Characteristics and outcomes of advanced cancer patients who miss outpatient supportive care consult appointments

Best Practices for Providing Patient-Centered Tele-Palliative Care to Cancer Patients

Cancer patients receiving palliative care may face significant challenges in attending outpatient appointments. Patients on controlled substances such as opioids require frequent visits and often rely on assistive devices and/or a caregiver to accompany them to these visits. In addition, pain, fatigue, and shortness of breath may magnify the challenges associated with in-person visits. The rapid adoption of telemedicine in response to the COVID-19 pandemic has proven to be highly beneficial for advanced cancer patients and caregivers. The hurried COVID-19-related implementation of telemedicine is now evolving into a permanent platform for providing palliative care. This review will focus on the best practices and recommendations to deliver high-quality, interdisciplinary tele-palliative care.

Association of Medical Appointment Cancellation Rates on Survival After Esophagectomy for Esophageal Cancer

BACKGROUND

Cancelled healthcare appointments, especially in patients with complex cancers, such as esophageal cancer, risk delayed treatment and adverse outcomes. We hypothesized that patients with greater rates of healthcare appointment cancellations would have decreased survival after esophagectomy for esophageal cancer.

METHODS

A retrospective analysis of patients from a single institution who underwent esophagectomy for esophageal cancer between 2004 and 2020 was performed. Appointment cancellations were queried 2 years pre-/post-esophagectomy and categorized as medical or ancillary. Continuous and categorical variables were compared by Mann-Whitney and chi-squared analyses, respectively. Survival associations post-esophagectomy were made by Kaplan-Meier analysis.

RESULT

Seventy-six patients were identified. Total medical and ancillary appointments post-esophagectomy increased by 188% and 136%, respectively. Per patient, there was a median increase of 57.5 medical appointments in the post-esophagectomy period. Of medical appointments, 23.7% were cancelled pre-esophagectomy but 33.4% post-esophagectomy (p < 0.001). This trend held true for ancillary appointments. Patients with increased medical cancellation rates post-esophagectomy had shortened recurrence-free (p = 0.09) and overall survival (p < 0.01) versus patients with low cancellation rates.

CONCLUSION

A significant increase in healthcare appointments is seen after esophagectomy. Patients with increased healthcare appointment cancellations have decreased post-esophagectomy survival which presents an opportunity to intervene in patients who historically have a high cancellation rate.

Factors associated with non-attendance at appointments in the gastroenterology endoscopy unit: a retrospective cohort study

Background and Aims

Gastrointestinal (GI) endoscopy is a limited health resource because of a scarcity of qualified personnel and limited availability of equipment. Non-adherence to endoscopy appointments therefore wastes healthcare resources and may compromise the early detection and treatment of GI diseases. We aimed to identify factors affecting non-attendance at scheduled appointments for GI endoscopy and thus improve GI healthcare outcomes.

Methods

This was a single-center retrospective cohort study performed at a tertiary hospital gastroenterology endoscopy unit, 12 months before and 12 months after the start of the COVID-19 pandemic. We used multiple logistic regression analysis to identify variables associated with non-attendance at scheduled appointments.

Results

Overall, 5,938 appointments were analyzed, and the non-attendance rate was 18.3% (1,088). The non-attendance rate fell significantly during the pandemic (22.6% vs. 11.6%, p < 0.001). Multivariable regression analysis identified the absence of deep sedation (OR: 3.253, 95% CI [2.386-4.435]; p < 0.001), a referral from a physician other than a gastroenterologist (OR: 1.891, 95% CI [1.630-2.193]; p < 0.001), a longer lead time (OR: 1.006, 95% CI [1.004-1.008]; p < 0.001), and female gender (OR: 1.187, 95% CI [1.033-1.363]; p = 0.015) as associated with appointment non-attendance.

Conclusions

Female patients, those undergoing endoscopic procedures without deep sedation, those referred by physicians other than gastroenterologists, and with longer lead time were less likely to adhere to appointments. Precautions should be directed at patients with one or more of these risk factors, and for those scheduled for screening procedures during the COVID-19 pandemic.

Telemedicine and Its Past, Present, and Future Roles in Providing Palliative Care to Advanced Cancer Patients

Simple Summary

The health care delivery model has dramatically changed due to the emergence of the global pandemic coronavirus disease (COVID-19). This can be seen in the innovative adoption of telemedicine in the delivery of palliative care to patients with advanced cancer. We provide an update on the adoption, delivery, benefits, and challenges faced in this model of health care delivery.

Abstract

The landscape of healthcare delivery has considerably changed due to the emergence of coronavirus disease 2019 (COVID-19). This is nowhere more evident than in the care of advanced cancer patients receiving palliative care. This population is susceptible to the severe complications of COVID-19, and immediate measures had to be taken to ensure their safety. Thus, the adoption of telemedicine as a health care delivery model emerged. This model provides many benefits, such as improved access to care while maintaining social distancing; however, there exist challenges to this model, including health care disparities, reimbursement, and monitoring of opioids in high-risk populations. This narrative review provides an overview of the unique benefits and barriers of telemedicine in palliative care patients.

Investigating the reasons for missing an outpatient appointment in Royal Hospital, Sultanate of Oman: Perspectives of patients and medical staff in a survey

Introduction

Missed appointments are a major health issue in the healthcare systems globally. They directly impact on the use of hospital resources, patient's health, and can lead to patient's dissatisfaction. This study was conducted to assess the reasons for missing a hospital appointment.

Methods

A survey was conducted with a randomly selected sample of patients who missed their outpatient appointment in Royal hospital, Sultanate of Oman, from March to April 2021 in six clinics. Patients were interviewed via telephone to answer a structured survey. In addition, a self‐administered survey was distributed to medical staff to explore their perspectives.

Results

Two hundred eighty patients and 52 medical staff participated in the study. Frequent patient‐reported reasons for missed appointment were transportation difficulties (11.4%), no longer needing (7.5%), or forgetting the appointment (6.8%); staff‐reported reasons were transportation (23.8%), no SMS received (16.9%), and forgetting the appointment (15.4%). Frequencies of reasons varied substantially between clinics. Family obligations were the main theme in obstetrics (odds ratio [OR] 9.48; 95% confidence interval [CI] 2.66‐33.78) and in diabetes clinic (OR 10.55; 95% CI 2.68‐38.58), where transportation issue was the main theme in Oncology clinic (OR 4.83; 95% CI 1.11‐21.02). The recommendations for improvement were mainly around improving the reminder system, the use of telephone reminders, and developing a flexible appointment scheduling system.

Conclusion

Knowing the reasons for missed appointment from patients and health professionals can help to develop effective interventions. The heterogeneity between clinics in reasons for missed appointment indicates for interventions tailored to clinic and frequent reasons.

Duration of palliative care before death in international routine practice: a systematic review and meta-analysis

BACKGROUND

Early provision of palliative care, at least 3-4 months before death, can improve patient quality of life and reduce burdensome treatments and financial costs. However, there is wide variation in the duration of palliative care received before death reported across the research literature. This study aims to determine the duration of time from initiation of palliative care to death for adults receiving palliative care across the international literature.

METHODS

We conducted a systematic review and meta-analysis that was registered with PROSPERO (CRD42018094718). Six databases were searched for articles published between Jan 1, 2013, and Dec 31, 2018: MEDLINE, Embase, CINAHL, Global Health, Web of Science and The Cochrane Library, as well undertaking citation list searches. Following PRISMA guidelines, articles were screened using inclusion (any study design reporting duration from initiation to death in adults palliative care services) and exclusion (paediatric/non-English language studies, trials influencing the timing of palliative care) criteria. Quality appraisal was completed using Hawker's criteria and the main outcome was the duration of palliative care (median/mean days from initiation to death).

RESULTS

One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Significant differences between duration were found by disease type (15 days for cancer vs 6 days for non-cancer conditions), service type (19 days for specialist palliative care unit, 20 days for community/home care, and 6 days for general hospital ward) and development index of countries (18.91 days for very high development vs 34 days for all other levels of development). Forty-three per cent of studies were rated as 'good' quality. Limitations include a preponderance of data from high-income countries, with unclear implications for low- and middle-income countries.

CONCLUSIONS

Duration of palliative care is much shorter than the 3-4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics. We welcome more consistent terminology and methodology in the assessment of duration of palliative care from all countries, alongside increased reporting from less-developed settings, to inform benchmarking, service evaluation and quality improvement.

<p>Who Misses Appointments Made Online? Retrospective Analysis of the Outpatient Department of a General Hospital in Jinan, Shandong Province, China</p>

Purpose

Missed appointments in outpatient registration pose challenges for hospital administrators, especially in the context of China’s shortage of medical resources. Previous studies have identified factors that affect healthcare access via traditional appointment systems. Few studies, however, have specifically investigated Internet appointment systems. Therefore, this study explored the key factors related to missed appointments made on the Internet appointment system of a general hospital in Jinan, Shandong Province.

Methods

Online appointment data were collected from the outpatient department of a general hospital in Jinan from September 2017 to February 2018. Logistic regression was used to analyze the relative importance of eight variables: gender, age, interval between scheduling and appointment, day of the week, physician’s academic rank, appointment fee, previous missed appointments, and clinical department.

Results

A total of 48,777 online appointment records were collected, which included a 15% no-show rate. The key factors associated with no-shows included age, interval between scheduling and appointment, previous missed appointments, and clinical department. No significant relationships were found between no-shows and gender, day of the week, and appointment fee.

Conclusion

No-show rates were influenced by many factors. Based on this study’s findings, targeted measures can be taken to decrease no-show frequency and improve medical efficiency.

Predictors of oral anticoagulant-associated adverse events in seniors transitioning from hospital to home: a retrospective cohort study protocol

INTRODUCTION

Oral anticoagulants (OACs) are widely prescribed in older adults. High OAC-related adverse event rates in the early period following hospital discharge argue for an analysis to identify predictors. Our objective is to identify and validate clinical and continuity of care variables among seniors discharged from hospital on an OAC, which are independently associated with OAC-related adverse events within 30 days.

METHODS AND ANALYSIS

We propose a population-based retrospective cohort study of all adults aged 66 years or older who were discharged from hospital on an OAC from September 2010 to March 2015 in Ontario, Canada. The primary outcome is a composite of the first hospitalisation or emergency department visit for a haemorrhage or thromboembolic event or mortality within 30 days of hospital discharge. A Cox proportional hazards model will be used to determine the association between the composite outcome and a set of prespecified covariates. A split sample method will be adopted to validate the variables associated with OAC-related adverse events.

ETHICS AND DISSEMINATION

The use of data in this project was authorised under section 45 of Ontario's Personal Health Information Protection Act, which does not require review by a research ethics board. Results will be disseminated via peer-reviewed publications and presentations at conferences and will determine intervention targets to improve OAC management in upcoming randomised trials.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT02777047; Pre-results.

Missed Opportunities of Integration of Palliative Care: Frequency, Causes, and Profile of Missed Visits in an Oncologic Palliative Care Outpatient Unit

CONTEXT

Many patients with cancer are referred to palliative care (PC) outpatient clinics but do not attend consultations, which increases the difficultly of integrating PC in a timely manner.

OBJECTIVES

To evaluate the frequency, causes, and profile of missing first-time consultations in a PC outpatient clinic.

METHODS

Data from patients with advanced cancer who were scheduled for first-time visits to the PC outpatient clinic from September 2018 to August 2019 were analyzed. Missed consultation was defined as a nonperformed consultation with no prior notice of cancellation, and missed opportunity of palliative care (MOPC) was defined as a nonperformed consultation regardless of being notified in advance. The causes of the absence were identified by telephone using a standardized form. Logistic regression models were used to identify the profile of patients who have MOPC.

RESULTS

About 1468 patients were scheduled for first-time visits to the PC outpatient clinic; missed consultation = 21.7% (n = 275) and MOPC = 32.5% (n = 478). Of the total number of patients who had MOPC, 86 (18%) were later seen in a median time (percentile p25-p75) of 29.5 days (range 7.0-66.5). The most common cause of MOPC was death before consultation (n = 92; 29.8%). Referral to PC using a standardized protocol (odds ratio 0.787; P = 0.044) and residence in distant cities (odds ratio 2.394; P < 0.001) were independently associated with MOPC.

CONCLUSION

Approximately one-third of patients eligible for PC miss the opportunity to be included earlier; only 18% of them are consulted later. Use of standardized referral protocols may help to reduce these absence rates.

Factors associated with attendance at primary care appointments after discharge from hospital: a retrospective cohort study

BACKGROUND

Follow-up with a primary care provider within 1-2 weeks of discharge from hospital has been associated with reduced readmissions. We sought to determine appointment attendance with primary care providers postdischarge and identify factors associated with attendance.

METHODS

We conducted a retrospective cohort study involving general medicine patients who had been discharged from hospital between Sept. 1, 2014, and Dec. 30, 2015, from 2 Ontario academic hospitals, and who had been supported by a transitional care specialist and advised to see a primary care provider within 1 week. Attendance was determined by self-report during follow-up by telephone. We used multivariable logistic regression to assess whether patient factors (e.g., comorbidity) or system factors (e.g., booking the appointment before discharge) predicted attendance. We used Cox proportional hazards modelling to assess whether attendance predicted readmission within 30 days.

RESULTS

Of the 214 patients included in our study, 35% (n = 75) attended a primary care appointment within 1 week of discharge; 52% (n = 124) of patients attended an appointment within 2 weeks. After adjusting for age, sex and comorbidity, significant predictors of attendance were booking the appointment before discharge (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.07-4.40), familiarity with the primary care provider (OR 5.43, 95% CI 2.25-14.1) and inclusion of a reminder, callback number and appointment time in the discharge summary (OR 15.3, 95% CI 2.09-326). Predictors of nonattendance were the presence of a home support worker (OR 0.38, 95% CI 0.17-0.80) and a booked specialist appointment before discharge (OR 0.37, 95% CI 0.18-0.73). Attendance was not associated with reduced readmissions (hazard ratio 0.66, 95% CI 0.40-1.09).

INTERPRETATION

Timely follow-up with PCPs postdischarge remains challenging. Efforts to improve attendance should focus on reinforcing need for follow-up and coordinating follow-up before discharge, particularly for those poorly connected with the health care system.

No-shows in appointment scheduling - a systematic literature review

No-show appointments significantly impact the functioning of healthcare institutions, and much research has been performed to uncover and analyze the factors that influence no-show behavior. In spite of the growing body of literature on this issue, no synthesis of the state-of-the-art is presently available and no systematic literature review (SLR) exists that encompasses all medical specialties. This paper provides a SLR of no-shows in appointment scheduling in which the characteristics of existing studies are analyzed, results regarding which factors have a higher impact on missed appointment rates are synthetized, and comparisons with previous findings are performed. A total of 727 articles and review papers were retrieved from the Scopus database (which includes MEDLINE), 105 of which were selected for identification and analysis. The results indicate that the average no-show rate is of the order of 23%, being highest in the African continent (43.0%) and lowest in Oceania (13.2%). Our analysis also identified patient characteristics that were more frequently associated with no-show behavior: adults of younger age; lower socioeconomic status; place of residence is distant from the clinic; no private insurance. Furthermore, the most commonly reported significant determinants of no-show were high lead time and prior no-show history.

Clinical characteristics of patients having single versus multiple patient encounters within a palliative care programme

OBJECTIVE

The objective of this study was to describe the clinical characteristics of patient initial presentations, and to explore associations between patients' clinical characteristics at initial presentation and number of encounters (single vs multiple) to an integrated palliative care programme.

METHODS

This was a retrospective study of a decedent cohort of 2922 patient initial presentations to the Edmonton Zone Palliative Care Program (EZPCP). Data included age, gender, setting of encounter, diagnosis, Edmonton Symptom Assessment System, CAGE, Mini-Mental Status Examination, Palliative Performance Status, Edmonton Classification System for Cancer Pain and time to death.

RESULTS

On initial presentation to the EZPCP, the mean age was 73 (SD 14 years), with 1358 (46%) being female, and the majority having a cancer diagnosis (n=2376, 81%), the most common of which was gastrointestinal primary (n=681, 29%). In univariate analyses, patients with younger age (<60), higher palliative performance status (>40%), a malignant diagnosis, gastrointestinal primary or unimpaired cognition at initial presentation were significantly associated with multiple encounters with an integrated palliative care programme (p<0.05). In a multivariate regression analysis, a malignant diagnosis, longer survival, higher performance status and initial entry through acute care sites were independently associated with multiple encounters in the programme (p<0.001).

CONCLUSIONS

Larger prospective studies are warranted to further elucidate the complex relationships between patient clinical characteristics, initial presentations and subsequent encounters to an integrated palliative care programme.