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Robison J, Shugrue N, Dillon E, Migneault D, Charles D, Wakefield D, Richards B. Racial and Ethnic Differences in Hospice Use Among Medicaid-Only and Dual-Eligible Decedents. JAMA HEALTH FORUM 2023; 4:e234240. [PMID: 38064239 PMCID: PMC10709774 DOI: 10.1001/jamahealthforum.2023.4240] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/03/2023] [Indexed: 12/18/2023] Open
Abstract
Importance Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population. Objective To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period. Design, Setting, and Participants This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020. Exposure Race and ethnicity. Main Outcomes and Measures Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death. Results Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85). Conclusions and Relevance Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.
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Affiliation(s)
- Julie Robison
- UConn Health, Center on Aging, Farmington, Connecticut
| | | | - Ellis Dillon
- UConn Health, Center on Aging, Farmington, Connecticut
| | | | | | | | - Bradley Richards
- Connecticut Department of Social Services, Hartford, Connecticut
- Yale School of Medicine, New Haven, Connecticut
- Yale School of Management, New Haven, Connecticut
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Yamarik RL, Wenziger C, Streja E, Pham ANT, Wei KS, Bedi B, Asch S. Changing Institutional Culture Around Hospice Using LEAN Tools to Improve Hospice Utilization in a Veteran Population. J Pain Symptom Manage 2021; 62:836-842. [PMID: 33831462 DOI: 10.1016/j.jpainsymman.2021.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Longer hospice length of stay improves the palliation of symptoms, quality of life, and the dying process for patients and their caregivers. We used a Lean designed Rapid Improvement Event (RIE) to facilitate earlier entry into hospice. MEASURES Our primary outcome was hospice length of stay. Secondary outcomes were avoiding unwanted inpatient utilization and hospice location. INTERVENTIONS We conducted a five-day RIE utilizing Lean tools targeting the inpatient medicine wards. OUTCOMES Hospice length of stay increased from a median (interquartile range [IQR]) of 11 (7,27) days prior to 37 (7,73) days following the RIE. Home hospice and outside Skilled Nursing Home (SNF) hospice use increased while use of the onsite VA hospice decreased. CONCLUSIONS/LESSONS LEARNED LEAN tools can be used successfully to improve end of life outcomes in an inpatient VA setting. The 90-day sustainment period following the RIE uncovers barriers to implementation and allows for adjustments to implementation.
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Affiliation(s)
| | - Cachet Wenziger
- Long Beach Veterans Affairs, Long Beach, California USA; Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, California, USA
| | - Elani Streja
- Long Beach Veterans Affairs, Long Beach, California USA; Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, California, USA
| | | | - Kevin S Wei
- University of California, Irvine School of Medicine, Irvine, California USA
| | - Bishen Bedi
- University of California San Diego School of Medicine, San Diego, California USA
| | - Steven Asch
- Department of Medicine, Stanford University, Stanford, California USA; Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California USA
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3
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Jordan RI, Allsop MJ, ElMokhallalati Y, Jackson CE, Edwards HL, Chapman EJ, Deliens L, Bennett MI. Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Med 2020; 18:368. [PMID: 33239021 PMCID: PMC7690105 DOI: 10.1186/s12916-020-01829-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Roberta I Jordan
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Matthew J Allsop
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Yousuf ElMokhallalati
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Catriona E Jackson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Helen L Edwards
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Emma J Chapman
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University, Ghent, Belgium.,Vrije Universiteit Brussel, Brussels, Belgium
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Grossoehme DH, Humphrey L, Friebert S, Ding L, Yang G, Allmendinger-Goertz K, Fryda Z, Fosselman D, Thienprayoon R. Patterns of Hospice and Home-Based Palliative Care in Children: An Ohio Pediatric Palliative Care and End-of Life Network Study. J Pediatr 2020; 225:152-156. [PMID: 32532649 DOI: 10.1016/j.jpeds.2020.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/25/2020] [Accepted: 04/01/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the demographic and clinical characteristics of a cohort of patients referred to pediatric hospice and home-based palliative care (HBPC) programs across Ohio in 2016. STUDY DESIGN Retrospective cohort study of patients referred to hospice/HBPC from 3 pediatric palliative care programs in Ohio in 2016. Demographic and clinical data were extracted from the medical record and analyzed with descriptive statistics. RESULTS There were 209 patients referred: 49 (24%) to hospice and 160 (77%) to HBPC. The most common diagnoses were genetic/chromosomal syndromes (23%), neurologic or neurodegenerative conditions (23%), and cancer (21%). Durable medical equipment use was frequent (85%), with gastrostomy or jejunostomy tubes (22%) the most common. Most patients (64%) retained full-code resuscitation status. Fifty-seven patients (27%) died before July 1, 2018: 37 in hospice (18% of the overall cohort, 65% of decedents) and 20 in HBPC (10% of the overall cohort, 35% of decedents). Sixty-seven percent of hospice and 40% of HBPC patients died at home. CONCLUSIONS Pediatric hospice and HBPC programs serve a diverse cohort of patients. Patients referred to pediatric HBPC programs commonly die and are likely to die at home despite not being enrolled in hospice care. The high proportion of decedent HBPC patients indicates that the notion of hospice vs palliative care may present a false dichotomy in many children with life-limiting conditions. Reimbursement models for HBPC should reflect the clinical similarity to hospice in the care of children with life-limiting illnesses.
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Affiliation(s)
- Daniel H Grossoehme
- Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, OH; Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, OH
| | - Lisa Humphrey
- Division of Hospice and Palliative Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Sarah Friebert
- Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, OH; Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, OH
| | - Lili Ding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Gang Yang
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kristine Allmendinger-Goertz
- Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, OH; Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, OH
| | - Zachary Fryda
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, OH
| | - David Fosselman
- Division of Hospice and Palliative Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Rachel Thienprayoon
- Division of Palliative Care, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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Desai AV, Klimek VM, Chow K, Epstein AS, Bernal C, Anderson K, Okpako M, Rawlins-Duell R, Kramer D, Romano D, Goldberg JI, Nelson JE. 1-2-3 Project: A Quality Improvement Initiative to Normalize and Systematize Palliative Care for All Patients With Cancer in the Outpatient Clinic Setting. J Oncol Pract 2019; 14:e775-e785. [PMID: 30537456 DOI: 10.1200/jop.18.00346] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Prior work to integrate early palliative care in oncology has focused on patients with advanced cancer and primarily on palliative care consultation. We developed this outpatient clinic initiative for newly diagnosed patients at any stage, emphasizing primary (nonspecialist) palliative care by oncology teams, with enhanced access to palliative care specialists. METHODS We piloted the project in two medical oncology specialty clinics (for patients with myelodysplastic syndrome and GI cancer, respectively) to establish feasibility. On a visit-based schedule, patients systematically reported symptoms, information/decision-making preferences, and illness understanding. They also participated in discussions of their core values with their oncology nurse. Oncology teams were first responders to palliative care needs, whereas specialists were available for clinician support and direct patient consultation. RESULTS All 58 eligible patients were enrolled. In both clinics, patient self-reports documented a heavy symptom burden. Information/decision-making preferences and illness understanding levels varied across patients. Patients prepared new advance directives. Oncology nurses documented discussions of core values. Requests for palliative care consultation decreased over time as oncology teams embraced their primary palliative care role with coaching from the specialists. Clinic workflow and patient volume were maintained. CONCLUSION Our pilot experience suggests that in outpatient oncology clinics, a structured, scheduled, and systematic approach is feasible to deliver palliative care to newly diagnosed patients with cancer at any stage and throughout their illness trajectory. This novel approach identified important, actionable palliative care needs, relying primarily on oncology teams to respond to these needs, while enhancing access to palliative care specialist input. Expansion to additional clinics will allow evaluation of scalability and generalizability, along with measurement of a broader range of important outcomes.
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Affiliation(s)
| | | | - Kimberly Chow
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Camila Bernal
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Molly Okpako
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Dana Kramer
- Memorial Sloan Kettering Cancer Center, New York, NY
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6
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The Development of Pathways in Palliative Medicine: Definition, Models, Cost and Quality Impact. Healthcare (Basel) 2019; 7:healthcare7010022. [PMID: 30717281 PMCID: PMC6473403 DOI: 10.3390/healthcare7010022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 01/31/2019] [Indexed: 01/23/2023] Open
Abstract
Palliative Care and its medical subspecialty, known as Palliative Medicine, is the care of anyone with a serious illness. This emerging field includes Hospice and comfort care, however, it is not limited to end-of-life care. Examples of the types of serious illness that Palliative Medicine clinicians care for include and are not limited to hematologic and oncologic diseases, such as cancer, advanced heart and lung diseases (e.g., congestive heart failure and chronic obstructive pulmonary disorder), advanced liver and kidney diseases, and advanced neurologic illnesses (e.g., Alzheimer’s and Parkinson’s disease). In the past decade, there has been tremendous growth of Palliative Medicine programs across the country. As the population of patients with serious illnesses increases, there is growing concentration on quality of care, including symptom management, meeting patients’ goals regarding their medical care and providing various types of support, all of which are provided by Palliative Medicine. In this review article we define Palliative Medicine, describe care pathways and their applicability to Palliative Medicine, identify different models for Palliative Care and provide evidence for its impact on cost and quality of care.
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7
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Kaufman BG, Klemish D, Kassner CT, Reiter JP, Li F, Harker M, O'Brien EC, Taylor DH, Bhavsar NA. Predicting Length of Hospice Stay: An Application of Quantile Regression. J Palliat Med 2018; 21:1131-1136. [PMID: 29762075 DOI: 10.1089/jpm.2018.0039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Use of the Medicare hospice benefit has been associated with high-quality care at the end of life, and hospice length of use in particular has been used as a proxy for appropriate timing of hospice enrollment. Quantile regression has been underutilized as an alternative tool to model distributional changes in hospice length of use and hospice payments outside of the mean. OBJECTIVE To test for heterogeneity in the relationship between patient characteristics and hospice outcomes across the distribution of hospice days. SETTING Medicare Beneficiary Summary File and survey data (2014) for hospice beneficiaries in North and South Carolina with common terminal diagnoses. MEASUREMENTS Distributional shifts associated with patient characteristics were evaluated at the 25th and 75th percentiles of hospice days and hospice payments using quantile regressions and compared to the mean shift estimated by ordinary least squares (OLS) regression. PRINCIPAL FINDINGS Significant (p < 0.001) heterogeneity in the marginal effects on hospice days and costs was observed, with patient characteristics associated with generally larger shifts in the 75th percentile than the 25th percentile. Mean effects estimated by OLS regression overestimate the magnitude of the median marginal effects for all patient characteristics except for race. Results for hospice payments in 2014 were similar. CONCLUSIONS Methodological decisions can have a meaningful impact in the evaluation of factors influencing hospice length of use or cost.
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Affiliation(s)
- Brystana G Kaufman
- 1 Department of Health Policy and Management, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
| | - David Klemish
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | | | - Jerome P Reiter
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | - Fan Li
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | - Matthew Harker
- 5 Margolis Center for Health Policy , Duke University, Durham, North Carolina
| | - Emily C O'Brien
- 2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
| | - Donald H Taylor
- 6 Sanford School of Public Policy , Duke University, Durham, North Carolina
| | - Nrupen A Bhavsar
- 2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
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Washington KT, Wilkes CM, Rakes CR, Otten SJ, Parker Oliver D, Demiris G. Relationships among Symptom Management Burden, Coping Responses, and Caregiver Psychological Distress at End of Life. J Palliat Med 2018; 21:1234-1241. [PMID: 29727256 DOI: 10.1089/jpm.2017.0584] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Family caregivers (FCGs) face numerous stressors and are at heightened risk of psychological distress. While theoretical explanations exist linking caregiving stressors with outcomes such as anxiety and depression, limited testing of these theories has occurred among FCGs of patients nearing the end of life. OBJECTIVE Researchers sought to evaluate mediational relationships among burden experienced by hospice FCGs because of symptom management demands, caregivers' coping responses, and caregivers' psychological distress. DESIGN Quantitative data for this descriptive exploratory study were collected through survey. Hypothesized relationships among caregiver variables were examined with structural equation modeling. SETTING/SUBJECTS Respondents were FCGs (N = 228) of hospice patients receiving services from a large, non-profit community hospice in the Mid-Southern United States. RESULTS Burden associated with managing hospice patients' psychological symptoms was shown to predict psychological distress for FCGs. Caregivers' use of escape-avoidance coping responses mediated this relationship. CONCLUSIONS Results suggest that FCGs would benefit from additional tools to address patients' psychological symptoms at end of life. When faced with psychological symptom management burden, caregivers need a range of coping skills as alternatives to escape-avoidance coping.
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Affiliation(s)
- Karla T Washington
- 1 Department of Family and Community Medicine, University of Missouri , Columbia, Missouri
| | - Chelsey M Wilkes
- 2 College of Health Professions, Rosalind Franklin University of Medicine and Science , North Chicago, Illinois.,3 Louis Stokes Cleveland Veterans Affairs Medical Center , Cleveland, Ohio
| | - Christopher R Rakes
- 4 Department of Education, University of Maryland , Baltimore County, Baltimore, Maryland
| | | | - Debra Parker Oliver
- 1 Department of Family and Community Medicine, University of Missouri , Columbia, Missouri
| | - George Demiris
- 6 School of Nursing and Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
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Bull J, Kamal AH, Harker M, Bonsignore L, Morris J, Massie L, Singh Bhullar P, Hendrix M, Bennett D, Taylor D. Tracking Patients in Community-Based Palliative Care through the Centers for Medicare & Medicaid Services Healthcare Innovation Project. J Palliat Med 2017; 20:1231-1236. [DOI: 10.1089/jpm.2017.0080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Janet Bull
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Arif H. Kamal
- Duke University Medical Center, Durham, North Carolina
| | | | | | - John Morris
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Lisa Massie
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | | | - Mark Hendrix
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Deeana Bennett
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Don Taylor
- Duke Sanford School of Policy, Durham, North Carolina
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10
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Bakitas MA, El-Jawahri A, Farquhar M, Ferrell B, Grudzen C, Higginson I, Temel JS, Zimmermann C, Smith TJ. The TEAM Approach to Improving Oncology Outcomes by Incorporating Palliative Care in Practice. J Oncol Pract 2017; 13:557-566. [DOI: 10.1200/jop.2017.022939] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Palliative care (PC) concurrent with usual oncology care is now the standard of care that is recommended for any patient with advanced cancer to begin within 8 weeks of diagnosis on the basis of evidence-driven national clinical practice guidelines; however, there are not enough interdisciplinary palliative care teams to provide such care. How and what can an oncology office incorporate into usual care, borrowing the tools used in PC randomized clinical trials (RCTs), to improve care for patients and their caregivers? We reviewed the multiple RCTs for common practical elements and identified methods and techniques that oncologists can use to deliver some parts of concurrent interdisciplinary PC. We recommend the standardized assessment of patient-reported outcomes, including the evaluation of symptoms with such tools as the Edmonton or Memorial Symptom Assessment Scales, spirituality with the FICA Spiritual History Tool or similar questions, and psychosocial distress with the Distress Thermometer. All patients should be assessed for how they prefer to receive information, their current understanding of their situation, and if they have considered some advance care planning. Approximately 1 hour of additional time with the patient is required each month. If the oncologist does not have established ties with spiritual care and social work, he or she should establish these relationships for counseling as required. Caregivers should be asked about coping and support needs. Oncologists can adapt PC techniques to achieve results that are similar to those in the RCTs of PC plus usual care compared with usual care alone. This is comparable to using data from RCTs of trastuzamab or placebo, adopting what was used in the RCTs without modification or dilution.
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Affiliation(s)
- Marie A. Bakitas
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Areej El-Jawahri
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Morag Farquhar
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Betty Ferrell
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Corita Grudzen
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Irene Higginson
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Jennifer S. Temel
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Camilla Zimmermann
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
| | - Thomas J. Smith
- University of Alabama at Birmingham, AL; Partners–Massachusetts General Hospital, Boston, MA; City of Hope Medical Center, Duarte, CA; New York University School of Medicine, New York, NY; University of East Anglia, Norwich; Kings College London, London, United Kingdom; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; and Johns Hopkins University, Baltimore, MD
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11
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Lindley LC. The Effect of Pediatric Palliative Care Policy on Hospice Utilization Among California Medicaid Beneficiaries. J Pain Symptom Manage 2016; 52:688-694. [PMID: 27693902 PMCID: PMC5107325 DOI: 10.1016/j.jpainsymman.2016.05.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/27/2016] [Accepted: 05/21/2016] [Indexed: 10/20/2022]
Abstract
CONTEXT California implemented pediatric palliative care legislations that allowed children to receive curative and supportive care from diagnosis of a life-threatening serious illness in 2010. Palliative care policies may improve access to hospice care as children near end of life. OBJECTIVES The aim of this study was to examine the effect of the palliative care policy on hospice utilization for children and their families was investigated. METHODS Using 2007 and 2010 California Medicaid data, a difference-in-difference analysis was conducted to analyze hospice use (i.e., hospice enrollment, hospice length of stay) changes for children who resided in pediatric policy counties relative to those who did not. The sample of children in California who died with a life-threatening serious illness in 2007 and 2010 equaled 979 children. RESULTS More than 10% of children enrolled in hospice care with an average of less than 3 days of hospice care. The palliative care policy did not have any effect on hospice enrollment. However, the policy was positively associated with increasing days in hospice care (incidence rate ratio = 5.61, P < 0.05). The rate of hospice length of stay increased by a factor of 5.61 for children in palliative care counties compared with children unaffected by the policy. CONCLUSION The pediatric palliative care policy was associated with longer lengths of stay in hospice once the children were enrolled. Policies promoting palliative care are critical to ensuring access to hospice care for children.
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Affiliation(s)
- Lisa C Lindley
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA.
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Waite K, Rhule J, Bush D, Meisenberg B. End-of-Life Care Patterns at a Community Hospital: The Rest of the Story. Am J Hosp Palliat Care 2016; 34:977-983. [PMID: 27729481 DOI: 10.1177/1049909116673300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We undertook a retrospective review of a subset of expired patients at our community hospital to evaluate end-of-life care patterns and the use of advanced care planning tools among patients who died in the hospital. These 162 expired patients fell into 1 of the 3 diagnosis-related groups of cardiac, respiratory, or infectious disease. Seventy-nine percent of patients arrived to the hospital with no requested limitations in the extent of resuscitative efforts, even though 98% of all patients had major or extreme severity of illness and risk of mortality scores. The presence of an advance directive requesting a limitation of resuscitative efforts modestly impacted resources and procedures, even though utilization in this group was high. Among the 21% of patients with preexisting limits, 21% requested more aggressive support during their course. Critical care unit utilization was seen in 69% of patients for a median of 48 hours. A request for palliative care consultation was received in 44% of patients but only occurred in 30% of all patients due to the short period between the consultation request and patient death (median 37 hours). Among this group of dying patients, engagement of the palliative care team came too late in the course of many patients, suggesting that automated tools embedded in the electronic medical record might be helpful in the identification of appropriate patients earlier.
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Affiliation(s)
- Kip Waite
- 1 Research Institute, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Jane Rhule
- 1 Research Institute, Anne Arundel Medical Center, Annapolis, MD, USA
| | - David Bush
- 1 Research Institute, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Barry Meisenberg
- 1 Research Institute, Anne Arundel Medical Center, Annapolis, MD, USA
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Abstract
A 2014 consensus report by the Institute of Medicine offers recommendations for healthcare providers to decrease unwanted care and improve the quality of life at the end of life. This article discusses the recommendations of interest to advanced practice registered nurses.
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Affiliation(s)
- Elizabeth H Dobbins
- Elizabeth H. Dobbins is a professor of nursing at Walters State Community College, Morristown, Tenn
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Rabow MW, Dahlin C, Calton B, Bischoff K, Ritchie C. New Frontiers in Outpatient Palliative Care for Patients With Cancer. Cancer Control 2016; 22:465-74. [PMID: 26678973 DOI: 10.1177/107327481502200412] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Although much evidence has accumulated demonstrating its benefit, relatively little is known about outpatient palliative care in patients with cancer. METHODS This paper reviews the literature and perspectives from content experts to describe the current state of outpatient palliative care in the oncology setting and current areas of innovation and promise in the field. RESULTS Evidence, including from controlled trials, documents the benefits of outpatient palliative care in the oncology setting. As a result, professional medical organizations have guidelines and recommendations based on the key role of palliative care in oncology. Six elements of the practice sit at the frontier of outpatient oncology palliative care, including the setting and timing of palliative care integration into outpatient oncology, the relationships between primary and specialty palliative care, quality and measurement, research, electronic and technical innovations, and finances. CONCLUSIONS Evidence of clinical and health care system benefits supports the recommendations of professional organizations to integrate palliative care into the routine treatment of patients with advanced cancer.
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