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Elliott-Button HL, Johnson MJ, Nwulu U, Clark J. Identification and Assessment of Breathlessness in Clinical Practice: A Systematic Review and Narrative Synthesis. J Pain Symptom Manage 2020; 59:724-733.e19. [PMID: 31655187 DOI: 10.1016/j.jpainsymman.2019.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/11/2019] [Accepted: 10/11/2019] [Indexed: 01/09/2023]
Abstract
CONTEXT Breathlessness is common in chronic conditions but often goes unidentified by clinicians. It is important to understand how identification and assessment of breathlessness occurs across health care settings, to promote routine outcome assessment and access to treatment. OBJECTIVE The objective of this study was to summarize how breathlessness is identified and assessed in adults with chronic conditions across different health care settings. METHODS This is a systematic review and descriptive narrative synthesis (PROSPERO registration: CRD42018089782). Searches were conducted on Medline, PsycINFO, Cochrane Library, Embase, and CINAHL (2000-2018) and reference lists. Screening was conducted by two independent reviewers, with access to a third, against inclusion criteria. Data were extracted using a bespoke proforma. RESULTS Ninety-seven studies were included, conducted in primary care (n = 9), secondary care (n = 53), and specialist palliative care (n = 35). Twenty-five measures of identification and 41 measures of assessment of breathlessness were used. Primary and secondary care used a range of measures to assess breathlessness severity, cause, and impact for people with chronic obstructive pulmonary disease. Specialist palliative care used measures assessing broader symptom severity and function with less focus on overall quality of life. Few studies were identified from primary care. CONCLUSION Various measures were identified, reflective of the setting's purpose. However, this highlights missed opportunities for breathlessness management across settings; primary care is particularly well placed to diagnose and support breathlessness. The chronic obstructive pulmonary disease approach (where symptoms and quality of life are part of disease management) could apply to other conditions. Better documentation of holistic patient-reported measures may drive service improvement in specialist palliative care.
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Affiliation(s)
- Helene L Elliott-Button
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom.
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Ugochinyere Nwulu
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Joseph Clark
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
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2
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Walling AM, Beron PJ, Kaprealian T, Kupelian PA, Wenger NS, McCloskey SA, King CR, Steinberg M. Considerations for Quality Improvement in Radiation Oncology Therapy for Patients with Uncomplicated Painful Bone Metastases. J Palliat Med 2017; 20:478-486. [PMID: 28437208 DOI: 10.1089/jpm.2016.0339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: There is an increasing need for evidence-based efficiency in providing a growing amount of cancer care. One example of a quality gap is the use of multiple-fraction palliative radiation for patients with advanced cancer who have uncomplicated bone metastases; evidence suggests similar pain outcomes for treatment regimens with a lower burden of treatments. Methods: During the first phase of quality improvement work, we used RAND/UCLA appropriateness methodology to understand how radiation oncologists at one academic medical center rate the appropriateness of different treatment regimens for painful uncomplicated bone metastases. We compared radiation oncologist appropriateness ratings for radiation treatments with radiation therapy provided by these oncologists to patients with painful bone metastases between July 2012 and June 2013. Results: Appropriateness ratings showed that single-fraction (8 Gy) treatment (a low burden treatment) was consistently considered an appropriate option to treat a variety of uncomplicated bone metastases. The use of >10 fractions was consistently rated as inappropriate regardless of other factors. Eighty-one patients receiving radiation therapy for painful bone metastases during the study period had an available medical record for chart abstraction. Almost one-third of metastases were considered complicated because of a concern of spinal cord compression, a history of prior irradiation, or an associated pathological fracture. Among uncomplicated bone metastases, 25% were treated with stereotactic body radiation treatment (SBRT). Among the 54 uncomplicated bone metastases treated with conformal radiation, only one was treated with single-fraction treatment and 32% were treated with greater than 10 fractions. Conclusions: Treatment at the study site demonstrates room for improvement in providing low-burden radiation oncology treatments for patients with painful bone metastases. Choosing a radiation treatment schedule for patients with advanced cancer and painful bone metastases requires consideration of many medical and patient-centered factors. Our experience suggests that it will take more than the existence of guidelines to change practice in this area.
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Affiliation(s)
- Anne M Walling
- VA Greater Los Angeles Healthcare System, Los Angeles, California.,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California.,RAND Health, Santa Monica, California
| | - Phillip J Beron
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Tania Kaprealian
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Patrick A Kupelian
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California.,RAND Health, Santa Monica, California
| | - Susan A McCloskey
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Christopher R King
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Michael Steinberg
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
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3
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Garrido MM, Prigerson HG, Neupane S, Penrod JD, Johnson CE, Boockvar KS. Mental Illness and Mental Healthcare Receipt among Hospitalized Veterans with Serious Physical Illnesses. J Palliat Med 2016; 20:247-252. [PMID: 27835066 DOI: 10.1089/jpm.2016.0261] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Psychosocial distress among patients with limited life expectancy influences treatment decisions, treatment adherence, and physical health. Veterans may be at elevated risk of psychosocial distress at the end of life, and understanding their mental healthcare needs may help identify hospitalized patients to whom psychiatric services should be targeted. OBJECTIVE To examine mental illness prevalence and mental health treatment rates among a national sample of hospitalized veterans with serious physical illnesses. Design, Subjects, and Measurements: This was a retrospective study of 11,286 veterans hospitalized in a Veterans Health Administration acute care facility in fiscal year 2011 with diagnoses of advanced cancer, congestive heart failure, chronic obstructive pulmonary disease, and/or advanced HIV/AIDS. Prevalent and incident mental illness diagnoses during and before hospitalization and rates of psychotherapy and psychotropic use among patients with incident depression and anxiety were measured. RESULTS At least one-quarter of the patients in our sample had a mental illness or substance use disorder. The most common diagnoses at hospitalization were depression (11.4%), followed by alcohol abuse or dependence (5.5%), and post-traumatic stress disorder (4.9%). Of the 831 patients with incident past-year depression and 258 with incident past-year anxiety, nearly two-thirds received at least some psychotherapy or guideline-concordant medication within 90 days of diagnosis. Of 191 patients with incident depression and 47 with incident anxiety at time of hospitalization, fewer than half received mental healthcare before discharge. CONCLUSIONS Many veterans hospitalized with serious physical illnesses have comorbid mental illnesses and may benefit from depression and anxiety treatment.
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Affiliation(s)
- Melissa M Garrido
- 1 GRECC, James J Peters VA Medical Center , Bronx, New York.,2 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Holly G Prigerson
- 3 Cornell Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York
| | - Suvam Neupane
- 2 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Joan D Penrod
- 1 GRECC, James J Peters VA Medical Center , Bronx, New York.,2 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Christopher E Johnson
- 4 Department of Health Management and Systems Sciences, University of Louisville , Louisville, Kentucky
| | - Kenneth S Boockvar
- 1 GRECC, James J Peters VA Medical Center , Bronx, New York.,2 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,5 Jewish Home Lifecare , New York, New York
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4
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Walling AM, Tisnado D, Ettner SL, Asch SM, Dy SM, Pantoja P, Lee M, Ahluwalia SC, Schreibeis-Baum H, Malin JL, Lorenz KA. Palliative Care Specialist Consultation Is Associated With Supportive Care Quality in Advanced Cancer. J Pain Symptom Manage 2016; 52:507-514. [PMID: 27401515 PMCID: PMC5173291 DOI: 10.1016/j.jpainsymman.2016.04.005] [Citation(s) in RCA: 10] [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: 07/17/2015] [Revised: 03/02/2016] [Accepted: 04/29/2016] [Indexed: 12/25/2022]
Abstract
CONTEXT Although recent randomized controlled trials support early palliative care for patients with advanced cancer, the specific processes of care associated with these findings and whether these improvements can be replicated in the broader health care system are uncertain. OBJECTIVES The aim of this study was to evaluate the occurrence of palliative care consultation and its association with specific processes of supportive care in a national cohort of Veterans using the Cancer Quality ASSIST (Assessing Symptoms Side Effects and Indicators of Supportive Treatment) measures. METHODS We abstracted data from 719 patients' medical records diagnosed with advanced lung, colorectal, or pancreatic cancer in 2008 over a period of three years or until death who received care in the Veterans Affairs Health System to evaluate the association of palliative care specialty consultation with the quality of supportive care overall and by domain using a multivariate regression model. RESULTS All but 54 of 719 patients died within three years and 293 received at least one palliative care consult. Patients evaluated by a palliative care specialist at diagnosis scored seven percentage points higher overall (P < 0.001) and 11 percentage points higher (P < 0.001) within the information and care planning domain compared with those without a consult. CONCLUSION Early palliative care specialist consultation is associated with better quality of supportive care in three advanced cancers, predominantly driven by improvements in information and care planning. This study supports the effectiveness of early palliative care consultation in three common advanced cancers within the Veterans Affairs Health System and provides a greater understanding of what care processes palliative care teams influence.
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Affiliation(s)
- Anne M Walling
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA; RAND Health, Santa Monica, California, USA.
| | - Diana Tisnado
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA; Department of Health Science, California State University, Fullerton, California, USA
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA; Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Steven M Asch
- VA Palo Alto Healthcare System, Palo Alto, California, USA; Stanford School of Medicine, Stanford, California, USA
| | - Sydney M Dy
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | | | - Martin Lee
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA
| | - Sangeeta C Ahluwalia
- RAND Health, Santa Monica, California, USA; Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | | | - Jennifer L Malin
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA
| | - Karl A Lorenz
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA; VA Palo Alto Healthcare System, Palo Alto, California, USA; Stanford School of Medicine, Stanford, California, USA
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Bergman J, Laviana AA. Opportunities to maximize value with integrated palliative care. J Multidiscip Healthc 2016; 9:219-26. [PMID: 27226721 PMCID: PMC4863682 DOI: 10.2147/jmdh.s90822] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Palliative care involves aggressively addressing and treating psychosocial, spiritual, religious, and family concerns, as well as considering the overall psychosocial structures supporting a patient. The concept of integrated palliative care removes the either/or decision a patient needs to make: they need not decide if they want either aggressive chemotherapy from their oncologist or symptom-guided palliative care but rather they can be comanaged by several clinicians, including a palliative care clinician, to maximize the benefit to them. One common misconception about palliative care, and supportive care in general, is that it amounts to “doing nothing” or “giving up” on aggressive treatments for patients. Rather, palliative care involves very aggressive care, targeted at patient symptoms, quality-of-life, psychosocial needs, family needs, and others. Integrating palliative care into the care plan for individuals with advanced diseases does not necessarily imply that a patient must forego other treatment options, including those aimed at a cure, prolonging of life, or palliation. Implementing interventions to understand patient preferences and to ensure those preferences are addressed, including preferences related to palliative and supportive care, is vital in improving the patient-centeredness and value of surgical care. Given our aging population and the disproportionate cost of end-of-life care, this holds great hope in bending the cost curve of health care spending, ensuring patient-centeredness, and improving quality and value of care. Level 1 evidence supports this model, and it has been achieved in several settings; the next necessary step is to disseminate such models more broadly.
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Affiliation(s)
- Jonathan Bergman
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Veterans Health Affairs-Greater Los Angeles, Los Angeles, CA, USA
| | - Aaron A Laviana
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Singer AE, Meeker D, Teno JM, Lynn J, Lunney JR, Lorenz KA. Symptom trends in the last year of life from 1998 to 2010: a cohort study. Ann Intern Med 2015; 162:175-83. [PMID: 25643305 PMCID: PMC4346253 DOI: 10.7326/m13-1609] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Calls for improvement in end-of-life care have focused attention on the management of pain and other troubling symptoms at the end of life. OBJECTIVE To describe changes in pain intensity and symptom prevalence during the last year of life from 1998 to 2010. DESIGN Observational study. SETTING The HRS (Health and Retirement Study), a nationally representative longitudinal survey of community-dwelling U.S. residents aged 51 years or older. PARTICIPANTS 7204 HRS participants who died while enrolled in the study and their family respondents. MEASUREMENTS Proxy-reported pain during the last year of life and other symptoms for at least 1 month during the last year of life. Trends in pain intensity and symptom prevalence were analyzed for all decedents and within the categories of sudden death, cancer, congestive heart failure or chronic lung disease, and frailty. RESULTS Between 1998 and 2010, proxy reports of the prevalence of any pain increased for all decedents from 54.3% (95% CI, 51.6% to 57.1%) to 60.8% (CI, 58.2% to 63.4%), an increase of 11.9% (CI, 3.1% to 21.4%). Reported prevalences of depression and periodic confusion also increased for all decedents by 26.6% (CI, 14.5% to 40.1%) and 31.3% (CI, 18.6% to 45.1%), respectively. Individual symptoms increased in prevalence among specific decedent categories, except in cancer, which showed no significant changes. The prevalence of moderate or severe pain did not change among all decedents or in any specific decedent category. LIMITATION Use of proxy reports and limited information about some patient and surrogate variables. CONCLUSION Despite national efforts to improve end-of-life care, proxy reports of pain and other alarming symptoms in the last year of life increased from 1998 to 2010. PRIMARY FUNDING SOURCE National Institute of Nursing Research.
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Affiliation(s)
- Adam E. Singer
- Pardee RAND Graduate School, RAND Corporation, Santa Monica, California
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | | | - Joan M. Teno
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Joanne Lynn
- Center for Elder Care and Advanced Illness, Altarum Institute, Washington, DC
| | - June R. Lunney
- Hospice and Palliative Nurses Association, Pittsburgh, Pennsylvania
| | - Karl A. Lorenz
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
- RAND Corporation, Santa Monica, California
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
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Bergman J, Ballon-Landa E, Lorenz KA, Saucedo J, Saigal CS, Bennett CJ, Litwin MS. Community-Partnered Collaboration to Build an Integrated Palliative Care Clinic. Am J Hosp Palliat Care 2014; 33:164-70. [DOI: 10.1177/1049909114555156] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: We partnered with patients, families, and palliative care clinicians to develop an integrated urology–palliative care clinic for patients with metastatic cancer. We assessed clinician satisfaction with a multidisciplinary palliative care clinic model. Methods: We conducted semi-structured interviews with 18 clinicians who practice in our integrated clinic. We analyzed transcripts using a multistage, cutting-and-sorting technique in an inductive approach based on grounded theory analysis. Finally, we administered a validated physician job satisfaction survey. Results: Clinicians found that referring a patient to palliative care in the urology clinic was feasible and appropriate. Patients were receptive to supportive care, and clinicians perceived that quality of care improved following the intervention. Conclusion: An integrated, patient-centered model for individuals with advanced urologic malignancies is feasible and well received by practitioners.
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Affiliation(s)
- Jonathan Bergman
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Eric Ballon-Landa
- Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- UC Irvine School of Medicine, Irvine, CA, USA
| | - Karl A. Lorenz
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
| | - Josemanuel Saucedo
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Christopher S. Saigal
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
| | - Carol J. Bennett
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Mark S. Litwin
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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Tanvetyanon T, Lee JH, Fulp WJ, Schreiber F, Brown RH, Levine RM, Cartwright TH, Abesada-Terk G, Kim GP, Alemany C, Faig D, Sharp PV, Markham MJ, Malafa M, Jacobsen PB. Changes in the care of non-small-cell lung cancer after audit and feedback: the Florida initiative for quality cancer care. J Oncol Pract 2014; 10:e247-54. [PMID: 24737876 DOI: 10.1200/jop.2013.001275] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Audit and feedback have been widely used to enhance the performance of various medical practices. Non-small-cell lung cancer (NSCLC) is one of the most common diseases encountered in medical oncology practice. We investigated the use of audit and feedback to improve the care of NSCLC. METHODS Medical records were reviewed for patients with NSCLC first seen by a medical oncologist in 2006 (n = 518) and 2009 (n = 573) at 10 oncology practices participating in the Florida Initiative for Quality Cancer Care. In 2008, feedback from 2006 audit results was provided to practices, which then independently undertook steps to improve their performance. Sixteen quality-of-care indicators (QCIs) were evaluated on both time points and were examined for changes in adherence over time. RESULTS A statistically significant increase in adherence was observed for five of 16 QCIs. Adherence to brain staging using magnetic resonance imaging or computed tomography scan for stage III NSCLC (57.8% in 2006 v 82.8% in 2009; P = .001), availability of chemotherapy flow sheet (89.2% v 97.0%; P < .001), documentation of performance status for stage III and IV disease (43.4% v 51.3%; P < .001), availability of pathology report for patients undergoing surgery (95.2% v 99.2%; P = .02), and availability of signed chemotherapy consent (69.5% v 76.3%; P = .04). There were no statistically significant decreases in adherence on any QCIs. CONCLUSION Audit with feedback was associated with a modest but important improvement in the treatment of NSCLC. Whether these changes are durable will require long-term follow-up.
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Affiliation(s)
- Tawee Tanvetyanon
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Ji-Hyun Lee
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - William J Fulp
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Fred Schreiber
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Richard H Brown
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Richard M Levine
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Thomas H Cartwright
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Guillermo Abesada-Terk
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - George P Kim
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Carlos Alemany
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Douglas Faig
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Philip V Sharp
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Merry-Jennifer Markham
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Mokenge Malafa
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
| | - Paul B Jacobsen
- H. Lee Moffitt Cancer Center and Research Institute, Tampa; Center for Cancer Care and Research at Watson Clinic, Lakeland; Florida Cancer Specialists and Research Institute, Sarasota; Spacecoast Cancer Center, Titusville; Ocala Oncology, Ocala; Coastal Oncology and Hematology, Stuart; Mayo Clinic, Jacksonville; Cancer Center of Florida, Orlando; North Broward Medical Center, Deerfield Beach; Tallahassee Memorial Healthcare, Tallahassee; and University of Florida, Gainesville, FL
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Vichare A, Eads N, Punglia R, Potters L. American Society for Radiation Oncology's Performance Assessment for the Advancement of Radiation Oncology Treatment: A practical approach for informing practice improvement. Pract Radiat Oncol 2014; 3:e37-43. [PMID: 24674319 DOI: 10.1016/j.prro.2012.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 09/18/2012] [Accepted: 09/24/2012] [Indexed: 11/17/2022]
Abstract
PURPOSE Performance Assessment for the Advancement of Radiation Oncology Treatment (PAAROT) is a practice quality improvement program. This study seeks to determine baseline performance rates and practice variation from PAAROT data. METHODS AND MATERIALS The cohort includes all physicians from academic, hospital, and free-standing settings who completed at least 10 consecutive self-audited medical records in the PAAROT program (version 2.5) from 2010 to 2011 (n = 519 medical records). Mean performance rates were analyzed at the physician and medical record levels and, where appropriate, were stratified by the physician's practice setting. RESULTS Forty-nine physicians were included in the study; 22 (45%), 17 (35%), and 10 (20%) physicians practiced in a hospital, academic, or a free-standing setting, respectively. The measures with a high adoption rate (more than 80%) include the following: documentation of history and physical; review of physics and dosimetry plan by radiation oncologist; patient informed risks of therapy; evaluation of acute symptoms during therapy; pathology in consultation note; communication of treatment summary within 30 days of treatment completion; documentation of intent of treatment, use of clinical guidelines or published data; and documentation of American Joint Committee on Cancer staging. Lower rates of adoption were noted (mean, 65%; range, 0-100%) when these measures were converted to a composite measure. Low adherence was noted for screening of a pain using a standard scale (mean, 58%; range, 0-100%). Physicians from an academic setting scored higher on the composite measure (40%) compared with those from a hospital setting (36%) and from a free-standing setting (24%); (P < .001). Physicians from a hospital setting scored higher on the quality indicator of screening for pain (54%) compared with physicians from an academic setting (35%) and free-standing setting (11%) (P < .001). CONCLUSIONS This first assessment of PAAROT (version 2.5) data provides an initial snapshot on the use of quality indicators and practice patterns for radiation oncology. Self-reported practice data and the use of quality indicators will become important for the purpose of continuous, prospective evidence-based learning on an individual basis. Despite the small sample size, the data from this study will help address potential improvement opportunities for the next iteration of the PAAROT program.
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Affiliation(s)
| | - Nadine Eads
- American Society for Radiation Oncology, Fairfax, Virginia
| | | | - Louis Potters
- North Shore-Long Island Jewish Health System, New Hyde Park, New York
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Dy SM, Walling AM, Mack JW, Malin JL, Pantoja P, Lorenz KA, Tisnado DM. Evaluating the quality of supportive oncology using patient-reported data. J Oncol Pract 2014; 10:e223-30. [PMID: 24618077 DOI: 10.1200/jop.2013.001237] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patient-reported data may provide valuable information for oncology quality measurement. We evaluated applying patient-reported data from the Cancer Care Outcomes Research and Surveillance Consortium national study to quality indicators addressing supportive oncology domains. METHODS We analyzed surveys including validated instruments for symptoms and care planning from 4,174 patients newly diagnosed with lung or colorectal cancer. We adapted existing supportive oncology indicators for use with patient-reported data from Cancer Quality-ASSIST and the American Society of Clinical Oncology Quality Oncology Practice Initiative. Where feasible, we examined indicators using medical record data for comparison purposes. RESULTS Using patient-reported data, the percentage of patients meeting indicator criteria for screening ranged from 74% (significant depressive symptoms) to 93% (pain, nausea/vomiting). The percentage meeting indicator criteria for symptom treatment ranged from 73% (significant depressive symptoms) to 99% (nausea/vomiting). Symptom severity did not affect the results. Using medical record data, the percentage meeting indicator criteria varied between 4% (significant depressive symptoms) and 23% (pain). For information and care planning, 44% met criteria for discussion about resuscitation and 32% for hospice discussion using survey data. Using medical record data, 11% met criteria for goals-of-care discussion in intensive care and 46% for hospice/pain management/palliative care referral before death. CONCLUSION Quality of care for symptoms measured using patient self-report was higher than when including medical record data. Use of patient-reported and medical record data allowed measurement of different perspectives on care planning indicators. Patient-reported data provide a complementary, patient-centered perspective on the quality of supportive oncology care.
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Affiliation(s)
- Sydney M Dy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Anne M Walling
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Jennifer W Mack
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Jennifer L Malin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Philip Pantoja
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Karl A Lorenz
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Diana M Tisnado
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
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Bergman J, Lorenz KA, Acquah-Asare S, Scales CD, Ryan G, Saigal CS, Bennett CJ, Litwin MS. Urologist Attitudes Toward End-of-life Care. Urology 2013; 82:48-52. [DOI: 10.1016/j.urology.2013.01.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 01/24/2013] [Accepted: 01/25/2013] [Indexed: 11/30/2022]
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Walling AM, Asch SM, Lorenz KA, Malin J, Roth CP, Barry T, Wenger NS. The quality of supportive care among inpatients dying with advanced cancer. Support Care Cancer 2012; 20:2189-94. [DOI: 10.1007/s00520-012-1462-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 04/02/2012] [Indexed: 11/24/2022]
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Kaufman CS, Landercasper J. Can We Measure the Quality of Breast Surgical Care? Ann Surg Oncol 2011; 18:3053-60. [DOI: 10.1245/s10434-011-1998-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Indexed: 11/18/2022]
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Dy SM, Asch SM, Lorenz KA, Weeks K, Sharma RK, Wolff AC, Malin JL. Quality of end-of-life care for patients with advanced cancer in an academic medical center. J Palliat Med 2011; 14:451-7. [PMID: 21391819 DOI: 10.1089/jpm.2010.0434] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE We assessed key aspects of the quality of end-of-life care using validated explicit process quality measures in an academic medical center (hospital and cancer center) before expanding to a broader palliative care initiative. METHODS We evaluated 21 indicators most relevant to end-of-life care from the Cancer Quality-ASSIST supportive oncology indicator set for 238 patients with advanced/metastatic solid tumors who died between 2-15 months after diagnosis. These included outpatient and hospital indicators for cancer symptoms and information and care planning that met criteria for feasibility, reliability, and validity. We abstracted detailed information from medical records to specify the necessary data elements. RESULTS Overall adherence was 53% (95% confidence interval [CI], 50%-56%); this varied widely among indicators. Adherence was highest for pain indicators; in particular, 97% of eligible subjects' hospitalizations had documented screening for pain, and, after an outpatient pain medication was changed, 97% of patients had a pain assessment at the subsequent visit. For other symptoms, adherence ranged from 0% for documentation of life expectancy for patients starting parenteral or enteral nutrition to 87% for assessment of nausea or vomiting on hospital admission. For information and care planning, results ranged from 6% for documentation of ventilation preferences prior to intubation to 68% for documented communication of risks and benefits or prognosis prior to starting chemotherapy. CONCLUSION In conclusion, Cancer Quality-ASSIST indicators are useful for practical quality assessment of cancer end-of-life care in an academic medical center. These results will serve as useful data for targeting areas for quality improvement and measuring progress.
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Affiliation(s)
- Sydney Morss Dy
- Department of Health Policy & Management, Johns Hopkins University, Baltimore, Maryland 21205, USA.
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