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Hadler RA, Gao Y, Beck B, Moeckli J, Massarweh N, Mosher H, Vaughan-Sarrazin M. Palliative Care Utilization and Hospital Transfers in Veterans Treated in Telecritical Care-Supported Intensive Care Units Versus Non-Telecritical Care Intensive Care Units. J Palliat Med 2024; 27:756-762. [PMID: 38324007 DOI: 10.1089/jpm.2023.0548] [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: 02/08/2024] Open
Abstract
Background: Although telecritical care (TCC) implementation is associated with reduced mortality and interhospital transfer rates, its impact on goal-concordant care delivery in critical illness is unknown. We hypothesized that implementation of TCC across the Veterans' Health Administration system resulted in increased palliative care consultation and goals of care evaluation, yielding reduced transfer rates. Methods: We included veterans admitted to intensive care units between 2008 and 2022. We compared palliative care consultation and transfer rates before and after TCC implementation with rates in facilities that never implemented TCC. We used generalized linear mixed multivariable models to assess the associations between TCC initiation, palliative care consultation, and transfer and subsequently used mediation analysis to evaluate potential causality in this relationship. Results: Overall, 1,020,901 veterans met inclusion criteria. Demographic characteristics of patients were largely comparable across groups, although TCC facilities served more rural veterans. Palliative care consultation rates increased substantially in both ever-TCC and never-TCC hospitals during the study period (2.3%-4.3%, and 1.6%-4.7%, p < 0.01). Admissions post-TCC implementation were associated with an increased likelihood of palliative care consultation (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.15). TCC implementation was also associated with a reduction in transfer rates (OR 0.90, 95% CI 0.84-0.95). Mediation analysis did not demonstrate a causal relationship between TCC implementation, palliative care consultation, and reductions in interhospital transfer rate. Conclusions: TCC is associated with increased palliative care engagement, while TCC and palliative care engagement are both independently related to reduced transfers.
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Affiliation(s)
- Rachel A Hadler
- VA Quality Scholars Fellow, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Department of Anesthesiology, Emory University, Atlanta, Georgia, USA
- Emory Critical Care Center, Emory University, Atlanta, Georgia, USA
- Division of Palliative Care, Department of Geriatrics and Extended Care, Atlanta Veterans Administration Health Care System, Decatur, Georgia, USA
| | - Yubo Gao
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Brice Beck
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Jane Moeckli
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Nader Massarweh
- Department of Surgery, Atlanta Veterans Administration Health Care System, Decatur, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Hilary Mosher
- Geriatric Research Education and Clinical Center, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Mary Vaughan-Sarrazin
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
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Fischer SM, Min SJ, Kline DM, Lester K, Gozansky W, Schifeling C, Himberger J, Lopez J, Fink RM. Patient Navigator Intervention to Improve Palliative Care Outcomes for Hispanic Patients With Serious Noncancer Illness: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:384-393. [PMID: 38345793 PMCID: PMC10862271 DOI: 10.1001/jamainternmed.2023.8145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/08/2023] [Indexed: 02/15/2024]
Abstract
Importance Disparities persist across the trajectory of serious illness, including at the end of life. Patient navigation has been shown to reduce disparities and improve outcomes for underserved populations. Objective To determine the effectiveness of a lay patient navigator intervention, Apoyo con Cariño, in improving palliative care outcomes among Hispanic patients. Design, Setting, and Participants This was a multicenter randomized clinical trial that took place across academic, nonprofit, safety-net, and community health care systems in urban, rural, and mountain/frontier regions of Colorado from January 2017 to January 2021. Self-identifying Hispanic adults with serious noncancer medical illness and limited prognosis were recruited. Data were collected and analyzed from July 2022 to July 2023. Interventions Participants randomized to the intervention group received 5 home visits from a bilingual, bicultural lay patient navigator; participants randomized to control received care as usual. Both groups received culturally tailored educational materials. Investigators/outcome accessors remained blinded to participant assignment. Main Outcomes and Measures Change in score from baseline to 3 months on the Functional Assessment of Chronic Illness Therapy (FACIT) General quality of life (QOL) scale (primary outcome), Advance Care Planning (ACP) Engagement Survey, Brief Pain Inventory, Edmonton Symptom Assessment Scale, and FACIT Spiritual Well-Being subscale; at 6 months, advance directive (AD) documentation; and at 46 months or death, hospice utilization and length of stay, as well as aggressiveness of care at end of life. Results Of 209 patients enrolled (mean [SD] age, 63.6 [14.3] years; 108 [51.7%] male), 105 patients were randomized to control and 104 patients to the intervention. There were no statistically significant differences in the change in mean (SD) QOL score between the intervention and control groups (5.0 [16.5] vs 4.3 [15.5]; P = .75). Participants in the intervention group, compared with the control group, had statistically significant greater increases in mean (SD) ACP engagement (0.8 [1.3] vs 0.1 [1.4]; P < .001) and were more likely to have a documented AD (62 of 104 [59.6%] vs 28 of 105 [26.9%]; P < .001). There were no statistically significant differences in mean (SD) change in pain intensity score (0-10) between patients in the intervention group compared with control (-0.4 [2.6] vs -0.5 [2.8]; P = .79), nor pain interference (-0.2 [3.7] vs -0.4 [3.7]; P = .71). Patients receiving the intervention were more likely to be referred to hospice compared with patients receiving control (19 of 43 patients [44.2%] vs 7 of 33 patients [21.2%]; P = .04) and less likely to receive aggressive care at end of life (27 of 42 patients [64.3%] vs 28 of 33 patients [84.8%]; P = .046). Conclusion and Relevance In this randomized clinical trial, a culturally tailored patient navigator intervention did not improve QOL for patients. However, the intervention did increase ACP engagement, AD documentation, and hospice utilization in Hispanic persons with serious medical illness. Trial Registration ClinicalTrials.gov Identifier: NCT03181750.
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Affiliation(s)
- Stacy M. Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | | | | | | | | | | | | | - Joseph Lopez
- University of Colorado Health North, Fort Collins
| | - Regina M. Fink
- University of Colorado School of Medicine, Aurora
- University of Colorado College of Nursing, Aurora
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3
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Cichon GJ, Betts LJ, McKillip KM, Silberstein PT. Patterns of Palliative Treatments in Stage IV Esophageal Cancer. Am J Hosp Palliat Care 2023; 40:1331-1338. [PMID: 36878494 DOI: 10.1177/10499091231159365] [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: 03/08/2023] Open
Abstract
Background: The 5 year survival rate of esophageal cancer is under 20%. Studies have shown that early palliative treatments can improve patient quality of life and lower depressed mood without expediting mortality. Despite these benefits, few studies have analyzed factors associated with the national variation among patients who received palliative treatment for esophageal cancer. Methods: This is a retrospective study of adults diagnosed with stage IV esophageal cancer between 2004 and 2018 in the National Cancer Database (NCDB) who received palliative treatment or not (n = 43,599). Cross tabulation and binary logistic regression were performed and evaluated using SPSS. Exclusion criteria included concurrent tumors, patients under age 18, and missing data. Results: Of the 43,599 patients, 26.1% of patients received palliative interventions (n = 11,371). The majority of palliative treatment patients lived less than 6 months after diagnosis (54%) and received radiation (35.7%) or chemotherapy (34.5%) with palliative intent. The patients who received palliative treatment tended to be non-Hispanic (96.6%), white (87.2%), male (83.3%) patients between age 61 and 75 (43.8%) at a comprehensive community cancer program (38.7%) with adenocarcinoma histology (71.8%). Palliative treatment patients most commonly relied on Medicare as their primary payor (45.9%) and had a median household income over $48,000 (54.5%). Conclusion: We identified trends among stage IV esophageal cancer patients receiving palliative treatments. Patients receiving palliative treatments tended to be white, non-Hispanic men. Compared to patients who did not receive palliating treatments, this cohort was more likely to receive treatment at a comprehensive, academic, or integrated network facility.
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Affiliation(s)
| | - Lucas J Betts
- Creighton University School of Medicine, Omaha, NE, USA
| | - Kathleen M McKillip
- Department of Internal Medicine, Division of Palliative Medicine, Creighton University Medical Center, Omaha, NE, USA
| | - Peter T Silberstein
- Department of Internal Medicine, Division of Hematology/Oncology, Creighton University Medical Center, Omaha, NE, USA
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4
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Toles M, Kistler C, Lin FC, Lynch M, Wessell K, Mitchell SL, Hanson LC. Palliative care for persons with late-stage Alzheimer's and related dementias and their caregivers: protocol for a randomized clinical trial. Trials 2023; 24:606. [PMID: 37743478 PMCID: PMC10518941 DOI: 10.1186/s13063-023-07614-4] [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: 06/23/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Limited access to specialized palliative care exposes persons with late-stage Alzheimer's disease and related dementias (ADRD) to burdensome treatment and unnecessary hospitalization and their caregivers to avoidable strain and financial burden. Addressing this unmet need, the purpose of this study was to conduct a randomized clinical trial (RCT) of the ADRD-Palliative Care (ADRD-PC) program. METHODS The study will use a multisite, RCT design and will be set in five geographically diverse US hospitals. Lead investigators and outcome assessors will be masked. The study will use 1:1 randomization of patient-caregiver dyads, and sites will enroll N = 424 dyads of hospitalized patients with late-stage ADRD with their family caregivers. Intervention dyads will receive the ADRD-PC program of (1) dementia-specific palliative care, (2) standardized caregiver education, and (3) transitional care. Control dyads will receive publicly available educational material on dementia caregiving. Outcomes will be measured at 30 days (interim) and 60 days post-discharge. The primary outcome will be 60-day hospital transfers, defined as visits to an emergency department or hospitalization ascertained from health record reviews and caregiver interviews (aim 1). Secondary patient-centered outcomes, ascertained from 30- and 60-day health record reviews and caregiver telephone interviews, will be symptom treatment, symptom control, use of community palliative care or hospice, and new nursing home transitions (aim 2). Secondary caregiver-centered outcomes will be communication about prognosis and goals of care, shared decision-making about hospitalization and other treatments, and caregiver distress (aim 3). Analyses will use intention-to-treat, and pre-specified exploratory analyses will examine the effects of sex as a biologic variable and the GDS stage. DISCUSSION The study results will determine the efficacy of an intervention that addresses the extraordinary public health impact of late-stage ADRD and suffering due to symptom distress, burdensome treatments, and caregiver strain. While many caregivers prioritize comfort in late-stage ADRD, shared decision-making is rare. Hospitalization creates an opportunity for dementia-specific palliative care, and the study findings will inform care redesign to advance comprehensive dementia-specific palliative care plus transitional care. TRIAL REGISTRATION ClinicalTrials.gov NCT04948866. Registered on July 2, 2021.
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Affiliation(s)
- M Toles
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - C Kistler
- Department of Family Medicine and Palliative Care Program, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - F C Lin
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M Lynch
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - K Wessell
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, and Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - L C Hanson
- Division of Geriatrics and Palliative Care Program, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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5
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McMahon KM, Eaton VP, Srikanth KK, Tupper CJ, Merwin MJ, Morris MW, Silberstein PJ, McKillip K. Survey of Palliative Care Use in Primary Malignant Bone Tumors: A National Cancer Database Review. J Palliat Med 2023; 26:1139-1146. [PMID: 37093019 DOI: 10.1089/jpm.2022.0365] [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: 04/25/2023] Open
Abstract
Background/Objectives: Palliative care (PC) has been associated with reduced patient symptom burden, improved physician satisfaction, and reduced cost of care. However, its use in primary bone tumors has not been well classified. Design/Setting and Subjects: Patients diagnosed with primary malignant bone tumors (osteosarcoma, chondrosarcoma, Ewing sarcoma, and chordoma) between 2004 and 2018 were identified in the National Cancer Database. Cross tabulations with chi-square analysis were performed to evaluate frequencies of PC use by patient, facility, and tumor characteristics. Multivariate logistic binary regression was performed to evaluate relationships between patient, treatment facility, and tumor characteristics and the use of PC. Results: Around 24,401 patients were identified. Overall, 2.52% had any form of PC utilization. Of those receiving PC, 55.5-65.1% were treated with only noncurative surgery, radiation, chemotherapy, or any combination of these modalities. Odds of PC utilization were decreased for patients with chordomas, patients living >24 miles from the treatment facility, or patients with private insurance, Medicare, or unknown insurance status. Odds of PC utilization were increased in patients with greater tumor diameter or unknown tumor size, tumors in midline, increased tumor grade, stage IV tumors, or living in urban areas. Conclusion: PC use in patients with primary bone tumors increases with tumor stage, tumor grade, tumor size, and if the tumor is midline, and in patients living in urban areas. However, overall utilization remains markedly low. Future studies should be done to investigate these patterns of care and help expand the utilization of PC.
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Affiliation(s)
- Kevin M McMahon
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Vincent P Eaton
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | | | - Connor J Tupper
- Creighton University School of Medicine, Omaha, Nebraska, USA
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6
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Kwong M, Rajasekar G, Utter GH, Nuno M, Mell MW. Poor utilization of palliative care among Medicare patients with chronic limb-threatening ischemia. J Vasc Surg 2023; 78:464-472. [PMID: 37088446 DOI: 10.1016/j.jvs.2023.02.023] [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: 11/15/2022] [Revised: 01/20/2023] [Accepted: 02/06/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE Patients with chronic limb-threatening ischemia (CLTI) experience high annual mortality and would benefit from timely palliative care intervention. We sought to better characterize use of palliative care among patients with CLTI in the Medicare population. METHODS Using Medicare data from 2017 to 2018, we identified patients with CLTI, defined as two or more encounters with a CLTI diagnosis code. Palliative care evaluations were identified using ICD-10-CM Z51.5 "Encounter for palliative care." Time intervals between CLTI diagnosis, palliative consultation, and death or end of follow-up were calculated. Associations between patient demographics, comorbidities, and palliative care consultation were assessed. RESULTS A total of 12,133 Medicare enrollees with complete data were categorized as having CLTI. Of these, 7.4% (894) underwent a palliative care evaluation at a median of 170 days (interquartile range, 45-352 days) from their CLTI diagnosis. Compared with those who did not undergo evaluation, palliative patients were more likely to be dual eligible for Medicaid (45.2% vs 38.1%; P < .001) and had more comorbid conditions (P < .001). After controlling for gender and race, age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.04), dual eligibility (OR, 1.40; 95% CI, 1.22-1.62), solid organ malignancy (OR, 2.82; 95% CI, 1.92-4.14), hematologic malignancy (OR, 2.24; 95% CI, 1.27-3.98), congestive heart failure (OR, 1.44; 95% CI, 1.15-1.88), complicated diabetes (OR, 1.35; 95% CI, 1.11-1.65), dementia (OR, 1.32; 95% CI, 1.04-1.66), and severe renal failure (OR, 1.56; 85% CI. 1.24-1.98) were independently associated with palliative care evaluation. During mean follow up of 410 ± 220 days, 16.9% (2044) of patients died at a mean of 268 (±189) days after their CLTI diagnosis. Among living patients, only 3.2% (325) underwent palliative evaluation. Comparatively, 27.8% (569) of patients who died received palliative care at a median of 196 days (interquartile range, 55-362 days) after their diagnosis and 15 days (interquartile range, 5-63 days) prior to death. CONCLUSIONS Despite high mortality, palliative care services were rarely provided to Medicare patients with CLTI. Age, medical complexity, and income status may play a role in the decision to consult palliative care. When obtained, evaluations occurred closer to time of death than to time of CLTI diagnosis, suggesting misuse of palliative care as end-of-life care.
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Affiliation(s)
- Mimmie Kwong
- Department of Surgery, Division of Vascular Surgery, University of California Davis School of Medicine, Sacremento, CA.
| | - Ganesh Rajasekar
- Department of Public Health Sciences, University of California Davis School of Medicine, Sacremento, CA
| | - Garth H Utter
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of California Davis School of Medicine, Sacremento, CA
| | - Miriam Nuno
- Department of Public Health Sciences, University of California Davis School of Medicine, Sacremento, CA
| | - Matthew W Mell
- Department of Surgery, Division of Vascular Surgery, University of California Davis School of Medicine, Sacremento, CA
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7
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Ogunseitan AB, Smith MM. Telehealth: An Avenue for Expanding Access to Specialist Palliative Care. Jt Comm J Qual Patient Saf 2022; 48:625-626. [PMID: 36184266 DOI: 10.1016/j.jcjq.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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8
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McMahon KM, Eaton VP, Cichon GJ, Griffin JB, Dahl ME, Silberstein PJ, McKillip K. Utilization of Palliative Care in Osteosarcoma: A National Cancer Database Review. Am J Hosp Palliat Care 2022:10499091221123274. [PMID: 36067349 DOI: 10.1177/10499091221123274] [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: 11/15/2022] Open
Abstract
Background: Osteosarcoma is the most common form of bone cancer, but the utilization of palliative care (PC) in patients with this cancer has not previously been investigated in the National Cancer Database (NCDB). Methods: Patients diagnosed with osteosarcoma (2004-2017) were identified within the NCDB. Cross tabulations with Chi-square analysis were performed to evaluate frequencies of palliative care use by patient, facility, and tumor characteristics. Multivariate logistic binary regression was performed to evaluate relationships between patient, treatment facility, and tumor characteristics and the use of palliative care. Results: A total of 7498 patients were analyzed with 2.8% of patients diagnosed having any form of palliative care utilization. Of this group, 53.37% received PC within the first 12 months after diagnosis. Of the 2.8% of patients receiving PC the most common forms of PC utilized were non-curative symptom-directed surgery, radiation, or chemotherapy, or a combination of these modalities (56.7%). Palliative care usage was increased in patients with greater tumor diameter, tumors in the bones of the midline, or stage IV tumors. Palliative care usage was decreased in patients living within 25-49 miles of their treatment facility, those living in pacific states, those with chondroblastic osteosarcoma, or those with private insurance. Conclusion: Palliative care use in patients with osteosarcoma increases with tumor stage, tumor size, or more proximal tumors, but overall utilization remains markedly low. Future studies should further define these patterns of care and help expand the utilization of PC.
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Affiliation(s)
- Kevin M McMahon
- School of Medicine, 12282Creighton University, Omaha, NE, USA
| | - Vincent P Eaton
- School of Medicine, 12282Creighton University, Omaha, NE, USA
| | | | - Julia B Griffin
- School of Medicine, 12282Creighton University, Omaha, NE, USA
| | - Mary E Dahl
- School of Medicine, 12282Creighton University, Omaha, NE, USA
| | | | - Kate McKillip
- School of Medicine, 12282Creighton University, Omaha, NE, USA
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9
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Gardner DS, Doherty M, Ghesquiere A, Villanueva C, Kenien C, Callahan J, Reid MC. Palliative care for case managers: Building capacity to extend community-based palliative care to underserved older adults. GERONTOLOGY & GERIATRICS EDUCATION 2022; 43:269-284. [PMID: 30442079 DOI: 10.1080/02701960.2018.1544129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Palliative care has demonstrated effectiveness in alleviating the biological, emotional, social, and spiritual symptoms that accompany serious illness, and improving quality of life for seriously ill individuals and their family members. Despite increasing availability, there are significant disparities in access to and utilization of palliative care, particularly among diverse, low-income, and community-dwelling older adults with chronic illness. Training frontline service providers is a novel approach to expanding access to palliative care among underserved elders. This article presents a process and outcome evaluation of a palliative care curriculum that was developed and piloted for geriatric case managers in a large urban area. We describe the background, planning, design, implementation, and preliminary outcomes associated with a pilot implementation of the curriculum. We conclude with implications for replicating efforts to enhance frontline providers' knowledge, skills, and self-efficacy in extending palliative care to communities that lack access to critical supports for their burdensome symptoms.
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Affiliation(s)
- Daniel S Gardner
- Silberman School of Social Work, Hunter College, CUNY, New York, NY, USA
| | - Meredith Doherty
- PhD Program in Social Welfare, CUNY Graduate Center, New York, NY, USA
| | - Angela Ghesquiere
- Brookdale Center for Healthy Aging, Hunter College, CUNY, New York, NY, USA
| | | | - Cara Kenien
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Jean Callahan
- Brookdale Center for Healthy Aging, Hunter College, CUNY, New York, NY, USA
| | - M Cary Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, NY, USA
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10
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Portz JD, Graney BA, Bekelman DB. " Made Me Realize That Life Is Worth Living": A Qualitative Study of Patient Perceptions of a Primary Palliative Care Intervention. J Palliat Med 2022; 25:28-38. [PMID: 34264752 PMCID: PMC8721497 DOI: 10.1089/jpm.2021.0015] [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: 01/03/2023] Open
Abstract
Background: Primary palliative care is needed to meet the complex needs of patients with serious illness and their families. However, patient perceptions of primary palliative care are not well understood and can inform subsequent primary palliative care interventions and implementation. Objective: Elicit the patient perspective on a primary palliative care intervention, Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA), from patient perspectives. Design: Qualitative study using patient interviews and two methods of triangulation. Setting/Subjects: Between July 2014 and September 2015, we interviewed 45 patients who participated in the intervention in a Veterans Affairs (VA) (primary site), academic, and urban safety-net health system in the United States. Main Measures: Participants were asked about what was most and least helpful, how the intervention affected participants' lives, and what should be changed about the intervention. Data were analyzed using a general inductive approach. To enhance validity of the results, we triangulated the findings from patient interviews, reviews of care coordinator documentation, and interprofessional palliative care providers. Results: The six themes identified that primary care intervention: (1) Cared for My Psychosocial Needs, (2) Encouraged Self-Management, (3) Medication Recommendations Worked, (4) Facilitated Goal Attainment, (5) Team was Beneficial, and (6) Good Visit Timing. Conclusions: Participants experienced benefits from the primary palliative care intervention and attributed these benefits to individualized assessment and support, facilitation of skill building and self-management, and oversight from an interprofessional care team. Future primary palliative care interventions may benefit from targeting these specific patient-valued processes.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,Address correspondence to: Jennifer Dickman Portz, PhD, MSW, Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Mailstop B180, 12631 East 17th Avenue, Aurora, CO 80045, USA
| | - Bridget A. Graney
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - David B. Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, Colorado, USA
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11
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Sullivan DR, Teno JM, Reinke LF. Evolution of Palliative Care in the Department of Veterans Affairs: Lessons from an Integrated Health Care Model. J Palliat Med 2021; 25:15-20. [PMID: 34665652 DOI: 10.1089/jpm.2021.0246] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Palliative care (PC) is beneficial, however, in many settings it is under-resourced and unable to consistently meet the needs of patients and their families. A lack of national health policy support for PC contributes to underutilization and the low value care experienced by many patients with serious illness at the end of life. Through a series of transformative health care structure and process improvements including developing robust initiatives and promoting institutional culture change, the Department of Veterans Affairs (VA) has significantly improved the quality of PC among veterans. VA's strategic simultaneous top-down and bottom-up approach to develop programs, policies, and initiatives provides important perspectives and deserves attention toward advancing PC in the broader U.S. health care system. Although opportunities for improvement exist, the comprehensive framework within VA should help inform the future of program development and serve as a model for integrated and accountable care organizations to emulate.
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Affiliation(s)
- Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA.,Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon, USA
| | - Joan M Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, OHSU, Portland, Oregon, USA
| | - Lynn F Reinke
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington, USA.,Department of Biobehavioral Nursing and Health Systems, University of Washington, School of Medicine, Seattle, Washington, USA
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12
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van Steijn D, Pons Izquierdo JJ, Garralda Domezain E, Sánchez-Cárdenas MA, Centeno Cortés C. Population's Potential Accessibility to Specialized Palliative Care Services: A Comparative Study in Three European Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910345. [PMID: 34639645 PMCID: PMC8507925 DOI: 10.3390/ijerph181910345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/15/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Palliative care is a priority for health systems worldwide, yet equity in access remains unknown. To shed light on this issue, this study compares populations' driving time to specialized palliative care services in three countries: Ireland, Spain, and Switzerland. METHODS Network analysis of the population's driving time to services according to geolocated palliative care services using Geographical Information System (GIS). Percentage of the population living within a 30-min driving time, between 30 and 60 minutes, and over 60 min were calculated. RESULTS The percentage of the population living less than thirty minutes away from the nearest palliative care provider varies among Ireland (84%), Spain (79%), and Switzerland (95%). Percentages of the population over an hour away from services were 1.87% in Spain, 0.58% in Ireland, and 0.51% in Switzerland. CONCLUSION Inequities in access to specialized palliative care are noticeable amongst countries, with implications also at the sub-national level.
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Affiliation(s)
- Danny van Steijn
- ATLANTES Research Group, Institute for Culture and Society, University of Navarra, 31009 Pamplona, Navarra, Spain; (J.J.P.I.); (E.G.D.); (M.A.S.-C.); (C.C.C.)
- Navarra Institute for Health Research (IdiSNA), Recinto de Complejo Hospitalario de Navarra C/Irunlarrea, 3, 31008 Pamplona, Navarra, Spain
- Correspondence:
| | - Juan José Pons Izquierdo
- ATLANTES Research Group, Institute for Culture and Society, University of Navarra, 31009 Pamplona, Navarra, Spain; (J.J.P.I.); (E.G.D.); (M.A.S.-C.); (C.C.C.)
- School of Humanities and Social Sciences, University of Navarra, 31009 Pamplona, Navarra, Spain
| | - Eduardo Garralda Domezain
- ATLANTES Research Group, Institute for Culture and Society, University of Navarra, 31009 Pamplona, Navarra, Spain; (J.J.P.I.); (E.G.D.); (M.A.S.-C.); (C.C.C.)
- Navarra Institute for Health Research (IdiSNA), Recinto de Complejo Hospitalario de Navarra C/Irunlarrea, 3, 31008 Pamplona, Navarra, Spain
| | - Miguel Antonio Sánchez-Cárdenas
- ATLANTES Research Group, Institute for Culture and Society, University of Navarra, 31009 Pamplona, Navarra, Spain; (J.J.P.I.); (E.G.D.); (M.A.S.-C.); (C.C.C.)
- Navarra Institute for Health Research (IdiSNA), Recinto de Complejo Hospitalario de Navarra C/Irunlarrea, 3, 31008 Pamplona, Navarra, Spain
| | - Carlos Centeno Cortés
- ATLANTES Research Group, Institute for Culture and Society, University of Navarra, 31009 Pamplona, Navarra, Spain; (J.J.P.I.); (E.G.D.); (M.A.S.-C.); (C.C.C.)
- Navarra Institute for Health Research (IdiSNA), Recinto de Complejo Hospitalario de Navarra C/Irunlarrea, 3, 31008 Pamplona, Navarra, Spain
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Underutilization of Palliative Care for Patients with Advanced Peripheral Arterial Disease. Ann Vasc Surg 2021; 76:211-217. [PMID: 34403753 DOI: 10.1016/j.avsg.2021.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Advanced peripheral arterial disease is associated with an overall annual mortality between 20-40%. Amputees are at particularly high risk for perioperative and long-term mortality and may benefit from palliative care programs to improve quality of life and to align medical treatments with their goals of care. As studies of palliative care in vascular patients are scarce, we sought to examine palliative care utilization using below knee amputation (BKA) as a surrogate for advanced peripheral arterial disease. METHODS All patients who underwent below knee amputation over a 5-year period at a single large academic medical center were identified through chart review. Demographics, preoperative conditions, intraoperative factors, and perioperative outcomes were recorded. The primary outcome was palliative care consultation at the time of the amputation. The secondary outcomes included one-year mortality and palliative care consultation prior to death. RESULTS The cohort comprised 111 patients (76 men, 35 women) who received BKA for chronic limb threatening ischemia. Three patients (2.7%) received palliative care consultations at the time of their amputation. Of these, one had been obtained remotely for an oncologic condition and the others for surgical decision-making. Follow-up was available for 73 patients. One-year mortality was 21.9% (n = 16) at a mean of 102 ± 86 days after BKA. Among patients who died within 1 year of their amputation, 37.5% (n = 6) received palliative care consultations prior to their death. The median interval between amputation and palliative consultation was 26 (IQR 14-81) days. The median interval between palliative consultation and death was 9 (IQR 4-39) days. CONCLUSION Palliative care services were rarely provided to patients with advanced peripheral arterial disease. When obtained, consultations occurred closer to death than to amputation suggesting a missed opportunity to receive the benefits of early evaluation. Future studies can be aimed at identifying a cohort of vascular patients who would most benefit from early palliative evaluation and determining if palliative consultations alter health care utilization patterns and outcomes for vascular patients.
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Evaluation of automated specialty palliative care in the intensive care unit: A retrospective cohort study. PLoS One 2021; 16:e0255989. [PMID: 34379687 PMCID: PMC8357176 DOI: 10.1371/journal.pone.0255989] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/28/2021] [Indexed: 01/31/2023] Open
Abstract
Introduction Automated specialty palliative care consultation (SPC) has been proposed as an intervention to improve patient-centered care in the intensive care unit (ICU). Existing automated SPC trigger criteria are designed to identify patients at highest risk of in-hospital death. We sought to evaluate common mortality-based SPC triggers and determine whether these triggers reflect actual use of SPC consultation. We additionally aimed to characterize the population of patients who receive SPC without meeting mortality-based triggers. Methods We conducted a retrospective cohort study of all adult ICU admissions from 2012–2017 at an academic medical center with five subspecialty ICUs to determine the sensitivity and specificity of the five most common SPC triggers for predicting receipt of SPC. Among ICU admissions receiving SPC, we assessed differences in patients who met any SPC trigger compared to those who met none. Results Of 48,744 eligible admissions, 1,965 (4.03%) received SPC; 979 (49.82%) of consultations met at least 1 trigger. The sensitivity and specificity for any trigger predicting SPC was 49.82% and 79.61%, respectively. Patients who met no triggers but received SPC were younger (62.71 years vs 66.58 years, mean difference (MD) 3.87 years (95% confidence interval (CI) 2.44–5.30) p<0.001), had longer ICU length of stay (11.43 days vs 8.42 days, MD -3.01 days (95% CI -4.30 –-1.72) p<0.001), and had a lower rate of in-hospital death (48.68% vs 58.12%, p<0.001). Conclusion Mortality-based triggers for specialty palliative care poorly reflect actual use of SPC in the ICU. Reliance on such triggers may unintentionally overlook an important population of patients with clinician-identified palliative care needs.
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Quinn KL, Stukel T, Huang A, Goldman R, Cram P, Detsky AS, Bell CM. Association Between Attending Physicians' Rates of Referral to Palliative Care and Location of Death in Hospitalized Adults With Serious Illness: A Population-based Cohort Study. Med Care 2021; 59:604-611. [PMID: 34100462 DOI: 10.1097/mlr.0000000000001524] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients who receive palliative care are less likely to die in hospital. OBJECTIVE To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness. RESEARCH DESIGN Population-based decedent cohort study using linked health administrative data in Ontario, Canada. SUBJECTS A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016. EXPOSURE Physician annual rate of referral to palliative care (high, average, low). MEASURES Odds of death in hospital versus home, adjusted for patient characteristics. RESULTS There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)]. CONCLUSIONS AND RELEVANCE An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.
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Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
| | - Thérèse Stukel
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | | | - Russell Goldman
- Interdepartmental Division of Palliative Care, Sinai Health System
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
| | - Allan S Detsky
- Department of Medicine, University of Toronto
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
| | - Chaim M Bell
- Department of Medicine, University of Toronto
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
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Islam JY, Saraiya V, Previs RA, Akinyemiju T. Health Care Access Measures and Palliative Care Use by Race/Ethnicity among Metastatic Gynecological Cancer Patients in the United States. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:6040. [PMID: 34199732 PMCID: PMC8200023 DOI: 10.3390/ijerph18116040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/30/2021] [Accepted: 06/02/2021] [Indexed: 12/25/2022]
Abstract
Palliative care improves quality-of-life and extends survival, however, is underutilized among gynecological cancer patients in the United States (U.S.). Our objective was to evaluate associations between healthcare access (HCA) measures and palliative care utilization among U.S. gynecological cancer patients overall and by race/ethnicity. We used 2004-2016 data from the U.S. National Cancer Database and included patients with metastatic (stage III-IV at-diagnosis) ovarian, cervical, and uterine cancer (n = 176,899). Palliative care was defined as non-curative treatment and could include surgery, radiation, chemotherapy, and pain management, or any combination. HCA measures included insurance type, area-level socioeconomic measures, distance-to-care, and cancer treatment facility type. We evaluated associations of HCA measures with palliative care use overall and by race/ethnicity using multivariable logistic regression. Our population was mostly non-Hispanic White (72%), had ovarian cancer (72%), and 24% survived <6 months. Five percent of metastatic gynecological cancer patients utilized palliative care. Compared to those with private insurance, uninsured patients with ovarian (aOR: 1.80,95% CI: 1.53-2.12), and cervical (aOR: 1.45,95% CI: 1.26-1.67) cancer were more likely to use palliative care. Patients with ovarian (aOR: 0.58,95% CI: 0.48-0.70) or cervical cancer (aOR: 0.74,95% CI: 0.60-0.88) who reside >45 miles from their provider were less likely to utilize palliative care than those within <2 miles. Ovarian cancer patients treated at academic/research programs were less likely to utilize palliative care compared to those treated at community cancer programs (aOR: 0.70, 95%CI: 0.58-0.84). Associations between HCA measures and palliative care utilization were largely consistent across U.S. racial-ethnic groups. Insurance type, cancer treatment facility type, and distance-to-care may influence palliative care use among metastatic gynecological cancer patients in the U.S.
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Affiliation(s)
- Jessica Y. Islam
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA;
- Cancer Epidemiology Program, Center for Immunization and Infection Research in Cancer (CIIRC), H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27701, USA
| | - Veeral Saraiya
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC 27514, USA;
| | - Rebecca A. Previs
- Division of Gynecological Oncology, Duke Cancer Institute, Durham, NC 27710, USA;
| | - Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27701, USA
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Rogers MM, Meier DE, Morrison RS, Moreno J, Aldridge M. Factors Associated with the Adoption and Closure of Hospital Palliative Care Programs in the United States. J Palliat Med 2021; 24:712-718. [PMID: 33058737 PMCID: PMC8064954 DOI: 10.1089/jpm.2020.0282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 11/13/2022] Open
Abstract
Background: In the United States, the percentage of hospitals over 50 beds with palliative care programs has risen substantially from 7% of hospitals in 2001 to 72% in 2017. Yet the dynamic nature of program adoption and closure over time is not known. Objective: To examine the rate of palliative care program adoption and closure and associated hospital and geographic characteristics in a national sample of U.S. hospitals. Design: Adoption and closure rates were calculated for 3696 U.S. hospitals between 2009 and 2017. We used multivariable logistic regression models to examine the association between adoption and closure status and hospital, geographic, and community characteristics. Setting/Subjects: All nonfederal general medical and surgical, cancer, heart, and obstetric or gynecological hospitals, of all sizes, in the United States in operation in both 2009 and 2017. Results: By 2017, 34.9% (812/2327) of the hospitals without palliative care in 2009 had adopted palliative care programs, and 15.0% (205/1369) of the hospitals with programs had closed them. In multivariable models, hospitals in metropolitan areas, nonprofit and public hospitals (compared to for-profit hospitals), and those with residency training approval by the Accreditation Council for Graduate Medical Education were significantly more likely to adopt and significantly less likely to close palliative care programs during the study period. Conclusions: This study indicates that palliative care is not equitably adopted nor sustained by hospitals in the United States. Federal and state interventions may be required to ensure that high-quality care is available to our nation's sickest patients.
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Affiliation(s)
- Maggie M. Rogers
- Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Diane E. Meier
- Center to Advance Palliative Care of the 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
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Melissa Aldridge
- 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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Triggers for Palliative Care Referral in Pediatric Oncology. Cancers (Basel) 2021; 13:cancers13061419. [PMID: 33808881 PMCID: PMC8003810 DOI: 10.3390/cancers13061419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Palliative care (PC) can improve the quality of life for pediatric cancer patients, yet these services remain underutilized, with referrals occurring late in the disease course or not at all. We previously described the patient and family characteristics that diverse pediatric oncology providers agree should be high yield triggers for PC referral in pediatric cancer patients. The current study examined how often those triggers were associated with a completed PC consult for a cohort of 931 patients. We discovered that PC referrals occur very infrequently and patients with stated triggers often do not get referred. These findings help support the need for a screening tool to standardize PC integration and improve care. Abstract Palliative care (PC) integration into the care of pediatric oncology patients is growing in acceptance and has been shown to improve the quality of life of children with cancer. Yet timing for referrals and referral practices remain inconsistent, and PC remains underutilized. We conducted a retrospective chart review of pediatric oncology patients treated at an academic institution between January 2015 to November 2018. Data collected included demographics, disease and therapy characteristics, and consultation notes, specifically documenting existence of predetermined “high yield triggers” for PC consultation. Among 931 eligible patients the prevalence of PC consultation was 5.6% while approximately 94% of patients had at least 1 trigger for PC consultation. The triggers that more often resulted in PC consultation included: symptom management needs (98%; n = 51) high-risk disease (86%; n = 45), poor prognosis (83%; n = 43), multiple lines of therapy (79%; n = 41) and a documented ICU admission (67%; n = 35). Our findings suggest that the high yield triggers for palliative care consultation that pediatric oncologists identify as important are not translating into practice; incorporating these triggers into a screening tool may be the next step to improve early PC integration.
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Sullivan CB, Al-Qurayshi Z, Chang K, Pagedar NA. Analysis of palliative care treatment among head and neck patients with cancer: National perspective. Head Neck 2020; 43:805-815. [PMID: 33151575 DOI: 10.1002/hed.26532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/13/2020] [Accepted: 10/23/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND To analyze the characteristics and survival patterns of patients with head and neck squamous cell carcinoma (SCC) who received palliative treatment during their first course of treatment. METHODS Cohort analysis utilizing the National Cancer Data Base (NCDB) of patients with a diagnosis of oral cavity/oropharyngeal, hypopharyngeal, and laryngeal SCC. Statistical analysis included multivariate logistic regression and Cox Hazard ratio modeling, and Kaplan-Meier survival analysis. RESULTS 165 081 patients were included, of which 2747 patients received palliative treatment. Patients who received palliative treatment tended to be ≥65 years old, black, Charlson/Deyo score ≥3, hypopharyngeal cancer, stage (III-IV), with Medicaid insurance (P < .05). Patients were more likely to be treated with palliative intent if they underwent chemotherapy/radiotherapy and declined surgery (P < .001) compared to patients who underwent surgery and declined chemotherapy/radiotherapy (P = .006). CONCLUSIONS Palliative care use in head and neck oncology is associated with older patients, non-whites, Medicaid patients, and nonsurgically treated patients.
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Affiliation(s)
- Christopher Blake Sullivan
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Zaid Al-Qurayshi
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Kristi Chang
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Nitin A Pagedar
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Hawkins-Taylor C, Mollman S, Walstrom B, Kerkvliet J, Minton M, Anderson D, Berke C. Perceptions of Palliative Care: Voices From Rural South Dakota. Am J Hosp Palliat Care 2020; 38:557-565. [DOI: 10.1177/1049909120953808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: This study aimed to explore health professional, patient, family, and caregiver perceptions of palliative care, availability of palliative care services to patients across South Dakota, and consistency and quality of palliative care delivery. Methods: Six focus groups were conducted over two months. Participants included interprofessional healthcare team members, patients, family members of patients, and caregivers. Individuals with palliative care experiences or interest in palliative care were invited to participate. Recruitment strategies included emails, flyers, and direct contact by members of the Network. Snowball sampling was used to recruit participants. Results: Forty-six participants included patients, family members, caregivers and interprofessional health care team members. Most participants were Caucasian (93.3%) and female (80%). Six primary themes emerged: Need for guidance toward the development of a holistic statewide palliative care model; Poor conceptual understanding and awareness; Insufficient resources to implement complete care in all South Dakota communities; Disparities in the availability and provision of care services in rural SD communities; Need for relationship and connection with palliative care team; and Secondary effects of palliative care on patients/family/caregivers and interprofessional healthcare team members. Significance of Results: Disproportionate access is a principle problem identified for palliative care in rural South Dakota. Palliative care is poorly understood by providers and recipients of care. Service reach is also tempered by lack of resources and payer reimbursement constraints. A model for palliative care in these rural communities requires concerted attention to their unique needs and design of services suited for the rural residents.
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Affiliation(s)
| | | | | | | | - Mary Minton
- South Dakota State University Brookings, SD, USA
| | - Debra Anderson
- University of Louisville School of Nursing, Louisville, KY, USA
| | - Charlene Berke
- Cancer Services Avera Cancer Institute, Mitchell, SD, USA
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Huo J, Hong YR, Turner K, Chen C, Guo Y, Wilkie DJ, Bian J. Geographic variation in palliative care delivery among patients diagnosed with metastatic lung cancer in the USA: Medicare population-based study. Support Care Cancer 2020; 29:813-821. [PMID: 32495033 DOI: 10.1007/s00520-020-05549-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/21/2020] [Indexed: 03/02/2023]
Abstract
PURPOSE The USA has observed a significant increase in the use of palliative care for patients diagnosed with advanced cancer. However, it is unknown how geographic variation affects patients' use of palliative care services. We examined temporal and demographic trends in receipt of and timing of palliative care by state and region. METHODS A retrospective cohort study of the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Study sample included community-dwelling patients aged ≥ 65 years with metastatic lung cancer who were diagnosed between 2001 and 2015. Cochran-Armitage trend test was used to evaluate temporal trends in receipt of and timing of palliative care by states and census region. RESULTS The proportion of metastatic lung cancer patients who received palliative care ranged from 16.4% in Washington and 16.3% in Connecticut to 6.4% in Louisiana. From 2001 to 2015, use of palliative care increased from 3.2 to 29.8% in the West region, from 3.3 to 31.9% in the Northeast region, from 3.8 to 36.2% in the Midwest region, and from 0.9 to 23.3% in the South region (all P < 0.001). The median time from the date of cancer diagnosis to the date of first palliative care visit varied geographically, from 44 days in Utah to 66 days in California. Hospital-based palliative care was most common in these states. CONCLUSION The substantial geographic variation in the use of palliative care suggesting a need for additional research on geographic disparities in palliative care and strategies that might improve state-level palliative care delivery.
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Affiliation(s)
- Jinhai Huo
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, 1225 Center Drive, HPNP 3111, PO Box 100195, Gainesville, FL, 32610, USA
| | - Young-Rock Hong
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, 1225 Center Drive, HPNP 3111, PO Box 100195, Gainesville, FL, 32610, USA.
| | - Kea Turner
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, 1225 Center Drive, HPNP 3111, PO Box 100195, Gainesville, FL, 32610, USA
| | - Cheng Chen
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Yi Guo
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Diana J Wilkie
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, FL, USA
| | - Jiang Bian
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
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Zeru T, Gerensea H, Berihu H, Zeru M, Wubayehu T. Nurses practice towards palliative care in Shire Endasilasie health facilities, Northern Ethiopia: a cross-sectional study. Pan Afr Med J 2020; 35:110. [PMID: 32637008 PMCID: PMC7321685 DOI: 10.11604/pamj.2020.35.110.18648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 09/11/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction The public health strategy of the World Health Organization for palliative care is to increase access to palliative care services by integrating it with the healthcare systems. Therefore, the value of palliative care service provision by nurses who deliver the majority of care to chronical patients is an important issue. The objective of the study is assessing nurses' practice of palliative care. Methods A facility based cross-sectional study was carried out among 278 nurses working in governmental health facilities of Shire Endasilasie town, Tigray region, Ethiopia from February to June 2018. The questionnaire was revised based on the findings of the pre-test. The collected data was checked for its completeness, consistency, and accuracy before analysis. Data were entered and analyzed using SPSS version 22. The final result was reported using text and tables. Results A total of 278 nurses were included in the study and the response rate was 100%. The majority of the participants (71.9%) were females and the mean age of the respondents was 32.08 years (range from 20 to 60). Approximately two-thirds (74.8%) of the respondents had poor knowledge of palliative care practice. Half of the study participants reported emotional support gained as primary psychological support. Commonly used drugs for severe pain were paracetamol or ibuprofen 202 (72.2%) and 47.8% nurses focus on quality patient pain assess. Conclusion The majority of the nurses had a poor practice of palliative care.
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Affiliation(s)
- Teklay Zeru
- Department of Pediatric Nursing, School of Nursing, College of Health Science and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia
| | - Hadgu Gerensea
- Department of Pediatric Nursing, School of Nursing, College of Health Science and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia
| | - Hagos Berihu
- Department of Maternity and Reproductive Health, School of Nursing, College of Health Science and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia
| | - Mebrahtom Zeru
- Department of Biomedical Science, College of Health Sciences, Adigrat University, Adigrat, Tigray, Ethiopia
| | - Tewolde Wubayehu
- Department of Pediatrics, School of Medicine, College of Health Science and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia
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Kross EK, Rosenberg AR, Engelberg RA, Curtis JR. Postdoctoral Research Training in Palliative Care: Lessons Learned From a T32 Program. J Pain Symptom Manage 2020; 59:750-760.e8. [PMID: 31775020 PMCID: PMC7029795 DOI: 10.1016/j.jpainsymman.2019.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 12/20/2022]
Abstract
Our aging population and advances in chronic disease management that prolong the time that patients live with a chronic illness have combined to create an enormous need for improved palliative care research across diverse diseases. In this article, we describe the structure and processes of a National Institutes of Health-funded T32 postdoctoral research fellowship at the University of Washington and our experiences in developing and implementing the program. We recognize a broad definition of palliative care research, including research focused on improving quality of life, minimizing symptoms, providing psychological and spiritual support, and improving communication about patients' values and goals of care, all in the context of a serious illness. We describe our four core principles for postdoctoral training in palliative care research, each with a number of specific approaches: 1) mastering a set of essential content and research skills; 2) structured mentoring and academic career development; 3) creating and supporting early success; and 4) interdisciplinary training and team science. In addition, we also describe our framework for the essential competencies necessary for a palliative care research training program, our methods for identification and selection of applicants, our outcomes to date, and our processes of continuous quality assessment and improvement. Our goal is to describe our successful postdoctoral research training program in palliative care to promote development of new programs and share information between programs to continue to build the field of collaborative and interdisciplinary palliative care research.
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Affiliation(s)
- Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Abby R Rosenberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Hematology/Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.
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Santivasi WL, Partain DK, Whitford KJ. The role of geriatric palliative care in hospitalized older adults. Hosp Pract (1995) 2020; 48:37-47. [PMID: 31825689 DOI: 10.1080/21548331.2019.1703707] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/10/2019] [Indexed: 06/10/2023]
Abstract
Take-Away Points:1. Geriatric palliative care requires integrating the disciplines of hospital medicine and palliative care in pursuit of delivering comprehensive, whole-person care to aging patients with serious illnesses.2. Older adults have unique palliative care needs compared to the general population, different prevalence and intensity of symptoms, more frequent neuropsychiatric challenges, increased social needs, distinct spiritual, religious, and cultural considerations, and complex medicolegal and ethical issues.3. Hospital-based palliative care interdisciplinary teams can take many forms and provide high-quality, goal-concordant care to older adults and their families.
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Affiliation(s)
- Wil L Santivasi
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel K Partain
- Center for Palliative Medicine & Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kevin J Whitford
- Center for Palliative Medicine & Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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25
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Bekelman DB, Fink RM, Sannes T, Kline DM, Borrayo EA, Turvey C, Fischer SM. Puente para cuidar (bridge to caring): A palliative care patient navigator and counseling intervention to improve distress in Latino/as with advanced cancer. Psychooncology 2019; 29:688-695. [DOI: 10.1002/pon.5313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/01/2019] [Accepted: 12/08/2019] [Indexed: 12/17/2022]
Affiliation(s)
- David B. Bekelman
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
- Department of MedicineEastern Colorado Health Care System, VA Aurora Colorado
| | - Regina M. Fink
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
| | - Timothy Sannes
- Division of Psychosocial Oncology and Palliative CareDana Farber Cancer Institute Boston Massachusetts
| | - Danielle M. Kline
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
| | - Evelinn A. Borrayo
- Department of Community and Behavioral Health, Colorado School of Public HealthUniversity of Colorado Denver Colorado
| | - Carolyn Turvey
- Carver College of MedicineUniversity of Iowa Iowa City Iowa
| | - Stacy M. Fischer
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
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Mistry NA, Raza SJ, Siddiqui SA. Analysis of Inpatient Palliative Care Consultations for Patients With Metastatic Prostate Cancer. Am J Hosp Palliat Care 2019; 37:136-141. [DOI: 10.1177/1049909119864576] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objective: To characterize the use of palliative care for patients with metastatic prostate cancer and identify its associations with costs, hospital course, and discharge. Materials and Methods: Using the National Inpatient Sample database from 2012 to 2013, we identified 99 070 patients with metastatic prostate cancer and analyzed the data from their hospital admissions using descriptive statistics, χ2 analysis, and regression modeling. Results: Palliative care services were consulted in 10.4% (10 300) of metastatic prostate cancer admissions. These admissions were associated with nonelective origin, acute complications, and reduced surgical procedures and chemotherapy. Patients in private, investor-owned hospitals had a 51.6% less consultations ( P < .001), while nonprofit and government, nonfederal hospitals had 4.7% and 7.8% more consultations ( P < .001). Median costs and charges were only marginally less (2.1% and 5.6%, respectively, P < .001), length of stay was 22% higher ( P < .001), and in-house mortality was 147.2% higher in the consultation group ( P < .001). Controlling for other factors, patients seen by palliative care were more likely to have do-not-resuscitate orders (odds ratio [OR]: 5.25, P < .001) and be transferred to another facility like hospice (OR: 3.90, P < .001) or to home health (OR: 3.85, P < .001). Conclusions: Palliative care consultation could improve care for patients with metastatic prostate cancer in a different manner than observed in other diseases. With our characterization of the incidence and patient and hospital factors, we can conclude that there is room to expand palliative care’s role beyond uninsured patients in large, urban teaching hospitals.
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Affiliation(s)
- Neil A. Mistry
- College for Public Health and Social Justice, St Louis University, St Louis, MO, USA
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Xu MJ, Su D, Deboer R, Garcia M, Tahir P, Anderson W, Kinderman A, Braunstein S, Sherertz T. Palliative Oncologic Care Curricula for Providers in Resource-Limited and Underserved Communities: a Systematic Review. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2019; 34:205-215. [PMID: 29264703 DOI: 10.1007/s13187-017-1310-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Familiarity with principles of palliative care, supportive care, and palliative oncological treatment is essential for providers caring for cancer patients, though this may be challenging in global communities where resources are limited. Herein, we describe the scope of literature on palliative oncological care curricula for providers in resource-limited settings. A systematic literature review was conducted using PubMed, Embase, Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Med Ed Portal databases, and gray literature. All available prospective cohort studies, case reports, and narratives published up to July 2017 were eligible for review. Fourteen articles were identified and referenced palliative care education programs in Argentina, Uganda, Kenya, Australia, Germany, the USA, or multiple countries. The most common teaching strategy was lecture-based, followed by mentorship and experiential learning involving role play and simulation. Education topics included core principles of palliative care, pain and symptom management, and communication skills. Two programs included additional topics specific to the underserved or American Indian/Alaskan Native community. Only one program discussed supportive cancer care, and no program reported educational content on resource-stratified decision-making for palliative oncological treatment. Five programs reported positive participant satisfaction, and three programs described objective metrics of increased educational or research activity. There is scant literature on effective curricula for providers treating cancer patients in resource-limited settings. Emphasizing supportive cancer care and palliative oncologic treatments may help address gaps in education; increased outcome reporting may help define the impact of palliative care curriculum within resource-limited communities.
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Affiliation(s)
- Melody J Xu
- Department of Radiation Oncology, University of California San Francisco, 1600 Divisadero St, San Francisco, CA, 94115, USA
- International Cancer Expert Corps, New York, NY, USA
| | - David Su
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rebecca Deboer
- Department of Internal Medicine, Division of Hematology/Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Michael Garcia
- Department of Radiation Oncology, University of California San Francisco, 1600 Divisadero St, San Francisco, CA, 94115, USA
| | - Peggy Tahir
- Department of Library, University of California San Francisco, San Francisco, CA, USA
| | - Wendy Anderson
- Department of Internal Medicine, Division of Hospital Medicine and Palliative Care, University of California San Francisco, San Francisco, CA, USA
| | - Anne Kinderman
- Department of Internal Medicine, Division of Hospital Medicine and Palliative Care, University of California San Francisco, San Francisco, CA, USA
- Supportive and Palliative Care Service, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Steve Braunstein
- Department of Radiation Oncology, University of California San Francisco, 1600 Divisadero St, San Francisco, CA, 94115, USA
| | - Tracy Sherertz
- Department of Radiation Oncology, University of California San Francisco, 1600 Divisadero St, San Francisco, CA, 94115, USA.
- International Cancer Expert Corps, New York, NY, USA.
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The Development of Pathways in Palliative Medicine: Definition, Models, Cost and Quality Impact. Healthcare (Basel) 2019; 7:healthcare7010022. [PMID: 30717281 PMCID: PMC6473403 DOI: 10.3390/healthcare7010022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 01/31/2019] [Indexed: 01/23/2023] Open
Abstract
Palliative Care and its medical subspecialty, known as Palliative Medicine, is the care of anyone with a serious illness. This emerging field includes Hospice and comfort care, however, it is not limited to end-of-life care. Examples of the types of serious illness that Palliative Medicine clinicians care for include and are not limited to hematologic and oncologic diseases, such as cancer, advanced heart and lung diseases (e.g., congestive heart failure and chronic obstructive pulmonary disorder), advanced liver and kidney diseases, and advanced neurologic illnesses (e.g., Alzheimer’s and Parkinson’s disease). In the past decade, there has been tremendous growth of Palliative Medicine programs across the country. As the population of patients with serious illnesses increases, there is growing concentration on quality of care, including symptom management, meeting patients’ goals regarding their medical care and providing various types of support, all of which are provided by Palliative Medicine. In this review article we define Palliative Medicine, describe care pathways and their applicability to Palliative Medicine, identify different models for Palliative Care and provide evidence for its impact on cost and quality of care.
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Assareh H, Stubbs JM, Trinh LTT, Greenaway S, Agar M, Achat HM. Variations in hospital inpatient palliative care service use: a retrospective cohort study. BMJ Support Palliat Care 2018; 10:e27. [PMID: 30409775 DOI: 10.1136/bmjspcare-2018-001578] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/26/2018] [Accepted: 10/03/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Use of palliative care in hospitals for people at end of life varies. We examined rate and time of in-hospital palliative care use and associated interhospital variations. METHODS We used admissions from all hospitals in New South Wales, Australia, within a 12-month period, for a cohort of adults who died in 73 public acute care hospitals between July 2010 and June 2014. Receiving palliative care and its timing were based on recorded use. RESULTS Among 90 696 adults who died, 27% received palliative care, and the care was initiated 7.6 days (mean; SD: 3.3 days) before death. Over the 5-year period, the palliative care rate rose by 58%, varying extent across chronic conditions. The duration of palliative care before death declined by 7%. Patient (demographics, morbidities and service use) and hospital factors (size, location and availability of palliative care unit) explained half of the interhospital variation in outcomes: adjusted IQR in rate and duration of palliative care among hospitals were 23%-39% and 5.2-8.7 days, respectively. Hospitals with higher rates often initiated palliative care earlier (correlation: 0.39; p<0.01). CONCLUSION Despite an increase over time in the palliative care rate, its initiation was late and of brief duration. Palliative care use was associated with patient and hospital characteristics; however, half of the between hospital variation remained unexplained. The observed suboptimal practices and variability indicate the need for expanded and standardised use of palliative care supported by assessment tools, service enhancement and protocols.
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Affiliation(s)
- Hassan Assareh
- Epidemiology and Health Analytics, Western Sydney Local Health District, North Parramatta, New South Wales, Australia
| | - Joanne M Stubbs
- Epidemiology and Health Analytics, Western Sydney Local Health District, North Parramatta, New South Wales, Australia
| | - Lieu T T Trinh
- Epidemiology and Health Analytics, Western Sydney Local Health District, North Parramatta, New South Wales, Australia
| | - Sally Greenaway
- Western Sydney Local Health District, Westmead Hospital, Westmead, New South Wales, Australia
| | - Meera Agar
- South Western Sydney Local Health District, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia.,Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Helen M Achat
- Epidemiology and Health Analytics, Western Sydney Local Health District, North Parramatta, New South Wales, Australia
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Sheckter CC, Hung KS, Rochlin D, Maan Z, Karanas Y, Curtin C. Trends and inpatient outcomes for palliative care services in major burn patients: A 10-year analysis of the nationwide inpatient sample. Burns 2018; 44:1903-1909. [PMID: 30115531 DOI: 10.1016/j.burns.2018.07.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/18/2018] [Accepted: 07/26/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite advances in critical care and the surgical management of major burns, highly moribund patients are unlikely to survive. Little is known regarding the utilization and effects of palliative care services in this population. METHODS All major burn hospitalizations were identified within the Nationwide Inpatient Sample. Patients were characterized by burn, demographic, facility, and diseases factors. Palliative care services were identified with International Classification Disease 9th edition code V6.67. Temporal trends were assessed with Poisson modeling. Inpatient mortality and death without surgical intervention were assessed with logistic regression. Outcomes were stratified by modified Baux scores. RESULTS 7424 major burns were included; 1.9% received palliative care services. Patients receiving palliation had a mean age of 63.6 years (SD 19.6), mean total body surface area of 62.2% (SD 24.9%), and mean modified Baux score of 127.1 (SD 26.7). Adjusting for covariates, the incidence rate ratio was 1.42 over the 10-year period (95% CI, 1.31-1.54, p<0.001). Independent predictors of palliative consultations included older age, larger burns, deeper burns, and higher Elixhauser comorbidity score. Among patients with modified Baux scores between 100-153, those receiving palliative care services were significantly more likely to die without surgery, OR 3.24 (95% CI 1.13-10.39, p=0.029), with no significant difference in mortality, OR 11.72 (95% CI 0.87-22.57, p=0.051) CONCLUSION AND RELEVANCE: Palliative care services were increasingly used during the study period. Palliative care services in highly moribund burn patients do not impact survival and may decrease the likelihood of surgical intervention in select patients.
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Affiliation(s)
- Clifford C Sheckter
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University, Stanford, CA, United States.
| | - Kay S Hung
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States
| | - Danielle Rochlin
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University, Stanford, CA, United States
| | - Zeshaan Maan
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States
| | - Yvonne Karanas
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Santa Clara Valley Medical Center-Regional Burn Center, San Jose, CA, United States
| | - Catherine Curtin
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Division of Plastic Surgery, Palo Alto Veterans Affairs, Palo Alto, CA, United States
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32
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Osagiede O, Colibaseanu DT, Spaulding AC, Frank RD, Merchea A, Kelley SR, Uitti RJ, Ailawadhi S. Palliative Care Use Among Patients With Solid Cancer Tumors: A National Cancer Data Base Study. J Palliat Care 2018; 33:149-158. [PMID: 29807486 DOI: 10.1177/0825859718777320] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Palliative care has been increasingly recognized as an important part of cancer care but remains underutilized in patients with solid cancers. There is a current gap in knowledge regarding why palliative care is underutilized nationwide. OBJECTIVE To identify the factors associated with palliative care use among deceased patients with solid cancer tumors. METHODS Using the 2016 National Cancer Data Base, we identified deceased patients (2004-2013) with breast, colon, lung, melanoma, and prostate cancer. Data were described as percentages. Associations between palliative care use and patient, facility, and geographic characteristics were evaluated through multivariate logistic regression. RESULTS A total of 1 840 111 patients were analyzed; 9.6% received palliative care. Palliative care use was higher in the following patient groups: survival >24 months (17% vs 2%), male (54% vs 46%), higher Charlson-Deyo comorbidity score (16% vs 8%), treatment at designated cancer programs (74% vs 71%), lung cancer (76% vs 28%), higher grade cancer (53% vs 24%), and stage IV cancer (59% vs 13%). Patients who lived in communities with a greater percentage of high school degrees had higher odds of receiving palliative care; Central and Pacific regions of the United States had lower odds of palliative care use than the East Coast. Patients with colon, melanoma, or prostate cancer had lower odds of palliative care than patients with breast cancer, whereas those with lung cancer had higher odds. CONCLUSIONS Palliative care use in solid cancer tumors is variable, with a preference for patients with lung cancer, younger age, known insurance status, and higher educational level.
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Affiliation(s)
- Osayande Osagiede
- 1 Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | | | - Aaron C Spaulding
- 1 Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Ryan D Frank
- 3 Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Amit Merchea
- 2 Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Scott R Kelley
- 4 Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ryan J Uitti
- 5 Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Sikander Ailawadhi
- 6 Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
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Colibaseanu DT, Osagiede O, Spaulding AC, Frank RD, Merchea A, Mathis KL, Parker AS, Ailawadhi S. The Determinants of Palliative Care Use in Patients With Colorectal Cancer: A National Study. Am J Hosp Palliat Care 2018; 35:1295-1303. [PMID: 29580075 DOI: 10.1177/1049909118765092] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Palliative care is associated with improved survival and quality of life, but its use among patients with colorectal cancer varies nationwide and the determinants of those variations are not clear. OBJECTIVE To determine the factors associated with palliative care use among patients who died of colorectal cancer. METHODS Deceased patients treated for colorectal cancer (2004-2013) were identified within the National Cancer Database. Multivariable logistic regression was used to evaluate patient and institutional characteristics associated with palliative care use. Patients were classified based on their length of survival (<6 months, 6-24 months, and 24+ months) to provide timing context. RESULTS A total of 287 923 patients were analyzed. Overall, 4.3% of the patients received palliative care. Patients who received palliative care were more likely to be younger, recently diagnosed, treated at academic hospitals, and have stage IV disease. Patients living in Mountain and Pacific regions had higher odds of palliative care receipt than those in the East Coast. Patients without insurance had higher odds of palliative care if they survived <24 months. Insurance coverage through Medicaid was associated with increased palliative care use among patients who survived 6 to 24 months. Patients who survived <6 months and lived >9 miles from the institution received more palliative care. CONCLUSION Palliative care use among patients with colorectal cancer is associated with a younger age, a more recent year of diagnosis, insurance status, academic hospitals, and living in Mountain and Pacific regions.
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Affiliation(s)
| | - Osayande Osagiede
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Aaron C Spaulding
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Ryan D Frank
- 3 Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Amit Merchea
- 1 Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Kellie L Mathis
- 4 Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alexander S Parker
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Sikander Ailawadhi
- 5 Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA
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Chen IH, Lin KY, Hu SH, Chuang YH, Long CO, Chang CC, Liu MF. Palliative care for advanced dementia: Knowledge and attitudes of long-term care staff. J Clin Nurs 2017; 27:848-858. [PMID: 29076605 DOI: 10.1111/jocn.14132] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 01/12/2023]
Abstract
AIMS AND OBJECTIVES To investigate the knowledge of and attitudes towards palliative care for advanced dementia and their associations with demographics among nursing staff, including nurses and nursing assistants, in long-term care settings. BACKGROUND Nursing facilities are places where persons with dementia die; therefore, providing quality end-of-life care to residents with advanced dementia is crucial. To date, little attention has been paid to palliative care practice for patients with advanced dementia. DESIGN A descriptive, cross-sectional, survey design was used. METHODS In total, a sample of 300 nurses (n = 125) and nursing assistants (n = 175) working in long-term care settings in Taiwan participated in this study. Two instruments were administered: demographic characteristics and responses to the Questionnaire of Palliative Care for Advanced Dementia. Descriptive statistics and multiple regression were used for data analysis. RESULTS Overall, the nurses and nursing assistants had moderate mean scores for both knowledge of and attitudes regarding palliative care for advanced dementia. Additionally, nursing staff who were nurses with greater work experience and those who had received palliative care and hospice training had greater knowledge of palliative care. In addition, nursing staff who had received dementia care training and who had worked in nursing homes had higher levels of positive attitudes towards palliative care. CONCLUSIONS This study indicates the need to provide nurses and nursing assistants with more information about palliative care practice for people with advanced dementia. Particularly, providing education to those who are nursing assistants, who have less working experience, who have not received palliative and dementia care training, and who have not worked in nursing homes can improve overall nursing staff knowledge of and attitudes towards palliative care. RELEVANCE TO CLINICAL PRACTICE Continuing education in principles of palliative care for advanced dementia is necessary for currently practicing nursing staff and should be developed according to their educational background and needs.
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Affiliation(s)
- I-Hui Chen
- Master Program of Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Kuan-Yu Lin
- Furoto Medical & Welfare Co., Ltd., Taipei, Taiwan
| | - Sophia H Hu
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Yeu-Hui Chuang
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan.,School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Carol O Long
- Capstone Healthcare, Palliative Care Essentials, Phoenix, AZ, USA.,Transcultural Nursing Society, Phoenix, AZ, USA.,College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Chia-Chi Chang
- School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Megan F Liu
- School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan
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Abstract
Palliative care demonstrably improves quality of life for the seriously ill in a manner that averts preventable health crises and their associated costs. Because of these outcomes, palliative care is now broadening its reach beyond hospitals, and hospice care for those near death, to patients and their families living in the community with chronic multimorbidities that have uncertain or long expected survival. In this article, we address research needed to enable policies supportive of palliative care access and quality, including changes in regulatory, accreditation, financing, and training approaches in the purview of policy makers. Mr. K. is an 86-year-old male with multimorbidities, including severe chronic obstructive pulmonary disease, congestive heart failure, peripheral vascular disease, and atrial fibrillation requiring anticoagulation therapy. He fell in his mobile home and was unable to reach the telephone to call for help. Six hours later, his neighbor found him lying on the bedroom floor in pain and confused, and called 911. On examination, he was found to have a cold blue foot complicated by a large hematoma. The vascular surgery service was consulted to evaluate Mr. K. for revascularization or amputation. Although Mr. K. had several risk factors complicating his candidacy for general anesthesia, the team thought the benefits of surgery would outweigh the risks. Mr. K's daughter agreed to surgery telling her father "the doctors know best." Mr. K. replied "I just want to be out of pain." Six months later, Mr. K. remains in a skilled nursing facility due to post-op complications, including pneumonia, worsened confusion, and the inability to recover to enough function to live safely at home. He now suffers from depression, cognitive deficits, and social isolation. His daughter has had to take on a second job because she is struggling to pay for his continued long-term care, which costs $6000 per month. Money she had saved for her own retirement and her daughter's college tuition is already gone. In retrospect, she realizes the surgical team did not discuss the possibility of his survival with chronic debility and long-term functional dependency, nor the fact that Medicare would not pay for the care he now requires.
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Affiliation(s)
- Lynn F. Reinke
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services R&D, Seattle, Washington
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington
| | - Diane E. Meier
- Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
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Bainbridge D, Seow H. Palliative Care Experience in the Last 3 Months of Life: A Quantitative Comparison of Care Provided in Residential Hospices, Hospitals, and the Home From the Perspectives of Bereaved Caregivers. Am J Hosp Palliat Care 2017; 35:456-463. [PMID: 28610431 PMCID: PMC5794103 DOI: 10.1177/1049909117713497] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective: This study captured the end-of-life care experiences across various settings from bereaved caregivers of individuals who died in residential hospice. Methods: A retrospective, observational design using the CaregiverVoice survey with bereaved caregivers of patients in 22 hospices in Ontario, Canada. The survey assessed various dimensions of the patient’s care experiences across multiple care settings in the last 3 months of life. Results: A total of 1153 caregivers responded to the survey (44% response rate). In addition to hospice care, caregivers reported that 74% of patients received home care, 61% had a hospitalization, 42% received care at a cancer center, and 10% lived in a nursing home. Most caregivers (84%-89%) rated the addressing of each support domain (relief of physical pain, relief of other symptoms, spiritual support, and emotional support) by hospice as either “excellent” or “very good.” These proportions were less favorable for home care (40%-47%), cancer center (46%-54%), and hospital (37%-48%). Significantly, better experiences were reported for the last week of life where hospice was considered the main setting of care, opposed to other settings (P < .0001 across domains). Overall, across settings pain management tended to be the highest-rated domain and spiritual support the lowest. Conclusion: This is one of few quantitative examinations of the care experience of patients who accessed multiple care settings in the last months of life and died in a specialized setting such as residential hospice. These findings emphasize the importance of replicating the hospice approach in institutional and home settings, including greater attention to emotional and spiritual dimensions of care.
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Affiliation(s)
- Daryl Bainbridge
- 1 Department of Oncology, McMaster University, Hamilton, Ontario, Canada.,2 Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Hsien Seow
- 1 Department of Oncology, McMaster University, Hamilton, Ontario, Canada.,2 Juravinski Cancer Centre, Hamilton, Ontario, Canada.,3 Escarpment Cancer Research Institute, Hamilton, Ontario, Canada
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Chavehpour Y, Rashidian A, Raghfar H, Emamgholipour Sefiddashti S, Maroofi A. 'Seeking affluent neighbourhoods?' a time-trend analysis of geographical distribution of hospitals in the Megacity of Tehran. Health Policy Plan 2017; 32:669-675. [PMID: 28453720 DOI: 10.1093/heapol/czw172] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Access to hospitals in megacities in low and middle income countries might be hampered by travel barriers and distance. We assessed the 'inverse care law' hypothesis: whether hospitals tended to be built in the relatively better-off areas through the time. METHODS A longitudinal time-series study (1966 to 2011) in Tehran to measure inequality in the distribution of hospital beds. We assessed correlations between the district socioeconomic status and availability of hospital beds via regression analyses, estimated correlation, Gini and concentration indices, and used GIS models to map hospital distributions through time. FINDING We found a clear relationship between socioeconomic status and number of hospital beds per capita ( P -values <0.05). Gini coefficients were about 0.6 and 0.8 for public and private beds, respectively. A third of the variations in hospital bed distribution was explained by the welfare status of the district. For every extra residential room per capita, 130 to 280 extra beds were observed per ten thousand population at the district level. In 2011, out of 162 hospitals, 110 were located in six districts around the centre and northern part of the city. During the time period only two private hospitals were built in relatively disadvantaged districts. CONCLUSION Over a period of about fifty years new hospitals had been established in the relatively affluent areas of the city and the relationship between socioeconomic status of district with total, private and public beds were direct and intensive. Results indicate the problem of inequality may remain over time and be resistant to policy initiatives and major political changes.
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Affiliation(s)
- Yousef Chavehpour
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Raghfar
- Department of Economics, Faculty of Social Sciences and Economics, Alzahra University, Tehran, Iran
| | - Sara Emamgholipour Sefiddashti
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Aiub Maroofi
- Department of Geography, Faculty of Earth Sciences, Shahid Beheshti University, Tehran, Iran
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Anderson KG. Adverse Childhood Environment: Relationship With Sexual Risk Behaviors and Marital Status in a Large American Sample. EVOLUTIONARY PSYCHOLOGY 2017; 15:1474704917710115. [PMID: 28580807 PMCID: PMC10481121 DOI: 10.1177/1474704917710115] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 03/28/2017] [Indexed: 09/09/2023] Open
Abstract
A substantial theoretical and empirical literature suggests that stressful events in childhood influence the timing and patterning of subsequent sexual and reproductive behaviors. Stressful childhood environments have been predicted to produce a life history strategy in which adults are oriented more toward short-term mating behaviors and less toward behaviors consistent with longevity. This article tests the hypothesis that adverse childhood environment will predict adult outcomes in two areas: risky sexual behavior (engagement in sexual risk behavior or having taken an HIV test) and marital status (currently married vs. never married, divorced, or a member of an unmarried couple). Data come from the Behavioral Risk Factor Surveillance System. The sample contains 17,530 men and 23,978 women aged 18-54 years living in 13 U.S. states plus the District of Columbia. Adverse childhood environment is assessed through 11 retrospective measures of childhood environment, including having grown up with someone who was depressed or mentally ill, who was an alcoholic, who used or abused drugs, or who served time in prison; whether one's parents divorced in childhood; and two scales measuring childhood exposure to violence and to sexual trauma. The results indicate that adverse childhood environment is associated with increased likelihood of engaging in sexual risk behaviors or taking an HIV test, and increased likelihood of being in an unmarried couple or divorced/separated, for both men and women. The predictions are supported by the data, lending further support to the hypothesis that childhood environments influence adult reproductive strategy.
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Gray SW, Kim B, Sholl L, Cronin A, Parikh AR, Klabunde CN, Kahn KL, Haggstrom DA, Keating NL. Medical Oncologists' Experiences in Using Genomic Testing for Lung and Colorectal Cancer Care. J Oncol Pract 2017; 13:e185-e196. [PMID: 28095174 PMCID: PMC5456256 DOI: 10.1200/jop.2016.016659] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Genomic testing improves outcomes for many at-risk individuals and patients with cancer; however, little is known about how genomic testing for non-small-cell lung cancer (NSCLC) and colorectal cancer (CRC) is used in clinical practice. PATIENTS AND METHODS In 2012 to 2013, we surveyed medical oncologists who care for patients in diverse practice and health care settings across the United States about their use of guideline- and non-guideline-endorsed genetic tests. Multivariable regression models identified factors that are associated with greater test use. RESULTS Of oncologists, 337 completed the survey (participation rate, 53%). Oncologists reported higher use of guideline-endorsed tests (eg, KRAS for CRC; EGFR for NSCLC) than non-guideline-endorsed tests (eg, Onco typeDX Colon; ERCC1 for NSCLC). Many oncologists reported having no patients with CRC who had mismatch repair and/or microsatellite instability (24%) or germline Lynch syndrome (32%) testing, and no patients with NSCLC who had ALK testing (11%). Of oncologists, 32% reported that five or fewer patients had KRAS and EGFR testing for CRC and NSCLC, respectively. Oncologists, rather than pathologists or surgeons, ordered the vast majority of tests. In multivariable analyses, fewer patients in nonprofit integrated health care delivery systems underwent testing than did patients in hospital or office-based single-specialty group settings (all P < .05). High patient volume and patient requests (CRC only) were also associated with higher test use (all P < .05). CONCLUSION Genomic test use for CRC and NSCLC varies by test and practice characteristics. Research in specific clinical contexts is needed to determine whether the observed variation reflects appropriate or inappropriate care. One potential way to reduce unwanted variation would be to offer widespread reflexive testing by pathology for guideline-endorsed predictive somatic tests.
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Affiliation(s)
- Stacy W. Gray
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Benjamin Kim
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Lynette Sholl
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Angel Cronin
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Aparna R. Parikh
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Carrie N. Klabunde
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Katherine L. Kahn
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - David A. Haggstrom
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Nancy L. Keating
- City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women’s Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN
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Spencer KL, Hammad Mrig E, Matlock DD, Kessler ER. A Qualitative Investigation of Cross-domain Influences on Medical Decision Making and the Importance of Social Context for Understanding Barriers to Hospice Use. ACTA ACUST UNITED AC 2017. [DOI: 10.1177/1936724417692377] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Hospice utilization has the potential to improve quality of life for patients while also decreasing healthcare costs at end of life. Barriers to hospice utilization have been identified, but less is known about how patient, provider, and system domains influence one another. We use in-depth interviews with physicians to examine the social, cultural, and economic contexts of decision making and how physician and organizational domains influence patient decision making around hospice. We identify sources of delay in physicians advocating for hospice referrals for their late-life patients that show how patient, physician, and system factors interact. Our results reveal incentives to postpone discussion of hospice that are not fully captured in policy perspectives, clinical guidelines, or current research paradigms focused on individual domains of influence. Opportunities to address previously identified barriers to hospice will benefit from consideration of how seemingly separate domains function in an integrated social context.
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Zalenski RJ, Jones SS, Courage C, Waselewsky DR, Kostaroff AS, Kaufman D, Beemath A, Brofman J, Castillo JW, Krayem H, Marinelli A, Milner B, Palleschi MT, Tareen M, Testani S, Soubani A, Walch J, Wheeler J, Wilborn S, Granovsky H, Welch RD. Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project. J Pain Symptom Manage 2017; 53:5-12.e3. [PMID: 27720791 DOI: 10.1016/j.jpainsymman.2016.08.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/12/2016] [Accepted: 08/03/2016] [Indexed: 11/22/2022]
Abstract
CONTEXT There are few multicenter studies that examine the impact of systematic screening for palliative care and specialty consultation in the intensive care unit (ICU). OBJECTIVE To determine the outcomes of receiving palliative care consultation (PCC) for patients who screened positive on palliative care referral criteria. METHODS In a prospective quality assurance intervention with a retrospective analysis, the covariate balancing propensity score method was used to estimate the conditional probability of receiving a PCC and to balance important covariates. For patients with and without PCCs, outcomes studied were as follows: 1) change to "do not resuscitate" (DNR), 2) discharge to hospice, 3) 30-day readmission, 4) hospital length of stay (LOS), 5) total direct hospital costs. RESULTS In 405 patients with positive screens, 161 (40%) who received a PCC were compared to 244 who did not. Patients receiving PCCs had higher rates of DNR-adjusted odds ratio (AOR) = 7.5; 95% CI 5.6-9.9) and hospice referrals-(AOR = 7.6; 95% CI 5.0-11.7). They had slightly lower 30-day readmissions-(AOR = 0.7; 95% CI 0.5-1.0); no overall difference in direct costs or LOS was found between the two groups. When patients receiving PCCs were stratified by time to PCC initiation, early consultation-by Day 4 of admission-was associated with reductions in LOS (1.7 days [95% CI -3.1, -1.2]) and average direct variable costs (-$1815 [95% CI -$3322, -$803]) compared to those who received no PCC. CONCLUSION Receiving a PCC in the ICUs was significantly associated with more frequent DNR code status and hospice referrals, but not 30-day readmissions or hospital utilization. Early PCC was associated with significant LOS and direct cost reductions. Providing PCC early in the ICU should be considered.
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Affiliation(s)
- Robert J Zalenski
- Wayne State University, Detroit, Michigan, USA; Tenet Healthcare, Dallas, Texas, USA.
| | | | | | | | | | | | | | | | | | | | | | | | - Maria Teresa Palleschi
- DMC Harper Hospital, Detroit, Michigan, USA; American Hospital Dubai, United Arab Emirates
| | - Mona Tareen
- American Hospital Dubai, United Arab Emirates
| | | | | | - Julie Walch
- Detroit Medical Center, Detroit, Michigan, USA
| | | | - Sonali Wilborn
- Detroit Medical Center, Detroit, Michigan, USA; Seasons Hospice and Palliative Care, Madison Heights, Michigan, USA
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Obermeyer Z, Powers BW, Makar M, Keating NL, Cutler DM. Physician Characteristics Strongly Predict Patient Enrollment In Hospice. Health Aff (Millwood) 2016; 34:993-1000. [PMID: 26056205 DOI: 10.1377/hlthaff.2014.1055] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Individual physicians are widely believed to play a large role in patients' decisions about end-of-life care, but little empirical evidence supports this view. We developed a novel method for measuring the relationship between physician characteristics and hospice enrollment, in a nationally representative sample of Medicare patients. We focused on patients who died with a diagnosis of poor-prognosis cancer in the period 2006-11, for whom palliative treatment and hospice would be considered the standard of care. We found that the proportion of a physician's patients who were enrolled in hospice was a strong predictor of whether or not that physician's other patients would enroll in hospice. The magnitude of this association was larger than that of other known predictors of hospice enrollment that we examined, including patients' medical comorbidity, age, race, and sex. Patients cared for by medical oncologists and those cared for in not-for-profit hospitals were significantly more likely than other patients to enroll in hospice. These findings suggest that physician characteristics are among the strongest predictors of whether a patient receives hospice care-which mounting evidence indicates can improve care quality and reduce costs. Interventions geared toward physicians, both by specialty and by previous history of patients' hospice enrollment, may help optimize appropriate hospice use.
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Affiliation(s)
- Ziad Obermeyer
- Ziad Obermeyer is an assistant professor of emergency medicine and health care policy at Harvard Medical School and an emergency physician at Brigham and Women's Hospital, in Boston, Massachusetts
| | - Brian W Powers
- Brian W. Powers is an MD candidate at Harvard Medical School
| | - Maggie Makar
- Maggie Makar is a research assistant in the Department of Emergency Medicine at Brigham and Women's Hospital
| | - Nancy L Keating
- Nancy L. Keating is a professor of health care policy and medicine at Harvard Medical School and an internist at Brigham and Women's Hospital
| | - David M Cutler
- David M. Cutler is the Otto Eckstein Professor of Applied Economics at Harvard University and a research associate at the National Bureau of Economic Research, both in Cambridge, Massachusetts
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Abstract
Until recently, palliative care was synonymous with hospice care and as such was initiated when treatments were terminated because all alternatives are exhausted. In the past few years, early initiation of palliative care has demonstrated positive outcomes in terms of treatment cost, improved quality of life, and longer survival rates for patients with serious illness. This article discusses the issues surrounding the concept of early initiation of palliative care.
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Seaman JB, Barnato AE, Sereika SM, Happ MB, Erlen JA. Patterns of palliative care service consultation in a sample of critically ill ICU patients at high risk of dying. Heart Lung 2016; 46:18-23. [PMID: 27717509 DOI: 10.1016/j.hrtlng.2016.08.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/09/2016] [Accepted: 08/22/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Describe patterns of palliative care service consultation among a sample of ICU patients at high risk of dying. BACKGROUND Patients receiving mechanical ventilation (MV) face threats to comfort, social connectedness and dignity due to pain, heavy sedation and physical restraint. Palliative care consultation services may mitigate poor outcomes. METHODS From a dataset of 1440 ICU patients with ≥2 days of MV and ≥12 h of sustained wakefulness, we identified those at high risk of dying and/or who died and assessed patterns of sub-specialty palliative care consultation. RESULTS About half (773/1440 [54%]) were at high risk of dying or died, 73 (9.4%) of whom received palliative care consultation. On average, referral occurred after 62% of the ICU stay had elapsed. Primary reason for consult was clarification of goals of care (52/73 [72.2%]). CONCLUSIONS Among MV ICU patients at high risk of dying, palliative care service consultation occurs late and infrequently, suggesting a role for earlier palliative care.
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Affiliation(s)
- Jennifer B Seaman
- The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 607 Scaife Hall, 3550 Terrace St., Pittsburgh, PA 15261, USA.
| | - Amber E Barnato
- Section of Decision Sciences, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600.13, Pittsburgh, PA 15213, USA
| | - Susan M Sereika
- Department of Health and Community Systems, University of Pittsburgh School of Nursing, 415 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15216, USA; Center for Research and Evaluation, University of Pittsburg School of Nursing, 360 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15216, USA
| | - Mary Beth Happ
- Center of Excellence in Critical and Complex Care, The Ohio State University College of Nursing, 352 Newton Hall, 1585 Neil Ave, Columbus, OH 43210, USA
| | - Judith A Erlen
- Department of Health and Community Systems, University of Pittsburgh School of Nursing, 415 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15216, USA
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Evaluation of a Peer Nurse Coach Quality Improvement Project on New Nurse Hire Attitudes Toward Care for the Dying. J Hosp Palliat Nurs 2016. [DOI: 10.1097/njh.0000000000000261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Clement L, Painter Q, Shaffer JA. Meeting the Unmet Needs of Aging Heart Failure Patients: A Role for Palliative Care. CURRENT CARDIOVASCULAR RISK REPORTS 2016. [DOI: 10.1007/s12170-016-0515-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Ramchandran K, Tribett E, Dietrich B, Von Roenn J. Integrating Palliative Care Into Oncology: A Way Forward. Cancer Control 2016; 22:386-95. [PMID: 26678965 DOI: 10.1177/107327481502200404] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients with cancer have complex physical, psychosocial, and spiritual needs that evolve throughout their disease trajectory. As patients are living longer with a diagnosis of cancer, the need is growing to address the morbidity due to the underlying illness as well as treatment-related adverse events. Palliative care includes treating physical symptoms as well as addressing psychosocial and spiritual needs. When these needs are addressed, the quality of care improves, costs decrease, and goals are aligned between the medical care provided and the patient and family. However, how best to integrate palliative care into oncology care is still an area of investigation. METHODS The authors conducted a literature search, including randomized clinical trials and practice reviews, to evaluate the evidence for integrating palliative care into oncology care. Barriers to integration as well as sustainable paths forward are highlighted. The authors also utilize case studies as representative examples of integration. RESULTS Current studies demonstrate that integrating palliative care into oncology care improves symptom control, rates of patient and family satisfaction, and quality of end-of-life care. However, for systemwide integration to be successful, commitment must be made to quality improvement, an infrastructure must be built to support palliative care screening, assessment, and intervention, and stakeholders must be engaged in the program. In addition, value must be demonstrated using metrics that affect quality, care utilization, and patient satisfaction. CONCLUSIONS Even though most US cancer centers have a palliative care program, palliative care remains limited in scope. An integrated approach for palliative care with oncology care requires a systems-based approach, with agreement between all parties on shared common metrics for value.
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Boss RD. Palliative care for extremely premature infants and their families. ACTA ACUST UNITED AC 2016; 16:296-301. [PMID: 25708072 DOI: 10.1002/ddrr.123] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Accepted: 04/24/2011] [Indexed: 11/11/2022]
Abstract
Extremely premature infants face multiple acute and chronic life-threatening conditions. In addition, the treatments to ameliorate or cure these conditions often entail pain and discomfort. Integrating palliative care from the moment that extremely premature labor is diagnosed offers families and clinicians support through the process of defining goals of care and making decisions about life support. For both the extremely premature infant who dies soon after birth and the extremely premature infant who experiences multiple complications over weeks and months in the neonatal intensive care unit, palliative care can maintain a focus on infant comfort and family support. This article highlights the ways in which palliative care can be incorporated into intensive care for all critically ill infants.
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Affiliation(s)
- Renee D Boss
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine and Berman Institute of Bioethics, Baltimore, Maryland.
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Cox CE, Curtis JR. Using Technology to Create a More Humanistic Approach to Integrating Palliative Care into the Intensive Care Unit. Am J Respir Crit Care Med 2016; 193:242-50. [PMID: 26599829 DOI: 10.1164/rccm.201508-1628cp] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A decade ago, the major obstacles to integration of palliative care into the intensive care unit (ICU) were the limited number of providers trained in palliative care, an immature evidence base, and a lack of appreciation for the importance of palliative care in the ICU. In 2016, the palliative care workforce has expanded markedly and there is growing appreciation of the benefits of palliative care, whether provided by a generalist (intensivist, nurse, social worker) or palliative care specialist. However, there is evidence that the quality of ICU-based palliative care is often suboptimal. A major barrier to more broadly addressing this quality problem is the lack of scalable ICU-based palliative care models that use technology to deliver efficient, collaborative palliative care in the ICU setting to the right patient at the right time. To address these challenges, we first review strengths and limitations of current care models as the basis for our novel conceptual framework that uses the electronic health record as a platform on which external innovations can be built, including: (1) screening for patients at risk for poor outcomes, (2) integrating patient- and family-reported needs, (3) personalizing care, and (4) directing generalist versus specialist triage algorithms. In the approaches considered, we describe current challenges and propose specific solutions that use technology to improve the quality of the human interaction in a stressful, complex environment.
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Affiliation(s)
- Christopher E Cox
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and.,2 Program to Support People and Enhance Recovery, Duke University, Durham, North Carolina; and
| | - J Randall Curtis
- 3 Cambia Palliative Care Center of Excellence, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
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Horton JR, Morrison RS, Capezuti E, Hill J, Lee EJ, Kelley AS. Impact of Inpatient Palliative Care on Treatment Intensity for Patients with Serious Illness. J Palliat Med 2016; 19:936-42. [PMID: 27248056 DOI: 10.1089/jpm.2015.0240] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Palliative care is associated with decreased treatment intensity and improved quality for individual patients at the end of life, but little is known about how hospital-wide outcomes are affected by the diffusion of palliative care principles. OBJECTIVE We examined the relationship between presence of palliative care programs and hospitals' average treatment intensity, as indicated by mean intensive care unit (ICU) length of stay (LOS) and days under Medicare hospice coverage, in the last six months of life among Medicare beneficiaries aged 67 and over with serious chronic illness. METHODS We linked hospital-level data from the American Hospital Association Annual Survey, National Palliative Care Registry, and Dartmouth Atlas of Health Care to examine hospital-level treatment intensity for chronically ill Medicare beneficiaries who died in 2010. We used propensity score-adjusted linear regression to estimate the relationship between palliative care programs and hospitals' mean ICU LOS and hospice length of enrollment. RESULTS Among 974 hospitals meeting inclusion criteria, we compared 295 hospitals with palliative care programs to 679 hospitals without. Hospitals with palliative care programs were higher volume, more likely to be teaching hospitals, and have oncology services and less likely to be located in rural areas. In propensity score weighted analyses, the mean ICU LOS in hospitals with palliative care was shorter by 0.23 days (standard error [SE] = 0.26), but this was not statistically significant (p = 0.76). In addition, the mean length of hospice enrollment among beneficiaries served by hospitals with palliative care was longer by 0.22 days (SE = 0.61), but also was not statistically significant (p = 0.76). CONCLUSIONS Hospital-based palliative care programs alone may not be sufficient to impact ICU LOS or hospice length of enrollment for all chronically ill older adults admitted to hospitals. Future work should measure hospital-wide palliative care outcomes and effects of core palliative knowledge and skills provided by nonpalliative care specialists.
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Affiliation(s)
- Jay R Horton
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - R Sean Morrison
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Elizabeth Capezuti
- 2 City University of New York , Hunter College School of Nursing, New York, New York
| | | | - Eric J Lee
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Amy S Kelley
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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