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Piscitello GM, Rogal S, Schell J, Schenker Y, Arnold RM. Equity in Using Artificial Intelligence Mortality Predictions to Target Goals of Care Documentation. J Gen Intern Med 2024:10.1007/s11606-024-08849-w. [PMID: 38858343 DOI: 10.1007/s11606-024-08849-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 05/31/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Artificial intelligence (AI) algorithms are increasingly used to target patients with elevated mortality risk scores for goals-of-care (GOC) conversations. OBJECTIVE To evaluate the association between the presence or absence of AI-generated mortality risk scores with GOC documentation. DESIGN Retrospective cross-sectional study at one large academic medical center between July 2021 and December 2022. PARTICIPANTS Hospitalized adult patients with AI-defined Serious Illness Risk Indicator (SIRI) scores indicating > 30% 90-day mortality risk (defined as "elevated" SIRI) or no SIRI scores due to insufficient data. INTERVENTION A targeted intervention to increase GOC documentation for patients with AI-generated scores predicting elevated risk of mortality. MAIN MEASURES Odds ratios comparing GOC documentation for patients with elevated or no SIRI scores with similar severity of illness using propensity score matching and risk-adjusted mixed-effects logistic regression. KEY RESULTS Among 13,710 patients with elevated (n = 3643, 27%) or no (n = 10,067, 73%) SIRI scores, the median age was 64 years (SD 18). Twenty-five percent were non-White, 18% had Medicaid, 43% were admitted to an intensive care unit, and 11% died during admission. Patients lacking SIRI scores were more likely to be younger (median 60 vs. 72 years, p < 0.0001), be non-White (29% vs. 13%, p < 0.0001), and have Medicaid (22% vs. 9%, p < 0.0001). Patients with elevated versus no SIRI scores were more likely to have GOC documentation in the unmatched (aOR 2.5, p < 0.0001) and propensity-matched cohorts (aOR 2.1, p < 0.0001). CONCLUSIONS Using AI predictions of mortality to target GOC documentation may create differences in documentation prevalence between patients with and without AI mortality prediction scores with similar severity of illness. These finding suggest using AI to target GOC documentation may have the unintended consequence of disadvantaging severely ill patients lacking AI-generated scores from receiving targeted GOC documentation, including patients who are more likely to be non-White and have Medicaid insurance.
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Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA.
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Shari Rogal
- Departments of Medicine and Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare Center, Pittsburgh, PA, USA
| | - Jane Schell
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert M Arnold
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Swiderski D, Taniguchi RN, Chuang E. Are Safety-Net Primary Care Physicians Prepared to Engage in Serious Illness Conversations? Am J Hosp Palliat Care 2024; 41:486-491. [PMID: 37533362 DOI: 10.1177/10499091231190354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Advance Care Planning (ACP) has not reliably improved care for patients at end-of-life. Serious Illness Conversations when patients are in the late stages of chronic illness might be more effective to address patients' goals. The Serious Illness Conversation (SIC) Guide has been helpful but was not developed for use in safety-net settings serving racial and ethnic minority populations. METHODS Physicians were recruited to complete a needs assessment survey prior to training in the use of the SIC Guide. RESULTS Of the 44 physician participants, most were female (82%) and white, non-Hispanic (62%). Less than half of respondents rated themselves as skilled or very skilled in basic serious illness communication related tasks such as setting up goals of care discussions (44%), assessing informational preferences (42%), sharing prognosis (38%), exploring goals for future care (49%) and managing family dynamics (44%). Respondents reported lower skill levels in conducting goals of care conversations via telehealth and establishing trust in racially discordant provider/patient pairs. CONCLUSIONS Most participants expressed the need for further training in critical end-of-life communications skills, including help with encounters with racial and/or language discordance. This may help to explain the failure of ACP discussions to reliably result in appropriate end-of-life care.
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Affiliation(s)
| | | | - Elizabeth Chuang
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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3
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King A, Tanumihardjo J, Ahn D, Zasadzinski L, Robinson E, Quinn M, Peek M, Saunders M. Assessing knowledge of end-stage kidney disease and treatment options in hospitalized African American patients undergoing hemodialysis. Chronic Illn 2024; 20:145-158. [PMID: 37106575 DOI: 10.1177/17423953231168803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVE African Americans are more likely to develop end-stage kidney disease (ESKD) than whites and face multiple inequities regarding ESKD treatment, renal replacement therapy (RRT), and overall care. This study focused on determining gaps in participants' knowledge of their chronic kidney disease and barriers to RRT selection in an effort to identify how we can improve health care interventions and health outcomes among this population. METHODS African American participants undergoing hemodialysis were recruited from an ongoing research study of hospitalized patients at an urban Midwest academic medical center. Thirty-three patients were interviewed, and the transcribed interviews were entered into a software program. The qualitative data were coded using template analysis to analyze text and determine key themes. Medical records were used to obtain demographic and additional medical information. RESULTS Three major themes emerged from the analysis: patients have limited information on ESKD causes and treatments, patients did not feel they played an active role in selecting their initial dialysis unit, and interpersonal interactions with the dialysis staff play a large role in overall unit satisfaction. DISCUSSION Although more research is needed, this study provides information and suggestions to improve future interventions and care quality, specifically for this population.
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Affiliation(s)
- Akilah King
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Jacob Tanumihardjo
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Daniel Ahn
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Eric Robinson
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Michael Quinn
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Monica Peek
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Milda Saunders
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
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4
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Nahm SH, Subramaniam S, Stockler MR, Kiely BE. Timing of prognostic discussions in people with advanced cancer: a systematic review. Support Care Cancer 2024; 32:127. [PMID: 38261070 DOI: 10.1007/s00520-023-08230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/03/2023] [Indexed: 01/24/2024]
Abstract
PURPOSE Many people with cancer (patients) want to know their prognosis (a quantitative estimate of their life expectancy) but this is often not discussed or poorly communicated. The optimal timing of prognostic discussions with people with advanced cancer is highly personalised and complex. We aimed to find, organise, and summarise research regarding the timing of discussions of prognosis with people with advanced cancer. METHODS We conducted a systematic review of publications from databases, clinical practice guidelines, and grey literature from inception to 2023. We also searched the reference lists of systematic reviews, editorials, and clinical trial registries. Eligibility criteria included publications regarding adults with advanced cancer that reported a timepoint when a discussion of prognosis occurred or should occur. RESULTS We included 63 of 798 identified references; most of which were cross-sectional cohort studies with a range of 4-9105 participants. Doctors and patients agreed on several timepoints including at diagnosis of advanced cancer, when the patient asked, upon disease progression, when there were no further anti-cancer treatments, and when recommending palliative care. Most of these timepoints aligned with published guidelines and expert recommendations. Other recommended timepoints depended on the doctor's clinical judgement, such as when the patient 'needed to know' or when the patient 'seemed ready'. CONCLUSIONS Prognostic discussions with people with advanced cancer need to be individualised, and there are several key timepoints when doctors should attempt to initiate these conversations. These recommended timepoints can inform clinical trial design and communication training for doctors to help improve prognostic understanding.
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Affiliation(s)
- Sharon H Nahm
- The NHMRC Clinical Trials Centre, The University of Sydney, Locked Bag 77, Camperdown, Sydney, NSW, 1450, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Shalini Subramaniam
- The NHMRC Clinical Trials Centre, The University of Sydney, Locked Bag 77, Camperdown, Sydney, NSW, 1450, Australia
- Bankstown Cancer Centre, Sydney, Australia
| | - Martin R Stockler
- The NHMRC Clinical Trials Centre, The University of Sydney, Locked Bag 77, Camperdown, Sydney, NSW, 1450, Australia
- Concord Cancer Centre, Sydney, Australia
| | - Belinda E Kiely
- The NHMRC Clinical Trials Centre, The University of Sydney, Locked Bag 77, Camperdown, Sydney, NSW, 1450, Australia.
- Concord Cancer Centre, Sydney, Australia.
- Macarthur Cancer Therapy Centre, Sydney, Australia.
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Tergas AI, Prigerson HG, Penedo FJ, Maciejewski PK. Human Connection: Oncologist Characteristics and Behaviors Associated With Therapeutic Bonding With Latino Patients With Advanced Cancer. JCO Oncol Pract 2024; 20:111-122. [PMID: 37988650 PMCID: PMC10827287 DOI: 10.1200/op.23.00329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/26/2023] [Accepted: 10/18/2023] [Indexed: 11/23/2023] Open
Abstract
PURPOSE Therapeutic alliances (TAs) between oncologists and patients are bonds characterized by mutual caring, trust, and respect. We here relate oncologist characteristics and behaviors to TA among Latino and non-Latino patients with advanced cancer. METHODS Participants included non-Latino oncologists (n = 41) and their Latino (n = 67) and non-Latino White (n = 90) patients with advanced cancer who participated in Coping with Cancer III, a multisite, US-based prospective cohort study of Latino/non-Latino disparities in end-of-life cancer care, conducted 2015-2019. Oncologist characteristics included age, sex, race, institution type, Spanish language proficiency, familismo practice style (emphasis on family) and clinical etiquette behaviors. Patient-reported TA was assessed using the average score of six items from The Human Connection scale. Hierarchical linear modeling (HLM) estimated effects of oncologist characteristics on TA. RESULTS Of 157 patients, a majority were female (n = 92, 58.6%) and age younger than 65 years (n = 95, 60.5%). Most oncologists were male (n = 24, 58.5%), non-Latino White (n = 25, 61%), and age 40 years and older (n = 25, 61%). An adjusted HLM in the full sample showed that Latino patient ethnicity was associated with significantly lower TA (β = -.25; P < .001). In an adjusted stratified HLM for TA, among Latino patients, oncologist familismo practice style (β = .19; P = .012), preference using first names (β = .25; P = .023), and greater Spanish fluency (β = .11; P < .001) were positively associated with TA. In contrast, familismo practice style had no impact on TA for non-Latino White patients. CONCLUSION Latino patients with advanced cancer had worse TAs with their oncologists versus non-Latino patients. Modifiable oncologist behaviors may be targeted in an intervention designed to improve the patient-physician relationship between oncologists and their Latino patients with advanced cancer.
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Affiliation(s)
- Ana I. Tergas
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, Duarte, CA
- Department of Population Science, Division of Health Equity, City of Hope Comprehensive Cancer Center, Duarte, CA
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY
| | - Holly G. Prigerson
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Frank J. Penedo
- Departments of Psychology and Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Paul K. Maciejewski
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY
- Department of Radiology, Weill Cornell Medicine, New York, NY
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6
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Heitner R, Rogers M, Chambers B, Pinotti R, Silvers A, Meier DE, Bowman B, Johnson KS. The Experience of Black Patients With Serious Illness in the United States: A Scoping Review. J Pain Symptom Manage 2023; 66:e501-e511. [PMID: 37442530 DOI: 10.1016/j.jpainsymman.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 06/29/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023]
Abstract
CONTEXT Black patients experience health disparities in access and quality of care. OBJECTIVE To identify and characterize the literature on the experiences of Black patients with serious illness across multiple domains - physical, spiritual, emotional, cultural, and healthcare utilization. METHODS We conducted a scoping review of US literature from the last ten years using the PRISMA-ScR framework. PubMed was used to conduct a comprehensive search, followed by recursive citation searches in Scopus. Two reviewers screened the resulting citations to determine eligibility for inclusion and extracted data, including study methods and sample populations. The included articles were categorized by topic and then further organized using the Social-Ecological Model. RESULTS From an initial review of 433 articles, a final sample of 160 were included in the scoping review. The majority of articles used quantitative research methods and were published in the last four years. Articles were categorized into 20 topics, ranging from Access to Hospice and Utilization (42 articles) to Community Outreach and Services (three articles). Three-quarters (76.3%) of the included studies provided evidence that racial disparities exist in serious illness care, while less than one-quarter examined causes of disparities. The most common Model levels were the Health Care System (102 articles) and Individual (71 articles) levels. CONCLUSION More articles focused on establishing evidence of disparities between Black and White patients than on understanding their root causes. Further investigation is warranted to understand how factors at the patient, provider, health system, and society levels interact to remediate disparities.
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Affiliation(s)
- Rachael Heitner
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Maggie Rogers
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brittany Chambers
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rachel Pinotti
- Gustave L. and Janet W. Levy Library (R.P.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Allison Silvers
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Diane E Meier
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brynn Bowman
- Brookdale Department of Geriatrics and Palliative Medicine (R.H., M.R., B.C., A.S., D.E.M., B.B.), Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kimberly S Johnson
- Department of Medicine, Division of Geriatrics (K.S.J.), Duke University School of Medicine, Durham, NC, USA, Geriatrics Research Education and Clinical Center, Veteran Affairs Health System, Durham, North Carolina, USA
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Koffman J, Bajwah S, Davies JM, Hussain JA. Researching minoritised communities in palliative care: An agenda for change. Palliat Med 2022; 37:530-542. [PMID: 36271636 DOI: 10.1177/02692163221132091] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Palliative care access, experiences and outcomes of care disadvantage those from ethnically diverse, Indigenous, First nation and First people communities. Research into this field of inquiry raises unique theoretical, methodological, and moral issues. Without the critical reflection of methods of study and reporting of findings, researchers may inadvertently compromise their contribution to reducing injustices and perpetuating racism. AIM To examine key evidence of the place of minoritised communities in palliative care research to devise recommendations that improve the precision and rigour of research and reporting of findings. METHODS Narrative review of articles identified from PubMed, CINAHL and Google Scholar for 10 years augmented with supplementary searches. RESULTS We identified and appraised 109 relevant articles. Four main themes were identified (i) Lack of precision when working with a difference; (ii) 'black box epidemiology' and its presence in palliative care research; (iii) the inclusion of minoritised communities in palliative care research; and (iv) the potential to cause harm. All stymie opportunities to 'level up' health experiences and outcomes across the palliative care spectrum. CONCLUSIONS Based on the findings of this review palliative care research must reflect on and justify the classification of minoritised communities, explore and understand intersectionality, optimise data quality, decolonise research teams and methods, and focus on reducing inequities to level up end-of-life care experiences and outcomes. Palliative care research must be forthright in explicitly indentifying instances of structural and systemic racism in palliative care research and engaging in non-judgemental debate on changes required.
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Affiliation(s)
- Jonathan Koffman
- University of Hull, Hull York Medical School, Wolfson Palliative Care Research Centre, Hull, UK
| | - Sabrina Bajwah
- King's College London, Cicely Saunders Institute, London, UK
| | - Joanna M Davies
- King's College London, Cicely Saunders Institute, London, UK
| | - Jamilla Akhter Hussain
- Bradford Institute for Health Research, Bradford Teaching Hospital NHS Foundation Trust, Bradford, UK
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Diendorfer T, Roider-Schur S, Lütgendorf-Caucig C, Masel EK, Watzke H, Pötter R, Kirchheiner K. 'It needs experience and courage': Awareness towards end of life communication practices in oncologists: A mixed methods study. Eur J Cancer Care (Engl) 2022; 31:e13737. [PMID: 36254927 DOI: 10.1111/ecc.13737] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE End of life communication (EOLC) is generally regarded as a challenging aspect of the medical profession, with high influences of culture, the physician's experience and awareness. The aim of the current study was to assess the awareness of Austrian oncologists towards EOLC practices in their daily clinical routine and to identify limiting and supporting factors of these conversations. METHODS Overall, 45 oncologists participated in the assessment in this cross-sectional, mixed-method design using semi-structured interviews and questionnaire. RESULTS Themes that occurred during the interviews included the initiation of EOLC, EOLC in practice, strategies for EOLC, limiting and supporting factors and consequences of EOLC. There were several variations in the EOLC approach, that is, the use of time frames, timing, initiation and the amount of details given to the patient. CONCLUSION Oncologists agreed that EOLC is important in their daily clinical routine and for their patients. Nevertheless, there seems to be an underlying variation in approaches chosen by Austrian oncologists. This variation might be reduced by asking patients about their information preferences in advance and by routine implementation of communication guidelines, nomograms and prognostic calculators to reduce uncertainty.
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Affiliation(s)
- Tamara Diendorfer
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Sophie Roider-Schur
- Clinical Division of Oncology, Department of Internal Medicine I, Sankt Josef Hospital Vienna, Vienna, Austria
| | | | - Eva Katharina Masel
- Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Herbert Watzke
- Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
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Gazaway S, Chuang E, Thompson M, White-Hammond G, Elk R. Respecting Faith, Hope, and Miracles in African American Christian Patients at End-of-Life: Moving from Labeling Goals of Care as "Aggressive" to Providing Equitable Goal-Concordant Care. J Racial Ethn Health Disparities 2022:10.1007/s40615-022-01385-5. [PMID: 35947300 PMCID: PMC10026148 DOI: 10.1007/s40615-022-01385-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
In this article, we demonstrate first how the term "aggressive care," used loosely by clinicians to denote care that can negatively impact quality of life in serious illness, is often used to inappropriately label the preferences of African American patients, and discounts, discredits, and dismisses the deeply held beliefs of African American Christians. This form of biased communication results in a higher proportion of African Americans than whites receiving care that is non-goal-concordant and contributes to the prevailing lack of trust the African American community has in our healthcare system. Second, we invite clinicians and health care centers to make the perspectives of socially marginalized groups (in this case, African American Christians) the central axis around which we find solutions to this problem. Based on this, we provide insight and understanding to clinicians caring for seriously ill African American Christian patients by sharing their beliefs, origins, and substantive importance to the African American Christian community. Third, we provide recommendations to clinicians and healthcare systems that will result in African Americans, regardless of religious affiliation, receiving equitable levels of goal-concordant care if implemented. KEY MESSAGE: Labeling care at end-of-life as "aggressive" discounts the deeply held beliefs of African American Christians. By focusing on the perspectives of this group clinicians will understand the importance of respecting their religious values. The focus on providing equitable goal-concordant care is the goal.
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Affiliation(s)
- Shena Gazaway
- Department of Family, School of Nursing, University of Alabama Birmingham, Community, and Health Systems 1720 2nd Avenue South, AB, N485C,35294-1210, Birmingham, USA.
| | | | | | | | - Ronit Elk
- School of Medicine, UAB, Birmingham, AL, USA
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Tarbi EC, Blanch-Hartigan D, van Vliet LM, Gramling R, Tulsky JA, Sanders JJ. Toward a basic science of communication in serious illness. PATIENT EDUCATION AND COUNSELING 2022; 105:1963-1969. [PMID: 35410737 DOI: 10.1016/j.pec.2022.03.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/09/2022] [Accepted: 03/24/2022] [Indexed: 06/14/2023]
Abstract
High-quality communication can mitigate suffering during serious illness. Innovations in theory and technology present the opportunity to advance serious illness communication research, moving beyond inquiry that links broad communication constructs to health outcomes toward operationalizing and understanding the impact of discrete communication functions on human experience. Given the high stakes of communication during serious illness, we see a critical need to develop a basic science approach to serious illness communication research. Such an approach seeks to link "what actually happens during a conversation" - the lexical and non-lexical communication content elements, as well as contextual factors - with the emotional and cognitive experiences of patients, caregivers, and clinicians. This paper defines and justifies a basic science approach to serious illness communication research and outlines investigative and methodological opportunities in this area. A systematic understanding of the building blocks of serious illness communication can help identify evidence-informed communication strategies that promote positive patient outcomes, shape more targeted communication skills training for clinicians, and lead to more tailored and meaningful serious illness care.
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Affiliation(s)
- Elise C Tarbi
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, USA.
| | | | | | - Robert Gramling
- University of Vermont. Department of Family Medicine, Burlington, USA.
| | - James A Tulsky
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, USA; Brigham and Women's Hospital, Division of Palliative Medicine, Department of Medicine, Boston, USA.
| | - Justin J Sanders
- McGill University, Division of Palliative Care, Department of Family Medicine, Montreal, Canada.
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Chuang E, Yu S, Georgia A, Nymeyer J, Williams J. A Decade of Studying Drivers of Disparities in End-of-Life Care for Black Americans: Using the NIMHD Framework for Health Disparities Research to Map the Path Ahead. J Pain Symptom Manage 2022; 64:e43-e52. [PMID: 35381316 PMCID: PMC9189009 DOI: 10.1016/j.jpainsymman.2022.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/02/2022] [Accepted: 03/24/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this paper is to provide a review of the existing literature on racial disparities in quality of palliative and end-of-life care and to demonstrate gaps in the exploration of underlying mechanisms that produce these disparities. BACKGROUND Countless studies over several decades have revealed that our healthcare system in the United States consistently produces poorer quality end-of-life care for Black compared with White patients. Effective interventions to reduce these disparities are sparse and hindered by a limited understanding of the root causes of these disparities. METHODS We searched PubMed, CINAHL and PsychInfo for research manuscripts that tested hypotheses about causal mechanisms for disparities in end-of-life care for Black patients. These studies were categorized by domains outlined in the National Institute of Minority Health and Health Disparities (NIMHD) framework, which are biological, behavioral, physical/built environment, sociocultural and health care systems domains. Within these domains, studies were further categorized as focusing on the individual, interpersonal, community or societal level of influence. RESULTS The majority of the studies focused on the Healthcare System and Sociocultural domains. Within the Health Care System domain, studies were evenly distributed among the individual, interpersonal, and community level of influence, but less attention was paid to the societal level of influence. In the Sociocultural domain, most studies focused on the individual level of influence. Those focusing on the individual level of influence tended to be of poorer quality. CONCLUSIONS The sociocultural environment, physical/built environment, behavioral and biological domains remain understudied areas of potential causal mechanisms for racial disparities in end-of-life care. In the Healthcare System domain, social influences including healthcare policy and law are understudied. In the sociocultural domain, the majority of the studies still focused on the individual level of influence, missing key areas of research in interpersonal discrimination and local and societal structural discrimination. Studies that focus on individual factors should be better screened to ensure that they are of high quality and avoid stigmatizing Black communities.
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Affiliation(s)
- Elizabeth Chuang
- Department of Family and Social Medicine (E.C.), Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Sandra Yu
- Columbia Mailman School of Public Health (S.Y.), New York, NY, USA
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Chen AT, Tsui S, Sharma RK. Characterizing uncertainty in goals-of-care discussions among black and white patients: a qualitative study. Palliat Care 2022; 21:24. [PMID: 35177049 PMCID: PMC8851788 DOI: 10.1186/s12904-022-00912-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uncertainty has been associated with distress and poorer quality of life in patients with advanced cancer. Prior studies have focused on prognostic uncertainty; little is known about other types of uncertainty that patients and family members experience when discussing goals of care. Understanding the types of uncertainty expressed and differences between Black and White patients can inform the development of uncertainty management interventions. METHODS This study sought to characterize the types of uncertainty expressed by Black and White patients and family members within the context of information needs during inpatient goals-of-care discussions. We performed a secondary analysis of transcripts from 62 recorded goals-of-care discussions that occurred between 2012 and 2014 at an urban, academic medical center in the United States. We applied an adapted taxonomy of uncertainty to data coded as describing information needs and used an inductive qualitative analysis method to analyze the discussions. We report the types of uncertainty expressed in these discussions. RESULTS Fifty discussions included patient or family expressions of information needs. Of these, 40 discussions (n=16 Black and n=24 White) included statements of uncertainty. Black and White patients and families most frequently expressed uncertainty related to processes and structures of care (system-centered uncertainty) and to treatment (scientific uncertainty). Statements of prognostic uncertainty focused on quantitative information among Whites and on qualitative information and expectations for the future among Blacks. CONCLUSIONS Black and White patients and families frequently expressed system-centered uncertainty, suggesting this may be an important target for intervention. Addressing other sources of uncertainty, such as prognostic uncertainty, may need more tailored approaches.
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Affiliation(s)
- Annie T Chen
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, 850 Republican St, Box 358047, 98109, Seattle, WA, United States.
| | - Shelley Tsui
- University of Washington, WA, Seattle, United States
| | - Rashmi K Sharma
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, United States
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13
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Penny CL, Tanino SM, Mosca PJ. Racial Disparities in Surgery for Malignant Bowel Obstruction. Ann Surg Oncol 2022; 29:3122-3133. [PMID: 35041096 DOI: 10.1245/s10434-021-11161-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Operative management of patients with malignant bowel obstruction (MBO) may provide effective palliation, but is associated with substantial risks. This study aimed to analyze racial and ethnic differences in surgical outcomes for patients with MBO. METHODS This retrospective study, using National Surgical Quality Improvement Program (NSQIP) registry data from 2010 to 2019, compared differences in outcomes by race and ethnicity for 2762 patients undergoing surgery for MBO. Multivariable logistic regression controlled for relevant covariates. RESULTS Black patients (n = 407) had higher rates of preoperative comorbidity and were more likely than White patients (n = 2081) to have major complications (28.5% vs 21.8%; p = 0.0031), overall complications (47.4% vs 40.4%; p = 0.0087), a longer median hospital stay (12 days; interquartile range [IQR, 8-19 days] vs 10 days [IQR, 7-17 days]; p = 0.0007), and unplanned readmission (17.1% vs 12.9%; p = 0.0266). Black patients had a similar mortality rate to that of White patients and were less frequently discharged to home (67.6% vs 73.0%; p = 0.0315). Differences in morbidity between Black patients and White patients persisted after controlling for potentially confounding variables. Hispanic patients had lower mortality than White patients (6.3% vs 13.1%; p = 0.0130) and a longer hospital stay (12 days [IQR, 8-18 days] vs 10 days [IQR, 7-17 days]; p = 0.0313). Outcomes did not differ between Asian patients and White patients. CONCLUSIONS This study demonstrated significant disparities for Black patients undergoing surgery for MBO. Understanding and addressing what drives these differences, including systemic inequalities such as access to care and racial biases, is essential to the achievement of more equitable, higher-quality patient care.
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Affiliation(s)
- Caitlin L Penny
- Duke University School of Medicine, Duke Health, Durham, NC, USA
| | - Sean M Tanino
- Duke University School of Medicine, Duke Health, Durham, NC, USA
| | - Paul J Mosca
- Duke University School of Medicine, Duke Health, Durham, NC, USA. .,Department of Surgery, Duke Health, Durham, NC, USA. .,Duke Network Services, Duke Health, Durham, NC, USA.
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14
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Sutar R, Chaudhary P. Prognostic disclosure in cancer care: a systematic literature review. Palliat Care Soc Pract 2022; 16:26323524221101077. [PMID: 35693193 PMCID: PMC9178750 DOI: 10.1177/26323524221101077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Collusion in cancer care is the diplomatic concealment of information between a triad of the health care professional (HCP), patient, and caregiver. Free and expressive communication is determined by multiple factors, which establishes a healthy balance between ‘patient-centric’ and ‘family-centric’ decision making. The lack of a universal approach to prognostic disclosure techniques emphasizes the need for a systematic review of contemporary practice. Methods: A systematic review of the literature was conducted till June 2020 using themes based on cancer, communication, prognostic disclosure, and collusion by using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: Fifty-three studies involving 10,569 subjects were studied for their utility on prognostic disclosure using different communication methods and interfaces. Twenty-three studies used a face-to-face interview with subjects while in-person telephonic interviews were conducted in two studies, 16 studies implicated semi-structured questionnaires, and 6 studies mentioned the development of a new technique/tool for disclosure. The duration of a session for prognosis-disclosure ranged from 22 min to 1 h. The involvement of palliative care specialists and mental health professionals was limited during the disclosure of the prognosis. Conclusion: The findings of the review indicate that patients in cancer care are aware of their diagnosis and to a certain extent of prognosis despite nondisclosure by their family members and treating teams. This review emphasizes the assessment of ‘disclosure wishes’ among patients and caregivers in separate interviews rather than simply relying on one specific method of interviewing. The nonconfrontational approach and training among HCPs are of utmost importance to build therapeutic resilience among the treating team involved in cancer care. Since many factors such as family wishes, cultural dissonance, medical model, and patient perception could become barriers to prognostic disclosure, there is a need to develop a universal approach to prognostic disclosure and handling associated collusion.
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Affiliation(s)
- Roshan Sutar
- Assistant Professor, Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bhopal, Saket Nagar, Bhopal 462020, India
| | - Pooja Chaudhary
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bhopal, Bhopal, India
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15
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Ivey GD, Johnston FM. Barriers to Equitable Palliative Care Utilization Among Patients with Cancer. Surg Oncol Clin N Am 2021; 31:9-20. [PMID: 34776067 DOI: 10.1016/j.soc.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Over the past half century, palliative care has grown to become a pillar of clinical oncology. Its practice revolves around relieving suffering and optimizing quality of life, not just dealing with end-of-life decisions. Despite evidence that palliative care has the potential to reduce health care utilization and improve advance care planning without affecting mortality, palliative care remains inequitably accessible and underutilized. Furthermore, it is still too often introduced late in the care of patients receiving surgical intervention. This article summarizes the numerous and complex barriers to equitable palliative care utilization among patients with cancer. Potential strategies for dismantling these barriers are also discussed.
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Affiliation(s)
- Gabriel D Ivey
- Department of Surgery, Division of Surgical Oncology, The Johns Hopkins University, 600 North Wolfe Street, Blalock 611, Baltimore, MD 21287, USA
| | - Fabian M Johnston
- Department of Surgery, Division of Surgical Oncology, The Johns Hopkins University, 600 North Wolfe Street, Blalock 606, Baltimore, MD 21287, USA.
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16
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Bergstraesser E, Thienprayoon R, Brook LA, Fraser LK, Hynson JL, Rosenberg AR, Snaman JM, Weaver MS, Widger K, Zernikow B, Jones CA, Schlögl M. Top Ten Tips Palliative Care Clinicians Should Know About Prognostication in Children. J Palliat Med 2021; 24:1725-1731. [PMID: 34726519 DOI: 10.1089/jpm.2021.0439] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pediatric palliative care (PPC) is different from palliative care (PC) for adults. However, conceptualizing PPC remains cumbersome due to the high heterogeneity of often rare diseases, the high diversity of disease trajectories, and the particular difficulty to predict the future of an individual, severely ill child. This article aims to provide an overview and critical reflection of different aspects of prognostication in children with PC needs. This includes different diseases from neurology to oncology, from the unborn baby to the young adult, new approaches in treatment, advance care planning, and, most important, communication with the affected child as well as parents.
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Affiliation(s)
- Eva Bergstraesser
- Department of Pediatric Palliative Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Rachel Thienprayoon
- Division of Palliative Care, Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lynda A Brook
- Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Lorna K Fraser
- Martin House Research Centre, University of York, Heslington, United Kingdom
| | - Jenny L Hynson
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Abby R Rosenberg
- Palliative Care and Resilience Lab, Seattle Children's Research Institute, Seattle, Washington, USA.,Department of Pediatrics, Division of Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence at the University of Washington, Seattle, Washington, USA
| | - Jennifer M Snaman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Meaghann S Weaver
- Division of Pediatric Palliative Care, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, Nebraska, USA.,National Center for Ethics in Healthcare, Washington, DC, USA
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, Univeristy of Toronto, Toronto, Ontario, Canada.,Pediatric Advanced Care Team, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Boris Zernikow
- Pediatric Palliative Care Centre, Children's and Adolescents' Hospital Datteln, Germany.,Department of Children's Pain Therapy and Pediatric Palliative Care, Datteln, Germany.,Faculty of Health-School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,Universtiy Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
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17
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Is physician implicit bias associated with differences in care by patient race for metastatic cancer-related pain? PLoS One 2021; 16:e0257794. [PMID: 34705826 PMCID: PMC8550362 DOI: 10.1371/journal.pone.0257794] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 08/28/2021] [Indexed: 11/19/2022] Open
Abstract
Rationale Implicit racial bias affects many human interactions including patient-physician encounters. Its impact, however, varies between studies. We assessed the effects of physician implicit, racial bias on their management of cancer-related pain using a randomized field experiment. Methods We conducted an analysis of a randomized field experiment between 2012 and 2016 with 96 primary care physicians and oncologists using unannounced, Black and White standardized patients (SPs)who reported uncontrolled bone pain from metastatic lung cancer. We assessed implicit bias using a pain-adaptation of the race Implicit Association Test. We assessed clinical care by reviewing medical records and prescriptions, and we assessed communication from coded transcripts and covert audiotapes of the unannounced standardized patient office visits. We assessed effects of interactions of physicians’ implicit bias and SP race with clinical care and communication outcomes. We conducted a slopes analysis to examine the nature of significant interactions. Results As hypothesized, physicians with greater implicit bias provided lower quality care to Black SPs, including fewer renewals for an indicated opioid prescription and less patient-centered pain communication, but similar routine pain assessment. In contrast to our other hypotheses, physician implicit bias did not interact with SP race for prognostic communication or verbal dominance. Analysis of the slopes for the cross-over interactions showed that greater physician bias was manifested by more frequent opioid prescribing and greater discussion of pain for White SPs and slightly less frequent prescribing and pain talk for Black SPs with the opposite effect among physicians with lower implicit bias. Findings are limited by use of an unvalidated, pain-adapted IAT. Conclusion Using SP methodology, physicians’ implicit bias was associated with clinically meaningful, racial differences in management of uncontrolled pain related to metastatic lung cancer. There is favorable treatment of White or Black SPs, depending on the level of implicit bias.
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18
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Abstract
OBJECTIVES Racial disparities in the United States healthcare system are well described across a variety of clinical settings. The ICU is a clinical environment with a higher acuity and mortality rate, potentially compounding the impact of disparities on patients. We sought to systematically analyze the literature to assess the prevalence of racial disparities in the ICU. DATA SOURCES We conducted a comprehensive search of PubMed/MEDLINE, Scopus, CINAHL, and the Cochrane Library. STUDY SELECTION We identified articles that evaluated racial differences on outcomes among ICU patients in the United States. Two authors independently screened and selected articles for inclusion. DATA EXTRACTION We dual-extracted study characteristics and outcomes that assessed for disparities in care (e.g., in-hospital mortality, ICU length of stay). Studies were assessed for bias using the Newcastle-Ottawa Scale. DATA SYNTHESIS Of 1,325 articles screened, 25 articles were included (n = 751,796 patients). Studies demonstrated race-based differences in outcomes, including higher mortality rates for Black patients when compared with White patients. However, when controlling for confounding variables, such as severity of illness and hospital type, mortality differences based on race were no longer observed. Additionally, results revealed that Black patients experienced greater financial impacts during an ICU admission, were less likely to receive early tracheostomy, and were less likely to receive timely antibiotics than White patients. Many studies also observed differences in patients' end-of-life care, including lower rates on the quality of dying, less advanced care planning, and higher intensity of interventions at the end of life for Black patients. CONCLUSIONS This systematic review found significant differences in the care and outcomes among ICU patients of different races. Mortality differences were largely explained by accompanying demographic and patient factors, highlighting the effect of structural inequalities on racial differences in mortality in the ICU. This systematic review provides evidence that structural inequalities in care persist in the ICU, which contribute to racial disparities in care. Future research should evaluate interventions to address inequality in the ICU.
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19
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Boyce-Fappiano D, Liao K, Miller C, Peterson SK, Elting L, Guadagnolo BA. Preferences for More Aggressive End-of-life Pharmacologic Care Among Racial Minorities in a Large Population-Based Cohort of Cancer Patients. J Pain Symptom Manage 2021; 62:482-491. [PMID: 33556498 PMCID: PMC8339155 DOI: 10.1016/j.jpainsymman.2021.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 11/21/2022]
Abstract
CONTEXT Minority patients receive more aggressive and potentially suboptimal care at the end of life (EOL). We investigated preferences about pharmacologic interventions at the EOL and their potential variation by sociodemographic factors among recently diagnosed cancer patients. METHODS A population-based cross-sectional survey of cancer patients identified through the Texas Cancer registry was conducted using a multi-scale inventory between March 2018 and June 2020. Item responses to questions about potential pharmacologic interventions at the EOL were the focus of this investigation. Inverse probability weighted multivariate analysis examined associations of sociodemographic characteristics, health literacy, and trust in medical professionals with pharmacologic preferences. RESULTS Of the 1480 included responses, 13.3% stated they would take a medication that may prolong life at the cost of feeling worse. Adjusted analyses showed Black or Hispanic race/ethnicity, living with another person, and having a higher trust score were more likely to express this preference. In contrast, 41-65 years (vs. 21-40 years), living in a rural area, and adequate or unknown health literacy were less likely to express this preference. Overall 16% of respondents were opposed to potentially life shortening palliative drugs. In adjusted analysis Black or Hispanic respondents were more likely to be opposed to potentially life shortening drugs although age 65-79 and ≥college education were associated with a decreased likelihood of opposition to this item. CONCLUSION Black and Hispanic cancer patients were more likely to express preferences toward more aggressive EOL pharmacologic care. These findings were independent of other sociodemographic characteristics, health literacy and trust in the medical profession.
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Affiliation(s)
| | - Kaiping Liao
- Department of Health Services Research, MD Anderson Cancer Center, Houston, Texas
| | - Christopher Miller
- Department of Behavioral Science, MD Anderson Cancer Center, Houston, Texas
| | - Susan K Peterson
- Department of Behavioral Science, MD Anderson Cancer Center, Houston, Texas
| | - Linda Elting
- Department of Health Services Research, MD Anderson Cancer Center, Houston, Texas
| | - B Ashleigh Guadagnolo
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, MD Anderson Cancer Center, Houston, Texas.
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20
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Abstract
PURPOSE OF REVIEW Our goal was to provide healthcare professionals (HCPs) with evidence-based data about what can be done to handle prognostic discussions with empathy. RECENT FINDINGS First, disclosing prognosis involves a good reason to do so and making sure that the patient will be able to process the discussion. Second, communication tips are given for the three dimensions of empathy: "establishing rapport with the patient," which should not be overlooked; the emotional dimension, which involves an accurate understanding of the patient and communication skills; and the "active/positive" dimension which is about giving hope, explaining things clearly and helping patients take control with shared decision-making and a planned future. Although communication tips are helpful, empathy training should be based more on the development of HCPs' emotional skills, in order to help them regulate their emotions and thus be more comfortable with those of patients and families. Furthermore, research into empathy toward minorities and relatives is needed.
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Affiliation(s)
- Sophie Lelorain
- Univ. Lille, CNRS, UMR 9193 - SCALab - Sciences Cognitives et Sciences Affectives, F-59000, Lille, France.
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21
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Tarbi EC, Gramling R, Bradway C, Broden EG, Meghani SH. "I Had a Lot More Planned": The Existential Dimensions of Prognosis Communication with Adults with Advanced Cancer. J Palliat Med 2021; 24:1443-1454. [PMID: 33534644 DOI: 10.1089/jpm.2020.0696] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Communication about prognosis is a key ingredient of effective palliative care. When patients with advanced cancer develop increased prognostic understanding, there is potential for existential distress to occur. However, the existential dimensions of prognosis communication are underexplored. Objective: To describe the existential dimensions of prognosis communication in naturally-occurring palliative care conversations. Methods: This study was an explanatory sequential mixed methods design. We analyzed a random subset of patients from the Palliative Care Communication Research Initiative (PCCRI) parent study (n = 34, contributing to 45 palliative care conversations). Data were based on audio-recorded and transcribed inpatient palliative care conversations between adults with advanced cancer, their families, and palliative care clinicians. We stratified the study sample by levels of prognosis communication, and qualitatively examined patterns of existential communication, comparing the intensity, frequency, and content, within and across levels. Results: Existential communication was more common, and of stronger intensity, within conversations with higher levels of prognosis communication. Conversations with more prognosis communication appeared to exhibit a shift toward the existential and away from the more physical nature of the serious illness experience. Conclusion: Existential and prognosis communication are intimately linked within palliative care conversations. Results highlight the multiplicity and mutuality of concerns that arise when contemplating mortality, drawing attention to areas of palliative care communication that warrant future research.
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Affiliation(s)
- Elise C Tarbi
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Robert Gramling
- Department of Family Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Christine Bradway
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Elizabeth G Broden
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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22
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Gramling R, Straton J, Ingersoll LT, Clarfeld LA, Hirsch L, Gramling CJ, Durieux BN, Rizzo DM, Eppstein MJ, Alexander SC. Epidemiology of Fear, Sadness, and Anger Expression in Palliative Care Conversations. J Pain Symptom Manage 2021; 61:246-253.e1. [PMID: 32822753 DOI: 10.1016/j.jpainsymman.2020.08.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Advancing the science of serious illness communication requires methods for measuring characteristics of conversations in large studies. Understanding which characteristics predict clinically important outcomes can help prioritize attention to scalable measure development. OBJECTIVES To understand whether audibly recognizable expressions of distressing emotion during palliative care serious illness conversations are associated with ratings of patient experience or six-month enrollment in hospice. METHODS We audiorecorded initial palliative care consultations involving 231 hospitalized people with advanced cancer at two large academic medical centers. We coded conversations for expressions of fear, anger, and sadness. We examined the distribution of these expressions and their association with pre/post ratings of feeling heard and understood and six-month hospice enrollment after the consultation. RESULTS Nearly six in 10 conversations included at least one audible expression of distressing emotion (59%; 137 of 231). Among conversations with such an expression, fear was the most prevalent (72%; 98 of 137) followed by sadness (50%; 69 of 137) and anger (45%; 62 of 137). Anger expression was associated with more disease-focused end-of-life treatment preferences, pre/post consultation improvement in feeling heard and understood and lower six-month hospice enrollment. Fear was strongly associated with preconsultation patient ratings of shorter survival expectations. Sadness did not exhibit strong association with patient descriptors or outcomes. CONCLUSION Fear, anger, and sadness are commonly expressed in hospital-based palliative care consultations with people who have advanced cancer. Anger is an epidemiologically useful predictor of important clinical outcomes.
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Affiliation(s)
- Robert Gramling
- Department of Family Medicine, University of Vermont, Burlington, VT, USA.
| | | | - Lukas T Ingersoll
- Department of Public Health, Purdue University, West Lafayette, IN, USA
| | | | | | | | | | - Donna M Rizzo
- Department of Civil & Environmental Engineering, University of Vermont, Burlington, VT, USA
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23
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Ciria-Suarez L, Jimenez-Fonseca P, Hernández R, Rogado J, Calderon C. Estimation of Risk of Recurrence and Toxicity Among Oncologists and Patients With Resected Breast Cancer: A Quantitative Study. Front Psychol 2020; 11:540083. [PMID: 33192784 PMCID: PMC7653019 DOI: 10.3389/fpsyg.2020.540083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022] Open
Abstract
Shared decision-making regarding adjuvant systemic therapy in breast cancer is based on both properly conveying information about the prognosis of the disease and the benefits and risks of adjuvant treatment, as well as the patient's ability to understand this information. This work proposed to analyze oncologists' and patients' perceptions of the risk of recurrence with and without chemotherapy and toxicity, and the factors influencing said impressions. This was a prospective, cross-sectional, multicenter study that involved 281 breast cancer patients and 23 oncologists. Prognosis (risk of recurrence with and without chemotherapy and risk of severe toxicity with chemotherapy) and shared decision making (SDM) questionnaires were completed by all participants; breast cancer patients also filled out the 18-item Brief Symptom Inventory (BSI-18). Oncologists' prediction of risk of relapse without and with chemotherapy (30.4 and 13.3%) and risk of severe toxicity (9.8%) were more optimistic than those of breast cancer patients (78.6, 29.6, and 61%, respectively). The greater the severity, the higher the risk of relapse according to the oncologists (p = 0.001); not so for the patients. Older physicians and more experienced ones predicted lower risk of relapse with and without chemotherapy and less severe toxicity than younger doctors and those with less experience (p < 0.001). Oncologists' SDM and their prediction of risk of relapsing with chemotherapy correlated negatively with patients' SDM and their prediction of risk of severe toxicity (p < 0.01). There is a positive correlation between psychological distress (BSI-18) and prognosis of risk of recurrence with chemotherapy in breast cancer patients (p < 0.001). These results stress the importance of improving doctor-patient communication in SDM. In breast cancer patients undergoing treatment with curative intent, expectations of being cured would increase and treatment-related anxiety would decrease by enhancing doctor-patient communication to coincide more with respect to risk of relapse and toxicity, thereby enhancing patients' quality of life.
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Affiliation(s)
- Laura Ciria-Suarez
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Barcelona, Spain
| | - Paula Jimenez-Fonseca
- Department of Medical Oncology, Central University Hospital of Asturias, Oviedo, Spain
| | - Raquel Hernández
- Department of Medical Oncology, Canary University Hospital, Santa Cruz de Tenerife, Spain
| | - Jacobo Rogado
- Department of Medical Oncology, Infanta Leonor University Hospital, Madrid, Spain
| | - Caterina Calderon
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Barcelona, Spain
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24
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Mack JW, Uno H, Twist CJ, Bagatell R, Rosenberg AR, Marachelian A, Granger MM, Glade Bender J, Baker JN, Park JR, Cohn SL, Fernandez JH, Diller LR, Shusterman S. Racial and Ethnic Differences in Communication and Care for Children With Advanced Cancer. J Pain Symptom Manage 2020; 60:782-789. [PMID: 32360991 PMCID: PMC7523916 DOI: 10.1016/j.jpainsymman.2020.04.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/17/2020] [Accepted: 04/21/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Racial and ethnic disparities in end-of-life care are well documented among adults with advanced cancer. OBJECTIVES To examine the extent to which communication and care differ by race and ethnicity among children with advanced cancer. METHODS We conducted a prospective cohort study at nine pediatric cancer centers enrolling 95 parents (42% racial/ethnic minorities) of children with poor prognosis cancer (relapsed/refractory high-risk neuroblastoma). Parents were surveyed about whether prognosis was discussed; likelihood of cure; intent of current treatment; and primary goal of care. Medical records were used to identify high-intensity medical care since the most recent recurrence. Logistic regression evaluated differences between white non-Hispanic and minority (black, Hispanic, and Asian/other race) parents. RESULTS About 26% of parents recognized the child's low likelihood of cure. Minority parents were less likely to recognize the poor prognosis (odds ratio [OR] = 0.19; 95% CI = 0.06-0.63; P = 0.006) and the fact that current treatment was unlikely to offer cure (OR = 0.07; 95% CI = 0.02-0.27; P < 0.0001). Children of minority parents were more likely to experience high-intensity medical care (OR = 3.01; 95% CI = 1.29-7.02; P = 0.01). After adjustment for understanding of prognosis, race/ethnicity was no longer associated with high-intensity medical care (adjusted odds ratio = 2.14; 95% CI = 0.84-5.46; P = 0.11), although power to detect an association was limited. CONCLUSION Parental understanding of prognosis is limited across racial and ethnic groups; racial and ethnic minorities are disproportionately affected. Perhaps as a result, minority children experience higher rates of high-intensity medical care. Work to improve prognostic understanding should include focused work to meet needs of minority populations.
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Affiliation(s)
- Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Hajime Uno
- Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Clare J Twist
- Roswell Park Cancer Institute Buffalo, New York, New York, USA
| | - Rochelle Bagatell
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abby R Rosenberg
- Department of Pediatric Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA; Pediatric Bioethics/Palliative Care, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
| | - Araz Marachelian
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - M Meaghan Granger
- Hematology and Oncology Center, Cook Children's Hospital, Fort Worth, Texas, USA
| | - Julia Glade Bender
- Department of Pediatric Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Julie R Park
- Department of Pediatric Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
| | - Susan L Cohn
- Department of Pediatrics, Comer Children's Hospital, University of Chicago, Chicago, Illinois, USA
| | - Jorge H Fernandez
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lisa R Diller
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Suzanne Shusterman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
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Boucher NA, Johnson KS. Cultivating Cultural Competence: How Are Hospice Staff Being Educated to Engage Racially and Ethnically Diverse Patients? Am J Hosp Palliat Care 2020; 38:169-174. [PMID: 32734763 DOI: 10.1177/1049909120946729] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Compared to Whites, racial/ethnic minorities are less likely to enroll in hospice and if they enroll, more likely to experience poor quality care. Building cultural competence (CC) among hospice staff is a strategy that may reduce disparities. OBJECTIVE To describe the state of CC training across hospices. DESIGN National survey of hospices' practices to promote CC. RESULTS A total of 197 hospices participated; most were not-for-profit (80%) with an average daily census less than 100 (47%); 73% offered staff cultural competence training (CCT). There were no differences in characteristics of hospices who offered CCT and those that did not. Of hospices offering CCT, 61% held it annually. Most trainings were 1 hour (60%); content was delivered via web (58%) and/or lecture (58%). While over 90% of staff (i.e., nurses, social workers, chaplains) completed CCT, a smaller proportion of medical directors (64%), senior leaders (71%) and board members (26%) did so. Most common topics were: cross-cultural communication, death/illness beliefs, spirituality's role, and healthcare disparities. The majority focused on African-Americans (83%), Hispanics (76%), and Asians (62%)-the most common U.S. minority groups. Almost 30% reported no effectiveness assessment of CCT, while 51% reported a quiz at the end of training. Most hospices offered some CCT. CONCLUSIONS CCT has been shown to improve healthcare providers' knowledge and skills in caring for diverse patients and it is associated with increased patient satisfaction. Future research should evaluate effectiveness of CCT in improving the ability of hospices to deliver high quality end-of-life care to diverse groups of older adults.
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Affiliation(s)
- Nathan A Boucher
- Duke University, Sanford School of Public Policy, Center for the Study of Aging and Human Development, Center for Palliative Care, Duke University School of Medicine, Duke-Margolis Center for Health Policy, Health Services Research & Development, 51780Durham VA Health System, Durham, NC, USA
| | - Kimberly S Johnson
- Department of Medicine, Division of Geriatrics, 169170Center for the Study of Aging and Human Development, Center for Palliative Care, Duke University School of Medicine, Geriatrics Rehabilitation and Clinical Center, Durham VA Health System, Durham, NC, USA
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Racial and socioeconomic disparities differentially affect overall and cause-specific survival in glioblastoma. J Neurooncol 2020; 149:55-64. [PMID: 32617722 DOI: 10.1007/s11060-020-03572-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/24/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The prognostic role of racial and socioeconomic factors in patients with glioblastoma is controversially debated. We aimed to evaluate how these factors may affect survival outcomes in an overall and cause-specific manner using large, national cancer registry cohort data in the temozolomide chemoradiation era. METHODS The National Cancer Institute's Surveillance, Epidemiology, and End Results database was queried for patients diagnosed with glioblastoma between 2005 and 2016. Overall survival was assessed using Cox proportional hazard models using disease intrinsic and extrinsic factors. Cause-specific mortality was assessed using cumulative incidence curves and modeled using multivariate cumulative risk regression. RESULTS A total of 28,952 patients met the prespecified inclusion criteria and were included in this analysis. The following factors were associated with all-cause mortality: age, calendar year of diagnosis, sex, treatment receipt, tumor size, tumor location, extent of resection, median household income, and race. Asian/Pacific Islanders and Hispanic Whites had lower mortality compared to Non-Hispanic Whites. Cause-specific mortality was associated with both racial and socioeconomic groups. After adjusting for treatment and tumor-related factors, Asian/Pacific and black patients had lower glioblastoma-specific mortality. However, lower median household income and black race were associated with significantly higher non-glioblastoma mortality. CONCLUSIONS Despite the aggressive nature of glioblastoma, racial and socioeconomic factors influence glioblastoma-specific and non-glioblastoma associated mortality. Our study shows that patient race has an impact on glioblastoma-associated mortality independently of tumor and treatment related factors. Importantly, socioeconomic and racial differences largely contribute to non-glioblastoma mortality, including death from other cancers, cardio- and cerebrovascular events.
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Starr LT, Ulrich CM, Junker P, Huang L, O’Connor NR, Meghani SH. Patient Risk Factor Profiles Associated With the Timing of Goals-of-Care Consultation Before Death: A Classification and Regression Tree Analysis. Am J Hosp Palliat Care 2020; 37:767-778. [DOI: 10.1177/1049909120934292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Early palliative care consultation (“PCC”) to discuss goals-of-care benefits seriously ill patients. Risk factor profiles associated with the timing of conversations in hospitals, where late conversations most likely occur, are needed. Objective: To identify risk factor patient profiles associated with PCC timing before death. Methods: Secondary analysis of an observational study was conducted at an urban, academic medical center. Patients aged 18 years and older admitted to the medical center, who had PCC, and died July 1, 2014 to October 31, 2016, were included. Patients admitted for childbirth or rehabilitationand patients whose date of death was unknown were excluded. Classification and Regression Tree modeling was employed using demographic and clinical variables. Results: Of 1141 patients, 54% had PCC “close to death” (0-14 days before death); 26% had PCC 15 to 60 days before death; 21% had PCC >60 days before death (median 13 days before death). Variables associated with receiving PCC close to death included being Hispanic or “Other” race/ethnicity intensive care patients with extreme illness severity (85%), with age <46 or >75 increasing this probability (98%). Intensive care patients with extreme illness severity were also likely to receive PCC close to death (64%) as were 50% of intensive care patients with less than extreme illness severity. Conclusions: A majority of patients received PCC close to death. A complex set of variable interactions were associated with PCC timing. A systematic process for engaging patients with PCC earlier in the care continuum, and in intensive care regardless of illness severity, is needed.
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Affiliation(s)
- Lauren T. Starr
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Center for Bioethics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Connie M. Ulrich
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Junker
- Program for Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Liming Huang
- BECCA Lab, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Nina R. O’Connor
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Salimah H. Meghani
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Chuang E, Fiter RJ, Sanon OC, Wang A, Hope AA, Schechter CB, Gong MN. Race and Ethnicity and Satisfaction With Communication in the Intensive Care Unit. Am J Hosp Palliat Care 2020; 37:823-829. [PMID: 32237996 DOI: 10.1177/1049909120916126] [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: 11/16/2022] Open
Abstract
PURPOSE Racial and ethnic minority patients receive poorer quality end-of-life (EoL) care compared with white patients. Differences in quality of communication (QOC) with clinicians may contribute to these disparities. We measured differences in satisfaction with communication in the intensive care unit (ICU) by race and ethnicity. MATERIALS AND METHODS This is a cross-sectional survey of family members of patients in ICUs of an academic medical center serving a diverse urban population using The Family Satisfaction with the ICU (FS-ICU) and QOC scales. RESULTS One hundred surveys were completed (18.8% white, non-Hispanic; 34.4% black, non-Hispanic; 31.3% Hispanic; 15.6% other race/ethnicity). Mean FS-ICU score was 84.2 (standard deviation [SD] 20.5) for white patients, 83.3 (SD 16.2) for black patients, 82.7 (SD 17.8) for Hispanic or Latino patients, and 80.9 (SD 18.8) for patients with other race/ethnicity (Kruskal-Wallis, P = .92). Differences remained insignificant when controlling for patient and respondent characteristics. The QOC scale was not scored due to nonresponse levels on questions about EoL communication. CONCLUSIONS Uniformly high ratings may have been influenced by avoidance of EoL discussion. This study is inconclusive regarding whether QOC influences disparities in EoL care since quality of EoL communication was not captured.
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Affiliation(s)
- Elizabeth Chuang
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ryan J Fiter
- Department of Medicine, Icahn School of Medicine at Mount Sinai Hospital, NY, USA
| | - Omar C Sanon
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ann Wang
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aluko A Hope
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, NY, USA
| | - Clyde B Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michelle N Gong
- Division of Critical Care, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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Janssen DJA, Rechberger S, Wouters EFM, Schols JMGA, Johnson MJ, Currow DC, Curtis JR, Spruit MA. Clustering of 27,525,663 Death Records from the United States Based on Health Conditions Associated with Death: An Example of big Health Data Exploration. J Clin Med 2019; 8:jcm8070922. [PMID: 31252579 PMCID: PMC6678953 DOI: 10.3390/jcm8070922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Insight into health conditions associated with death can inform healthcare policy. We aimed to cluster 27,525,663 deceased people based on the health conditions associated with death to study the associations between the health condition clusters, demographics, the recorded underlying cause and place of death. Methods: Data from all deaths in the United States registered between 2006 and 2016 from the National Vital Statistics System of the National Center for Health Statistics were analyzed. A self-organizing map (SOM) was used to create an ordered representation of the mortality data. Results: 16 clusters based on the health conditions associated with death were found showing significant differences in socio-demographics, place, and cause of death. Most people died at old age (73.1 (18.0) years) and had multiple health conditions. Chronic ischemic heart disease was the main cause of death. Most people died in the hospital or at home. Conclusions: The prevalence of multiple health conditions at death requires a shift from disease-oriented towards person-centred palliative care at the end of life, including timely advance care planning. Understanding differences in population-based patterns and clusters of end-of-life experiences is an important step toward developing a strategy for implementing population-based palliative care.
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Affiliation(s)
- Daisy J A Janssen
- Department of Research & Education, CIRO, Centre of expertise for chronic organ failure, 6085NM Horn, The Netherlands.
- Centre of Expertise for Palliative Care, Maastricht University Medical Centre (MUMC+), 6229HX Maastricht, The Netherlands.
- Department of Health Services Research, Maastricht University, 6229GT Maastricht, The Netherlands.
| | | | - Emiel F M Wouters
- Department of Research & Education, CIRO, Centre of expertise for chronic organ failure, 6085NM Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), 6229HX Maastricht, The Netherlands
| | - Jos M G A Schols
- Department of Health Services Research, Maastricht University, 6229GT Maastricht, The Netherlands
- Department of Family Medicine, Maastricht University, 6229HA Maastricht, The Netherlands
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull and York Medical School, University of Hull, Hull HU6 7RX, UK
| | - David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW2007 New South Wales, Australia
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA
| | - Martijn A Spruit
- Department of Research & Education, CIRO, Centre of expertise for chronic organ failure, 6085NM Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), 6229HX Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, 6229ER Maastricht, The Netherlands
- REVAL-Rehabilitation Research Center, BIOMED-Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, BE3590 Diepenbeek, Belgium
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Kaye EC, Gushue CA, DeMarsh S, Jerkins J, Li C, Lu Z, Snaman JM, Blazin L, Johnson LM, Levine DR, Morrison RR, Baker JN. Impact of Race and Ethnicity on End-of-Life Experiences for Children With Cancer. Am J Hosp Palliat Care 2019; 36:767-774. [DOI: 10.1177/1049909119836939] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: Racial and ethnic disparities in the provision of end-of-life care are well described in the adult oncology literature. However, the impact of racial and ethnic disparities at end of life in the context of pediatric oncology remains poorly understood. Objective: To investigate associations between end-of-life experiences and race/ethnicity for pediatric patients with cancer. Methods: A retrospective cohort study was conducted on 321 children with cancer enrolled on a palliative care service at an urban pediatric cancer who died between 2011 and 2015. Results: Compared to white patients, black patients were more likely to receive cardiopulmonary resuscitation (CPR; odds ratio [OR]: 4.109, confidence interval [CI]: 1.432-11.790, P = .009) and underwent 3.136 (CI: 1.433-6.869, P = .004) CPR events for every 1 white patient CPR event. The remainder of variables related to treatment and end-of-life care were not significantly correlated with race. Hispanic patients were less likely to receive cancer-directed therapy within 28 days prior to death (OR: 0.493, CI: 0.247-0.982, P = .044) as compared to non-Hispanic patients, yet they were more likely to report a goal of cure over comfort as compared to non-Hispanic patients (OR: 3.094, CI: 1.043-9.174, P = .042). The remainder of variables were not found to be significantly correlated with ethnicity. Conclusions: Race and ethnicity influenced select end-of-life variables for pediatric palliative oncology patients treated at a large urban pediatric cancer center. Further multicenter investigation is needed to ascertain the impact of racial/ethnic disparities on end-of-life experiences of children with cancer.
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Affiliation(s)
- Erica C. Kaye
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Courtney A. Gushue
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Samantha DeMarsh
- Ohio University Heritage College of Osteopathic Medicine, Cleveland, OH, USA
| | | | - Chen Li
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Zhaohua Lu
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Jennifer M. Snaman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Lindsay Blazin
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Liza-Marie Johnson
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Deena R. Levine
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - R. Ray Morrison
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Justin N. Baker
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
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