ersek M. Quality of end-of-life care for Vietnam-era Veterans: Implications for practice and policy. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100494. [PMID: 33992224 DOI: 10.1016/j.hjdsi.2020.100494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 09/04/2020] [Accepted: 10/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND In federal response to the aging population of Vietnam-era Veterans, Congress directed the Department of Veterans Affairs (VA) to create a pilot program to identify and develop best practices for improving hospice care for this population. A first step in VA's response was to identify whether the end-of-life (EOL) care needs and outcomes of Vietnam-era Veterans differed from previous generations. METHODS Using medical records and bereaved family surveys, we examined clinical characteristics, healthcare utilization, and EOL quality indicators for Vietnam-era Veterans who died in VA inpatient settings between fiscal year 2013-2017. Contemporaneous comparisons were made with World War II/Korean War-era Veterans. RESULTS Compared to prior generations, higher percentages of Vietnam-era Veterans had mental health/substance use diagnoses and disability. Similar percentages of family members in both groups reported that overall EOL care was excellent; however, post-traumatic stress disorder management ratings by families of Vietnam-era Veterans were significantly lower. CONCLUSIONS Although current VA EOL practices are largely meeting the needs of Vietnam-era Veterans, greater focus on mental health comorbidity, including post-traumatic stress disorder, Agent Orange-related conditions, and ensuring access to quality EOL care in the community is warranted. IMPLICATIONS Policymakers and healthcare professionals should anticipate more physical and mental health comorbidities among Veterans at EOL as Vietnam-era Veterans continue to age. Findings are being used to inform the development of standardized EOL care protocols and training programs for non-VA healthcare providers that are tailored to the needs of this population.
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Affiliation(s)
- Ann Kutney-Lee
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of Pennsylvania, School of Nursing, Philadelphia, PA, USA.
| | - Dawn Smith
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Hilary Griffin
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of Pennsylvania, School of Nursing, Philadelphia, PA, USA
| | - Daniel Kinder
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Joan Carpenter
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of Pennsylvania, School of Nursing, Philadelphia, PA, USA
| | - Joshua Thorpe
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of North Carolina- Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA; Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrew Murray
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of Pennsylvania, School of Nursing, Philadelphia, PA, USA
| | - Scott Shreve
- Hospice and Palliative Care Program, Department of Veterans Affairs, Lebanon VA Medical Center, Lebanon, PA, USA
| | - Mary Ersek
- Veteran Experience Center (VEC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of Pennsylvania, School of Nursing, Philadelphia, PA, USA; University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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21
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Varilek BM, Isaacson MJ. Female Veteran Use of Palliative and Hospice Care: A Scoping Review. Mil Med 2021; 186:1100-1105. [PMID: 33512462 DOI: 10.1093/milmed/usab005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/11/2020] [Accepted: 01/05/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The number of female veterans in the USA in the age range of 55-64 years increased 7-fold from 2000 to 2015. Female veterans are more likely to suffer from certain mental health disorders, respiratory diseases, neurologic diseases, and some forms of cancer when compared to their male counterparts. Veterans Affairs (VA) healthcare providers need to be prepared to care for this growth of female veterans with serious illness. These serious illnesses require appropriate medical management, which often includes palliative care. It is imperative to determine how VA healthcare providers integrate palliative and hospice care for this population. The purpose of our scoping review was to explore the palliative and hospice care literature specific to female veterans to learn: (1) what evidence is available regarding female veterans' use of palliative and hospice care? (2) To meet the needs of this growing population, what gaps exist specific to female veterans' use of palliative and hospice care? METHODS A scoping review methodology was employed following the nine-step process described by the Joanna Briggs Institute for conducting scoping reviews. RESULTS Nineteen articles met the inclusion criteria. Fourteen quantitative articles were included which comprised 10 retrospective chart reviews, one randomized controlled trial, one correlation, one quality improvement, and one cross-sectional. The remaining five were qualitative studies. The sample populations within the articles were overwhelmingly male and white. Content analysis of the articles revealed three themes: quality of end of life care, distress, and palliative care consult. CONCLUSIONS The female veteran population is increasing and becoming more ethnically diverse. Female veterans are not well represented in the literature. Our review also uncovered a significant gap in the study methodologies. We found that retrospective chart reviews dominated the palliative and hospice care literature specific to veterans. More prospective study designs are needed that explore the veteran and family experience while receiving end of life care. With the rising number of older female veterans and their risk for serious illness, it is imperative that research studies purposefully recruit, retain, analyze, and report female veteran statistics along with their male counterparts. We can no longer afford to disregard the value of the female veterans' perspective.
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Affiliation(s)
- Brandon M Varilek
- College of Nursing, Graduate Nursing, South Dakota State University, Sioux Falls, SD 57107, USA
| | - Mary J Isaacson
- College of Nursing, Graduate Nursing, South Dakota State University, Rapid City, SD 57701, USA
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22
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Rising ML, Hassouneh D, Berry P, Lutz K. Mistrust Reported by US Mexicans With Cancer at End of Life and Hospice Enrollment. ANS Adv Nurs Sci 2021; 44:E14-E31. [PMID: 33497104 DOI: 10.1097/ans.0000000000000344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hospice research with Hispanics mostly focuses on cultural barriers. Mindful of social justice and structural violence, we used critical grounded theory in a postcolonial theory framework to develop a grounded theory of hospice decision making in US Mexicans with terminal cancer. Findings suggest that hospice avoidance is predicted by mistrust, rather than culture, whereas hospice enrollers felt a sense of belonging. Cultural accommodation may do little to mitigate hospice avoidance rooted in discrimination-fueled mistrust. Future research with nondominant populations should employ research designs mitigating Eurocentric biases. Policy makers should consider concurrent therapy for nondominant populations with low trust in the health care system.
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Affiliation(s)
- Margaret L Rising
- OHSU Knight Cancer Institute and OHSU School of Nursing, Portland, Oregon (Dr Rising); Oregon Health & Science University School of Nursing, Portland (Drs Hassouneh and Lutz); Livio Health, Minneapolis, Minnesota (Dr Berry); and Department of Internal Medicine, University of Minnesota, Robbinsdale (Dr Berry)
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23
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Gidwani R, Asch SM, Needleman J, Faricy-Anderson K, Boothroyd DB, Illarmo S, Lorenz KA, Patel MI, Hsin G, Ramchandran K, Wagner TH. End-of-Life Cost Trajectories in Cancer Patients Treated by Medicare versus the Veterans Health Administration. J Am Geriatr Soc 2020; 69:916-923. [PMID: 33368171 DOI: 10.1111/jgs.16941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/29/2020] [Accepted: 10/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA). DESIGN A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equations to evaluate monthly cost trajectories experienced by patients in their last year of life, with patients nested within hospital referral region. SETTING Care received at VA facilities or by Medicare-reimbursed providers nationwide. PARTICIPANTS A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare. MEASUREMENTS We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12 months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life. RESULTS All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care. CONCLUSION Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.
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Affiliation(s)
- Risha Gidwani
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Jack Needleman
- Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Katherine Faricy-Anderson
- Providence VA Medical Center, Providence, Rhode Island, USA.,Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Derek B Boothroyd
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Manali I Patel
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA.,Division of Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Gary Hsin
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Kavitha Ramchandran
- Division of Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Todd H Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Surgery, Stanford University, Stanford, California, USA
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24
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Minegishi T, Garrido MM, Stein M, Oliva EM, Frakt AB. Opioid Discontinuation Among Patients Receiving High-Dose Long-Term Opioid Therapy in the Veterans Health Administration. J Gen Intern Med 2020; 35:903-909. [PMID: 33145683 PMCID: PMC7728867 DOI: 10.1007/s11606-020-06252-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/17/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prior opioid discontinuation studies have focused on one of two characteristics of opioid prescribing, its duration (long term vs not) or dosage (high vs low). Questions remain about the experience of patients with high-dose, long-term opioid therapy (HLOT) prescriptions who are likely to be at the highest risk for adverse events. OBJECTIVE We address the following questions among the Veterans Health Administration (VHA) patients receiving HLOT: 1), How has the prevalence of discontinuation of opioids changed over time? 2), How do patient characteristics vary between those who do and do not discontinue? And 3), how does the prevalence of discontinuation vary geographically? DESIGN A retrospective observational study of VHA patients with HLOT between fiscal year (FY) 2014 and FY2018. PARTICIPANTS We identified 1,281,330 patients from VHA outpatient opioid prescription data with at least a 1-day opioid supply between FY2014 and FY2018. We identified and excluded those receiving palliative care or diagnosed with metastatic cancer. MAIN MEASURES For a given patient and month, a patient having a 3-month moving average of ≥ 90 daily morphine milligram equivalent (MME) was defined as having HLOT. Similarly, we used a three-month average MME of zero as discontinuation. KEY RESULTS The prevalence of discontinuation among patients with HLOT increased from 6.3% in FY2014 to 7.8% in FY2018. Across the years, patients who discontinued were younger, less likely to be married, and more likely to have comorbidities related to substance use disorders compared with patients who continued to receive HLOT. Incidence of discontinuation among those with HLOT increased in more than half (64%) of the 129 VHA medical centers. CONCLUSION Prevalence of patients receiving HLOT in the VHA decreased as the incidence of discontinuation increased. Further research is needed to understand the process by which patients are discontinued and to assess the relationship between discontinuation and health outcomes.
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Affiliation(s)
- Taeko Minegishi
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, MA, Boston, USA.
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA.
- Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA.
| | - Melissa M Garrido
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, MA, Boston, USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Michael Stein
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Elizabeth M Oliva
- VA Office of Mental Health and Suicide Prevention, VA Program Evaluation and Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- VA Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Austin B Frakt
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, MA, Boston, USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA
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25
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Cullen G. End-of-Life Care: Use of Antineoplastic Therapy and Nonessential Medications in Veteran Patients Receiving Palliative Care. Clin J Oncol Nurs 2020; 24:667-672. [PMID: 33216053 DOI: 10.1188/20.cjon.667-672] [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]
Abstract
BACKGROUND The use of antineoplastic therapy and nonessential medications at the end of life can lead to poorer quality of life for patients, decreased satisfaction with care among caregivers, financial toxicity, increased use of the emergency department, and hospitalization. OBJECTIVES This study evaluated the incidence of antineoplastic therapy administration and use of nonessential medications at 30 and 14 days prior to death among patients with metastatic lung, prostate, colon, or pancreatic cancer who were also receiving palliative care. METHODS Using retrospective chart review, this study evaluated patients admitted to a U.S. Department of Veterans Affairs healthcare system during a two-year period. Variables assessed included use of antineoplastic therapy and nonessential medications, emergency department visits, hospitalizations, palliative care accessibility, and hospice referrals. FINDINGS All patients in the study (N = 57) received palliative care. Sixteen percent of patients in this study received antineoplastic therapy, 14% received nonessential medications, and 40% were hospitalized or visited the emergency department within 30 days of death.
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26
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Patel MN, Nicolla JM, Friedman FAP, Ritz MR, Kamal AH. Hospice Use Among Patients With Cancer: Trends, Barriers, and Future Directions. JCO Oncol Pract 2020; 16:803-809. [PMID: 33186083 DOI: 10.1200/op.20.00309] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Patients with advanced cancer and their families frequently encounter clinical and logistical challenges related to end-of-life care. Hospice provides interdisciplinary and holistic care to meet patients' biomedical, psychosocial, and spiritual needs in the last phases of life. Despite increasing general acceptance and use among patients with cancer, hospice remains underused. Underuse stems from ongoing misconceptions regarding hospice and its purpose, coupled with the rapid development of novel anticancer treatments, such as immunotherapies and targeted therapies, that have changed the landscape of possibilities. Furthermore, rapid evolutions in how end-of-life care is structured and reimbursed for will affect how oncology patients will intersect with hospice care. In this review, we explore the current and future challenges to greater integration of hospice care in the care of patients with advanced cancer and propose five recommendations as part of the path forward.
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Affiliation(s)
- Mihir N Patel
- Trinity College of Arts and Sciences, Duke University, Durham, NC
| | | | | | - Michala R Ritz
- Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, NC.,Duke Fuqua School of Business, Durham, NC
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27
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Yefimova M, Aslakson RA, Yang L, Garcia A, Boothroyd D, Gale RC, Giannitrapani K, Morris AM, Johanning JM, Shreve S, Wachterman MW, Lorenz KA. Palliative Care and End-of-Life Outcomes Following High-risk Surgery. JAMA Surg 2020; 155:138-146. [PMID: 31895424 DOI: 10.1001/jamasurg.2019.5083] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance Palliative care has the potential to improve care for patients and families undergoing high-risk surgery. Objective To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation. Design, Setting, and Participants This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included. Exposures Palliative-care consultation within 30 days before or 90 days after surgery. Main Outcomes and Measures The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes. Results A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery. Conclusions and Relevance Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.
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Affiliation(s)
- Maria Yefimova
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.,Office of Research, Patient Care Services, Stanford Healthcare, Stanford, California
| | - Rebecca A Aslakson
- Section of Palliative Care, Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California.,Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University, Stanford, California
| | - Lingyao Yang
- Quantitative Sciences Unit, Stanford University, Stanford, California
| | - Ariadna Garcia
- Quantitative Sciences Unit, Stanford University, Stanford, California
| | - Derek Boothroyd
- Quantitative Sciences Unit, Stanford University, Stanford, California
| | - Randall C Gale
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Karleen Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Arden M Morris
- Stanford-Surgery Policy, Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Jason M Johanning
- Department of Surgery, Quality and Compliance, University of Nebraska Medical Center, Omaha.,Veterans Integrated Service Network 23, Nebraska-Western Iowa VA Medical Center, Omaha
| | - Scott Shreve
- Hospice and Palliative Care Program, Hospice and Palliative Care Unit Department of Veteran Affairs, Lebanon VA Medical Center, Lebanon, Pennsylvania
| | - Melissa W Wachterman
- Section of General Internal Medicine, VA Boston Health Care System, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.,Section of Palliative Care, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
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28
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Kaiser U, Vehling-Kaiser U, Kück F, Mechie NC, Hoffmann A, Kaiser F. Use of symptom-focused oncological cancer therapies in hospices: a retrospective analysis. BMC Palliat Care 2020; 19:140. [PMID: 32919468 PMCID: PMC7488695 DOI: 10.1186/s12904-020-00648-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 09/06/2020] [Indexed: 12/04/2022] Open
Abstract
Background There is controversy regarding the practical implementation of symptom-focused oncological cancer therapies to hospice residents. In this study, we aim to analyse the use and indication of supportive-oncological cancer therapies in hospices. Methods We conducted a retrospective survey of all residents of two hospice centres in the government district of Lower Bavaria, Germany. Hospice 1 (H1) was a member of an oncological–palliative medical network, and hospice 2 (H2) was independently organized. The evaluation period was the first 40 months after the opening of the respective hospice care centre. Demographical and epidemiological data as well as indications and type of supportive-oncological cancer therapies were recorded. A descriptive analysis and statistical tests were performed. Results Of the 706 residents, 645 had an underlying malignant disease. The average age was 72 years and the mean residence time was 28 days. The most frequent cancer types were gastrointestinal cancers, gynaecological cancers and bronchial carcinomas. Overall 39 residents (33 in H1 and 6 in H2, p < 0.01) received symptom-focused oncological cancer therapy. The average age of these residents was 68 years, and the mean residence time was 55 days. The most common therapeutic indications were dyspnoea and pain. The most common symptom-focused oncological cancer therapies were bisphosphonates, transfusions (erythrocyte- and platelet- concentrates), radiotherapy and anti-proliferative drugs (chemotherapy, anti-hormonal- and targeted- therapies). Patients with therapy lived significantly longer than patients without therapy (p < 0.01). Conclusions Symptom-focused oncological cancer therapies can be implemented in hospices; however, their implementation seems to require certain structural and organizational prerequisites as well as careful patient selection. As a palliative medical approach, the focus is to ameliorate the symptoms and not prolong life. Symptom-focused oncology treatment could be a further and important part for the therapy of hospice patients in the future.
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Affiliation(s)
- Ulrich Kaiser
- University Hospital Regensburg, Clinic and Polyclinic for Internal Medicine III, Regensburg, Germany
| | | | - Fabian Kück
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Nicolae-Catalin Mechie
- University Medicine Göttingen, Clinic for Gastroenterology and Gastrointestinal Oncology, Göttingen, Germany
| | | | - Florian Kaiser
- University Medicine Göttingen, Clinic for Haematology and Medical Oncology, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
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29
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O'Hare AM, Butler CR, Taylor JS, Wong SPY, Vig EK, Laundry RS, Wachterman MW, Hebert PL, Liu CF, Rios-Burrows N, Richards CA. Thematic Analysis of Hospice Mentions in the Health Records of Veterans with Advanced Kidney Disease. J Am Soc Nephrol 2020; 31:2667-2677. [PMID: 32764141 DOI: 10.1681/asn.2020040473] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 06/29/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Patients with advanced kidney disease are less likely than many patients with other types of serious illness to enroll in hospice. Little is known about real-world clinical decision-making related to hospice for members of this population. METHODS We used a text search tool to conduct a thematic analysis of documentation pertaining to hospice in the electronic medical record system of the Department of Veterans Affairs, for a national sample of 1000 patients with advanced kidney disease between 2004 and 2014 who were followed until October 8, 2019. RESULTS Three dominant themes emerged from our qualitative analysis of the electronic medical records of 340 cohort members with notes containing hospice mentions: (1) hospice and usual care as antithetical care models: clinicians appeared to perceive a sharp demarcation between services that could be provided under hospice versus usual care and were often uncertain about hospice eligibility criteria. This could shape decision-making about hospice and dialysis and made it hard to individualize care; (2) hospice as a last resort: patients often were referred to hospice late in the course of illness and did not so much choose hospice as accept these services after all treatment options had been exhausted; and (3) care complexity: patients' complex care needs at the time of hospice referral could complicate transitions to hospice, stretch the limits of home hospice, and promote continued reliance on the acute care system. CONCLUSIONS Our findings underscore the need to improve transitions to hospice for patients with advanced kidney disease as they approach the end of life.
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Affiliation(s)
- Ann M O'Hare
- Department of Medicine, University of Washington, Seattle, Washington .,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | | | - Janelle S Taylor
- Department of Anthropology, University of Toronto, Toronto, Ontario, Canada
| | - Susan P Y Wong
- Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Elizabeth K Vig
- Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ryan S Laundry
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Paul L Hebert
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Chuan-Fen Liu
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Nilka Rios-Burrows
- Chronic Kidney Disease Initiative, Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Claire A Richards
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,School of Nursing, University of Washington, Seattle, Washington
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30
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Lindley LC, Keim-Malpass J, Svynarenko R, Cozad MJ, Mack JW, Hinds PS. Pediatric Concurrent Hospice Care: A Scoping Review and Directions for Future Nursing Research. J Hosp Palliat Nurs 2020; 22:238-245. [PMID: 32282559 PMCID: PMC7716801 DOI: 10.1097/njh.0000000000000648] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 2010, forgoing curative therapies were removed as a hospice eligibility criterion for children through section 2302 of the Patient Protection and Affordable Care Act called Concurrent Care for Children. Given that concurrent care is a federally mandated option for children and their families, no review of the science has been conducted. The purpose of this study was to systematically collect the evidence on concurrent hospice care, critically appraise the evidence, and identify areas for future nursing research. Of the 186 articles identified for review, 14 met the inclusion and exclusion criteria. Studies in this review described concurrent hospice care from a variety of perspectives: policy, legal, and ethics. However, only 1 article evaluated the impact of concurrent hospice care on outcomes, whereas several studies explained clinical and state-level implementation. There is a need for further studies that move beyond conceptualization and generate baseline and outcomes data. Understanding the effectiveness of concurrent hospice care might provide important information for future nursing research. The approaches used to disseminate and implement concurrent hospice care at state, provider, and family levels should be explored.
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31
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Levy C, Ersek M, Scott W, Carpenter JG, Kononowech J, Phibbs C, Lowry J, Cohen J, Foglia M. Life-Sustaining Treatment Decisions Initiative: Early Implementation Results of a National Veterans Affairs Program to Honor Veterans' Care Preferences. J Gen Intern Med 2020; 35:1803-1812. [PMID: 32096084 PMCID: PMC7280392 DOI: 10.1007/s11606-020-05697-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/31/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND On July 1, 2018, the Veterans Health Administration (VA) National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI). Its goal is to identify, document, and honor LST decisions of seriously ill veterans. Providers document veterans' goals and decisions using a standardized LST template and order set. OBJECTIVE Evaluate the first 7 months of LSTDI implementation and identify predictors of LST template completion. DESIGN Retrospective observational study of clinical and administrative data. We identified all completed LST templates, defined as completion of four required template fields. Templates also include four non-required fields. Results were stratified by risk of hospitalization or death as estimated by the Care Assessment Need (CAN) score. SUBJECTS All veterans with VA utilization between July 1, 2018, and January 31, 2019. MAIN MEASURES Completed LST templates, goals and LST preferences, and predictors of documentation. RESULTS LST templates were documented for 108,145 veterans, and 85% had one or more of the non-required fields completed in addition to the required fields. Approximately half documented a preference for cardiopulmonary resuscitation. Among those who documented specific goals, half wanted to improve or maintain function, independence, and quality of life while 28% had a goal of life prolongation irrespective of risk of hospitalization/death and 45% expressed a goal of comfort. Only 7% expressed a goal of being cured. Predictors of documentation included VA nursing home residence, older age, frailty, and comorbidity, while non-Caucasian race, rural residence, and receipt of care in a lower complexity medical center were predictive of no documentation. CONCLUSIONS LST decisions were documented for veterans at high risk of hospitalization or death. While few expressed a preference for cure, half desire, cardiopulmonary resuscitation. Predictors of documentation were generally consistent with existing literature. Opportunities to reduce observed disparities exist by leveraging available VA resources and programs.
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Affiliation(s)
- Cari Levy
- Department of Veterans Affairs, Rocky Mountain VA Medical Center, Aurora, CO, USA.
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Mary Ersek
- Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Joan G Carpenter
- Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Jennifer Kononowech
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Jill Lowry
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA
| | - Jennifer Cohen
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
| | - Marybeth Foglia
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA
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32
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Fernandes R, Fess EG, Sullivan S, Brack M, DeMarco T, Li D. Supportive Care for Superutilizers of a Managed Care Organization. J Palliat Med 2020; 23:1444-1451. [PMID: 32456602 PMCID: PMC7583336 DOI: 10.1089/jpm.2019.0288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Ohana Health Plan, Inc., (OHP) is one of the first managed care organizations offering supportive care services targeted to superutilizers. Bristol Hospice Hawaii, LLC, partnered with OHP to provide interdisciplinary supportive care services to home-bound OHP members. Objectives: The purpose of this study was to measure symptom relief, satisfaction, resource utilization, and cost savings associated with supportive care. Design: Prospective study. Setting: Over 12 months, 27 superutilizer members residing in the community were referred by OHP, 21 members were enrolled into supportive care. Measurements: Data were collected upon admission and repeatedly thereafter using the Edmonton Symptom Assessment Scale (ESAS) and the Missoula-Vitas Quality of Life Index (MVQOLI). The Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale was administered at discharge. Emergency department (ED) visits and hospital utilization were tracked. Results: Median age was 63 years; more than half had cardiac diagnoses. Majority of members were Hawaiian and other Pacific Islander. Median length of stay in supportive care was 90 days. Five (23%) members enrolled in hospice following supportive care. Symptom improvement occurred in pain (p < 0.0001), anxiety (p = 0.0052), and shortness of breath (p = 0.0447). This model has shown a 79.5% reduction of ED visits per thousand members and a 75% reduction of hospitalizations per thousand. Overall net savings was 36%. Discussions and documentation of end-of-life wishes increased from 23% to 85%. Conclusion: Supportive care is highly effective in reducing costs associated with superutilizers. Our experience demonstrates the effectiveness of supportive care approaches in this population through improved care and lower health care costs overall.
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Affiliation(s)
- Ritabelle Fernandes
- Division of Palliative Medicine, Department of Geriatric Medicine, John A Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA.,Bristol Hospice Hawaii, LLC, Honolulu, Hawaii, USA
| | - Ed G Fess
- Ohana Health Plan, Inc., Honolulu, Hawaii, USA
| | | | - Mona Brack
- Ohana Health Plan, Inc., Honolulu, Hawaii, USA
| | - Tara DeMarco
- Bristol Hospice Hawaii, LLC, Honolulu, Hawaii, USA
| | - Dongmei Li
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Gidwani-Marszowski R, Faricy-Anderson K, Asch SM, Illarmo S, Ananth L, Patel MI. Potentially avoidable hospitalizations after chemotherapy: Differences across medicare and the Veterans Health Administration. Cancer 2020; 126:3297-3302. [PMID: 32401340 DOI: 10.1002/cncr.32896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 03/11/2020] [Accepted: 03/19/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) has released quality measures regarding potentially avoidable hospitalizations visits in the 30 days after receipt of outpatient chemotherapy. This study evaluated the proportions of patients treated by Medicare-reimbursed clinicians and Veterans Health Administration (VA) clinicians who experienced avoidable acute care in order to evaluate differences in health system performance. METHODS This retrospective evaluation of Medicare and VA administrative data used a cohort of cancer decedents (fiscal years 2010-2014). Cohort members were veterans aged 66 years or older at death who were dually enrolled in Medicare and the VA. Chemotherapy was identified through International Classification of Diseases, Ninth Revision and Current Procedural Terminology (ICD-9) codes. CMS defines avoidable hospitalizations as those related to anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, or sepsis in the 30 days after chemotherapy. Following CMS guidance, this study compared the proportions of patients with potentially avoidable hospitalizations, using hierarchical generalized estimating equations. RESULTS There were 27,443 patients who received outpatient chemotherapy. Patients receiving Medicare chemotherapy were significantly more likely to have potentially avoidable hospitalizations than patients receiving VA chemotherapy (adjusted odds ratio, 1.58; 95% confidence interval, 1.41-1.78; P < .001). In predicted estimates, 7.1% of Medicare-treated veterans had potentially avoidable hospitalizations in the 30 days after chemotherapy, compared with 4.6% of VA-treated veterans. CONCLUSIONS Results indicate veterans with cancer receiving chemotherapy in the VA have higher quality care with respect to avoidable hospitalizations than veterans receiving chemotherapy through Medicare. As more veterans seek care in the private sector under the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, concerted efforts may be warranted to ensure that veterans do not experience a decline in care quality.
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Affiliation(s)
- Risha Gidwani-Marszowski
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.,Department of Health Management and Policy, UCLA School of Public Health, Los Angeles, California
| | - Katherine Faricy-Anderson
- Providence VA Medical Center, Providence, Rhode Island.,Alpert Medical School, Brown University, Providence, Rhode Island
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Lakshmi Ananth
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Manali I Patel
- VA Palo Alto Health Care System, Palo Alto, California.,Division of Oncology, Stanford University School of Medicine, Stanford, California
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34
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Presley CJ, Han L, O'Leary JR, Zhu W, Corneau E, Chao H, Shamas T, Rose M, Lorenz K, Levy CR, Mor V, Gross CP. Concurrent Hospice Care and Cancer-Directed Treatment for Advanced Lung Cancer and Receipt of Aggressive Care at the End of Life in the Veteran's Health Administration. J Palliat Med 2020; 23:1038-1044. [PMID: 32119800 DOI: 10.1089/jpm.2019.0485] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Aggressive care at the end of life (EOL) is a persistent issue for patients with stage IV nonsmall cell lung cancer (NSCLC). We evaluated the use of concurrent care (CC) with hospice care and cancer-directed treatment simultaneously within the Veteran's Health Administration (VHA) and aggressive care at the EOL. Objective: To determine whether VHA facility-level CC is associated with changes in aggressive care at the EOL. Design/Setting: Veterans with stage IV NSCLC who died between 2006 and 2012 and received lung cancer care within the VHA. Measurements: The primary outcome was aggressive care at EOL (i.e., hospital admissions, chemotherapy, and intensive care unit) within the last month of life. To compare aggressive care across VHA facilities, we used a random intercept multilevel logistic regression model to examine the association between facility-level CC within each study year (<10%, 10% to 19%, and ≥20%) and aggressive care at the EOL among the decedents as a binary outcome. Results: In total, 18,371 veterans with NSCLC at 154 VHA facilities were identified. Facilities delivering CC for ≥20% of veterans (high CC) increased from 20.0% in 2006 to 43.2% in 2012 (p < 0.001). Overall, hospice care significantly increased and aggressive care at EOL decreased over the study period. However, facility-level CC adoption was not associated with any difference in aggressive care at EOL (adjusted odds ratio high CC vs. low CC: 0.91 [95% CI, 0.79 to 1.05], p = 0.21). Conclusions: Although the VHA adoption of CC increased hospice use among patients with NSCLC, additional measures may be needed to decrease aggressive care at the EOL.
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Affiliation(s)
- Carolyn J Presley
- Department of Internal Medicine, Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ling Han
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - John R O'Leary
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Weiwei Zhu
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Emily Corneau
- Providence Veterans Health Administration Medical Center, Center of Innovation, Providence, Rhode Island, USA
| | - Herta Chao
- Yale University School of Medicine, New Haven, Connecticut, USA.,Connecticut Veterans Health Administration Medical Center, West Haven, Connecticut, USA
| | - Tracy Shamas
- Connecticut Veterans Health Administration Medical Center, West Haven, Connecticut, USA
| | - Michal Rose
- Yale University School of Medicine, New Haven, Connecticut, USA.,Connecticut Veterans Health Administration Medical Center, West Haven, Connecticut, USA
| | - Karl Lorenz
- Department of Medicine, Primary Care and Population Health, Stanford University, Palo Alto, California, USA
| | - Cari R Levy
- Eastern Colorado VA Healthcare System, Aurora, Colorado, USA
| | - Vincent Mor
- Providence Veterans Health Administration Medical Center, Center of Innovation, Providence, Rhode Island, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Cary P Gross
- National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut, USA
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Mor V, Wagner TH, Levy C, Ersek M, Miller SC, Gidwani-Marszowski R, Joyce N, Faricy-Anderson K, Corneau EA, Lorenz K, Kinosian B, Shreve S. Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer. JAMA Oncol 2020; 5:810-816. [PMID: 30920603 DOI: 10.1001/jamaoncol.2019.0081] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Medicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans' end-of-life care is unknown. Objective To determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life. Design, Setting, and Participants A modified difference-in-differences study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13 085 veterans newly diagnosed with stage IV non-small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018. Exposures Using VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability. Main Outcomes and Measures Receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first 6 months after diagnosis. Results Of the 13 085 veterans included in the study, 12 858 (98%) were men; 10 531 (81%) were white, and 5949 (46%) were older than 65 years. Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67-3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53-0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62-0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, -$358 to -$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference. Conclusions and Relevance Increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.
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Affiliation(s)
- Vincent Mor
- Center of Innovation in Long-term Services and Supports (LTSS COIN), Providence VA Medical Center, Providence, Rhode Island.,Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Todd H Wagner
- Health Economics Resource Center, VA Palo Alto Healthcare System, Palo Alto, California.,Center of Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California.,Stanford University School of Medicine, Palo Alto, California
| | - Cari Levy
- Eastern Colorado VA Healthcare System, Denver.,University of Colorado, Division of Health Care Policy and Research, Aurora
| | - Mary Ersek
- Veteran Experience Center (formerly, the PROMISE Center), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,University of Pennsylvania School of Nursing, Philadelphia
| | - Susan C Miller
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Risha Gidwani-Marszowski
- Health Economics Resource Center, VA Palo Alto Healthcare System, Palo Alto, California.,Center of Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California.,Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Nina Joyce
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Katherine Faricy-Anderson
- Center of Innovation in Long-term Services and Supports (LTSS COIN), Providence VA Medical Center, Providence, Rhode Island.,Alpert Medical School of Brown University, Providence, Rhode Island
| | - Emily A Corneau
- Center of Innovation in Long-term Services and Supports (LTSS COIN), Providence VA Medical Center, Providence, Rhode Island
| | - Karl Lorenz
- Center of Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California.,Stanford University School of Medicine, Palo Alto, California
| | - Bruce Kinosian
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Scott Shreve
- Hospice and Palliative Care Program, U.S. Department of Veterans Affairs.,Penn State College of Medicine, Hershey, Pennsylvania
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Way D, Ersek M, Montagnini M, Nathan S, Perry SA, Dale H, Savage JL, Luhrs CA, Shreve ST, Jones CA. Top Ten Tips Palliative Care Providers Should Know About Caring for Veterans. J Palliat Med 2019; 22:708-713. [DOI: 10.1089/jpm.2019.0190] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Deborah Way
- Department of Palliative Care, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Division of Geriatric Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Ersek
- Division of Geriatric Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Palliative Care, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Marcos Montagnini
- Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan
- Ann Arbor VA Healthcare System, Ann Arbor, Michigan
| | - Susan Nathan
- VA Boston Healthcare System, Boston, Massachusetts
- Section of Geriatrics and Palliative Care, Department of Internal Medicine, Harvard Medical School, Boston, Massachusetts
- Section of Geriatrics and Palliative Care, Department of Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Sherena A. Perry
- Section of Geriatrics and Palliative Care, Department of Internal Medicine, VA Medical Center, Boise, Idaho
| | - Heather Dale
- Division of Geriatric Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Carol A. Luhrs
- VA New York Harbor Healthcare System, Brooklyn, New York
| | - Scott T. Shreve
- VA Medical Center, Lebanon, Pennsylvania
- Hospice and Palliative Care Program, US Department of Veterans Affairs, Washington, DC
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Christopher A. Jones
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
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Smith CEP, Kamal AH, Kluger M, Coke P, Kelley MJ. National Trends in End-of-Life Care for Veterans With Advanced Cancer in the Veterans Health Administration: 2009 to 2016. J Oncol Pract 2019; 15:e568-e575. [PMID: 31046573 DOI: 10.1200/jop.18.00559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE It is imperative to provide quality end-of-life (EOL) care for patients with cancer. Although rates of hospice use within the Veterans Health Administration have improved, antineoplastic administration and intensive care unit (ICU) admission at the EOL, indicators of aggressive care, have not clearly declined over recent years. METHODS We identified 32,665 veterans diagnosed with stage IV lung, colorectal, or pancreatic cancer who died between 2009 and 2016 using a novel EOL Dashboard Tool created from Veterans Administration Cancer Registry data. This EOL tool reports the incidence of antineoplastic drug use in the last 14 days of life, ICU admission in the last 30 days of life, and hospice admission or consult. Change from 2009 to 2016 was assessed using a repeated measures one-way analysis of variance with post hoc test for linear trend of time for individual cancers and two-way analysis of variance for all cancers combined. RESULTS Antineoplastic use in the last 14 days of life declined from 6.8% in 2009 to 4.4% in 2016 (P = .03). ICU admission in the last 30 days did not change significantly, from 13.3% in 2009 to 14.7% in 2016. The exception was patients with stage IV lung cancer, in whom ICU admissions increased from 12.9% to 16.2% (P = .01). Patients using hospice services increased from 32.4% to 52.6% (P < .01). CONCLUSION Although antineoplastic administration at the EOL is declining for veterans with stage IV cancer, ICU admissions are unchanged and becoming more common in stage IV lung cancer despite increasing hospice use.
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Affiliation(s)
| | | | - Monica Kluger
- 2 Veterans Health Administration Support Service Center, Washington, DC
| | - Patty Coke
- 3 Central Arkansas Veterans Healthcare System, Little Rock, AR
| | - Michael J Kelley
- 1 Duke University Medical Center, Durham, NC.,4 Veterans Administration Medical Center and Veterans Administration National Oncology Program, Durham, NC
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Affiliation(s)
- Nathan R. Handley
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Justin E. Bekelman
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Heller DR, Jean RA, Chiu AS, Feder SI, Kurbatov V, Cha C, Khan SA. Regional Differences in Palliative Care Utilization Among Geriatric Colorectal Cancer Patients Needing Emergent Surgery. J Gastrointest Surg 2019; 23:153-162. [PMID: 30328071 PMCID: PMC6751557 DOI: 10.1007/s11605-018-3929-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/10/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The benefits of palliative care (PC) in critical illness are validated across a range of diseases, yet it remains underutilized in surgical patients. This study analyzed patient and hospital factors predictive of PC utilization for elderly patients with colorectal cancer (CRC) requiring emergent surgery. METHODS The National Inpatient Sample was queried for patients aged ≥ 65 years admitted emergently with CRC from 2009 to 2014. Patients undergoing colectomy, enterectomy, or ostomy formation were included and stratified according to documentation of PC consultation during admission. Chi-squared testing identified unadjusted group differences, and multivariable logistic regression identified predictors of PC. RESULTS Of 86,573 discharges meeting inclusion criteria, only 3598 (4.2%) had PC consultation. Colectomy (86.6%) and ostomy formation (30.4%) accounted for the operative majority. PC frequency increased over time (2.9% in 2009 to 6.2% in 2014, P < 0.001) and was nearly twice as likely to occur in the West compared with the Northeast (5.7 vs. 3.3%, P < 0.001) and in not-for-profit compared with proprietary hospitals (4.5 vs. 2.3%, P < 0.001). PC patients were more likely to have metastases (60.1 vs. 39.9%, P < 0.001) and die during admission (41.5 vs. 6.4%, P < 0.001). On multivariable logistic regression, PC predictors (P < 0.05) included region outside the Northeast, increasing age, more recent year, and metastatic disease. CONCLUSIONS In the USA, PC consultation for geriatric patients with surgically managed complicated CRC is low. Regional variation appears to play an important role. With mounting evidence that PC improves quality of life and outcomes, understanding the barriers associated with its provision to surgical patients is paramount.
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Affiliation(s)
- Danielle R Heller
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208088, New Haven, CT, 06520-8088, USA
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Shelli I Feder
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208088, New Haven, CT, 06520-8088, USA
- US Department of Veterans Affairs, 950 Campbell Ave, West Haven, CT, 06516, USA
| | - Vadim Kurbatov
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Charles Cha
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, CT, 06520-8062, USA
| | - Sajid A Khan
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, CT, 06520-8062, USA.
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40
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The experience of providing hospice care concurrent with cancer treatment in the VA. Support Care Cancer 2018; 27:1263-1270. [PMID: 30467792 DOI: 10.1007/s00520-018-4552-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/12/2018] [Indexed: 01/28/2023]
Abstract
PURPOSE Veterans with advanced cancer can receive hospice care concurrently with treatments such as radiation and chemotherapy. However, variations exist in concurrent care use across Veterans Affairs (VA) medical centers (VAMCs), and overall, concurrent care use is relatively rare. In this qualitative study, we aimed to identify, describe, and explain factors that influence the provision of concurrent cancer care (defined as chemotherapy or radiation treatments provided with hospice) for veterans with terminal cancer. METHODS From August 2015 to April 2016, we conducted six site visits and interviewed 76 clinicians and staff at six VA sites and their contracted community hospices, including community hospices (n = 16); VA oncology (n = 25); VA palliative care (n = 17); and VA inpatient hospice and palliative care units (n = 18). RESULTS Thematic qualitative content analysis found three themes that influenced the provision of concurrent care: (1) clinicians and staff at community hospices and at VAs viewed concurrent care as a viable care option, as it preserved hope and relationships while patient goals are clarified during transitions to hospice; and (2) the presence of dedicated liaisons facilitated care coordination and education about concurrent care; however, (3) clinicians and staff concerns about Medicare guideline compliance hindered use of concurrent care. CONCLUSIONS While concurrent care is used by a small number of veterans with advanced cancer, VA staff valued having the option available and as a bridge to hospice. Hospice staff felt concurrent care improved care coordination with VAMCs, but use may be tempered due to concerns related to Medicare compliance.
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Mudumbi SK, Bourgeois CE, Hoppman NA, Smith CH, Verma M, Bakitas MA, Brown CJ, Markland AD. Palliative Care and Hospice Interventions in Decompensated Cirrhosis and Hepatocellular Carcinoma: A Rapid Review of Literature. J Palliat Med 2018; 21:1177-1184. [PMID: 29698124 PMCID: PMC6104656 DOI: 10.1089/jpm.2017.0656] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Patients with decompensated cirrhosis (DC) and/or hepatocellular carcinoma (HCC) have a high symptom burden and mortality and may benefit from palliative care (PC) and hospice interventions. OBJECTIVE Our aim was to search published literature to determine the impact of PC and hospice interventions for patients with DC/HCC. METHODS We searched electronic databases for adults with DC/HCC who received PC, using a rapid review methodology. Data were extracted for study design, participant and intervention characteristics, and three main groups of outcomes: healthcare resource utilization (HRU), end-of-life care (EOLC), and patient-reported outcomes. RESULTS Of 2466 results, eight were included in final results. There were six retrospective cohort studies, one prospective cohort, and one quality improvement study. Five of eight studies had a high risk of bias and seven studied patients with HCC. A majority found a reduction in HRU (total cost of hospitalization, number of emergency department visits, hospital, and critical care admissions). Some studies found an impact on EOLC, including location of death (less likely to die in the hospital) and resuscitation (less likely to have resuscitation). One study evaluated survival and found hospice had no impact and another showed improvement of symptom burden. CONCLUSION Studies included suggest that PC and hospice interventions in patients with DC/HCC reduce HRU, impact EOLC, and improve symptoms. Given the few number of studies, heterogeneity of interventions and outcomes, and high risk of bias, further high-quality research is needed on PC and hospice interventions with a greater focus on DC.
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Affiliation(s)
- Sandhya K. Mudumbi
- Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Health Services and Outcomes Research Post-Doctoral Training Program, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Nicholas A. Hoppman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Catherine H. Smith
- Lister Hill Library of the Health Sciences, University of Alabama at Birmingham, Birmingham, Alabama
| | - Manisha Verma
- Division of Hepatology, Department of Transplantation, Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - Marie A. Bakitas
- Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
- University of Alabama at Birmingham School of Nursing, Birmingham, Alabama
| | - Cynthia J. Brown
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Veterans Affairs Birmingham/Atlanta Geriatric Research, Education and Clinical Center, Birmingham, Alabama
- Comprehensive Center for Healthy Aging, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alayne D. Markland
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Veterans Affairs Birmingham/Atlanta Geriatric Research, Education and Clinical Center, Birmingham, Alabama
- Comprehensive Center for Healthy Aging, University of Alabama at Birmingham, Birmingham, Alabama
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Miller SC, Intrator O, Scott W, Shreve ST, Phibbs CS, Kinosian B, Allman RM, Edes TE. Increasing Veterans' Hospice Use: The Veterans Health Administration's Focus On Improving End-Of-Life Care. Health Aff (Millwood) 2018; 36:1274-1282. [PMID: 28679815 DOI: 10.1377/hlthaff.2017.0173] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 2009 the Department of Veterans Affairs (VA) began a major, four-year investment in improving the quality of end-of-life care. The Comprehensive End of Life Care Initiative increased the numbers of VA medical center inpatient hospice units and palliative care staff members as well as the amount of palliative care training, quality monitoring, and community outreach. We divided male veterans ages sixty-six and older into categories based on their use of the VA and Medicare and examined whether the increases in their rates of hospice use in the last year of life differed from the concurrent increase among similar nonveterans enrolled in Medicare. After adjusting for age, race and ethnicity, diagnoses, nursing home use in the last year of life, census region, and urbanicity of a person's last residence, we found a 6.9-7.9-percentage-point increase in hospice use over time for the veteran categories, compared to a 5.6-percentage-point increase for nonveterans (the relative increases were 20-42 percent and 16 percent, respectively). The VA's substantial investment in palliative care appears to have resulted in greater hospice use by older male veterans enrolled in the VA, a critical step forward in caring for veterans with serious illnesses.
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Affiliation(s)
- Susan C Miller
- Susan C. Miller is a professor of health services, policy, and practice at the Center for Gerontology and Health Care Research, Brown University School of Public Health, in Providence, Rhode Island
| | - Orna Intrator
- Orna Intrator is director of the Geriatrics and Extended Care Data Analysis Center (GECDAC) at the Canandaigua Veterans Affairs Medical Center (VAMC) and a professor of public health sciences at the University of Rochester, both in New York
| | - Winifred Scott
- Winifred Scott is a health science specialist at GECDAC and at the Health Economics Resource Center at the Palo Alto VAMC, in Menlo Park, California
| | - Scott T Shreve
- Scott T. Shreve is national director of hospice and palliative care at the Lebanon VAMC, in Pennsylvania
| | - Ciaran S Phibbs
- Ciaran S. Phibbs is associate director of GECDAC and a health economist at the Health Economics Resource Center at the Palo Alto VAMC and a professor of neonatology at Stanford University, both in California
| | - Bruce Kinosian
- Bruce Kinosian is associate director of GECDAC at the Center for Health Equity Research and Promotion, Philadelphia VAMC, and an associate professor of medicine at the University of Pennsylvania, in Philadelphia
| | - Richard M Allman
- Richard M. Allman is chief consultant in the Office of Geriatrics and Extended Care Services, Department of Veterans Affairs, in Washington, D.C
| | - Thomas E Edes
- Thomas E. Edes is executive director of geriatrics and extended care operations in the Office of Geriatrics and Extended Care services, Department of Veterans Affairs
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Bekelman DB, Johnson-Koenke R, Bowles DW, Fischer SM. Improving Early Palliative Care with a Scalable, Stepped Peer Navigator and Social Work Intervention: A Single-Arm Clinical Trial. J Palliat Med 2018; 21:1011-1016. [PMID: 29461908 DOI: 10.1089/jpm.2017.0424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with cancer could benefit from early primary (i.e., basic) palliative care. Scalable models of care delivery are needed. OBJECTIVE Examine the feasibility of a stepped peer navigator and social work intervention developed to improve palliative care outcomes. DESIGN Single-arm prospective clinical trial. The peer navigator educated patients to advocate for pain and symptom management with their healthcare providers, motivated patients to pursue advance care planning, and discussed the role of hospice. The social worker saw patients with persistent psychosocial distress. SETTING/SUBJECTS Patients with advanced cancer at a VA Medical Center not currently in palliative care or hospice whose oncologist would not be surprised if the patient died in the subsequent year. MEASUREMENTS Participation and retention rates, patient-reported symptoms and quality of life, advance directive documentation, patient satisfaction survey, and semistructured interviews. RESULTS The participation rate was 38% (17/45), and 35% (7/17) completed final survey measures. Patients had stage IV (81%) and primarily genitourinary (47%) and lung (24%) malignancies. Median Eastern Cooperative Oncology Group performance status was 0. Patient-reported surveys indicated low distress (mean scores: Functional Assessment of Cancer Therapy-General, 75.3 [standard deviation {SD} 17.6]; Edmonton Symptom Assessment Scale symptom scores ranged from 1.6 to 3.8; Patient Health Questionnaire-9, 5.7 [SD 5.2]; and Generalized Anxiety Disorder-7, 2.8 [SD 4.1]). Of those who had not completed advance directives at baseline (n = 11, 65%), five completed them by the end of study (5/11, 45%). Patients who completed satisfaction surveys (n = 7) and interviews (n = 4) provided mixed reviews of the intervention. CONCLUSIONS At a single site, a stepped peer navigator and social work palliative care study had several challenges to feasibility, including low patient-reported distress and loss to follow-up.
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Affiliation(s)
- David B Bekelman
- 1 Department of Medicine, Veterans Affairs Eastern Colorado Health Care System , Denver, Colorado.,2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado
| | - Rachel Johnson-Koenke
- 1 Department of Medicine, Veterans Affairs Eastern Colorado Health Care System , Denver, Colorado
| | - Daniel W Bowles
- 1 Department of Medicine, Veterans Affairs Eastern Colorado Health Care System , Denver, Colorado.,2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado
| | - Stacy M Fischer
- 2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado
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Boucher NA, Johnson KS, LeBlanc TW. Acute Leukemia Patients' Needs: Qualitative Findings and Opportunities for Early Palliative Care. J Pain Symptom Manage 2018; 55:433-439. [PMID: 28935132 DOI: 10.1016/j.jpainsymman.2017.09.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/08/2017] [Accepted: 09/10/2017] [Indexed: 12/20/2022]
Abstract
CONTEXT Patients with acute leukemias likely have needs that palliative care can respond to, yet little is known about specific challenges they face, particularly during active treatment. We examined acute myeloid leukemia (AML) patients' expressed challenges and supports after intensive induction chemotherapy. OBJECTIVES We aimed to understand opportunities for palliative care interventions in this population. METHODS We conducted a qualitative study of AML patients with high-risk disease at Duke University Hospital, Durham, NC. Patients were interviewed about care experiences approximately 3 months after treatment initiation. Multiple coders used descriptive content analysis to identify common and recurrent themes. RESULTS We analyzed 22 patient transcripts. Sample demographics included 10 (45.5%) females, 12 (54.5%) males, mean age 62 (SD 10.9), 19 (86.4%) non-Hispanic white, and three (13.6%) nonwhite/non-Hispanic. All had high-risk disease, by age, relapse status, or molecular markers. We identified four themes in our analysis: physical symptoms, psychological issues, uncertainty regarding prognosis, and patients' sources of support. Specific challenges noted by patients included feelings of helplessness/hopelessness, activity restriction, fatigue, fevers, caregiver stress, and lack of clarity regarding treatment decision making. CONCLUSION AML patients face substantial challenges regarding physical symptoms, psychological distress, and uncertainty regarding prognosis. These challenges signal needs for which palliative care in high-risk AML patients may help. Our findings highlight opportunities to develop targeted palliative care interventions addressing unmet needs in AML patients.
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Affiliation(s)
- Nathan A Boucher
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kimberly S Johnson
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
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Tukey MH, Faricy-Anderson K, Corneau E, Youssef R, Mor V. Procedural Aggressiveness in Veterans with Advanced Non-Small-Cell Lung Cancer at the End of Life. J Palliat Med 2017; 21:445-451. [PMID: 29265906 DOI: 10.1089/jpm.2017.0022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Evidence suggests that the aggressiveness of care in cancer patients at the end of life is increasing. We sought to evaluate the use of invasive procedures at the end of life in patients with advanced non-small-cell lung cancer (NSCLC). OBJECTIVE To evaluate the utilization of invasive procedures at the end of life in Veterans with advanced NSCLC. DESIGN Retrospective cohort study of Veterans with newly diagnosed stage IV NSCLC who died between 2006 and 2012. SETTING/SUBJECTS Subjects were identified from the Veterans Affairs Central Cancer Registry. MEASUREMENTS All Veterans Administration (VA) and Medicare fee-for-service healthcare utilization and expenditure data were assembled for all subjects. The primary outcome was the number of invasive procedures performed in the last month of life. We classified procedures into three categories: minimally invasive, life-sustaining, and major-operative procedures. Logistic regression analysis was used to evaluate factors associated with the receipt of invasive procedures. RESULTS Nineteen thousand nine hundred thirty subjects were included. Three thousand (15.1%) subjects underwent 5523 invasive procedures during the last month of life. The majority of procedures (69.6%) were classified as minimally invasive. The receipt of procedures in the last month of life was associated with receipt of chemotherapy (odds ratio [OR] 3.68, 95% confidence interval [CI] 3.38-4.0) and ICU admission (OR 3.13, 95% CI 2.83-3.45) and was inversely associated with use of hospice services (OR 0.35, 95% CI 0.33-0.38). CONCLUSIONS Invasive procedures are commonly performed among Veterans with stage IV NSCLC during their last month of life and are associated with other measures of aggressive end-of-life care.
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Affiliation(s)
- Melissa H Tukey
- 1 Division of Pulmonary, Critical Care, and Sleep, Alpert Medical School of Brown University , Providence, Rhode Island
| | - Katherine Faricy-Anderson
- 2 Center of Innovation, Providence Veterans Health Administration (VA) Medical Center , Providence, Rhode Island
| | - Emily Corneau
- 2 Center of Innovation, Providence Veterans Health Administration (VA) Medical Center , Providence, Rhode Island
| | | | - Vincent Mor
- 2 Center of Innovation, Providence Veterans Health Administration (VA) Medical Center , Providence, Rhode Island.,4 Department of Health Services, Policy and Practice, Brown University School of Public Health , Providence, Rhode Island
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Abstract
Patients with cancer continue to have unmet palliative care needs. Concurrent palliative care is tailored to the needs of patients as well as their families to relieve suffering. Specialty palliative care referral is associated with improved symptom management, improved end-of-life quality, and higher family-rated satisfaction. Optimal timing for palliative care referral has not been determined. Barriers to palliative care referral include workforce limitations, provider attitudes and perceptions, and potential ethnic and racial disparities in access to palliative care. Future work should focus on novel, patient-centered approaches to identify and address unmet palliative care needs for patients living with cancer.
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Affiliation(s)
- Kathleen M Akgün
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, VA Connecticut Healthcare System, Yale University School of Medicine, 950 Campbell Avenue, MS11 ACSLG, West Haven, CT 06516, USA.
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Kanwal F, Tansel A, Kramer JR, Feng H, Asch SM, El-Serag HB. Trends in 30-Day and 1-Year Mortality Among Patients Hospitalized With Cirrhosis From 2004 to 2013. Am J Gastroenterol 2017; 112:1287-1297. [PMID: 28607480 DOI: 10.1038/ajg.2017.175] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 05/12/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Recent data suggest decreasing in-patient mortality in patients hospitalized with cirrhosis. We sought to determine if improvements in short-term outcomes for patients with cirrhosis are associated with changes in longer-term outcomes. METHODS We examined temporal trends in 30 days and 1-year postdischarge mortality among patients hospitalized with cirrhosis at any of the 126 Veterans Administration hospitals from 2004 and 2013. We adjusted for a range of demographic, liver disease severity, and comorbidity-related factors to account for differences in patient cohorts over time. RESULTS We identified 109,358 unique patients who were hospitalized with cirrhosis between 2004 and 2013. In-hospital mortality decreased from 11.4 to 7.6%, whereas 1-year mortality decreased from 34.5 to 33.2%. Over a third of out-of-hospital deaths occurred within the first 30 days after discharge; 30-day mortality increased from 9.3 to 10.1%. After adjusting for patient factors, the odds of in-hospital mortality in 2013 were 30% lower (adjusted odds ratio (OR)=0.70, 95% confidence interval (CI), 0.64-0.78), 1-year mortality were 13% lower (adjusted OR=0.87, 95% CI=0.82-0.93), whereas the 30-day mortality were 10% higher than 2004 (adjusted OR=1.10, 95% CI=0.99-1.21), although the latter did not reach statistical significance. CONCLUSIONS In patients admitted with cirrhosis, reduction in in-hospital mortality was associated with less marked reduction in 1-year mortality, and an unchanged, if not higher, 30-day mortality following discharge. Our data suggest that some of the burden of mortality in cirrhosis has shifted from in-hospital to the immediate postdischarge period.
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Affiliation(s)
- Fasiha Kanwal
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Aylin Tansel
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Jennifer R Kramer
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Hua Feng
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i), Palo Alto Veterans Affairs Medical Center, Palo Alto, California, USA.,Division of General Medical Disciplines, Stanford University, Palo Alto, California, USA
| | - Hashem B El-Serag
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Ersek M, Miller SC, Wagner TH, Thorpe JM, Smith D, Levy CR, Gidwani R, Faricy-Anderson K, Lorenz KA, Kinosian B, Mor V. Association between aggressive care and bereaved families' evaluation of end-of-life care for veterans with non-small cell lung cancer who died in Veterans Affairs facilities. Cancer 2017; 123:3186-3194. [PMID: 28419414 DOI: 10.1002/cncr.30700] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/21/2017] [Accepted: 03/13/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND To the authors' knowledge, little is known regarding the relationship between patients' and families' satisfaction with aggressive end-of-life care. Herein, the authors examined the associations between episodes of aggressive care (ie, chemotherapy, mechanical ventilation, acute hospitalizations, and intensive care unit admissions) within the last 30 days of life and families' evaluations of end-of-life care among patients with non-small cell lung cancer (NSCLC). METHODS A total of 847 patients with NSCLC (34% of whom were aged <65 years) who died in a nursing home or intensive care, acute care, or hospice/palliative care (HPC) unit at 1 of 128 Veterans Affairs Medical Centers between 2010 and 2012 were examined. Data sources included Veterans Affairs administrative and clinical data, Medicare claims, and the Bereaved Family Survey. The response rate for the Bereaved Family Survey was 62%. RESULTS Greater than 72% of veterans with advanced lung cancer who died in an inpatient setting had at least 1 episode of aggressive care and 31% received chemotherapy within the last 30 days of life. For all units except for HPC, when patients experienced at least 1 episode of aggressive care, bereaved families rated care lower compared with when patients did not receive any aggressive care. For patients dying in an HPC unit, the associations between overall ratings of care and ≥2 inpatient admissions or any episode of aggressive care were not found to be statistically significant. Rates of aggressive care were not associated with age, and family ratings of care were similar for younger and older patients. CONCLUSIONS Aggressive care within the last month of life is common among patients with NSCLC and is associated with lower family evaluations of end-of-life care. Specialized care provided within an HPC unit may mitigate the negative effects of aggressive care on these outcomes. Cancer 2017;123:3186-94. © 2017 American Cancer Society.
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Affiliation(s)
- Mary Ersek
- Veteran Experience Center (formerly the PROMISE Center), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Susan C Miller
- Center for Gerontology and Health Care Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Todd H Wagner
- Health Economics Resource Center and Center for Innovation to Implementation, Palo Alto VA Health Care System, Menlo Park, California.,Department of Health Research and Policy, Stanford University, Stanford, California
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Dawn Smith
- Veteran Experience Center (formerly the PROMISE Center), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Cari R Levy
- VA Eastern Colorado Health Care System, Denver, Colorado.,Division of Health Care Policy and Research, University of Colorado, Aurora, Colorado
| | - Risha Gidwani
- Health Economics Resource Center and Center for Innovation to Implementation, Palo Alto VA Health Care System, Menlo Park, California.,Division of Primary Care and Population Health, Stanford School of Medicine, Palo Alto, California
| | - Katherine Faricy-Anderson
- Center for Innovation, Providence VA Medical Center, Providence, Rhode Island.,Alpert Medical School of Brown University, Providence, Rhode Island
| | - Karl A Lorenz
- Division of Primary Care and Population Health, Stanford School of Medicine, Palo Alto, California.,VA Palo Alto Healthcare System, Palo Alto, California
| | - Bruce Kinosian
- Veteran Experience Center (formerly the PROMISE Center), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Vincent Mor
- Center for Gerontology and Health Care Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center for Innovation, Providence VA Medical Center, Providence, Rhode Island
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