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Goldstein NE, Winter S, Mather H, DeCherrie LV, Kelley AS, McKendrick K, Zhao D, Espino C, Sealy L, Zhang M, Morrison RS. A randomized controlled trial of a novel home-based palliative care program: A report of a trial that could not be completed. J Am Geriatr Soc 2024; 72:2842-2852. [PMID: 38822734 DOI: 10.1111/jgs.19022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 04/25/2024] [Accepted: 05/02/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND In response to a growing need for accessible, efficient, and effective palliative care services, we designed, implemented, and evaluated a novel palliative care at home (PC@H) model for people with serious illness that is centered around a community health worker, a registered nurse, and a social worker, with an advanced practice nurse and a physician for support. Our objectives were to measure the impact of receipt of PC@H on patient symptoms, quality of life, and healthcare utilization and costs. METHODS We enrolled 136 patients with serious illness in this parallel, randomized controlled trial. Our primary outcome was change in symptom burden at 6 weeks. Secondary outcomes included change in symptom burden at 3 months, change in quality of life at 6 weeks and 3 months, estimated using a group t-test. In an exploratory aim, we examined the impact of PC@H on healthcare utilization and cost using a generalized linear model. RESULTS PC@H resulted in a greater improvement in patient symptoms at 6 weeks (1.30 score improvement, n = 37) and 3 months (3.14 score improvement, n = 21) compared with controls. There were no differences in healthcare utilization and costs between the two groups. Unfortunately, due to the COVID-19 pandemic and a loss of funding, the trial was not able to be completed as originally intended. CONCLUSIONS A palliative care at home model that leverages community health workers, registered nurses, and social workers as the primary deliverers of care may result in improved patient symptoms and quality of life compared with standard care. We did not demonstrate significant differences in healthcare utilization and cost associated with receipt of PC@H, likely due to inability to reach the intended sample size and insufficient statistical power, due to elements beyond the investigators' control such as the COVID-19 public health emergency and changes in grant funding.
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Affiliation(s)
- Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Medicine, Dartmouth Health and the Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Shira Winter
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda V DeCherrie
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Medically Home, Boston, Massachusetts, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J Peters VA Medical Center, Bronx, New York, USA
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Duzhi Zhao
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christian Espino
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - LaToya Sealy
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Meng Zhang
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J Peters VA Medical Center, Bronx, New York, USA
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Oliver DP, Ersek M, White P, Jorgenson L, Pitzer K, Rolbiecki A, Mayahara M, Washington K, Demiris G. Addressing Statistical Power and Increasing Diversity in Hospice Research: Electronic Medical Record Participant Identification Compared to Nurse Referral Approaches to Recruitment. J Pain Symptom Manage 2024:S0885-3924(24)00920-5. [PMID: 39197694 DOI: 10.1016/j.jpainsymman.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 09/01/2024]
Abstract
CONTEXT Recruitment of targeted samples into hospice clinical trials is often challenging. While electronic medical records (EMR) are commonly used in hospital-based research, it is uncommon in hospice research. The community setting and the variability in hospices and their medical record creates unique challenges. OBJECTIVES This paper compares recruitment in two hospice randomized controlled trials, each of which had a group recruited by using the EMR identification and a group recruited by nurse referral. We sought to answer three questions: 1) What is the impact of using the EMR to identify hospice participants for clinical research? 2) How do the referral count and consent rate (referrals that ultimately result in verbal informed consent to participate in research) differ between hospice agencies using an EMR participant identification approach compared to those using a nurse referral approach? and 3) What are the challenges associated with using the EMR to identify potential research participants? METHOD Recruitment data from two hospice clinical trials was combined into a new database. Data from hospice nurse referral agencies was compared with data from those agencies who participated in EMR-identified referrals. RESULTS The EMR identification process was feasible and efficient, resulting in more referrals and more consented participants than the nurse referral method. Of particular interest is that 8% more black caregivers were recruited using the EMR identification process than the nurse referral. CONCLUSIONS The EMR-identified recruitment process is the recommended method in hospice research.
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Affiliation(s)
- Debra Parker Oliver
- Ira Kodner Professor of Supportive Care Research, Division of Palliative Medicine, Department of Medicine, Washington University in St. Louis, Goldfarb School of Nursing, 4590 Children's Place, Mailstop 90-29-931, St. Louis, MO. 63110.
| | - Mary Ersek
- University of Pennsylvania School of Nursing, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, s
| | - Patrick White
- Stokes Family Endowed Chair and chief, Division of Palliative Medicine, Department of Medicine, Washington University in St. Louis
| | - Lucas Jorgenson
- Division of Palliative Medicine, Department of Medicine, Washington University in St. Louis
| | - Kyle Pitzer
- Assistant Professor, Division of Palliative Medicine, Department of Medicine, Washington University in St. Louis
| | - Abigail Rolbiecki
- Assistant Professor, Department of Family Medicine, University of Missouri
| | - Masako Mayahara
- Associate Professor, Goldfarb School of Nursing, Barnes Jewish College of Nursing
| | - Karla Washington
- Associate Professor, Division of Palliative Medicine, Department of Medicine, Washington University in St. Louis
| | - George Demiris
- Penn Integrates Knowledge University Professor, Department of Biobehavioral and Health Science, School of Nursing; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania
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Tjia J, Clayton M, Chiriboga G, Staples B, Puerto G, Rappaport L, DeSanto-Madeya S. Stakeholder-engaged process for refining the design of a clinical trial in home hospice. BMC Med Res Methodol 2021; 21:92. [PMID: 33941089 PMCID: PMC8091786 DOI: 10.1186/s12874-021-01275-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 04/12/2021] [Indexed: 11/18/2022] Open
Abstract
Background Clinical trials in home hospice settings are important to build the evidence base for practice, but balancing the burden and benefit of clinical trial conduct for clinicians, patients, and family caregivers is challenging. A stakeholder-engaged process can help inform and refine key aspects of home hospice clinical trials. The aim of this study was to describe a stakeholder-engaged process to refine, design, and implement aspects of an educational intervention trial in home hospice, including recommendations for refining intervention content and delivery, recruitment and enrollment strategies, and content and frequency of outcome measurement. Methods A panel of interprofessional (1 hospice administrator, 3 nurses, 2 physicians, 2 pharmacists) and 2 former family caregiver stakeholders was systematically selected and invited to participate based on expertise, representing 2 geographically distinct hospices who were participating in the clinical trial. Teleconferences followed a predetermined procedural sequence: 1. pre-meeting materials distribution and review; 2. pre-meeting email solicitation of concerns in response to materials; 3. teleconference with structured and guided discussion; and 4. documentation and distribution of minutes for accuracy review and future meeting guidance. Discussion topics were distinct for each panel meeting. Written reflections on the stakeholder engagement process were collected from panel members to further refine our process. Results Five initial biweekly teleconferences resulted in recommendations for recruitment strategy, enrollment process, measurement frequency, patient inclusion, and primary care physician notification of the patient’s trial involvement. The panel continues to participate in quarterly teleconferences to review progress and unexpected questions and concerns. Panelist reflections reveal personal and professional benefit from participation. Conclusions An interprofessional stakeholder process is feasible and invaluable for developing home hospice intervention studies, contributing to better science, successful trial implementation, and relevant, valid outcomes. Trial registration Clinicaltrials.gov, NCT03972163, Registered June 3, 2019.
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Affiliation(s)
- Jennifer Tjia
- University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA, 01605, USA.
| | | | - Germán Chiriboga
- University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA, 01605, USA
| | - Brooke Staples
- University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA, 01605, USA
| | - Geraldine Puerto
- University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA, 01605, USA
| | - Lynley Rappaport
- University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA, 01605, USA
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Ehrlich O, Walker RK. Recruiting and Retaining Patient-Caregiver-Nurse Triads for Qualitative Hospice Cancer Pain Research. Am J Hosp Palliat Care 2018; 35:1009-1014. [PMID: 29458257 DOI: 10.1177/1049909118756623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Qualitative pain research for hospice patients with cancer and their caregivers involves recruiting and retaining participants with multiple vulnerabilities and ethical and logistical challenges. These have been reported for studies of individuals or dyads. However, there are no reports of the related challenges and outcomes where the sampled population was a hospice triad. OBJECTIVES Qualitative research about pain management for home hospice patients with cancer contributes rich descriptive data and such studies are critical to improving cancer pain outcomes. We describe the ethical and pragmatic challenges we faced in a study of the hospice caring triad, operationalized as the patient, family caregiver, and nurse; how our study design anticipated them; and related outcomes. RESULTS We found that having an established relationship with the hospice agency at which we recruited participants, clearly identifying potential participants at the onset of hospice care, practice using a recruitment script, patient recruitment of caregivers, establishing rapport, and participants determining when interviews should end helped us recruit and retain our sample. We were unable to accrue our anticipated triad sample, partially because of nurse gatekeeping and the condition at admission of patient participants who enrolled but had physical decline or died prior to written consent. CONCLUSIONS Although researchers will always face challenges to enrolling individuals and groups in cancer pain studies, with careful study design, recruitment, and retention planning and research team-participant engagement, it is possible to gather a robust corpus of qualitative data.
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Affiliation(s)
- Olga Ehrlich
- 1 Dana-Farber Cancer Institute, The Phyllis F. Cantor Center for Research in Nursing and Patient Care Services/UMass Boston P54 Center for Cancer and Health Disparities, Boston, MA, USA
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Snowden A, Young J. A screening tool for predicting gatekeeping behaviour. Nurs Open 2017; 4:187-199. [PMID: 29085645 PMCID: PMC5653390 DOI: 10.1002/nop2.83] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/28/2017] [Indexed: 11/30/2022] Open
Abstract
AIM To develop a typology and screening tool for gatekeeping behaviours by nurses responsible for recruitment in palliative care research. DESIGN Concurrent analysis. METHOD Two focus groups were conducted in 2015 with nine qualified hospice community nurses involved in recruitment to a trial in palliative care. The literature was searched for research into gatekeeping from 2000-2016. All narrative examples of gatekeeping activity were coded using gerunds. Common codes were then grouped and interpreted as a social process. RESULTS Gatekeeping is normal and should be expected. A continuum typology emerged, ranging from unintentional to active disengagement. Justification ranged from forgetting to deliberately not mentioning the study for fear of burdening patients. Viewing gatekeeping as a continuum allowed for the creation of a screening tool designed to collaboratively discuss and hence mitigate specific types of gatekeeping behaviour before they occur. This is a unique international contribution to this persistent issue.
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Affiliation(s)
| | - Jenny Young
- Edinburgh Napier UniversityEdinburghEH11 4BNUK
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Kars MC, van Thiel GJ, van der Graaf R, Moors M, de Graeff A, van Delden JJ. A systematic review of reasons for gatekeeping in palliative care research. Palliat Med 2016; 30:533-48. [PMID: 26577927 DOI: 10.1177/0269216315616759] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND When healthcare professionals or other involved parties prevent eligible patients from entering a trial as a research subject, they are gatekeeping. This phenomenon is a persistent problem in palliative care research and thought to be responsible for the failure of many studies. AIM To identify potential gatekeepers and explore their reasons for gatekeeping in palliative care research. DESIGN A 'Review of Reasons' based on the systematic Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach and a thematic synthesis. DATA SOURCE PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO from 2000 to May 20 2015 were searched. Studies in children (aged <18 years) and patients with dementia were excluded. RESULTS Thirty papers on gatekeeping in palliative care research were included. Five groups of potential gatekeepers were identified: healthcare professionals, research ethics committees, management, relatives and researchers. The fear of burdening vulnerable patients was the most reported reason for gatekeeping. Other reasons included 'difficulty with disclosure of health status', 'fear of burdening the patient's relatives', 'doubts about the importance or quality of the study', 'reticent attitude towards research and (research) expertise' and 'logistics'. In hospice and homecare settings, the pursuit of comfort care may trigger a protective attitude. Gatekeeping is also rooted in a (perceived) lack of skills to recruit patients with advanced illness. CONCLUSION Gatekeeping is motivated by the general assumption of vulnerability of patients, coupled with an emphasis on the duty to protect patients. Research is easily perceived as a threat to patient well-being, and the benefits appear to be overlooked. The patients' perspective concerning study participation is needed to gain a full understanding and to address gatekeeping in palliative care research.
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Affiliation(s)
- Marijke C Kars
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ghislaine Jmw van Thiel
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rieke van der Graaf
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marleen Moors
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexander de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes Jm van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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7
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Boland J, Currow DC, Wilcock A, Tieman J, Hussain JA, Pitsillides C, Abernethy AP, Johnson MJ. A systematic review of strategies used to increase recruitment of people with cancer or organ failure into clinical trials: implications for palliative care research. J Pain Symptom Manage 2015; 49:762-772.e5. [PMID: 25546286 DOI: 10.1016/j.jpainsymman.2014.09.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 08/31/2014] [Accepted: 09/22/2014] [Indexed: 11/27/2022]
Abstract
CONTEXT The challenges of palliative care clinical trial recruitment are well documented. OBJECTIVES The aim of the study was to review tested strategies to improve recruitment to trials of people with a range of conditions who may access palliative care services but are not explicitly stated to be "palliative." METHODS This was a systematic review with narrative description. The Cochrane, Embase, PubMed, PsycINFO, and CINAHL electronic databases were searched (English; January 2002 to February 2014) for quasi-experimental and randomized controlled trials (RCTs) testing the effect of recruitment strategies on accrual to clinical trials of people with organ failure and cancer. Titles, abstracts, and retrieved articles were screened by two researchers and categorized by recruitment challenge: 1) patients with reduced cognition, 2) those requiring emergency treatment, and 3) willingness of patients and clinical staff to contribute to trials. RESULTS Of 549 articles identified, 15 were included. Thirteen reported RCTs and two papers reported three quasi-experimental studies. Five were cluster RCTs of recruiting sites/institutions. One was a randomized cluster, crossover, feasibility study. Seven studies recruited patients with cancer. Others included patients with dementia, stroke, cardiovascular disease, diabetes, frail elderly, and bereaved carers. Some interventions improved recruitment: memory aid, contact before arrival, cluster consent, "opt out" consent. Others either reduced recruitment (formal mental capacity assessment) or made no difference (advance research directive; a variety of educational, supportive, and advertising interventions). CONCLUSION Successful strategies from other disciplines could be considered by palliative care researchers. Tailored, efficient, evidence-based strategies must be developed, acknowledging that strategies with face validity are not necessarily the most effective.
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Affiliation(s)
- Jason Boland
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia
| | | | - Jennifer Tieman
- Discipline, Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia
| | | | | | - Amy P Abernethy
- Discipline, Palliative and Supportive Services, Flinders University, Daw Park, South Australia, Australia; Division of Medical Oncology, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
| | - Miriam J Johnson
- Hull York Medical School, University of Hull, Hull, United Kingdom.
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Abernethy AP, Capell WH, Aziz NM, Ritchie C, Prince-Paul M, Bennett RE, Kutner JS. Ethical conduct of palliative care research: enhancing communication between investigators and institutional review boards. J Pain Symptom Manage 2014; 48:1211-21. [PMID: 24879998 PMCID: PMC4247357 DOI: 10.1016/j.jpainsymman.2014.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/21/2014] [Accepted: 05/06/2014] [Indexed: 11/22/2022]
Abstract
Palliative care has faced moral and ethical challenges when conducting research involving human subjects. There are currently no resources to guide institutional review boards (IRBs) in applying standard ethical principles and terms-in a specific way-to palliative care research. Using as a case study a recently completed multisite palliative care clinical trial, this article provides guidance and recommendations for both IRBs and palliative care investigators to facilitate communication and attain the goal of conducting ethical palliative care research and protecting study participants while advancing the science. Beyond identifying current challenges faced by palliative care researchers and IRBs reviewing palliative care research, this article suggests steps that the palliative care research community can take to establish a scientifically sound, stable, productive, and well-functioning relationship between palliative care investigators and the ethical bodies that oversee their work.
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Affiliation(s)
- Amy P Abernethy
- Duke Clinical Research Institute, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Warren H Capell
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Noreen M Aziz
- Division of Extramural Activities, National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Christine Ritchie
- University of California at San Francisco, San Francisco, California, USA
| | - Maryjo Prince-Paul
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Jean S Kutner
- University of Colorado School of Medicine, Aurora, Colorado, USA.
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10
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Hsu CY, O'Connor M, Lee S. The difficulties of recruiting participants from a non-dominant culture into palliative care research. PROGRESS IN PALLIATIVE CARE 2013. [DOI: 10.1179/1743291x12y.0000000019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Stone PC, Gwilliam B, Keeley V, Todd C, Kelly LC, Barclay S. Factors affecting recruitment to an observational multicentre palliative care study. BMJ Support Palliat Care 2013; 3:318-23. [PMID: 24644750 PMCID: PMC3756458 DOI: 10.1136/bmjspcare-2012-000396] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives To identify those factors which adversely affected recruitment to a large multicentre palliative care study. Methods Patient accrual to a multicentre, observational, palliative care study was monitored at three critical junctures in the research process. (1) Eligibility—did the patient fulfil the study entry criteria? (2) Accessibility—was it possible to access the patient to be able to inform them about the study? (3) Consent—did the patient agree to participate in the study? The reasons why patients were ineligible, inaccessible or refused consent were recorded. Results 12 412 consecutive referrals to participating clinical services were screened for study inclusion of whom 5394 (43%) were deemed to be ineligible. Of the remaining patients 4617/7018 (66%) were inaccessible to the research team. The most common reasons being precipitous death, ‘gatekeeping’ by clinical staff or rapid discharge. Of the 2410 patients who were visited by the research team and asked to participate in the study 1378 (57%) declined. Overall 8.2% (1018/12 412) of patients screened participated in the study. There were significant differences in recruitment patterns between hospice inpatient units, hospital support and community palliative care teams. Conclusions Systematic monitoring and analysis of patient flows through the clinical trial accrual process provided valuable insights about the reasons for failure to recruit patients to a clinical trial and may help to improve recruitment in future studies.
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Affiliation(s)
- Patrick C Stone
- Division of Population, Health Sciences and Education, St George's University of London, Cranmer Terrace, London, UK
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12
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Wohleber AM, McKitrick DS, Davis SE. Designing Research With Hospice and Palliative Care Populations. Am J Hosp Palliat Care 2011; 29:335-45. [DOI: 10.1177/1049909111427139] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Research in palliative care and hospice populations is important for improving quality of care, quality of life, and provider understanding of individuals at the end of life. However, this research involves many potential challenges. This review seeks to inform and assist researchers targeting to design studies targeting hospice and palliative care patients by presenting a thorough review of the published literature. This review covers English-language articles published from 1990 through 2009 listed in the PsycInfo, Medline, or CINAHL research databases under relevant keywords. Articles on pediatric hospice were not included. Issues discussed include study design, informed consent, and recruitment for participants. Synthesized recommendations for researchers in these populations are presented.
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Affiliation(s)
- Ashley M. Wohleber
- School of Professional Psychology, Pacific University, Hillsboro, OR, USA
| | | | - Shawn E. Davis
- School of Professional Psychology, Pacific University, Hillsboro, OR, USA
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Kutner J, Smith M, Mellis K, Felton S, Yamashita T, Corbin L. Methodological challenges in conducting a multi-site randomized clinical trial of massage therapy in hospice. J Palliat Med 2010; 13:739-44. [PMID: 20597707 DOI: 10.1089/jpm.2009.0408] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Researchers conducting multi-site studies of interventions for end-of-life symptom management face significant challenges with respect to obtaining an adequate sample and training and retaining on-site study teams. The purpose of this paper is to describe the strategies and responses to these challenges in a multi-site randomized clinical trial (RCT) of the efficacy of massage therapy for decreasing pain among patients with advanced cancer in palliative care/hospice settings. Over a period of 36 months, we enrolled 380 participants across 15 sites; 27% of whom withdrew prior to study completion (less than the anticipated 30% rate). We saw an average of 68% turnover amongst study staff. Three key qualities characterized successful on-site study teams: (1) organizational commitment; (2) strong leadership from on-site study coordinators; and (3) effective lines of communication between the on-site study coordinators and both their teams and the university-based research team. Issues of recruitment, retention and training should be accounted for in hospice-based research study design and budgeting.
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Affiliation(s)
- Jean Kutner
- Department of Internal Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado 80045, USA.
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14
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Sheehan DK. Recruiting for end of life research: lessons learned in family research. Nurs Clin North Am 2010; 45:441-8. [PMID: 20804888 DOI: 10.1016/j.cnur.2010.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A main hurdle for end of life research is recruitment of patients. Researchers can enroll interested patients and their families for end of life studies by gaining the trust of the hospice staff, who can make valuable referrals of patients nearing the end of life. Participants in the study should be made as comfortable as possible and not be coerced into the interview process. Once the patients have confidence in the researchers, they are more than willing to be a part of the research process because it can prove to be cathartic to many of the patients and their family members.
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Affiliation(s)
- Denice K Sheehan
- Department of Nursing, Kent State University, PO Box 5190, Kent, OH 44242-0001, USA.
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LeBlanc TW, Wheeler JL, Abernethy AP. Research in End-of-Life Settings: An Ethical Inquiry. J Pain Palliat Care Pharmacother 2010; 24:244-50. [DOI: 10.3109/15360288.2010.493579] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Thomas W. LeBlanc
- Thomas W. LeBlanc, MD, MA, and Jane L. Wheeler, MSPH, are with the Division of Medical Oncology, Department of Medicine, Duke University Medical Center; Amy P. Abernethy, MD, is with the Division of Medical Oncology, Department of Medicine, and the Duke Cancer Care Research Program, Duke University Medical Center, Durham, North Carolina, USA
| | - Jane L. Wheeler
- Thomas W. LeBlanc, MD, MA, and Jane L. Wheeler, MSPH, are with the Division of Medical Oncology, Department of Medicine, Duke University Medical Center; Amy P. Abernethy, MD, is with the Division of Medical Oncology, Department of Medicine, and the Duke Cancer Care Research Program, Duke University Medical Center, Durham, North Carolina, USA
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Duke S, Bennett H. Review: a narrative review of the published ethical debates in palliative care research and an assessment of their adequacy to inform research governance. Palliat Med 2010; 24:111-26. [PMID: 19965950 DOI: 10.1177/0269216309352714] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The quality of research, and the resulting quality of evidence available to guide palliative care, is dependent on the ethical decisions underpinning its design, conduct and report. Whilst much has been published debating the ethics of palliative care research, an assessment of the quality and synthesis of the central debates is not available. Such a review is timely to inform research governance. The methodology of this study is based on the principles of systematic reviews. Fifty-seven papers were reviewed following a thorough search, and were critically appraised for their literary quality, the knowledge on which they drew and the research standards they addressed. The debates identified address vulnerability, moral appropriateness, consent, gate-keeping and inclusion and research culture. The quality of debate and the sources of knowledge varied. The debate was rich in quality and knowledge with respect to the protection of the dignity, rights and safety of research participants, but less developed in relation to those of researchers and other staff. There is also little debate about the ethics of reporting of research and the ethics underpinning research leadership. A framework is offered that reconciles the ethical issues raised with potential methodological strategies identified from the review.
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Affiliation(s)
- Sue Duke
- University of Southampton, Southampton, UK.
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Sanders S, Butcher HK, Swails P, Power J. Portraits of caregivers of end-stage dementia patients receiving hospice care. DEATH STUDIES 2009; 33:521-556. [PMID: 19565686 DOI: 10.1080/07481180902961161] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The purpose of this study was to investigate how caregivers respond to the end stages of dementia with the assistance from hospice. Data were collected from 27 family caregivers over the course of 10 months, with each caregiver being interviewed up to 4 times during the time that the patient received hospice care. Chart review data were also collected. Four distinct caregiver portraits emerged: (a) disengaged; (b) questioning; (c) all-consumed; and (d) reconciled. Caregivers in each portrait differed in how they responded to the impending death of the care recipient, the disease progression, and hospice care. Recognizing the differences in the ways that caregivers respond to the final stages of the disease will assist hospice and other providers in best meeting the needs of the caregivers.
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Affiliation(s)
- Sara Sanders
- University of Iowa, School of Social Work, 308 North Hall, Iowa City, IA 52242, USA.
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Todd AMH, Laird BJA, Boyle D, Boyd AC, Colvin LA, Fallon MT. A systematic review examining the literature on attitudes of patients with advanced cancer toward research. J Pain Symptom Manage 2009; 37:1078-85. [PMID: 19419837 DOI: 10.1016/j.jpainsymman.2008.07.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Revised: 07/15/2008] [Accepted: 07/25/2008] [Indexed: 10/20/2022]
Abstract
The attitudes of heterogeneous groups of cancer patients towards research have been studied extensively. Less is known about these attitudes in the advanced cancer population. Such patients may have differing attitudes for a variety of reasons, including burden of disease and social factors. This systematic review examines the literature on attitudes of patients with advanced cancer toward research and aims to define common themes. The following databases were searched electronically: CINAHL (1982-2007), the Cochrane Database of Systematic Reviews (2007), Embase (1996-2007), and Medline (1996-2007). Additionally, the following journals were hand searched: Palliative Medicine, Journal of Pain and Symptom Management, and the European Journal of Palliative Care. The search terminologies used were: "Cancer" AND "Attitudes" AND "Research" AND "Palliative Care." All subheadings were included. Results were limited to English-language journals and studies involving humans. Of the 637 articles retrieved, 11 were included after an appraisal process. Both positive and negative attitudes toward research in advanced cancer were identified. Common themes of altruism, hope, and self-benefit were identified in 10 studies as a motivation for trial participation. Negative attitudes toward symptom control and risk of increased hospital admissions were identified in four studies. Most of the studies involved patients' views about participating in hypothetical trials, limiting the generalizability of results. An important step for future work would be to examine the experiences and opinions of patients with advanced cancer who have actually participated in a clinical trial.
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Affiliation(s)
- Anne M H Todd
- Edinburgh Palliative and Supportive Care Group, Edinburgh Cancer Research Centre, Western General Hospital, Crewe Road, Edinburgh EH4 2XR, Scotland, United Kingdom.
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"I will do it if it will help others:" motivations among patients taking part in qualitative studies in palliative care. J Pain Symptom Manage 2008; 35:347-55. [PMID: 18243642 DOI: 10.1016/j.jpainsymman.2007.05.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Revised: 05/07/2007] [Accepted: 05/08/2007] [Indexed: 11/17/2022]
Abstract
The aim of this study was to explore patients' and carers' preferences and expectations regarding their contribution to research in palliative care through the use of qualitative interviews. Data were collected in the context of two studies exploring the experiences of care of palliative care patients and carers. Both studies recorded the recruitment process, numbers of patients or carers accepting and declining, and the circumstances of interviews. Participants were asked about their motivation to participate in research. The data were analyzed by labeling patients' reflections on their motivations for participating in these studies and identifying themes. Analysis of the recruitment process revealed differential patterns in decline and acceptance of interviews by patients with different conditions and across settings. Among cancer patients, 21/51 declined; the proportion with other conditions that declined was small, and was 0/10 for patients with motor neuron disease. Motivation to participate in the studies was related to (1) altruism, (2) gratitude and concerns about care, (3) the need to have somebody to talk to, and (4) the need for information or access to services. Palliative care patients and carers were capable of deciding whether to participate in interviews and negotiating how they wanted this to happen. This strengthens the argument for patients' autonomy in deciding whether to participate in research. Patients and carers have different motivations for participation, reflecting the heterogeneity of the palliative care population. This suggests a need for ethics committees to reconsider their views and widen their perspectives on the involvement of palliative care patients and carers in research.
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Williams BR, Woodby LL, Bailey FA, Burgio KL. Identifying and responding to ethical and methodological issues in after-death interviews with next-of-kin. DEATH STUDIES 2008; 32:197-236. [PMID: 18705168 DOI: 10.1080/07481180701881297] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
After-death research with next-of-kin can enhance our understanding of end-of-life care and translate into better services for dying persons and their survivors. This article describes ethical and methodological issues that emerged in a pilot of a face-to-face interview guide designed to elicit next-of-kin's perceptions of end-of-life care. The pilot study was part of a larger Veterans Affairs (VA) Health Services Research protocol to improve end-of-life care in VA Medical Centers. By deconstructing the research process from an ethical perspective and engaging in critical self-assessment, the authors aim to inform other researchers of potential problems involved in after-death research with next-of-kin.
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Affiliation(s)
- Beverly R Williams
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, 700 South 19th Street, 11-G, Birmingham, Alabama, USA.
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Abstract
A great deal of time, attention, and funding has been dedicated to research concerned with improving care at the end of life. However, sizes of samples for such research are reduced by recruitment problems unique to end-of-life studies, which limits their power and generalizability. In this article, experiences are shared and suggestions are offered to increase recruitment using 4 recent studies on end-of-life topics as examples. The issues in this article include those related to participants (patients or family members) and those related to the health care providers or systems. A researcher who is forewarned about higher-than-usual rates for lack of contact, refusals, and no-shows in end-of-life research can plan appropriately for the time and effort needed during the recruitment phase of the study.
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Affiliation(s)
- Karin T Kirchhoff
- School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin 53792-2455, USA.
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Williams CJ, Shuster JL, Clay OJ, Burgio KL. Interest in Research Participation among Hospice Patients, Caregivers, and Ambulatory Senior Citizens: Practical Barriers or Ethical Contraints? J Palliat Med 2006; 9:968-74. [PMID: 16910811 DOI: 10.1089/jpm.2006.9.968] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The purpose of this survey study was to explore hypothetical interest in research participation among hospice patients and caregivers compared to ambulatory senior citizens. DESIGN Cross-sectional survey. SETTING Twenty-one community-based hospice offices, a university medical center geriatric ambulatory care clinic, and 3 community-based senior citizen centers. PARTICIPANTS Participants were hospice patients, caregivers, and ambulatory senior citizens not enrolled in hospice. MEASUREMENTS Using a self-administered questionnaire, participants rated their interest in participating in survey/interview and therapeutic studies, identified potential benefits and barriers to research participation, and reported their preferences for who they would want to approach them about research participation. RESULTS Forty-six percent of hospice patients and 60% of caregivers reported an interest in interview or survey research participation; 45% and 57%, respectively, expressed interest in therapeutic research. Compared to hospice patients, caregivers reported higher rates of personal interest in both survey research (p =< 0.001) and therapeutic research (p=<0.001) and were more likely to report that the hospice patients they cared for would be interested (p = 0.005 and p = 0.027). Younger hospice patients were more favorably disposed toward both survey and therapeutic research participation than hospice patients over the age of 75 (p = 0.063 and 0.011). The proportion of older hospice patients showing interest in research did not differ significantly from ambulatory senior citizens for either type of research (p = 0.56, 0.98). CONCLUSION This study suggests that many hospice patients are interested in research participation and are able to articulate benefits and barriers, which supports the inclusion of this population in research.
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Affiliation(s)
- Charlotte J Williams
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Birmingham, Alabama 35294-2041, USA.
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Kutner JS, Main DS, Westfall JM, Pace W. The practice-based research network as a model for end-of-life care research: challenges and opportunities. Cancer Control 2005; 12:186-95. [PMID: 16062166 DOI: 10.1177/107327480501200309] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jean S Kutner
- Population-based Palliative Care Research Network and Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver 80262 USA.
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