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Kamal AH, Check DK, Bull J, Wolf S, Troy J, Samsa G, Nicolla JM, Harker M, Taylor DH. Associations of Patient Characteristics and Care Setting with Complexity of Specialty Palliative Care Visits. J Palliat Med 2020; 24:83-90. [PMID: 32634037 DOI: 10.1089/jpm.2020.0149] [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: 11/13/2022] Open
Abstract
Background: Information routinely collected during a palliative care consultation request may help predict the level of complexity of that patient encounter. Objectives: We examined whether patient and consultation characteristics, as captured in consultation requests, are associated with the number of unmet palliative care needs that emerge during consultation, as an indicator of complexity. Design: We performed a retrospective cohort analysis of palliative care consultations. Setting: We analyzed quality-of-care data from specialty palliative care consultations contained in the Quality Data Collection Tool of the Global Palliative Care Quality Alliance from 2012 to 2017. Measurements: Using 13 point-of-care assessments of quality of life, symptoms, advance care planning, and prognosis, we created a complexity score ranging from 0 (not complex) to 13 (highest complexity). Using multivariable linear regression, we examined the relationships of consultation setting and patient characteristics with complexity score. Results: Patients in our cohort (N = 3121) had an average complexity score of 6.7 (standard deviation = 3.7). Female gender, nonwhite race, and neurological (e.g., dementia) and noncancer primary diagnosis were associated with increased complexity score. The hospital intensive care unit, compared with the general floor, was associated with higher complexity scores. In contrast, outpatient and residence, compared with the general floor, were associated with lower complexity scores. Conclusion: Patient, disease, and care setting factors known at the time of specialty palliative care consultation request are associated with level of complexity, and they may inform teams about the right service provisions, including time and expertise, required to meet patient needs.
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Affiliation(s)
- Arif H Kamal
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA.,Duke Fuqua School of Business, Durham, North Carolina, USA
| | - Devon K Check
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke School of Medicine, Durham, North Carolina, USA
| | - Janet Bull
- Four Seasons, Hendersonville, North Carolina, USA
| | - Steven Wolf
- Department of Biostatistics, Duke School of Medicine, Durham, North Carolina, USA
| | - Jesse Troy
- Department of Pediatrics, Duke School of Medicine, Durham, North Carolina, USA
| | - Greg Samsa
- Department of Biostatistics, Duke School of Medicine, Durham, North Carolina, USA
| | - Jonathan M Nicolla
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Matthew Harker
- Duke Clinical Research Institute, Duke Margolis Center for Health Policy, Durham, North Carolina, USA
| | - Donald H Taylor
- Duke Clinical Research Institute, Duke Margolis Center for Health Policy, Durham, North Carolina, USA.,Department of Family Medicine and Community Health, Duke Sanford School of Public Policy, Durham, North Carolina, USA
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Dudgeon D. The Impact of Measuring Patient-Reported Outcome Measures on Quality of and Access to Palliative Care. J Palliat Med 2020; 21:S76-S80. [PMID: 29283866 DOI: 10.1089/jpm.2017.0447] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Measuring performance for palliative care is complex as care is delivered in many sites, over time and jointly to the patient and family. Measures of structural processes do not necessarily capture aspects that are important to patients and families nor reflect holistic multidisciplinary outcomes of care. This article focuses on the question as to whether measurement of patient-reported outcome measures improves the outcomes of quality and access to palliative care. OBJECTIVES To review the international evidence that measurement of indicators of desired outcomes improves the quality of and access to palliative care, in order to apply them to the Canadian context. DESIGN Rapid review. SETTING Canadian context. FINDINGS This review identified six systematic reviews and forty-seven studies that describe largely national efforts to arrive at a consensus as to what needs to be measured to assess quality of palliative care. Patient-reported outcome measures (PROMs) are becoming more prevalent, with emerging evidence to suggest that their measurement improves outcomes that are important to patients. Several Canadian initiatives are in place, including the Canadian Partnership Against Cancer's efforts, in conjunction with other partners, to develop common quality measures. Results from Australia's Palliative Care Outcomes Collaborative demonstrate that patient-centered improvements in palliative care can be measured by using patient-reported outcomes derived at the point of care and delivered nationally. CONCLUSIONS Measurement of quality palliative and end-of-life care is very complex. It requires that both administrative data and PROMs be assessed to reflect outcomes that are important to patients and families. Australia's national initiative is a promising exemplar for continued work in this area.
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Affiliation(s)
- Deborah Dudgeon
- School of Medicine, Queen's University , Kingston, Ontario, Canada
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Kamal AH, Bull J, Kavalieratos D, Nicolla JM, Roe L, Adams M, Abernethy AP. Development of the Quality Data Collection Tool for Prospective Quality Assessment and Reporting in Palliative Care. J Palliat Med 2016; 19:1148-1155. [PMID: 27348507 DOI: 10.1089/jpm.2016.0036] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Assessing and reporting the quality of care provided are increasingly important in palliative care, but we currently lack practical, efficient approaches for collection and reporting. OBJECTIVE In response, the Global Palliative Care Quality Alliance ("Alliance") sought to create a Quality Data Collection Tool for Palliative Care (QDACT-PC). METHODS We collaboratively and iteratively developed QDACT-PC, an electronic, point-of-care quality monitoring system for palliative care that supports prospective quality assessment and reporting in any clinical setting. QDACT-PC is the web-based data collection and reporting interface. Quality measures selected to be used in QDACT-PC were derived from a systematic review summarizing all published palliative care quality measure sets; Alliance clinical providers prioritized measures to be included in QDACT-PC to ensure maximal clinical relevance. Data elements and variables required to ascertain conformance to all selected quality measures were included in the QDACT-PC data dictionary. Whenever possible, variables collected in QDACT-PC align with validated surveys and/or nationally recognized common data elements. QDACT-PC data elements and software programmed business rules inform real-time assessments of conformance to selected quality measures. Data are deposited into a centralized registry for future analyses. RESULTS QDACT-PC can be used to report on >80% of all published palliative care quality measures and 100% of high-priority measure. CONCLUSION Electronic methods for collecting point-of-care quality monitoring data can be developed using collaborative partnerships between community and academic palliative care providers. Feasibility testing and creation of feedback reports are ongoing.
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Affiliation(s)
| | - Janet Bull
- 2 Four Seasons , Flat Rock, North Carolina
| | - Dio Kavalieratos
- 3 Division of General Internal Medicine, Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | | | - Laura Roe
- 1 Duke University , Durham, North Carolina
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Costantini M, Rabitti E, Beccaro M, Fusco F, Peruselli C, La Ciura P, Valle A, Suriani C, Berardi MA, Valenti D, Mosso F, Morino P, Zaninetta G, Tubere G, Piazza M, Sofia M, Di Leo S, Higginson IJ. Validity, reliability and responsiveness to change of the Italian palliative care outcome scale: a multicenter study of advanced cancer patients. BMC Palliat Care 2016; 15:23. [PMID: 26920738 PMCID: PMC4768331 DOI: 10.1186/s12904-016-0095-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 02/18/2016] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND There is an increasing requirement to assess outcomes, but few measures have been tested for advanced medical illness. We aimed to test the validity, reliability and responsiveness of the Palliative care Outcome Scale (POS), and to analyse predictors of change after the transition to palliative care. METHODS Phase 1: multicentre, mixed method study comprising cognitive and qualitative interviews with patients and staff, cultural refinement and adaption. Phase 2: consecutive cancer patients on admission to 8 inpatient hospices and 7 home-based teams were asked to complete the POS, the EORTC QLQ-C15-PAL and the FACIT-Sp (T0), to assess internal consistency, convergent and divergent validity. After 6 days (T1) patients and staff completed the POS to assess responsiveness to change (T1-T0), and agreement between self-assessed POS and POS completed by the staff. Finally, we asked hospices an assessment 24-48 h after T1 to assess its reliability (test re-test analysis). RESULTS Phase I: 209 completed POS questionnaires and 29 cognitive interviews were assessed, revisions made and one item substituted. Phase II: 295 consecutive patients admitted to 15 PCTs were approached, 175 (59.3 %) were eligible, and 150 (85.7 %) consented. Consent was limited by the severity of illness in 40 % patients. We found good convergent validity, with strong and moderate correlations (r ranged 0.5-0.8) between similar items from the POS, the QLQ-C15-PAL and the FACIT-Sp. As hypothesised, the physical function subscale of QLQ-C15-PAL was not correlated with any POS item (r ranged -0.16-0.02). We found acceptable to good test re-test reliability in both versions for 6 items. We found significant clinical improvements during the first week of palliative care in 7/10 items assessed-pain, other symptoms, patient and family anxiety, information, feeling at peace and wasted time. CONCLUSIONS Both the patient self-assessed and professional POS versions are valid and with an acceptable internal consistency. POS detected significant clinical improvements during palliative care, at a time when patients are usually expected to deteriorate. These results suggest that there is room for substantial improvement in the management of patients with advanced disease, across all key domains-symptoms, psychological, information, social and spiritual.
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Affiliation(s)
- Massimo Costantini
- />Palliative Care Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Elisa Rabitti
- />Palliative Care Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Monica Beccaro
- />Academy of Sciences of Palliative Medicine, Bentivoglio, Bologna Italy
| | - Flavio Fusco
- />Palliative Care Unit, ASL3 Genovese, Genoa, Italy
| | | | | | | | | | - Maria Alejandra Berardi
- />Psycho-Oncology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | | | | | - Piero Morino
- />Convento delle Oblate Hospice, Azienda Sanitaria, Florence, Italy
| | | | | | - Massimo Piazza
- />S. Felice a Ema Hospice, Azienda Sanitaria, Florence, Italy
| | | | - Silvia Di Leo
- />Psycho-Oncology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Irene J. Higginson
- />Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King’s College London, London, UK
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Bausewein C, Daveson BA, Currow DC, Downing J, Deliens L, Radbruch L, Defilippi K, Lopes Ferreira P, Costantini M, Harding R, Higginson IJ. EAPC White Paper on outcome measurement in palliative care: Improving practice, attaining outcomes and delivering quality services - Recommendations from the European Association for Palliative Care (EAPC) Task Force on Outcome Measurement. Palliat Med 2016; 30:6-22. [PMID: 26068193 DOI: 10.1177/0269216315589898] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Outcome measurement plays an increasing role in improving the quality, effectiveness, efficiency and availability of palliative care. AIM To provide expert recommendations on outcome measurement in palliative care in clinical practice and research. METHODS Developed by a European Association for Palliative Care Task Force, based on literature searches, international expert workshop, development of outcome measurement guidance and international online survey. A subgroup drafted a first version and circulated it twice to the task force. The preliminary final version was circulated to wider expert panel and 28 international experts across 20 European Association for Palliative Care member associations and the European Association for Palliative Care Board of Directors and revised according to their feedback. The final version was approved by the European Association for Palliative Care Board for adoption as an official European Association for Palliative Care position paper. RESULTS In all, 12 recommendations are proposed covering key parameters of measures, adequate measures for the task, introduction of outcome measurement into practice, and national and international outcome comparisons and benchmarking. Compared to other recommendations, the White Paper covers similar aspects but focuses more on outcome measurement in clinical care and the wider policy impact of implementing outcome measurement in clinical palliative care. Patient-reported outcome measure feedback improves awareness of unmet need and allows professionals to act to address patients' needs. However, barriers and facilitators have been identified when implementing outcome measurement in clinical care that should be addressed. CONCLUSION The White Paper recommends the introduction of outcome measurement into practice and outcomes that allow for national and international comparisons. Outcome measurement is key to understanding different models of care across countries and, ultimately, patient outcome having controlled for differing patients characteristics.
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Affiliation(s)
- Claudia Bausewein
- Department of Palliative Medicine, Munich University Hospital, Munich, Germany
| | | | | | | | - Luc Deliens
- Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Kath Defilippi
- Hospice Palliative Care Association of South Africa, Cape Town, South Africa
| | | | | | - Richard Harding
- King's College London, Cicely Saunders Institute, London, UK
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Kamal AH, Hanson LC, Casarett DJ, Dy SM, Pantilat SZ, Lupu D, Abernethy AP. The quality imperative for palliative care. J Pain Symptom Manage 2015; 49:243-53. [PMID: 25057987 PMCID: PMC4405112 DOI: 10.1016/j.jpainsymman.2014.06.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 06/09/2014] [Accepted: 06/25/2014] [Indexed: 12/25/2022]
Abstract
Palliative medicine must prioritize the routine assessment of the quality of clinical care we provide. This includes regular assessment, analysis, and reporting of data on quality. Assessment of quality informs opportunities for improvement and demonstrates to our peers and ourselves the value of our efforts. In fact, continuous messaging of the value of palliative care services is needed to sustain our discipline; this requires regularly evaluating the quality of our care. As the reimbursement mechanisms for health care in the U.S. shift from fee-for-service to fee-for-value models, palliative care will be expected to report robust data on quality of care. We must move beyond demonstrating to our constituents (including patients and referrers), "here is what we do," and increase the focus on "this is how well we do it" and "let us see how we can do it better." It is incumbent on palliative care professionals to lead these efforts. This involves developing standardized methods to collect data without adding additional burden, comparing and sharing our experiences to promote discipline-wide quality assessment and improvement initiatives, and demonstrating our intentions for quality improvement on the clinical frontline.
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Affiliation(s)
- Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA; Center for Learning Health Care, Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David J Casarett
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sydney M Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Steven Z Pantilat
- Palliative Care Program, Division of Hospital Medicine, University of California, San Francisco, California, USA
| | - Dale Lupu
- Center for Aging, Health and Humanities, George Washington University, Washington, DC, USA
| | - Amy P Abernethy
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA; Center for Learning Health Care, Duke Clinical Research Institute, Durham, North Carolina, USA
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7
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Bainbridge D, Brazil K, Krueger P, Ploeg J, Taniguchi A, Darnay J. Measuring horizontal integration among health care providers in the community: an examination of a collaborative process within a palliative care network. J Interprof Care 2014; 29:245-52. [PMID: 25418319 DOI: 10.3109/13561820.2014.984019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
In many countries formal or informal palliative care networks (PCNs) have evolved to better integrate community-based services for individuals with a life-limiting illness. We conducted a cross-sectional survey using a customized tool to determine the perceptions of the processes of palliative care delivery reflective of horizontal integration from the perspective of nurses, physicians and allied health professionals working in a PCN, as well as to assess the utility of this tool. The process elements examined were part of a conceptual framework for evaluating integration of a system of care and centred on interprofessional collaboration. We used the Index of Interdisciplinary Collaboration (IIC) as a basis of measurement. The 86 respondents (85% response rate) placed high value on working collaboratively and most reported being part of an interprofessional team. The survey tool showed utility in identifying strengths and gaps in integration across the network and in detecting variability in some factors according to respondent agency affiliation and profession. Specifically, support for interprofessional communication and evaluative activities were viewed as insufficient. Impediments to these aspects of horizontal integration may be reflective of workload constraints, differences in agency operations or an absence of key structural features.
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Affiliation(s)
- Daryl Bainbridge
- Department of Oncology, Juravinski Cancer Centre, McMaster University , Hamilton, Ontario , Canada
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Luckett T, Phillips J, Agar M, Virdun C, Green A, Davidson PM. Elements of effective palliative care models: a rapid review. BMC Health Serv Res 2014; 14:136. [PMID: 24670065 PMCID: PMC3986907 DOI: 10.1186/1472-6963-14-136] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 03/10/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Population ageing, changes to the profiles of life-limiting illnesses and evolving societal attitudes prompt a critical evaluation of models of palliative care. We set out to identify evidence-based models of palliative care to inform policy reform in Australia. METHOD A rapid review of electronic databases and the grey literature was undertaken over an eight week period in April-June 2012. We included policy documents and comparative studies from countries within the Organisation for Economic Co-operation and Development (OECD) published in English since 2001. Meta-analysis was planned where >1 study met criteria; otherwise, synthesis was narrative using methods described by Popay et al. (2006). RESULTS Of 1,959 peer-reviewed articles, 23 reported systematic reviews, 9 additional RCTs and 34 non-randomised comparative studies. Variation in the content of models, contexts in which these were implemented and lack of detailed reporting meant that elements of models constituted a more meaningful unit of analysis than models themselves. Case management was the element most consistently reported in models for which comparative studies provided evidence for effectiveness. Essential attributes of population-based palliative care models identified by policy and addressed by more than one element were communication and coordination between providers (including primary care), skill enhancement, and capacity to respond rapidly to individuals' changing needs and preferences over time. CONCLUSION Models of palliative care should integrate specialist expertise with primary and community care services and enable transitions across settings, including residential aged care. The increasing complexity of care needs, services, interventions and contextual drivers warrants future research aimed at elucidating the interactions between different components and the roles played by patient, provider and health system factors. The findings of this review are limited by its rapid methodology and focus on model elements relevant to Australia's health system.
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Affiliation(s)
- Tim Luckett
- Improving Palliative Care through Clinical Trials (ImPaCCT), Sydney, NSW, Australia
- University of Technology Sydney (UTS), Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Jane Phillips
- University of Technology Sydney (UTS), Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia
- The Cunningham Centre for Palliative Care Sydney, Sacred Heart Hospice, Sydney, NSW, Australia
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
| | - Meera Agar
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
- HammondCare, Sydney, NSW, Australia
- The Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
| | - Claudia Virdun
- University of Technology Sydney (UTS), Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia
| | - Anna Green
- University of Technology Sydney (UTS), Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia
| | - Patricia M Davidson
- University of Technology Sydney (UTS), Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia
- School of Nursing, Johns Hopkins University, Baltimore, MD, USA
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Kamal AH, Bull J, Stinson CS, Blue DL, Abernethy AP. Conformance with supportive care quality measures is associated with better quality of life in patients with cancer receiving palliative care. J Oncol Pract 2014; 9:e73-6. [PMID: 23942504 DOI: 10.1200/jop.2013.000948] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE As palliative care further integrates into cancer care, descriptions of how supportive care quality measures improve patient outcomes are necessary to establish best practices. METHODS We assessed the relationship between conformance to 18 palliative care quality measures and quality of life from data obtained using our novel point-of-care, electronic quality monitoring system, the Quality Data Collection Tool for Palliative Care (QDACT-PC). All patients with cancer from January 2008 through March 2011 seen in the Carolinas Palliative Care Consortium were evaluated for demographic, disease, prognostic, performance status, and measure conformance variables. Using univariate and multivariate regression, we examined the relationship between these variable and high quality of life at the initial specialty palliative care consultation. RESULTS Our cohort included 459 patients, the majority of whom were over age 65 years (66%) and white (84%). Lung (29.1%) and GI (24.7%) cancers were most common. In univariate analyses, conformance to assessment of comprehensive symptoms, fatigue and constipation assessment, timely management of pain and constipation, and timely emotional well-being assessment were associated with highest levels of quality of life (all Ps < .05). In a multivariate model (C-stat = 0.66), performance status (odds ratio [OR], 5.21; P = .003), estimated life expectancy (OR, 22.6; P = .003), conformance to the measure related to emotional well-being assessment (OR, 1.60; P = .026), and comprehensive screening of symptoms (OR, 1.74, P = .008) remained significant. CONCLUSION Oncology care pathways that routinely incorporate supportive care principles, such as comprehensive symptom and emotional well-being assessments, may improve patient outcomes.
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Affiliation(s)
- Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA.
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Edlynn ES, Derrington S, Morgan H, Murray J, Ornelas B, Cucchiaro G. Developing a pediatric palliative care service in a large urban hospital: challenges, lessons, and successes. J Palliat Med 2012; 16:342-8. [PMID: 23249403 DOI: 10.1089/jpm.2012.0187] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND AIM We report the process of creating a new palliative care service at a large, urban children's hospital. Our aim was to provide a detailed guide to developing an inpatient consultation service, along with reporting on the challenges, lessons, and evaluation. METHODS We examined the hiring process of personnel and marketing strategies, a clinical database facilitated ongoing quality review and identified trends, and a survey project assessed provider satisfaction and how referring physicians used the palliative care service. RESULTS AND CONCLUSION The pilot phase of service delivery laid the groundwork for a more effective service by creating documentation templates and identifying relevant data to track growth and outcomes. It also allowed time to establish a clear delineation of team members and distinction of roles. The survey of referring physicians proved a useful evaluation starting point, but conclusions could not be generalized because of the low response rate. It may be necessary to reconsider the survey technique and to expand the sample to include patients and families. Future research is needed to measure the financial benefits of a well-staffed inpatient pediatric palliative care service.
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Affiliation(s)
- Emily S Edlynn
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA.
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11
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Current World Literature. Curr Opin Support Palliat Care 2012; 6:543-52. [DOI: 10.1097/spc.0b013e32835ad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bull JH, Whitten E, Morris J, Hooper RN, Wheeler JL, Kamal A, Abernethy AP. Demonstration of a sustainable community-based model of care across the palliative care continuum. J Pain Symptom Manage 2012; 44:797-809. [PMID: 22771124 DOI: 10.1016/j.jpainsymman.2011.12.278] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 12/03/2011] [Accepted: 12/14/2011] [Indexed: 10/28/2022]
Abstract
CONTEXT In the U.S., the number of hospital-based palliative care programs has increased rapidly, but availability of outpatient palliative care remains limited. Multiple barriers impede the financial viability of these programs. Four Seasons, a nonprofit organization in western North Carolina, delivers a full spectrum of palliative care in hospitals, nursing homes, assisted living facilities, patients' homes, and outpatient clinics; its catchment area encompasses approximately 350,000 people. Initially focused on hospice care, Four Seasons added its palliative care program in 2003. Before the inquiry described herein, financial losses from outpatient palliative care (2003-2008) were escalating. OBJECTIVES We explored organizational and financial barriers to sustainability of palliative care, so as to 1) identify reasons for financial losses; 2) devise and implement solutions; and 3) develop a sustainable model for palliative care delivery across settings, including the outpatient setting. METHODS In 2008, Four Seasons's palliative care program served 305 patients per day (average) with 10.5 providers (physicians, nurse practitioners, and physician assistants); financial losses approached $400,000 per year. We used Quality Assessment and Performance Improvement cycles to identify challenges to and inefficiencies in service provision, developed targeted strategies for overcoming identified barriers to cost-efficiency, instituted these measures, and tracked results. RESULTS In 2011, Four Seasons served 620 palliative care patients per day (average) with 14 providers; financial losses decreased by 40%. CONCLUSION With health care reform promoting integration of care across settings, outpatient palliative care will gain importance in the health care continuum. Process changes can help reduce financial losses that currently impede outpatient palliative care programs.
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Affiliation(s)
- Janet H Bull
- Four Seasons, Flat Rock, North Carolina 28731, USA.
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Abstract
PURPOSE OF REVIEW The aim of this review is to summarize the current state of the science in physical symptoms and other end-of-life care domains and/or illness-specific outcomes in palliative care. The review includes progress in outcome measure development and interpretation, with specific reference to the clinical trial context. RECENT FINDINGS There are validated measures in a wide range of domains, which can measure outcomes specific to palliative care interventions; which are sufficiently validated to ensure the results of the trial are robust and measuring differences which are both clinically meaningful. In several areas, consensus is emerging which will allow consolidation of outcome measurement and the ability to extend measurement from the clinical trial setting into routine clinical practice. Potential exists for composite measures covering areas prioritized by patients to improve comparability and efficiency. Adverse events need to be measured with the same degree of rigor as efficacy outcomes. SUMMARY Clinical trials of palliative care interventions need to consider a range of outcomes, however, the choice and timing of measurement of the primary outcome need to be guided by the domain most likely to be influenced by the intervention.
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Current World Literature. Curr Opin Support Palliat Care 2012; 6:402-16. [DOI: 10.1097/spc.0b013e3283573126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Currow, Senior Associate Editor DC. We Need Champions, Passionate Champions. J Palliat Med 2012; 15:842-3. [DOI: 10.1089/jpm.2012.9573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Currow DC, Rowett D, Doogue M, To TH, Abernethy AP. An International Initiative To Create a Collaborative for Pharmacovigilance in Hospice and Palliative Care Clinical Practice. J Palliat Med 2012; 15:282-6. [DOI: 10.1089/jpm.2012.9605] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- David C. Currow
- Discipline of Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia
| | - Debra Rowett
- Drug and Therapeutic Information Service, Repatriation General Hospital, Daw Park, South Australia, Australia
| | - Matthew Doogue
- Department of Clinical Pharmacology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Discipline Clinical Pharmacology, Flinders University, Bedford Park, South Australia, Australia
| | - Timothy H.M. To
- Discipline of Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia
- Department of Rehabilitation and Aged Care, Repatriation General Hospital, Daw Park, South Australia, Australia
| | - Amy P. Abernethy
- Discipline of Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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17
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Kamal AH, Bull J, Kavalieratos D, Taylor DH, Downey W, Abernethy AP. Palliative care needs of patients with cancer living in the community. J Oncol Pract 2011; 7:382-8. [PMID: 22379422 PMCID: PMC3219466 DOI: 10.1200/jop.2011.000455] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2011] [Indexed: 12/25/2022] Open
Abstract
PURPOSE With improved effectiveness of early detection and treatment, many patients with cancer are now living with advanced disease and associated symptoms. As cancer becomes a chronic illness, adequate attention to patients' symptoms and psychosocial needs in the community setting requires positioning of palliative care alongside cancer care. This article describes the current palliative care needs of a population of community-dwelling patients with advanced cancer who are not yet ready for transition to hospice. METHODS This secondary analysis used quality-monitoring data collected in three community-based palliative care organizations. Analyses focused on people with cancer-related diagnoses who were receiving palliative care during 2008 to 2011. RESULTS The analytic data set included 4,980 people, 10% of whom had cancer. Median age was 71 years. Forty-eight percent had been hospitalized at least once in the 6 months before palliative care referral. Forty-nine percent had a Palliative Performance Score (PPS) of 40% to 60%; 40% had PPS ≤ 30%. Although 81% had an estimated prognosis of ≤ 6 months, 58% were expected to live weeks to months. Thirty-three percent had no identified healthcare surrogate; 59% had no do-not-resuscitate order despite declining functional status and limited prognosis. Ninety-five percent reported ≥ 1 symptom, and 67% reported ≥ 3 symptoms; a substantial proportion did not receive treatment for symptoms. CONCLUSIONS Patients referred to community-based palliative care experience multiple often-severe symptoms that have been insufficiently addressed. They tend to have declining performance status. Earlier palliative care intervention could improve outcomes but will require delivery models that better coordinate inpatient/outpatient oncology and community-based palliative care.
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Affiliation(s)
- Arif H. Kamal
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janet Bull
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Dio Kavalieratos
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Donald H. Taylor
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William Downey
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Amy P. Abernethy
- Division of Medical Oncology, Department of Medicine; Duke Cancer Care Research Program, Duke Cancer Institute, Duke University Medical Center; Sanford Institute of Public Policy, Duke University, Durham; Four Seasons, Flat Rock; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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