Patterns of Symptom Management Medication Receipt at End-of-Life Among Medicare Beneficiaries With Lung Cancer

End-of-Life Symptoms in Adult Patients With Stroke in the Last Two Years of Life: An Integrative Review

BACKGROUND

Stroke is a leading cause of death globally, yet End-of-Life (EOL) symptoms and their management in these patients are not well understood.

PURPOSE

This integrative review aims to critique and synthesize research on EOL symptoms and symptom management in adult patients with stroke in the last 2 years of life in all settings.

METHODS

The Whittemore and Knafl integrative review methodology guided this review. PubMed, CINAHL, Scopus, Web of Science, and Google Scholar were used for the literature search. Included studies were published in English and quantitatively examined symptoms and symptom management. Quality appraisal was guided by the Effective Public Health Practice Project (EPHPP) assessment tool.

RESULTS

Seven studies, all rated weak, were included in this review. A total of 2175 adult patients from six countries were represented. Results are classified into three main themes: EOL symptom experience, symptom assessment, and symptom management. Commonly reported EOL symptoms among adults with stroke include both stroke-specific (dysphagia, dysarthria) and non-specific symptoms (pain, dyspnea, constipation, and psychological distress). However, communication difficulties and the infrequent use of standardized tools for symptom assessment limit what is known about the EOL symptom experience. Although the relief of pain is generally well-documented, dyspnea and anxiety are much more poorly controlled.

CONCLUSIONS

There is a need for better assessment and management of EOL symptoms in patients with stroke. Established palliative and EOL care guidelines need to be incorporated into clinical practice to ensure access to high-quality care.

Quality of Care at the End of Life: Applying the Intersection of Race and Gender

BACKGROUND AND OBJECTIVES

Research on racial and gender disparities in end-of-life care quality has burgeoned over the past few decades, but few studies have incorporated the theory of intersectionality, which posits that membership in 2 or more vulnerable groups may result in increased hardships across the life span. As such, this study aimed to examine the intersectional effect of race and gender on the quality of care received at the end of life among older adults.

RESEARCH DESIGN AND METHODS

Data were derived from the combined Round 3 to Round 10 of the National Health and Aging Trends Study. For multivariate analyses, 2 logistic regression models were run; Model 1 included the main effects of race and gender and Model 2 included an interaction term for race and gender.

RESULTS

Results revealed that White men were the most likely to have excellent or good care at the end of life, followed by White women, Black men, and Black women, who were the least likely to have excellent or good care at the end of life.

DISCUSSION AND IMPLICATIONS

These results point to a significant disadvantage for Black women, who had worse end-of-life care quality than their gender and racial peers. Practice interventions may include cultural humility training and a cultural match between patients and providers. From a policy standpoint, a universal health insurance plan would reduce the gap in end-of-life service access and quality for Black women, who are less likely to have supplemental health care coverage.

The effects of tislelizumab treatment on the health-related quality of life of patients with advanced non-small cell lung cancer

This study examined the health-related quality of life (HRQoL) of patients with advanced non-small cell lung cancer (NSCLC) receiving tislelizumab versus docetaxel in the open-label, multicenter, Phase 3 trial called RATIONALE-303 (NCT03358875). HRQoL was assessed with the EORTC QLQ-C30, EORTC QLQ-LC13, and the EQ-5D-5L instruments. A longitudinal analysis of covariance assessed the change from baseline to Week 12 and from baseline to Week 18. A time to deterioration analysis was also performed using the Kaplan-Meier method. Eight hundred and five patients were randomized to either tislelizumab (n = 535) or docetaxel, respectively (535 and 270 to tislelizumab and docetaxel, respectively). The tislelizumab arm improved while the docetaxel arm worsened in the QLQ-C30 global health status/QoL scale score (difference LS mean change Week 18: 5.7 [95% CI: 2.38, 9.07, p = 0.0008]), fatigue (Week 12: -3.2 [95% CI: -5.95, -0.37, p < 0.0266]; Week 18: -4.9 [95% CI: -8.26, -1.61, p = 0.0037]), and QLQ-LC13 symptom index score (Week 12: -5.5 [95% CI: -6.93, -4.04, P < 0.0001]; Week 18: -6.6 [95% CI: -8.25, -4.95, p < 0.0001]). The tislelizumab arm had improvements in coughing versus the docetaxel arm (Week 12: -4.7 [95% CI: -8.57, -0.78, p = 0.0188]; Week 18: -8.3 [95% CI: -13.02, -3.51, p = 0.0007]). The patients who received tislelizumab were less at risk for clinically meaningful worsening in the overall lung cancer symptom index scale (hazard ratio (HR): 0.24 [95% CI: 0.162, 0.356], p < 0.0001), dyspnea (HR: 0.74 [95% CI: 0.567, 0.958], p = 0.0109), coughing (HR: 0.74 [95% CI: 0.534, 1.019], p = 0.0309), and peripheral neuropathy (HR: 0.55 [95% CI: 0.370, 0.810] p = 0.0011). In general, tislelizumab versus docetaxel was associated with improved HRQoL and symptoms of lung cancer in patients who previously failed treatment with platinum-containing chemotherapy.

Predicting Acute Care Events Among Patients Initiating Chemotherapy: A Practice-Based Validation and Adaptation of the PROACCT Model

PURPOSE

Acute care events (ACEs), comprising emergency department visits and hospitalizations, are a priority area for reduction in oncology. Prognostic models are a compelling strategy to identify high-risk patients and target preventive services, but have yet to be broadly implemented, partly because of challenges with electronic health record (EHR) integration. To facilitate EHR integration, we adapted and validated the previously published PRediction Of Acute Care use during Cancer Treatment (PROACCT) model to identify patients at highest risk for ACEs after systemic anticancer treatment.

METHODS

A retrospective cohort of adults with a cancer diagnosis starting systemic therapy at a single center between July and November 2021 was divided into development (70%) and validation (30%) sets. Clinical and demographic variables were extracted, limited to those in structured format in the EHR, including cancer diagnosis, age, drug category, and ACE in prior year. Three logistic regression models of increasing complexity were developed to predict risk of ACEs.

RESULTS

Five thousand one hundred fifty-three patients were evaluated (3,603 development and 1,550 validation). Several factors were predictive of ACEs: age (in decades), receipt of cytotoxic chemotherapy or immunotherapy, thoracic, GI or hematologic malignancy, and ACE in the prior year. We defined high-risk as the top 10% of risk scores; this population had 33.6% ACE rate compared with 8.3% for the remaining 90% in the low-risk group. The simplest Adapted PROACCT model had a C-statistic of 0.79, sensitivity of 0.28, and specificity of 0.93.

CONCLUSION

We present three models designed for EHR integration that effectively identify oncology patients at highest risk for ACE after initiation of systemic anticancer treatment. By limiting predictors to structured data fields and including all cancer types, these models offer broad applicability for cancer care organizations and may offer a safety net to identify and target resources to this high risk.

A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness

Background: World population is not only aging but suffering from serious chronic illnesses, requiring an increasing need for end-of-life care. However, studies show that many healthcare providers involved in the care of dying patients sometimes express challenges in knowing when to stop non-beneficial investigations and futile treatments that tend to prolong undue suffering for the dying person. Objective: To evaluate the clinical signs and symptoms that show end-of-life is imminent in individuals with advanced illness. Design: Narrative review. Methods: Computerized databases, including PubMed, Embase, Medline,CINAHL, PsycInfo, and Google Scholar were searched from 1992 to 2022 for relevant original papers written in or translated into English language that investigated clinical signs and symptoms of imminent death in individuals with advanced illness. Results: 185 articles identified were carefully reviewed and only those that met the inclusion criteria were included for review. Conclusion: While it is often difficult to predict the timing of death, the ability of healthcare providers to recognize the clinical signs and symptoms of imminent death in terminally-ill individuals may lead to earlier anticipation of care needs and better planning to provide care that is tailored to individual's needs, and ultimately results in better end-of-life care, as well as a better bereavement adjustment experience for the families.

End-of-life care trajectories among older adults with lung cancer

INTRODUCTION

Medicare decedents with cancer often receive intensive care during the last month of life; however, little information exists on longer end-of-life care trajectories.

MATERIALS AND METHODS

Using SEER-Medicare data, we selected older adults diagnosed with lung cancer between 2008 and 2013 who survived at least six months and died between 2008 and 2014. Each month we assessed claims to assign care categories ordered by intensity as follows: full-month inpatient/skilled nursing facility > cancer-directed therapy (CDT) only > concurrent CDT and symptom management and supportive care services (SMSCS) > SMSCS only > full-month hospice. We assigned each decedent to one of six trajectories: stable hospice, stable SMSCS, stable CDT with or without concurrent SMSCS, decreasing intensity, increasing intensity, and mixed. Multinomial logistic regression estimated associations between socio-demographics, calendar year, and area hospice use rates with end-of-life trajectory.

RESULTS

The sample (N = 24,342) was predominantly aged ≥75 years (59.4%) and non-Hispanic White (80.5%); 19.1% lived in healthcare referral regions where ≤50% of cancer decedents received hospice care. Overall, 6.5% were continuously hospice enrolled, 25.6% received SMSCS only, and 29.4% experienced decreasing intensity; 3.9% received CDT or concurrent care, while 8.7% experienced an increase in intensity. Higher healthcare referral region hospice rates were associated with decreasing end-of-life intensity; Black, non-Hispanic decedents had a higher risk of increasing intensity and mixed patterns.

DISCUSSION

Among older decedents with lung cancer, 62% had six-month end-of-life trajectories indicating low or decreasing intensity, but few received persistent CDT. Demographic characteristics, including race/ethnicity, and contextual measures, including area hospice use patterns, were associated with end-of-life trajectory.

The end of life experiences of people living with socio-economic deprivation in the developed world: an integrative review

Background

Those experiencing socioeconomic deprivation have poorer quality of health throughout their life course which can result in poorer quality of death – with decreased access to palliative care services, greater use of acute care, and reduced access to preferred place of care compared with patients from less deprived populations.

Aim

To summarise the current global evidence from developed countries on end-of-life experience for those living with socio-economic deprivation.

Design

Integrative review in accordance with PRISMA. A thorough search of major databases from 2010–2020, using clear definitions of end-of-life care and well-established proxy indicators of socio-economic deprivation. Empirical research describing experience of adult patients in the last year of life care were included.

Results

Forty studies were included from a total of 3508 after screening and selection. These were deemed to be of high quality; from a wide range of countries with varying healthcare systems; and encompassed all palliative care settings for patients with malignant and non-malignant diagnoses. Three global themes were identified: 1) multi-dimensional symptom burden, 2) preferences and planning and 3) health and social care interactions at the end of life.

Conclusions

Current models of healthcare services are not meeting the needs of those experiencing socioeconomic deprivation at the end-of-life. Further work is needed to understand the disparity in care, particularly around ensuring patients voices are heard and can influence service development and delivery.

Application of Critical Race Theory in Palliative Care Research: A Scoping Review

CONTEXT

Structural racism negatively impacts individuals and populations. In the medical literature, including that of palliative care, structural racism's influence on interracial differences in outcomes remains poorly examined. Examining the contribution of structural racism to outcomes is paramount to promoting equity.

OBJECTIVES

We examined portrayals of race and racial differences in outcomes in the palliative care literature and created a framework using critical race theory (CRT) to aid in this examination.

METHODS

We reviewed the CRT literature and iteratively developed a rubric to examine when and how differences between races are described. Research articles published in The Journal of Pain and Symptom Management presenting empiric data specifically including findings about racial differences were examined independently by three reviewers using the rubric.

RESULTS

Fifty-seven articles met inclusion criteria. Articles that specifically described racial differences were common in the topic areas of quality (75% of articles), hospice (53%), palliative care services (40%) and spirituality/religion (40%). The top three reasons posited for racial differences were patient preference (26%), physician bias (23%), and cultural barriers (21%). Using the CRT rubric we found that 65% of articles posited that a racial difference was something that needed to be rectified, while articles rarely provided narrative (5%) or other data on perspectives of people of color (11%) to explain assumptions about differences.

CONCLUSION

Palliative care research frequently highlights racial differences in outcomes. Articles that examine racial differences often assume that differences need to be fixed but posit reasons for differences without the narratives of those most affected by them.

Does ethnicity affect pain management for people with advanced disease? A mixed methods cross-national systematic review of 'very high' Human Development Index English-speaking countries

BACKGROUND

Racial disparities in pain management have been observed in the USA since the 1990s in settings such as the emergency department and oncology. However, the palliative care context is not well described, and little research has focused outside of the USA or on advanced disease. This review takes a cross-national approach to exploring pain management in advanced disease for people of different racial and ethnic groups.

METHODS

Mixed methods systematic review. The primary outcome measure was differences in receiving pain medication between people from different racial and ethnic groups. Five electronic databases were searched. Two researchers independently assessed quality using JBI checklists, weighted evidence, and extracted data. The quantitative findings on the primary outcome measure were cross-tabulated, and a thematic analysis was undertaken on the mixed methods studies. Themes were formulated into a conceptual/thematic matrix. Patient representatives from UK ethnically diverse groups were consulted. PRISMA 2020 guidelines were followed.

RESULTS

Eighteen papers were included in the primary outcome analysis. Three papers were rated 'High' weight of evidence, and 17/18 (94%) were based in the USA. Ten of the eighteen (56%) found no significant difference in the pain medication received between people of different ethnic groups. Forty-six papers were included in the mixed methods synthesis; 41/46 (89%) were based in the USA. Key themes: Patients from different ethnically diverse groups had concerns about tolerance, addiction and side effects. The evidence also showed: cultural and social doctor-patient communication issues; many patients with unmet pain management needs; differences in pain assessment by racial group, and two studies found racial and ethnic stereotyping.

CONCLUSIONS

There was not enough high quality evidence to draw a conclusion on differences in receiving pain medication for people with advanced disease from different racial and ethnic groups. The mixed methods findings showed commonalities in fears about pain medication side effects, tolerance and addiction across diverse ethnic groups. However, these fears may have different foundations and are differently prioritised according to culture, faith, educational and social factors. There is a need to develop culturally competent pain management to address doctor-patient communication issues and patients' pain management concerns.

TRIAL REGISTRATION

PROSPERO- CRD42020167890 .

Sociodemographic disparities in the management of advanced lung cancer: a narrative review

Treatment of advanced non-small cell lung cancer (NSCLC) has markedly changed in the past decade with the integration of biomarker testing, targeted therapies, immunotherapy, and palliative care. These advancements have led to significant improvements in quality of life and overall survival. Despite these improvements, racial and socioeconomic disparities in lung cancer mortality persist. This narrative review aims to assess and synthesize the literature on sociodemographic disparities in the management of advanced NSCLC. A narrative overview of the literature was conducted using PubMed and Scopus and was narrowed to articles published from January 1, 2010, until July 22, 2020. Articles relevant to sociodemographic variation in (I) chemoradiation for stage III NSCLC, (II) molecular biomarker testing, (III) systemic treatment, including chemotherapy, targeted therapy, and immunotherapy, and (IV) palliative and end of life care were included in this review. Twenty-two studies were included. Sociodemographic disparities in the management of advanced NSCLC varied, but recurring findings emerged. Across most treatment domains, Black patients, the uninsured, and patients with Medicaid were less likely to receive recommended lung cancer care. However, some of the literature was limited due to incomplete data to adequately assess appropriateness of care, and several studies were out of date with current practice guidelines. Sociodemographic disparities in the management of advanced lung cancer are evident. Given the rapidly evolving treatment paradigm for advanced NSCLC, updated research is needed. Research on interventions to address disparities in advanced NSCLC is also needed.

Pain, symptom distress, and pain barriers by age among patients with cancer receiving hospice care: Comparison of baseline data

OBJECTIVES

Age group differences have been reported for pain and symptom presentations in outpatient and inpatient oncology settings, but it is unknown if these differences occur in hospice. We examined whether there were differences in pain, symptom distress, pain barriers, and comorbidities among three age groups (20-64 years, 65-84 years, and 85+) of hospice patients with cancer.

MATERIALS AND METHODS

Participants were recruited from two hospices. Half were women; 49% White and 34% Black. 42% were 20-64 y, 43% 65-84 y, and 15% 85+ y. We analyzed baseline data for 230 hospice patients with cancer (enrolled 2014-2016, mean age 68.2 ± 14.0, 20-100 years) from a stepped-wedge randomized controlled trial. Measures were the Average pain intensity (API, 0-10: current, least and worst pain intensity during the past 24 h), Symptom Distress Scale (SDS, 13-65), Barriers Questionnaire-13 (BQ-13, 0-5), and comorbid conditions. Descriptive, bivariate association, and multiple regression analyses were performed.

RESULTS

Mean API scores differed (p < .001) among the three age groups (5.6 ± 2.0 [20-64 years], 4.7 ± 2.0 [65-84 years], and 4.4 ± 1.8 [85+], as did the mean SDS scores (36.1 ± 7.3, 33.5 ± 8.1, and 31.6 ± 6.6, p = .004). BQ-13 mean scores (2.6 ± 0.9, 2.7 ± 0.8, and 2.5 ± 0.7) and comorbidities were not significantly different across age groups. In multiple regression analyses, age-related differences in API and SDS remained significant after adjusting for gender, race, cancer, palliative performance score, and comorbidities. Comorbidities were positively associated with SDS (p = .046) but not with API (p = .64) in the regression model.

CONCLUSION

Older hospice patients with cancer reported less pain and symptoms than younger patients, but all groups reported similar barriers to pain management. These findings suggest the need for age- and race-sensitive interventions to reduce pain and symptom distress levels at life's end.

End-of-life patterns of symptom management and cancer-directed care among Medicare beneficiaries with lung cancer: a claims-based analysis

BACKGROUND

Rather than early hospice enrollment, most Medicare beneficiaries receive "usual care" in the last months of life, outside of the hospice setting. While care intensity during the last weeks of life has been studied extensively, patterns of symptom management services (SMS) and/or cancer-directed therapies (CDT) received over a 6-month end-of-life period have not.

METHODS

This retrospective study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify decedents diagnosed with lung cancer at age ≥ 66 years between January 2007 and December 2013 who survived ≥ 6 months from diagnosis. Medicare claims identified receipt of SMS and/or CDT. We created monthly indicators for care content (SMS-only, CDT-only, or both; otherwise full-month hospice or inpatient/skilled nursing). Multinomial logistic regression estimated associations between sociodemographics and comorbidity, with care content in the final month.

RESULTS

Between 6 and 1 months before death, full-month hospice and inpatient/skilled nursing increased; CDT decreased from 31.9 to 18.5%; SMS increased from 86.6 to 97.7%. Relative to full-month hospice, the percentage of patients receiving SMS-only was higher for males, unmarried, younger age, and higher comorbidity; the percentage receiving CDT was also higher for males, unmarried, and younger age, but decreased with increasing comorbidity and over calendar time.

CONCLUSION

Among lung cancer decedents observed in the outpatient, nonhospice setting, SMS receipt increased and was nearly universal as death approached. CDT diminished dramatically over the end-of-life period. Associations between sociodemographic characteristics and care setting suggest differences in care preferences or access barriers. Claims represent an important resource for characterizing end-of-life care patterns.