1
|
Pereira CFR, Dijxhoorn AFQ, Koekoek B, van den Broek M, van der Steen K, Engel M, van Rijn M, Meijers JM, Hasselaar J, van der Heide A, Onwuteaka-Philipsen BD, van den Beuken-van Everdingen MHJ, van der Linden YM, Boddaert MS, Jeurissen PPT, Merkx MAW, Raijmakers NJH. Potentially Inappropriate End of Life Care and Healthcare Costs in the Last 30 Days of Life in Regions Providing Integrated Palliative Care in the Netherlands: A Registration-based Study. Int J Integr Care 2024; 24:6. [PMID: 39005964 PMCID: PMC11243768 DOI: 10.5334/ijic.7504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 06/19/2024] [Indexed: 07/16/2024] Open
Abstract
Introduction This study aimed to assess the effect of integrated palliative care (IPC) on potentially inappropriate end- of-life care and healthcare-costs in the last 30 days of life in the Netherlands. Methods Nationwide health-insurance claims data were used to assess potentially inappropriate end-of-life care (≥2 emergency room visits; ≥2 hospital admissions; >14 days hospitalization; chemotherapy; ICU admission; hospital death) and healthcare-costs in all deceased adults in IPC regions pre- and post- implementation and in those receiving IPC compared to a 1:2 matched control group. Results In regions providing IPC deceased adults (n = 37,468) received significantly less potentially inappropriate end-of-life care post-implementation compared to pre-implementation (26.5% vs 27.9%; p < 0.05). Deceased adults who received IPC (n = 210) also received significantly less potentially inappropriate end-of-life care compared to a matched control group (14.8% vs 28.3%; p < 0.05). Mean hospital costs significantly decreased for deceased adults who received IPC (€2,817), while mean costs increased for general practitioner services (€311) and home care (€1,632). Discussion These results highlight the importance of implementation of integrated palliative care and suitable payment. Further research in a larger sample is needed. Conclusion This study shows less potentially inappropriate end-of-life care and a shift in healthcare costs from hospital to general practitioner and home care with IPC.
Collapse
Affiliation(s)
| | - Anne-floor Q. Dijxhoorn
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
- Netherlands Association for Palliative Care, Utrecht, The Netherlands
- Center of Expertise in Palliative Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Berdine Koekoek
- Gelre Hospitals, Apeldoorn, Netherlands Apeldoorn, The Netherlands
| | | | | | - Marijanne Engel
- Center of Expertise in Palliative Care Utrecht, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marjon van Rijn
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC –Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Science, Amsterdam, the Netherlands
| | - Judith M. Meijers
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Zuyderland Care, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bregje D. Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC –. Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Yvette M. van der Linden
- Center of Expertise in Palliative Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Manon S. Boddaert
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
- Netherlands Association for Palliative Care, Utrecht, The Netherlands
- Center of Expertise in Palliative Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Patrick P. T. Jeurissen
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Matthias A. W. Merkx
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Natasja J. H. Raijmakers
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
- Netherlands Association for Palliative Care, Utrecht, The Netherlands
| |
Collapse
|
2
|
Han HJ, Ouellette MC, Yeh JC, Dodge LE, Finlay E, Cullinan AM, Buss MK. Outpatient Training During Hospice and Palliative Medicine Fellowship: A National Survey. J Pain Symptom Manage 2024:S0885-3924(24)00841-8. [PMID: 38945458 DOI: 10.1016/j.jpainsymman.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 07/02/2024]
Abstract
CONTEXT Outpatient palliative care (PC) has strong evidence demonstrating impact across serious illnesses, resulting in growing demand for skilled outpatient PC clinicians. However, there is limited literature examining the existing state and quality of outpatient PC education during postgraduate training. OBJECTIVES Characterize the current state of outpatient training in United States (US) Hospice and Palliative Medicine (HPM) physician fellowships and elicit perceptions regarding quality of outpatient PC education. METHODS A cross-sectional survey of US adult HPM fellowship program directors (PDs) or their designee conducted between March and July, 2023. RESULTS Of 161 programs, 85 participated (53% response rate) with representation across all US regions. HPM fellows spend a median of 4.8 weeks in outpatient PC compared to 24 weeks inpatient PC and 10.5 weeks in hospice settings. Over half (51%) of fellows saw outpatients from primarily one disease type with limited exposure to patients with other serious illnesses. Across programs, fellows' clinic structure, interdisciplinary team composition, and didactic experiences varied. On a 5-point rating scale, PDs reported significantly lower quality outpatient versus inpatient training (mean rating: 3.58 vs. 4.62, P<0.001) and perceived fellows as less prepared for independent outpatient practice upon graduation (mean: 4.06 vs. 4.73, P<0.001). CONCLUSION Our survey of US HPM fellowships identified multiple gaps between outpatient and inpatient PC education and training during fellowship and raises concern about the adequacy of outpatient PC training. To prepare the HPM workforce to meet the diverse needs of seriously ill populations and ensure adequate access, outpatient PC training requires reform.
Collapse
Affiliation(s)
- Harry J Han
- Section of Palliative Care (H.J.H, M.C.O., J.C.Y.), Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Michelle C Ouellette
- Section of Palliative Care (H.J.H, M.C.O., J.C.Y.), Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan C Yeh
- Section of Palliative Care (H.J.H, M.C.O., J.C.Y.), Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura E Dodge
- Department of Obstetrics and Gynecology (L.E.D.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Department of Epidemiology (L.E.D.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Esme Finlay
- Division of Palliative Medicine (E.F.), Department of Medicine, University of New Mexico School of Medicine, and the Raymond G Murphy Veterans Affairs Medical Center, Albuquerque, New Mexico
| | - Amelia M Cullinan
- Section of Palliative Care (A.M.C.), Department of Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, New Hampshire, Lebanon
| | - Mary K Buss
- Division of Palliative Care (M.K.B.), Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Baird CE, Wulff-Burchfield E, Egan PC, Hugar LA, Vyas A, Trikalinos NA, Liu MA, Bélanger E, Olszewski AJ, Bantis LE, Panagiotou OA. Predictors of high-intensity care at the end of life among older adults with solid tumors: A population-based study. J Geriatr Oncol 2024; 15:101774. [PMID: 38676975 PMCID: PMC11162260 DOI: 10.1016/j.jgo.2024.101774] [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: 11/01/2023] [Revised: 03/05/2024] [Accepted: 04/12/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION High-intensity end-of-life (EoL) care can be burdensome for patients, caregivers, and health systems and does not confer any meaningful clinical benefit. Yet, there are significant knowledge gaps regarding the predictors of high-intensity EoL care. In this study, we identify risk factors associated with high-intensity EoL care among older adults with the four most common malignancies, including breast, prostate, lung, and colorectal cancer. MATERIALS AND METHODS Using SEER-Medicare data, we conducted a retrospective analysis of Medicare beneficiaries aged 65 and older who died of breast, prostate, lung, or colorectal cancer between 2011 and 2015. We used multivariable logistic regression to identify clinical, demographic, socioeconomic, and geographic predictors of high-intensity EoL care, which we defined as death in an acute care hospital, receipt of any oral or parenteral chemotherapy within 14 days of death, one or more admissions to the intensive care unit within 30 days of death, two or more emergency department visits within 30 days of death, or two or more inpatient admissions within 30 days of death. RESULTS Among 59,355 decedents, factors associated with increased likelihood of receiving high-intensity EoL care were increased comorbidity burden (odds ratio [OR]:1.29; 95% confidence interval [CI]:1.28-1.30), female sex (OR:1.05; 95% CI:1.01-1.09), Black race (OR:1.14; 95% CI:1.07-1.23), Other race/ethnicity (OR:1.20; 95% CI:1.10-1.30), stage III disease (OR:1.11; 95% CI:1.05-1.18), living in a county with >1,000,000 people (OR:1.23; 95% CI:1.16-1.31), living in a census tract with 10%-<20% poverty (OR:1.09; 95% CI:1.03-1.16) or 20%-100% poverty (OR:1.12; 95% CI:1.04-1.19), and having state-subsidized Medicare premiums (OR:1.18; 95% CI:1.12-1.24). The risk of high-intensity EoL care was lower among patients who were older (OR:0.98; 95% CI:0.98-0.99), lived in the Midwest (OR:0.69; 95% CI:0.65-0.75), South (OR:0.70; 95% CI:0.65-0.74), or West (OR:0.81; 95% CI:0.77-0.86), lived in mostly rural areas (OR:0.92; 95% CI:0.86-1.00), and had poor performance status (OR:0.26; 95% CI:0.25-0.28). Results were largely consistent across cancer types. DISCUSSION The risk factors identified in our study can inform the development of new interventions for patients with cancer who are likely to receive high-intensity EoL care. Health systems should consider incorporating these risk factors into decision-support tools to assist clinicians in identifying which patients should be referred to hospice and palliative care.
Collapse
Affiliation(s)
- Courtney E Baird
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Elizabeth Wulff-Burchfield
- Medical Oncology Division and Palliative Medicine Division, Department of Internal Medicine, University of Kansas School of Medicine, University of Kansas Cancer Center, The University of Kansas Health System, Kansas City, KS, USA
| | - Pamela C Egan
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lee A Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Ami Vyas
- University of Rhode Island, College of Pharmacy, Department of Pharmacy Practice, Kingston, RI, USA
| | - Nikolaos A Trikalinos
- Division of Oncology, Department of Medicine, Washington University Medical School Campus, St. Louis, MO, USA; Siteman Cancer Center, St. Louis, MO, USA
| | - Michael A Liu
- Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Emmanuelle Bélanger
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Adam J Olszewski
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Leonidas E Bantis
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Orestis A Panagiotou
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| |
Collapse
|
4
|
Juan DWK, Ng IAT, Wong LCK, Fong WJ, Lee PP, Lie SA, Zhou JX, Cai M, Ong JCA, Seo JCJ, Chia CS, Wong JSM. Knowledge and thresholds for palliative care and surgery among healthcare providers caring for adults with serious illness. Front Med (Lausanne) 2024; 11:1351864. [PMID: 38882666 PMCID: PMC11179431 DOI: 10.3389/fmed.2024.1351864] [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: 12/18/2023] [Accepted: 05/20/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Timely palliative care and surgical interventions improve symptoms, health-related quality of life (HRQoL), and reduce medical cost for seriously ill adults at end of life (EOL). However, there is still poor delivery and underutilization of these palliative services. We hypothesize that the sub-optimal delivery is due to limited understanding among healthcare providers. Methods A nationwide cross-sectional online survey was conducted among primary and tertiary healthcare providers. The survey assessed challenges faced, palliative education, confidence in managing palliative patients, and knowledge on palliative surgery. Overall palliative care awareness and knowledge was assessed using a 6-point score. Likelihood of considering various palliative interventions at EOL was also determined using a threshold score (higher score = higher threshold). Results There were 145 healthcare providers who completed the survey (81.9% response rate); majority reported significant challenges in providing various aspects of palliative care: 57% (n = 82) in the provision of emotional support. Sixty-nine percent (n = 97) in managing social issues, and 71% (n = 103) in managing family expectations. Most expressed inadequate palliative care training in both under-graduate and post-graduate training and lack confidence in managing EOL issues. Up to 57% had misconceptions regarding potential benefits, morbidity and mortality after palliative surgery. In general, most providers had high thresholds for Intensive Care Unit admissions and palliative surgery, and were more likely to recommend endoscopic or interventional radiology procedures at EOL. Conclusion Healthcare providers in Singapore have poor knowledge and misconceptions about palliative care and surgery. Improving awareness and education among those caring for seriously ill adults is essential.
Collapse
Affiliation(s)
- Darryl Wen Kai Juan
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Irene Ai Ting Ng
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Louis Choon Kit Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Wei Jing Fong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Piea Peng Lee
- Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Sui An Lie
- Division of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Jamie Xuelian Zhou
- Division of Supportive and Palliative Care, National Cancer Centre, Singapore, Singapore
| | - Mingzhe Cai
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Johnny Chin-Ann Ong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
- SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
- SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
- Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore, Singapore
- Institute of Molecular and Cell Biology, A*STAR Research Entities, Singapore, Singapore
| | - Jane Chin Jin Seo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Claramae Shulyn Chia
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
- SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - Jolene Si Min Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
- SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| |
Collapse
|
5
|
Sun BJ, Tennakoon L, Spain DA, Lee B. Palliative Intervention for Malignant Bowel Obstruction Comes at a Cost: A National Inpatient Study. Am Surg 2024:31348241256083. [PMID: 38782409 DOI: 10.1177/00031348241256083] [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: 05/25/2024]
Abstract
Background: Malignant bowel obstruction (MBO) due to peritoneal carcinomatosis (PC) is associated with poor outcomes. Optimal management for palliation remains unclear. This study aims to characterize nonoperative, procedural, and operative management strategies for MBO and evaluate its association with mortality and cost.Materials and Methods: ICD-10 coding identified patient admissions from the 2018 to 2019 National Inpatient Sample (NIS) for MBO with PC from gastrointestinal or ovarian primary cancers. Management was categorized as nonoperative, procedural, or surgical. Multivariate analysis was used to associate treatment with mortality and cost.Results: 356,316 patient admissions were identified, with a mean age of 63 years. Gender, race, and insurance status were similar among groups. Length of stay (LOS) was longest in the surgical group (surgical: 17 days; procedural: 14 days; nonoperative: 7 days; P = .001). In comparison to nonoperative, procedural and surgical patients had statistically higher hospital charges, post-discharge medical needs, palliative care consults, and admission to rehab centers. Mortality was 7% in nonoperative, 9% in procedural, and 8% in surgical (P = .007) groups. In adjusted analyses, older age, palliative care consult, and non-Medicare payer status were associated with higher mortality. Compared to nonoperative, procedural and surgical groups resulted in increased costs (procedural: $17K more; surgical: $30K more).Conclusions: Admissions for procedural and surgical treatment of MBO are associated with increased LOS, hospital costs, and discharge needs. Optimal management remains challenging. Clinicians must examine all options prior to recommending palliative interventions given a trend towards higher resource utilization and mortality.
Collapse
Affiliation(s)
- Beatrice J Sun
- Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Lakshika Tennakoon
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - David A Spain
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Byrne Lee
- Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
6
|
Giannubilo I, Battistuzzi L, Blondeaux E, Ruelle T, Poggio FB, Buzzatti G, D'Alonzo A, Della Rovere F, Latocca MM, Molinelli C, Razeti MG, Nardin S, Arecco L, Perachino M, Favero D, Borea R, Pronzato P, Del Mastro L, Bighin C. Patterns of care at the end of life: a retrospective study of Italian patients with advanced breast cancer. BMC Palliat Care 2024; 23:129. [PMID: 38778303 PMCID: PMC11110270 DOI: 10.1186/s12904-024-01460-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVES To better understand the type of care offered to Italian patients with advanced breast cancer at the End-of-Life (EoL), we conducted a retrospective observational study. EoL was defined as the period of six months before death. METHODS One hundred and twenty-one patients with advanced breast cancer (ABC) treated at IRCCS San Martino Policlinic Hospital who died between 2017 and 2021 were included. Data about patient, disease, and treatment characteristics from breast cancer diagnosis to death, along with information about comorbidities, medications, imaging, specialist evaluations, hospitalization, palliative care and home care, hospice admissions, and site of death were collected. RESULTS 98.3% of the patients received at least one line of active treatment at EoL; 52.8% were hospitalized during the selected period. Palliative (13.9%), psychological (7.4%), and nutritional evaluations (8.2%) were underutilized. Palliative home care was provided to 52% of the patients. Most of the patients died at home (66.1%) and fewer than one out of five (18.2%) died at the hospital. Among the patients who died at home, 27.3% had no palliative support. CONCLUSIONS Our findings indicate that palliative care in EoL breast cancer patients is still inadequate. Only a minority of patients had psychological and nutritional support While low nutritional support may be explained by the fact that typical symptoms of ABC do not involve the gastrointestinal tract, the lack of psychological support suggests that significant barriers still exist. Data on the site of death are encouraging, indicating that EoL management is increasingly home centered in Italy.
Collapse
Affiliation(s)
- Irene Giannubilo
- U.O. Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy.
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy.
| | - Linda Battistuzzi
- U.O. Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Eva Blondeaux
- U.O. Epidemiologia Clinica, IRCCS Ospedale Policlinico San Martino, Genova, IT, Italy
| | - Tommaso Ruelle
- U.O. Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | | | - Giulia Buzzatti
- U.O. Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Alessia D'Alonzo
- U.O. Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Federica Della Rovere
- SSD Cure Palliative Ed Hospice, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Chiara Molinelli
- U.O. Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Maria Grazia Razeti
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
- U.O.C. Clinica Di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Simone Nardin
- U.O. Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Luca Arecco
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
- U.O.C. Clinica Di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marta Perachino
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
- U.O.C. Clinica Di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Diletta Favero
- U.O. Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Roberto Borea
- U.O. Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Paolo Pronzato
- U.O. Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Lucia Del Mastro
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
- U.O.C. Clinica Di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Claudia Bighin
- U.O. Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| |
Collapse
|
7
|
Meehan CP, White E, CVitan A, Jiang L, Wu WC, Wice M, Stafford J, Rudolph JL. Factors Associated With Early Palliative Care Among Patients With Heart Failure. J Palliat Med 2024. [PMID: 38608234 DOI: 10.1089/jpm.2023.0539] [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: 04/14/2024] Open
Abstract
Background: Heart failure (HF) is a progressive, life-limiting illness for which palliative care (PC) is considered standard of care. Among patients that do receive PC, consultation tends to occur late in the illness course. Objective: Our primary aim was to examine patient factors associated with receiving PC in HF. Secondarily, we sought to determine factors associated with early PC encounters. Design: This was a retrospective cohort study of U.S. Veterans with prior hospitalization who died between January 1, 2011 and December 31, 2020. Setting/Subjects: Subjects were Veterans with HF who died with a prior admission to a Veterans Affairs hospital in the United States. Measurements: We calculated the time from PC encounter to death. We characterized HF patients who died without PC, with late PC (≤90 days before death), and with early PC (>90 days before death). Results: We identified 232,079 Veterans with a mean age of (76.5 ± 10.7) years. Within the cohort, 56.5% (n = 131,122) of Veterans died with no PC, 22.5% (n = 52,114) had PC <90 days before death, and 21.0% (n = 48,843) had PC >90 days before death. Veterans who died without PC tended to be younger with fewer comorbidities. Conclusions: While more than 20% of HF patients in our cohort had PC well in advance of death, more than half died without PC. PC involvement seemed to be driven by comorbidities rather than HF. Effective collaboration with Cardiology is needed to identify patients who would benefit from earlier PC involvement.
Collapse
Affiliation(s)
- Caroline P Meehan
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Emily White
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Alexander CVitan
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Lan Jiang
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Wen-Chih Wu
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mitchell Wice
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Geriatrics and Extended Care, Providence VA Healthcare System, Providence, Rhode Island, USA
| | - Jensy Stafford
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
8
|
Lilley EJ, Farber ON, Cooper Z. Palliative surgery: state of the science and future directions. Br J Surg 2024; 111:znae068. [PMID: 38502548 PMCID: PMC10949962 DOI: 10.1093/bjs/znae068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/07/2024] [Accepted: 02/24/2024] [Indexed: 03/21/2024]
Abstract
Palliative surgical procedures are operations that aim to alleviate symptoms in a patient with serious, life-limiting illness. They are common, particularly within the field of surgical oncology. However, few high-quality studies have attempted to measure the durability of improvements in symptoms and quality of life after palliative surgery. Furthermore, many of the studies that do exist are outdated and employ highly inconsistent definitions of palliative surgery. Consequently, the paucity of robust and reliable evidence on the benefits, risks, and trade-offs of palliative surgery hampers clinical decision-making for patients and their surgeons. The evidence for palliative surgery suggests that, with effective communication about goals of care and careful patient selection, palliative surgery can provide symptomatic relief and reduce healthcare burdens for certain seriously ill patients.
Collapse
Affiliation(s)
- Elizabeth J Lilley
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Orly N Farber
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Zara Cooper
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
9
|
Rao K, Goldstein NE, Peikes DN, Polt L, Kornitzer B. Effects of Primary Care-Led, Integrated Palliative Care for Medicare Patients in a Value-Based Model. J Pain Symptom Manage 2024; 67:195-203. [PMID: 37972717 DOI: 10.1016/j.jpainsymman.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
CONTEXT Faced with a projected shortage of specialized palliative care physicians, scalable palliative solutions are required to better meet the aging population's needs. OBJECTIVES To determine whether a multi-site, primary care-led, integrated palliative care model improves clinical, utilization, and economic outcomes. METHODS Propensity score-matched comparison group formed from participants who were Medicare beneficiaries, died January 1, 2021-January 31, 2023, were patients of eight primary care practices that partner with agilon health, and enrolled in palliative care for at least seven days. Each practice operates in a value-based model, where primary care providers (PCPs) take on full-risk for the cost and quality of patient outcomes. Each program includes symptom management, defining goals of care/advance directives, PCP care coordination, and assistance with care transitions if patients enroll in hospice. RESULTS Final sample included 1778 decedents, with 889 in both enrolled and matched cohorts, average age 83. Palliative care is associated with improved patient outcomes from palliative care enrollment until death, including 5.4 more days at home (p < 0.001), 0.4 fewer hospitalizations (p < 0.001), 17% fewer deaths in a hospital (p < 0.001), and $10,393 lower overall healthcare costs (p < 0.001). CONCLUSION A primary care-led, integrated approach of delivering palliative care within a full-risk model can be an effective care delivery mechanism to meet the healthcare needs of an aging population by impacting patient outcomes and reducing avoidable utilization and cost at the end of life. These findings demonstrate that PCPs in a scaled, full-risk model can simultaneously improve care for patients while reducing costs to the healthcare system.
Collapse
Affiliation(s)
- Karthik Rao
- agilon health (K.R., B.K.), Boston, Massachusetts, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine (N.E.G.), Icahn School of Medicine, New York City, New York USA
| | - Deborah N Peikes
- Blue Cross Blue Shield of Massachusetts (D.N.P.), Princeton, New Jersey, USA
| | - Lauren Polt
- agilon health (L.P.), St. Petersburg, Florida, USA
| | - Benjamin Kornitzer
- agilon health (K.R., B.K.), Boston, Massachusetts, USA; Department of Medicine (B.K.), Icahn School of Medicine, New York City, New York, USA.
| |
Collapse
|
10
|
Maessen M, Fliedner MC, Gahl B, Maier M, Aebersold DM, Zwahlen S, Eychmüller S. An economic evaluation of an early palliative care intervention among patients with advanced cancer. Swiss Med Wkly 2024; 154:3591. [PMID: 38579309 DOI: 10.57187/s.3591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Early integration of palliative care into oncology care has shown positive effects on patient symptoms and quality of life. It may also reduce health care costs. However given the heterogeneity of settings and interventions and the lack of information on the minimally effective dose for influencing care utilisation and costs, it remains uncertain whether early palliative care reduces costs. OBJECTIVES We sought to determine whether an early palliative care intervention integrated in usual oncology care in a Swiss hospital setting reduced utilisation and costs of health care in the last month of life when compared with usual oncology care alone. METHODS We performed a cost-consequences analysis alongside a multicentre trial. We extracted costs from administrative health insurance data and health care utilisation from family caregiver surveys to compare two study arms: usual oncology care and usual oncology care plus the palliative care intervention. The intervention consisted of a single-structured, multiprofessional conversation with the patient about symptoms, end-of-life decisions, network building and support for carers (SENS). The early palliative care intervention was performed within 16 weeks of the diagnosis of a tumour stage not amenable or responsive to curative treatment. RESULTS We included 58 participants with advanced cancer in our economic evaluation study. Median overall health care costs in the last month of life were 7892 Swiss Francs (CHF) (interquartile range: CHF 5637-13,489) in the intervention arm and CHF 8492 [CHF 5411-12,012] in the control arm. The average total intervention treatment cost CHF 380 per patient. Integrating an early palliative care intervention into usual oncology care showed no significant difference in health care utilisation or overall health care costs between intervention and control arms (p = 0.98). CONCLUSION Although early palliative care is often presented as a cost-reducing care service, we could not show a significant effect of the SENS intervention on health care utilisation and costs in the last month of life. However, it may be that the intervention was not intensive enough, the timeframe too short or the study population too small for measurable effects. Patients appreciated the intervention. Single-structured early palliative care interventions are easy to implement in clinical practice and present low treatment costs. Further research about the economic impact of early palliative care should focus on extracting large, detailed cost databases showing potential shifts in cost and cost-effectiveness. CLINICAL TRIALS gov Identifier: NCT01983956.
Collapse
Affiliation(s)
- Maud Maessen
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
- University Centre for Palliative Care, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Monica C Fliedner
- University Centre for Palliative Care, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Marina Maier
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Susanne Zwahlen
- Unit for Specialised Palliative Care, Lindenhof Hospital, Bern, Switzerland
| | - Steffen Eychmüller
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
- University Centre for Palliative Care, Inselspital, Bern University Hospital, University of Bern, Switzerland
| |
Collapse
|
11
|
Boddaert MS, Fransen HP, de Nijs EJM, van Gerven D, Spierings LEA, Raijmakers NJH, van der Linden YM. Association between Inappropriate End-of-Life Cancer Care and Specialist Palliative Care: A Retrospective Observational Study in Two Acute Care Hospitals. Cancers (Basel) 2024; 16:721. [PMID: 38398112 PMCID: PMC10886868 DOI: 10.3390/cancers16040721] [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: 12/21/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
A substantial number of patients with life-threatening illnesses like cancer receive inappropriate end-of-life care. Improving their quality of end-of-life care is a priority for patients and their families and for public health. To investigate the association between provision, timing, and initial setting of hospital-based specialist palliative care and potentially inappropriate end-of-life care for patients with cancer in two acute care hospitals in the Netherlands, we conducted a retrospective observational study using hospital administrative databases. All adults diagnosed with or treated for cancer in the year preceding their death in 2018 or 2019 were included. The main exposure was hospital-based specialist palliative care initiated >30 days before death. The outcome measures in the last 30 days of life were six quality indicators for inappropriate end-of-life care (≥2 ED-visits, ≥2 hospital admissions, >14 days hospitalization, ICU-admission, chemotherapy, hospital death). We identified 2603 deceased patients, of whom 14% (n = 359) received specialist palliative care >30 days before death (exposure group). Overall, 27% (n = 690) received potentially inappropriate end-of-life care: 19% in the exposure group, versus 28% in the non-exposure group (p < 0.001). The exposure group was 45% less likely to receive potentially inappropriate end-of-life care (AOR 0.55; 95% CI 0.41 to 0.73). Early (>90 days) and late (≤90 and >30 days) initiation of specialist palliative care, as well as outpatient and inpatient initiation, were all associated with less potentially inappropriate end-of-life care (AOR 0.49; 0.62; 0.32; 0.64, respectively). Thus, timely access to hospital-based specialist palliative care is associated with less potentially inappropriate end-of-life care for patients with cancer. The outpatient initiation of specialist palliative care seems to enhance this result.
Collapse
Affiliation(s)
- Manon S. Boddaert
- Netherlands Comprehensive Cancer Organisation (IKNL), 3501 DB Utrecht, The Netherlands
- Center of Expertise in Palliative Care, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Netherlands Association for Palliative Care (PZNL), 3501 DB Utrecht, The Netherlands
| | - Heidi P. Fransen
- Netherlands Comprehensive Cancer Organisation (IKNL), 3501 DB Utrecht, The Netherlands
- Netherlands Association for Palliative Care (PZNL), 3501 DB Utrecht, The Netherlands
| | - Ellen J. M. de Nijs
- Center of Expertise in Palliative Care, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Dagmar van Gerven
- Department of Medical Oncology, Alrijne Hospital, 2353 GA Leiderdorp, The Netherlands
| | | | - Natasja J. H. Raijmakers
- Netherlands Comprehensive Cancer Organisation (IKNL), 3501 DB Utrecht, The Netherlands
- Netherlands Association for Palliative Care (PZNL), 3501 DB Utrecht, The Netherlands
| | - Yvette M. van der Linden
- Netherlands Comprehensive Cancer Organisation (IKNL), 3501 DB Utrecht, The Netherlands
- Center of Expertise in Palliative Care, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| |
Collapse
|
12
|
Wice M, Rudolph JL, Jiang L, Edmonson HM, Page JS, Wu WC, Defillo-Draiby J. Trends in Palliative Care Utilization in Deceased Veterans With Heart Failure. Palliat Med Rep 2023; 4:344-349. [PMID: 38155911 PMCID: PMC10754341 DOI: 10.1089/pmr.2023.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/30/2023] Open
Abstract
Background Specialist-level palliative care in the final days does not allow time to alleviate symptoms and suffering. This analysis examined the change in the time from initial specialty-level palliative care to death among Veterans with heart failure. Methods This retrospective cohort study examined Veterans with a diagnosis of heart failure (HF) who died between 2011 and 2021. We examined the decedents from each year as a separate cohort. The primary outcome was time from specialty-level palliative care (SPC) encounter to death in the year death occurred. Results Of the cohort (n = 232,079), 56.5% did not receive SPC. Specialist-level palliative care >90 days before death more than doubled from 10.1% (2011) to 26.2% (2021), and Specialist-level palliative care in the last day of life was cut from 2.5% to 0.9%. Conclusion For Veterans with HF, specialist-level palliative care moved earlier in the disease course and has a substantial growth opportunity.
Collapse
Affiliation(s)
- Mitchell Wice
- Center of Innovation in Long Term Services and Support, Providence VA Healthcare System, Providence, Rhode Island, USA
- Geriatrics and Extended Care, Providence VA Healthcare System, Providence, Rhode Island, USA
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - James L. Rudolph
- Center of Innovation in Long Term Services and Support, Providence VA Healthcare System, Providence, Rhode Island, USA
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Center for Gerontology and Health Services Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Lan Jiang
- Center of Innovation in Long Term Services and Support, Providence VA Healthcare System, Providence, Rhode Island, USA
| | - Hal M. Edmonson
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - John S. Page
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Wen Chih Wu
- Center of Innovation in Long Term Services and Support, Providence VA Healthcare System, Providence, Rhode Island, USA
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Julio Defillo-Draiby
- Center of Innovation in Long Term Services and Support, Providence VA Healthcare System, Providence, Rhode Island, USA
- Geriatrics and Extended Care, Providence VA Healthcare System, Providence, Rhode Island, USA
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
13
|
Tsai YS, Tsai WC, Chiu LT, Kung PT. Effectiveness of Palliative Care before Death in Reducing Emergency Care Utilization for Patients with Terminal Cancer and Trends in the Utilization of Palliative Care from 2005-2018. Healthcare (Basel) 2023; 11:2907. [PMID: 37958051 PMCID: PMC10647500 DOI: 10.3390/healthcare11212907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023] Open
Abstract
This retrospective cohort study aimed to examine the effect of palliative care for patients with terminal cancer on healthcare utilization. The National Health Insurance (NHI) Research Database and death certificates were utilized to identify patients who died of cancer between 2005 and 2018. The number of terminal cancer patients between 2005 and 2018 was 605,126. Propensity score matching and conditional logistic regression were performed. The odds ratios (ORs) for "emergency care utilization", "CPR", "endotracheal intubation", and "ICU admission" were significantly lower for enrolled patients regardless of enrollment time compared to unenrolled patients. Compared to unenrolled patients, the OR for "emergency care utilization" increased from 0.34 to 0.68, the OR for "CPR use" increased from 0.13 to 0.26, the OR for "intubation" increased from 0.15 to 0.26, and the OR for "ICU admission" increased from 0.27 to 0.40 in enrolled patients. Between 2005 and 2010, CPR utilization, intubation, and ICU admission in patients enrolled in palliative care declined each year. Since the inclusion of palliative care in NHI (from 2010 onward), its utilization has increased slightly each year. Patients with terminal cancer enrolled in palliative care consume fewer medical resources before death than unenrolled patients; however, the difference decreases with longer times before death.
Collapse
Affiliation(s)
- Yi-Shiun Tsai
- Department of Orthopedics, Feng Yuan Hospital, Feng Yuan, Taichung 420210, Taiwan;
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung 406040, Taiwan; (W.-C.T.); (L.-T.C.)
| | - Wen-Chen Tsai
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung 406040, Taiwan; (W.-C.T.); (L.-T.C.)
| | - Li-Ting Chiu
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung 406040, Taiwan; (W.-C.T.); (L.-T.C.)
| | - Pei-Tseng Kung
- Department of Healthcare Administration, Asia University, Taichung 413305, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung 404327, Taiwan
| |
Collapse
|
14
|
Allaudeen N, Millhouse CF, Huberman DB, Wang H, Heidenreich PA. Late to Palliate? Inpatient Palliative Care Consultation at an Academic Veterans Affairs Hospital. Mil Med 2023; 188:e3363-e3367. [PMID: 36794805 DOI: 10.1093/milmed/usad038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/25/2023] [Accepted: 02/01/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Despite robust evidence describing the benefits of palliative care consultation (PCC), this service is underutilized. Hospital admission provides an important opportunity to obtain PCC. METHODS We evaluated all inpatients who received PCC at a Veterans Affairs academic hospital from January 1, 2019 to December 31, 2019. Logistic regression was used to determine factors associated with early versus late PCC, with early defined as >30 days from consult to death and late defined as ≤30 days. RESULTS The median time from PCC to death was 37 days. The majority of PCCs were early (58.4%). Of all patients receiving inpatient PCC, 13.2% died that admission. Cardiac (odds ratio = 0.3, 95% CI = 0.11-0.73) and neurological (odds ratio = 0.21, 95% CI = 0.05-0.70) diagnoses were more likely to receive early PCC compared to malignancy. Of the late PCCs receiving first-time consults, 58.9% had at least one admission during the last year. CONCLUSIONS Many patients are introduced to palliative care services within a month of death. These patients were often admitted during the prior year, presenting a missed opportunity to involve inpatient PCC earlier.
Collapse
Affiliation(s)
- Nazima Allaudeen
- Medical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | | | - David B Huberman
- Research Administration Office, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - Hui Wang
- Cooperative Studies Program Palo Alto Coordinating Center, Veterans Affairs Palo Alto Health Care System, Mountain View, CA 94043, USA
| | - Paul A Heidenreich
- Medical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| |
Collapse
|
15
|
Liao YS, Tsai WC, Chiu LT, Kung PT. Effects of the Time of Hospice and Palliative Care Enrollment before Death on Morphine, Length of Stay, and Healthcare Expense in Patients with Cancer in Taiwan. Healthcare (Basel) 2023; 11:2867. [PMID: 37958010 PMCID: PMC10648820 DOI: 10.3390/healthcare11212867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 10/25/2023] [Accepted: 10/29/2023] [Indexed: 11/15/2023] Open
Abstract
We aimed to investigate the effects of the time from hospice and palliative care enrollment to death on the quality of care and the effectiveness and trend of healthcare utilization in patients with terminal cancer. Data on the cancer-related mortality rates between 2005 and 2018 reported in the National Health Insurance Research Database in Taiwan were obtained. The effect of hospice and palliative care enrollment at different timepoints before death on healthcare utilization was explored. This retrospective cohort study included 605,126 patients diagnosed with terminal cancer between 2005 and 2018; the percentage of patients receiving hospice and palliative care before death increased annually. Terminal cancer patients who enrolled in hospice and palliative care at different timepoints before death received higher total morphine doses; the difference in the total morphine doses between the two groups decreased as the time to death shortened. The difference in the total morphine doses between the groups gradually decreased from 2005 to 2018. The enrolled patients had longer hospital stays; the length of hospital stays for both groups increased as the time to death lengthened, but the difference was not significant. The enrolled patients incurred lower total medical expenses, but the difference between the two groups increased as the time to death shortened.
Collapse
Affiliation(s)
- Yi-Shu Liao
- Department of Pathology, Taichung Armed Forces General Hospital, National Defense Medical Center, Taichung 411228, Taiwan;
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung 406040, Taiwan; (W.-C.T.); (L.-T.C.)
| | - Wen-Chen Tsai
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung 406040, Taiwan; (W.-C.T.); (L.-T.C.)
| | - Li-Ting Chiu
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung 406040, Taiwan; (W.-C.T.); (L.-T.C.)
| | - Pei-Tseng Kung
- Department of Healthcare Administration, Asia University, No. 500 Lioufeng Road, Wufeng, Taichung 413305, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung 404327, Taiwan
| |
Collapse
|
16
|
Chen JW, Chanbour H, Bendfeldt GA, Gangavarapu LS, Karlekar MB, Abtahi AM, Stephens BF, Zuckerman SL, Chotai S. Palliative Care Consultation Utilization Among Patient Undergoing Surgery for Metastatic Spinal Tumors. World Neurosurg 2023; 178:e549-e558. [PMID: 37532016 DOI: 10.1016/j.wneu.2023.07.118] [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: 05/11/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE In patients undergoing surgery for spinal metastasis, we sought to: (1) describe patterns of palliative care consultation, (2) evaluate the factors that trigger palliative care consultation, and (3) determine the association of palliative care consultation on longer-term outcomes. METHODS A single-center, retrospective, case-control study was conducted for patients undergoing spinal metastasis surgery from February 2010 to January 2021. The primary outcome was receiving a palliative care consultation, and the timing of consultation was divided into same hospital stay consultation, preoperative versus postoperative consultation, and early ( RESULTS Of 363 patients undergoing surgery for spinal metastasis, 62 (17.0%) patients received palliative care consultation during the same hospitalization, 11 (17.7%) were preoperative, and 51 (82.2%) were postoperative. Among same-stay consultations, 32 (51.6%) were early and 30 (48.4%) were late. Palliative care consultation recipients had worse preoperative Karnofsky Performance Scale (KPS) score (P < 0.001), were more likely to have other organ metastases (P = 0.005) or cord compression (P = 0.026), had longer hospitalization (P < 0.001), and were less likely to be discharged home (P < 0.001). Patients presenting with mechanical pain were more likely to receive preoperative consults compared with postoperative (P = 0.029), and earlier compared with later consultations (P = 0.046). Regarding long-term outcomes, patients with same-stay palliative care consultation had significantly shorter overall survival (log-rank; P < 0.001), worse KPS postoperatively (P = 0.017), and worse KPS and Modified McCormick Scale at the last follow-up (P < 0.001). CONCLUSIONS Only 1 in 6 patients received palliative care consultation. Patients receiving same-stay palliative care consultation had more advanced local and systemic disease burden. Increased utilization of palliative care consultation in patients with spine metastasis is needed.
Collapse
Affiliation(s)
- Jeffrey W Chen
- Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
| | - Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Mohana B Karlekar
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amir M Abtahi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Byron F Stephens
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| |
Collapse
|
17
|
Abunasser M, Abu-Fares H, Abdel-Razeq S, Shamieh O, Salama O, Ashouri K, Al Qudah A, Taqash A, Abu-Jaish H, Saadah SS, Abdel-Razeq H. Aggressiveness of Cancer Care at End of Life in Patients with Metastatic Breast Cancer in Jordan. J Multidiscip Healthc 2023; 16:2873-2881. [PMID: 37790988 PMCID: PMC10543079 DOI: 10.2147/jmdh.s422391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/22/2023] [Indexed: 10/05/2023] Open
Abstract
Background Contrary to Western societies, more than 15% of patients with breast cancer in Jordan are diagnosed with stage IV disease. In this study, we evaluate the value of early palliative care integration in the end-of-life care of such patients. Methods All consecutive adult patients who died between 2014 to 2018, while under the care of our institution, with a confirmed diagnosis of breast cancer at the time of death, irrespective of place of death, were retrospectively reviewed. Results During the study period, a total of 433 patients, median age 51.6 years, were included in the analysis. Among the whole group, 102 (23.6%) were referred to palliative care service early (≥30 days prior to death), 182 (42.0%) had late referral (<30 days from death), while 149 (34.4%) were never referred and were followed up by their medical oncologists. During the last 30 days prior to death, patients who were never referred to palliative care were more likely to visit the Emergency Room (ER) more than once (OR 1.89, 95% CI 1.20-2.99, p = 0.006), more likely to be admitted to the hospital more than once (OR 2.27, 95% CI 1.38-3.73, p = 0.001), and more likely to be admitted to the intensive care unit (ICU) (OR 3.07, 95% CI 1.48-6.38, p = 0.0027). Fewer patients in the "no referral" group died with advance directives compared to those who had early or late referral; 60.8%, 75.0% and 82.5%, respectively, p = 0.0003. Survival of patients followed by medical oncologist was not better than those referred to palliative care, either late or early; median survival was 19.0, 19.1 and 23.8 months, respectively (p = 0.2338). Conclusion Findings suggest that earlier palliative care referral is associated with less aggressive end-of-life care, leading to less frequent ER visits, hospital and ICU admissions during the last month of life, and does not compromise survival.
Collapse
Affiliation(s)
- Mahmoud Abunasser
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
- School of Medicine, the University of Jordan, Amman, Jordan
- Department of Palliative Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Hala Abu-Fares
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | | | - Omar Shamieh
- School of Medicine, the University of Jordan, Amman, Jordan
- Department of Palliative Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Osama Salama
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Khaled Ashouri
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Abdullah Al Qudah
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Ayat Taqash
- Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, Jordan
| | - Hala Abu-Jaish
- School of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Salwa S Saadah
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
- School of Medicine, the University of Jordan, Amman, Jordan
| | - Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
- School of Medicine, the University of Jordan, Amman, Jordan
| |
Collapse
|
18
|
Bischoff KE, Vanegas G, O'Riordan DL, Sumser B, Long J, Lin J, Berkey AR, Kobayashi E, Zapata C, Rabow MW, Pantilat SZ. A Systematic Approach to Assessing and Addressing Palliative Care Needs in an Outpatient Population. J Pain Symptom Manage 2023; 66:270-280.e8. [PMID: 37380147 DOI: 10.1016/j.jpainsymman.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/10/2023] [Accepted: 06/13/2023] [Indexed: 06/30/2023]
Abstract
CONTEXT/OBJECTIVES A critical frontier for palliative medicine is to develop systems to routinely and equitably address the palliative care (PC) needs of seriously ill populations. METHODS An automated screen identified Medicare primary care patients who had serious illness based on diagnosis codes and utilization patterns. A stepped-wedge design was used to evaluate a six-month intervention through which a healthcare navigator assessed these seriously ill patients and their care partners for PC needs in the domains of 1) physical symptoms, 2) emotional distress, 3) practical concerns, and 4) advance care planning (ACP) via telephone surveys. Identified needs were addressed with tailored PC interventions. RESULTS A total of 292/2175 (13.4%) patients screened positive for serious illness. A total of 145 completed an intervention phase; 83 completed a control phase. Severe physical symptoms were identified in 27.6%, emotional distress in 57.2%, practical concerns in 37.2%, and ACP needs in 56.6%. Twenty-five intervention patients (17.2%) were referred to specialty PC compared to six control patients (7.2%). Prevalence of ACP notes increased 45.5%-71.7% (p = 0.001) during the intervention and remained stable during the control phase. Quality of life remained stable during the intervention and declined 7.4/10-6.5/10 (P =0.04) during the control phase. CONCLUSION Through an innovative program, patients with serious illness were identified from a primary care population, assessed for PC needs, and offered specific services to meet those needs. While some patients were appropriate for specialty PC, even more needs were addressed without specialty PC. The program resulted in increased ACP and preserved quality of life.
Collapse
Affiliation(s)
- Kara E Bischoff
- Division of Palliative Medicine, Department of Medicine (K.E.B., G.V., D.L.O-R., B.S., J.L., C.Z., M.W.R., S.Z.P.), University of California, San Francisco, California, USA.
| | - Gabriela Vanegas
- Division of Palliative Medicine, Department of Medicine (K.E.B., G.V., D.L.O-R., B.S., J.L., C.Z., M.W.R., S.Z.P.), University of California, San Francisco, California, USA
| | - David L O'Riordan
- Division of Palliative Medicine, Department of Medicine (K.E.B., G.V., D.L.O-R., B.S., J.L., C.Z., M.W.R., S.Z.P.), University of California, San Francisco, California, USA
| | - Bridget Sumser
- Division of Palliative Medicine, Department of Medicine (K.E.B., G.V., D.L.O-R., B.S., J.L., C.Z., M.W.R., S.Z.P.), University of California, San Francisco, California, USA
| | - Judy Long
- Division of Palliative Medicine, Department of Medicine (K.E.B., G.V., D.L.O-R., B.S., J.L., C.Z., M.W.R., S.Z.P.), University of California, San Francisco, California, USA
| | - Jessica Lin
- University Medical Partners (J.L.), Stanford Healthcare, Stanford, California, USA
| | - Ann R Berkey
- The Berkey Group (A.R.B.), San Francisco, California, USA
| | - Edward Kobayashi
- Department of Family and Community Medicine (E.K.), University of California, San Francisco, San Francisco, California, USA
| | - Carly Zapata
- Division of Palliative Medicine, Department of Medicine (K.E.B., G.V., D.L.O-R., B.S., J.L., C.Z., M.W.R., S.Z.P.), University of California, San Francisco, California, USA
| | - Michael W Rabow
- Division of Palliative Medicine, Department of Medicine (K.E.B., G.V., D.L.O-R., B.S., J.L., C.Z., M.W.R., S.Z.P.), University of California, San Francisco, California, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine (K.E.B., G.V., D.L.O-R., B.S., J.L., C.Z., M.W.R., S.Z.P.), University of California, San Francisco, California, USA
| |
Collapse
|
19
|
Tsang M, Bischoff K, Schoenbeck KL, Berry K, O’Riordan D, Fakhri B, Wong SW, Shah N, Olin R, Andreadis C, Vieaux J, Cohen E, Lopez NS, Mannis GN, Rabow M. Value of embedded palliative care: outpatient palliative care and health care utilization for patients with hematologic malignancies. Blood Adv 2023; 7:3146-3149. [PMID: 36809787 PMCID: PMC10362539 DOI: 10.1182/bloodadvances.2022009039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/11/2023] [Accepted: 01/28/2023] [Indexed: 02/23/2023] Open
Affiliation(s)
- Mazie Tsang
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Kara Bischoff
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Kelly L. Schoenbeck
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
- Division of Hematology and Oncology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Kim Berry
- Executive Finance Consultant, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - David O’Riordan
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Bita Fakhri
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA
| | - Sandy W. Wong
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Nina Shah
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Rebecca Olin
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Charalambos Andreadis
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jules Vieaux
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Eve Cohen
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Nancy Shepard Lopez
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Gabriel N. Mannis
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA
| | - Michael Rabow
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| |
Collapse
|
20
|
Bassette E, Salyer C, McCammon S, Veazey Brooks J, Spoozak L. Value of Hospice and Palliative Medicine Fellowship After Surgical Training: Bridging the Gap for Improved Patient Care. Am J Hosp Palliat Care 2023; 40:711-719. [PMID: 36154697 DOI: 10.1177/10499091221128966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Surgeons comprise 2% of HPM-trained physicians. Little is known about the perceived value of HPM training to the surgeon or medical community. We aim to demonstrate the value of HPM fellowship training to surgeons and surgical practice from the point of view of HPM fellowship trained surgeons. Design: A qualitative analysis was performed using semi-structured zoom interviews that elicited the lived experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis. Setting: Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings. Participants: Eligibility included training in general surgery, obstetrics and gynecology, or affiliated subspecialties and completion of a 1-year HPM fellowship. Results: 17 interviews were performed. Several themes emerged regarding the transformative value of HPM training to their medical and surgical practice: (1) Learning to apply shared decision making and goal-concordant care to surgical decision making, and (2) Decreasing personal bias in medical decision making, and (3) Enabling wellness in surgeons. Two themes emerged regarding the perceived value to both the surgical community and the HPM community: (1) Value of the HPM Fellowship Trained Surgeon to the Surgical Community, and (2) Value of the HPM Fellowship Trained Surgeon to the HPM Community. All study participants valued their HPM training and felt highly valued by the healthcare team. Conclusion: HPM trained surgeons are highly valued on the healthcare team and improve patient-centered surgical care.
Collapse
Affiliation(s)
- Emma Bassette
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Chelsea Salyer
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Susan McCammon
- Department of Otolaryngology, University of Alabama School of Medicine, Birmingham, AL, USA
- Department of Internal Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Joanna Veazey Brooks
- Department of Population Health, University of Kansas School of Medicine, Kansas City, KS, USA
- Department of Internal Medicine, Palliative Medicine Division, University of Kansas School of Medicine, Kansas, USA
| | - Lori Spoozak
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Kansas School of Medicine, Kansas City, KS, USA
- Department of Internal Medicine, Palliative Medicine Division, University of Kansas School of Medicine, Kansas, USA
| |
Collapse
|
21
|
Latif Z, Makuvire T, Feder SL, Abrahm J, Quintero Pinzon P, Warraich HJ. Experiences of Medical Interpreters During Palliative Care Encounters With Limited English Proficiency Patients: A Qualitative Study. J Palliat Med 2023; 26:784-789. [PMID: 36516127 PMCID: PMC11079501 DOI: 10.1089/jpm.2022.0320] [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] [Accepted: 11/18/2022] [Indexed: 12/15/2022] Open
Abstract
Background: There are many challenges in communication and cultural barriers for patients with limited English proficiency (LEP) who suffer from serious illnesses. Palliative care utilization among this population remains limited and the experiences of medical interpreters during palliative care encounters remain understudied. Methods: We conducted semistructured video interviews with interpreters working at an academic medical center. Interview questions explored interpreters' observations and experiences during palliative care encounters with LEP patients. We performed thematic analysis of the interview contents. Results: Our study included 20 interpreters who interpret in 9 languages with a mean experience of 16.3 years. We identified four themes from the interviews that shed light on the challenges of incorporating palliative care into the care of patients with LEP: (1) lack of a verbatim interpretation for the term "palliative care," (2) poor patient understanding of their treatment goals, (3) suboptimal timing of palliative care involvement, and (4) fears and misconceptions related to palliative care. Owing to challenges in word choice, the timing of palliative care involvement, and poor understanding of palliative care, interpreters observed that many patients with LEP declined palliative care involvement in their treatment plan. Conclusions: In this study, we identified several actionable barriers interpreters noted to incorporating palliative care into care of patients with LEP. Interventions directed toward providing LEP patients with standardized culturally appropriate information on palliative care are needed.
Collapse
Affiliation(s)
- Zara Latif
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tracy Makuvire
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Janet Abrahm
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pablo Quintero Pinzon
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Haider J. Warraich
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Cardiology Section, Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| |
Collapse
|
22
|
Chawla M, Villarreal ME, Waterman BL, Di Tosto G, Gonzalez R, Sarna A, Patel R, Cloyd J, Pawlik TM, Rush LJ, McAlearney A, Ejaz A. Utilization of Palliative and Hospice Care Among Pancreatic Cancer Patients at an Academic Center. J Surg Res 2023; 289:22-26. [PMID: 37075607 DOI: 10.1016/j.jss.2023.03.014] [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: 12/02/2022] [Revised: 02/19/2023] [Accepted: 03/09/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION Pancreatic ductal adenocarcinoma has the lowest 5-y relative survival of all solid tumor malignancies. Palliative care can improve the quality of life of both patients and their caregivers. However, the utilization patterns of palliative care in patients with pancreatic cancer are unclear. METHODS Pancreatic cancer patients who were diagnosed between October 2014 and December 2020 at the Ohio State University were identified. Palliative care and hospice utilization and referral patterns were assessed. RESULTS Of the 1458 pancreatic cancer patients, 55% (n = 799) were male, median age at diagnosis was 65 y (interquartile range [IQR]: 58, 73), and most were Caucasian (n = 1302, 89%). Palliative care was utilized by 29% (n = 424) of the cohort, with the initial consultation obtained after an average of 6 ± 9 mo from diagnosis. Patients who received palliative care were younger (62 y, IQR: 55, 70 versus 67 y, IQR: 59, 73; P < 0.001) and more frequently members of racial and ethnic minorities (15% versus 9%; P < 0.001) versus those who did not receive palliative care. Among the 344 (24%) patients who received hospice care, 153 (44%) had no prior palliative care consultation. Patients referred to hospice care survived a median of 14 d (95% CI, 12-16) after hospice referral. CONCLUSIONS Only 3 out of 10 patients with pancreatic cancer received palliative care at an average of 6 mo from initial diagnosis. More than two out of every five patients referred to hospice had no previous palliative care consultation. Efforts to understand the impact of improved integration of palliative care into pancreatic cancer programs are needed.
Collapse
Affiliation(s)
- Mehak Chawla
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael E Villarreal
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Brittany L Waterman
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Gennaro Di Tosto
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Roberto Gonzalez
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Angela Sarna
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Romal Patel
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Laura J Rush
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ann McAlearney
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
| |
Collapse
|
23
|
Inoue M, Li MH, Hashemi M, Yu Y, Jonnalagadda J, Kulkarni R, Kestenbaum M, Mohess D, Koizumi N. Opinion and Sentiment Analysis of Palliative Care in the Era of COVID-19. Healthcare (Basel) 2023; 11:healthcare11060855. [PMID: 36981512 PMCID: PMC10048418 DOI: 10.3390/healthcare11060855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023] Open
Abstract
During the COVID-19 pandemic, the value of palliative care has become more evident than ever. The current study quantitatively investigated the perceptions of palliative care emerging from the pandemic experience by analyzing a total of 26,494 English Tweets collected between 1 January 2020 and 1 January 2022. Such an investigation was considered invaluable in the era of more people sharing and seeking healthcare information on social media, as well as the emerging roles of palliative care. Using a web scraping method, we reviewed 6000 randomly selected Tweets and identified four themes in the extracted Tweets: (1) Negative Impact of the Pandemic on Palliative Care; (2) Positive Impact of the Pandemic on Palliative Care; (3) Recognized Benefits of Palliative Care; (4) Myth of Palliative Care. Although a large volume of Tweets focused on the negative impact of COVID-19 on palliative care as expected, we found almost the same volume of Tweets that were focused on the positive impact of COVID-19 on palliative care. We also found a smaller volume of Tweets associated with myths about palliative care. Using these manually classified Tweets, we trained machine learning (ML) algorithms to automatically classify the remaining tweets. The automatic classification of Tweets was found to be effective in classifying the negative impact of the COVID-19.
Collapse
Affiliation(s)
- Megumi Inoue
- Department of Social Work, George Mason University, 4400 University Drive, MS 1F8, Fairfax, VA 22030, USA
- Correspondence:
| | - Meng-Hao Li
- Schar School of Policy and Government, George Mason University, Arlington, VA 22201, USA
| | - Mahdi Hashemi
- Department of Information Sciences and Technology, George Mason University, Fairfax, VA 22030, USA
| | - Yang Yu
- Schar School of Policy and Government, George Mason University, Arlington, VA 22201, USA
| | - Jahnavi Jonnalagadda
- Department of Information Sciences and Technology, George Mason University, Fairfax, VA 22030, USA
| | - Rajendra Kulkarni
- Schar School of Policy and Government, George Mason University, Arlington, VA 22201, USA
| | | | - Denise Mohess
- Yale New Haven Health System, Bridgeport, CT 06610, USA
| | - Naoru Koizumi
- Schar School of Policy and Government, George Mason University, Arlington, VA 22201, USA
| |
Collapse
|
24
|
Oertel M, Schmidt R, Steike DR, Eich HT, Lenz P. Palliative care on the radiation oncology ward-improvements in clinical care through interdisciplinary ward rounds. Strahlenther Onkol 2023; 199:251-257. [PMID: 35951037 PMCID: PMC9938032 DOI: 10.1007/s00066-022-01989-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/15/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Palliative care is essential for patients with terminal diseases and aims at effective symptom control. This may stand in opposition to radiation treatment as an oncological treatment modality. The hereby presented work demonstrates the successful integration of a palliative care service in the radiation oncology ward. METHODS Since 2015, 1018 patients were seen by the palliative care service on the radiation oncology ward and have been analyzed in this single center study. To assess teaching efficacy of the consultation service, a survey was conducted among 15 radiation oncology residents. RESULTS Cooperation between the two departments proved to be efficient with rising patient numbers. Palliative care was able to guide appropriate postdischarge care with the number of patients dying on the radiation oncology ward decreasing significantly (p = 0.009). The main topics for consultation were pain medication (92.3%), organization of postdischarge care (92.3%), and psycho-oncological support (84.6%). Most residents had a positive image of the palliative care service and consented on adjectives like "enriching", "empathic", "collegial", "professionally founded", and a "low threshold for consultation". All participants agreed that cooperation deepened their knowledge on palliative care. CONCLUSION A synergistic cooperation between a palliative care consultation service and a radiation oncology department addresses patient symptoms on an individual level. It confers advanced knowledge on palliative care which is essential for resident education and patient treatment.
Collapse
Affiliation(s)
- Michael Oertel
- Department of Radiation Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
| | - Renate Schmidt
- Department of Palliative Care, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - David Rene Steike
- Department of Radiation Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Philipp Lenz
- Department of Palliative Care, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| |
Collapse
|
25
|
Khan H, Cherla D, Mehari K, Tripathi M, Butler TW, Crook ED, Heslin MJ, Johnston FM, Fonseca AL. Palliative Therapies in Metastatic Pancreatic Cancer: Does Medicaid Expansion Make a Difference? Ann Surg Oncol 2023; 30:179-188. [PMID: 36169753 DOI: 10.1245/s10434-022-12563-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/28/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of medicaid expansion (ME) on receipt of palliative therapies in metastatic pancreatic cancer patients. PATIENTS AND METHODS A difference-in-differences (DID) approach was used to analyze patients with metastatic pancreatic cancer identified from the National Cancer Database diagnosed during two time periods: pre-expansion (2010-2012) and post-expansion (2014-2016). Patients diagnosed while residing in ME states were compared with those in non-ME states. Multivariable logistic regression was used to identify predictors of receipt of palliative therapies. RESULTS Of 87,738 patients overall, 7483(18.1%) received palliative therapies in the pre-expansion, while 10,211(21.5%) received palliative therapies in the post-expansion period. In the pre-expansion period, treatment at a high-volume facility (HVF) (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.02-1.18) and non-west geographic location were predictive of increased palliative therapies. In the post-expansion period, treatment at an HVF (OR 1.09, 95% CI 1.02-1.16), geographic location, and living in an ME state at the time of diagnosis (OR 1.14, 95% CI 1.06-1.22) were predictive of increased palliative therapies. Older age, highest quartile median income (zip-code based), and treatment at a nonacademic facility were independently associated with decreased palliative therapies in both periods. DID analysis demonstrated that patients with metastatic pancreatic cancer living in ME states had increased receipt of palliative therapies relative to those in non-ME states (DID = 2.68, p < 0.001). CONCLUSIONS The overall utilization of palliative therapies in metastatic pancreatic cancer is low. Multiple sociodemographic disparities exist in the receipt of palliative therapies. ME is associated with increased receipt of palliative therapies in patients with metastatic pancreatic cancer.
Collapse
Affiliation(s)
- Hamza Khan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Deepa Cherla
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Krista Mehari
- Department of Psychology, The University of South Alabama, Mobile, AL, USA
| | - Manish Tripathi
- Kellogg School of Management, Northwestern University, Chicago, IL, USA
| | - Thomas W Butler
- Department of Internal Medicine, The University of South Alabama, Mobile, AL, USA
| | - Errol D Crook
- Department of Internal Medicine, The University of South Alabama, Mobile, AL, USA
| | - Martin J Heslin
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | |
Collapse
|
26
|
Schultz K, Howard S, Moreno K, Siegel T, Zonies D, Brasel K, Cook M. What Should the Surgeons Do at the Family Meeting: A Multi-Disciplinary Qualitative Description of Surgeon Participation in Palliative Care Discussions. JOURNAL OF SURGICAL EDUCATION 2023; 80:110-118. [PMID: 36089480 DOI: 10.1016/j.jsurg.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/12/2022] [Accepted: 08/14/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE National guidelines have suggested that quality surgical care should incorporate effective palliative care (PC). Numerous barriers to surgeon participation remain and the domains of optimal surgeon participation are unclear. DESIGN Eight semi-structured and multi-professional focus groups with 34 total participants. Discussion was transcribed, and qualitative approaches were used to encode, identify, and categorize emergent themes. SETTING Oregon Health & Science University, Portland Oregon. A tertiary care teaching hospital. PARTICIPANTS 34 multi-disciplinary participants in eight focus groups, identified on a volunteer basis. RESULTS Key themes defining domains of optimal surgeon/palliative practice include: (1) "primary/secondary PC" which detailed conflict between the surgeon's desire to be part of palliative discussions and competing clinical/time demands. (2) "role/responsibility" described the tension surgeons feel around a desire to provide honest and goal concordant care (3) "teamwork/conflict" detailed the approach to disagreement among multidisciplinary teams. CONCLUSIONS In this qualitative analysis, emergent themes suggest that surgeons want to be involved in the PC of their patients but are limited by available time and competing for ethical obligations. Tension between competing communication and care obligations and PC goals is common, and discord around patient goals remains an issue. This work highlights the need for a standardized curriculum to improve the PC of surgical patients.
Collapse
Affiliation(s)
- Kristen Schultz
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Shannon Howard
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Kirstin Moreno
- Office of Educational Improvement Innovation, Oregon Health & Science University, Portland, Oregon
| | - Timothy Siegel
- Department of Medicine, Division of Hematology/Medical Oncology, Oregon Health & Science University, Portland, Oregon
| | - David Zonies
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Karen Brasel
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Mackenzie Cook
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon.
| |
Collapse
|
27
|
Rohlfing AB, Bischoff KE, Kolaitis NA, Kronmal RA, Kime NA, Gray MP, Bartolome S, Chakinala MM, Frantz RP, Ventetuolo CE, Mathai SC, De Marco T. Palliative care referrals in patients with pulmonary arterial hypertension: The Pulmonary Hypertension Association Registry. Respir Med 2023; 206:107066. [PMID: 36470050 DOI: 10.1016/j.rmed.2022.107066] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/07/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a life limiting disease with substantial symptom burden and healthcare utilization. Palliative care alleviates physical and emotional symptoms for patients with serious illness, and has been underutilized for these patients. OBJECTIVE To characterize patients with PAH referred to palliative care and identify predictors of referral. METHODS We conducted an observational study of adult patients enrolled in the Pulmonary Hypertension Association Registry from January 2015 through June 2021, performing descriptive statistics on patient characteristics at baseline for all patients and the subset referred to palliative care. These characteristics were modeled in a backwards elimination Cox regression with time to referral to palliative care as the primary outcome. RESULTS 92 of 1,578 patients were referred to palliative care (5.8%); 43% were referred at their last visit prior to death. Referrals were associated with increasing age per decade (hazard ratio 1.35 [95% confidence interval 1.16-1.58]), lower body mass index (hazard ratio 0.97 [95% confidence interval 0.94-0.998]), supplemental oxygen use (hazard ratio 2.01 [95% confidence interval 1.28-3.16]), parenteral prostanoid use (hazard ratio 2.88 [95% confidence interval 1.84-4.51]), and worse quality of life, measured via lower physical (hazard ratio 0.97 [95% confidence interval 0.95-0.99]) and mental (hazard ratio 0.98 [95% confidence interval 0.96-0.995]) scores on the 12-item Short Form Health Survey. CONCLUSION Patients with PAH are infrequently referred to palliative care, even at centers of excellence. Referrals occur in sicker patients with lower quality of life scores, often close to the end of life.
Collapse
Affiliation(s)
- Anne B Rohlfing
- Extended Care & Palliative Medicine Service, VA Palo Alto Health Care System, Palo Alto, CA, United States; Division of Primary Care & Population Health, Stanford Medicine, Stanford, CA, United States.
| | - Kara E Bischoff
- Division of Palliative Medicine, University of California San Francisco, San Francisco, CA, United States.
| | - Nicholas A Kolaitis
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, University of California San Francisco, San Francisco, CA, United States.
| | - Richard A Kronmal
- Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Noah A Kime
- Department of Biostatistics, University of Washington, Seattle, WA, United States.
| | - Michael P Gray
- Faculty of Medicine & Health, Division of Cardiology, University of Sydney Royal North Shore Hospital, Sydney, NSW, Australia.
| | - Sonja Bartolome
- Division of Pulmonary & Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States.
| | - Murali M Chakinala
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, St Louis, MO, United States.
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Corey E Ventetuolo
- Division of Pulmonary, Critical Care & Sleep Medicine, Brown University, Providence, RI, United States.
| | - Stephen C Mathai
- Division of Pulmonary & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Teresa De Marco
- Division of Cardiology, University of California San Francisco, San Francisco, CA, United States.
| | | |
Collapse
|
28
|
Chiaruttini MV, Corli O, Pizzuto M, Nobili A, Fortini G, Fortino I, Leoni O, Bosetti C. Palliative medicine favourably influences end-of-life cancer care intensity: a large retrospective database study. BMJ Support Palliat Care 2022:spcare-2022-004050. [PMID: 36522144 DOI: 10.1136/spcare-2022-004050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Hospice and home palliative care have been associated to a reduction of aggressive treatments in the end-of-life, but data in the Italian context are scanty. Therefore, we aim to investigate the role of palliative care on indicators of end-of-life intensity of care among patients with cancer in Lombardy, the largest Italian region. METHODS Within a retrospective study using the healthcare utilisation databases of Lombardy, Italy, we selected all residents who died in 2019 with a diagnosis of cancer. We considered as exposure variables admission to palliative care and time at palliative care admission, and as indicators of aggressive care hospitalisations, diagnostic/therapeutic procedures, in-hospital death, emergency department visits and chemotherapy over a time window of 30 days before death; chemotherapy in the last 14 days was also considered. RESULTS Our cohort included 26 539 individuals; of these, 14 320 (54%) were admitted to palliative care before death. Individuals who were admitted to palliative care had an odds ratio (OR) of 0.27 for one hospitalisation, 0.14 for ≥2 hospitalisations, 0.25 for hospital stay ≥12 days, 0.38 for minor diagnostic/therapeutic procedures, 0.18 for major diagnostic/therapeutic procedures, 0.02 for in-hospital death, 0.35 for one emergency department visit, 0.29 for ≥2 emergency department visits and 0.66 for chemotherapy use in the last 30 days; the OR was 0.56 for chemotherapy use in the last 14 days. CONCLUSIONS This large real-world analysis confirms and further support the importance of palliative care assistance for patients with cancer in the end- of- life; this is associated to a significant reduction in unnecessary treatments.
Collapse
Affiliation(s)
| | - Oscar Corli
- Dipartimento di Oncologia, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Alessandro Nobili
- Dipartimento di Politiche per la Salute, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Ida Fortino
- Regione Lombardia Direzione Generale Welfare, Milano, Italy
| | - Olivia Leoni
- Regione Lombardia Direzione Generale Welfare, Milano, Italy
| | - Cristina Bosetti
- Dipartimento di Oncologia, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| |
Collapse
|
29
|
Müller S, Fink M, Hense J, Comino MRS, Schuler M, Teufel M, Tewes M. Palliative care outpatients in a German comprehensive cancer center-identifying indicators for early and late referral. BMC Palliat Care 2022; 21:221. [PMID: 36503625 PMCID: PMC9743520 DOI: 10.1186/s12904-022-01114-z] [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: 05/27/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Despite that early integration of palliative care is recommended in advanced cancer patients, referrals to outpatient specialised palliative care (SPC) frequently occur late. Well-defined referral criteria are still missing. We analysed indicators associated with early (ER) and late referral (LR) to SPC of an high volume outpatient unit of a comprehensive cancer center. METHODS Characteristics, laboratory parameters and symptom burden of 281 patients at first SPC referral were analysed. Timing of referral was categorized as early, intermediate and late (> 12, 3-12 and < 3 months before death). Ordinal logistic regression analysis was used to identify factors related to referral timing. Kruskal-Wallis test was used to determine symptom severity and laboratory parameter in each referral category. RESULTS LRs (50.7%) had worse scores of weakness, loss of appetite, drowsiness, assistance of daily living (all p < 0.001) and organisation of care (p < 0.01) in contrast to ERs. The mean symptom sum score was significantly higher in LRs than ERs (13.03 vs. 16.08; p < 0.01). Parameters indicative of poor prognosis, such as elevated LDH, CRP and neutrophil-to-lymphocyte ratio (NLR) (p < 0.01) as well as the presence of ascites (p < 0.05), were significantly higher (all p < 0.001) in LRs. In univariable analyses, psychological distress (p < 0.05) and female gender (p < 0.05) were independently associated with an ER. CONCLUSION A symptom sum score and parameters of poor prognosis like NLR or LDH might be useful to integrate into palliative care screening tools.
Collapse
Affiliation(s)
- S. Müller
- grid.410718.b0000 0001 0262 7331Department of Palliative Medicine, West German Cancer Center Essen, University Hospital Essen, 45147 Essen, Germany
| | - M. Fink
- grid.5718.b0000 0001 2187 5445Clinic of Psychosomatic Medicine and Psychotherapy, University of Duisburg-Essen, LVR-Klinikum Essen, 45147 Essen, Germany
| | - J. Hense
- grid.410718.b0000 0001 0262 7331Department of Medical Oncology, West German Cancer Center Essen, University Hospital Essen, 45147 Essen, Germany
| | - M. R. Salvador Comino
- grid.410718.b0000 0001 0262 7331Department of Palliative Medicine, West German Cancer Center Essen, University Hospital Essen, 45147 Essen, Germany
| | - M. Schuler
- grid.410718.b0000 0001 0262 7331Department of Medical Oncology, West German Cancer Center Essen, University Hospital Essen, 45147 Essen, Germany ,grid.410718.b0000 0001 0262 7331German Cancer Consortium (DKTK), Partner Site University Hospital Essen, 45147 Essen, Germany
| | - M. Teufel
- grid.5718.b0000 0001 2187 5445Clinic of Psychosomatic Medicine and Psychotherapy, University of Duisburg-Essen, LVR-Klinikum Essen, 45147 Essen, Germany
| | - M. Tewes
- grid.410718.b0000 0001 0262 7331Department of Palliative Medicine, West German Cancer Center Essen, University Hospital Essen, 45147 Essen, Germany
| |
Collapse
|
30
|
Ullgren H, Sharp L, Fransson P, Bergkvist K. Exploring Health Care Professionals' Perceptions Regarding Shared Clinical Decision-Making in Both Acute and Palliative Cancer Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16134. [PMID: 36498204 PMCID: PMC9737093 DOI: 10.3390/ijerph192316134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 06/17/2023]
Abstract
UNLABELLED Developments in cancer care have resulted in improved survival and quality of life. Integration of acute and palliative cancer care is desirable, but not always achieved. Fragmented care is associated with sub-optimal communication and collaboration, resulting in unnecessary care transitions. The aim of this study was to explore how health care professionals, from both acute and palliative care, perceive clinical decision-making when caring for patients undergoing active cancer treatment in parallel with specialized palliative care at home. METHODS Qualitative explorative design, using online focus-group interviews, based on patient-cases, among health care professionals (physicians and nurses) and Framework Analysis. RESULTS Six online focus-group interviews were performed. Few signs of systematic integration were found, risking fragmented care, and putting the patients in a vulnerable situation. Different aspects of uncertainty related to mandates and goals-of-care impacted clinical decision-making. Organizational factors appeared to hinder mutual clinical decision-making as well as the uncertainty related to responsibilities. These uncertainties seemed to be a barrier to timely end-of-life conversations and clinical decisions on optimal care, for example, the appropriateness of transfer to acute care. CONCLUSIONS Lack of integration between acute and palliative care have negative consequences for patients (fragmented care), health care professionals (ethical stress), and the health care system (inadequate use of resources).
Collapse
Affiliation(s)
- Helena Ullgren
- Department of Nursing, Umeå University, 901 87 Umeå, Sweden
- Department of Oncology and Pathology, Karolinska Institute, 171 77 Stockholm, Sweden
- ME Head & Neck, Lung & Skin Cancer, Karolinska Comprehensive Cancer Center, 171 76 Stockholm, Sweden
| | - Lena Sharp
- Department of Nursing, Umeå University, 901 87 Umeå, Sweden
- Regional Cancer Center, 104 25 Stockholm, Sweden
| | - Per Fransson
- Department of Nursing, Umeå University, 901 87 Umeå, Sweden
| | - Karin Bergkvist
- Department of Nursing Science, Sophiahemmet University, 114 86 Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institute, 171 77 Stockholm, Sweden
| |
Collapse
|
31
|
Raghavan K, Copeland TP, Rabow M, Ladenheim M, Marks A, Pantilat SZ, O'Riordan D, Seidenwurm D, Franc B. Palliative care and imaging utilisation for patients with cancer. BMJ Support Palliat Care 2022; 12:e813-e820. [PMID: 30826736 PMCID: PMC6773516 DOI: 10.1136/bmjspcare-2018-001572] [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: 05/23/2018] [Revised: 01/01/2019] [Accepted: 01/16/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE This observational study explores the association between palliative care (PC) involvement and high-cost imaging utilisation for patients with cancer patients during the last 3 months of life. METHODS Adult patients with cancer who died between 1 January 2012 and 31 May 2015 were identified. Referral to PC, intensity of PC service use, and non-emergent oncological imaging utilisation were determined. Associations between PC utilisation and proportion of patients imaged and mean number of studies per patient (mean imaging intensity (MII)) were assessed for the last 3 months and the last month of life. Similar analyses were performed for randomly matched case-control pairs (n = 197). Finally, the association between intensity of PC involvement and imaging utilisation was assessed. RESULTS 3784 patients were included, with 3523 (93%) never referred to PC and 261 (7%) seen by PC, largely before the last month of life (61%). Similar proportions of patients with and without PC referral were imaged during the last 3 months, while a greater proportion of patients with PC referral were imaged in the last month of life. PC involvement was not associated with significantly different MII during either time frame. In the matched-pairs analysis, a greater proportion of patients previously referred to PC received imaging in the period between the first PC encounter and death, and in the last month of life. MII remained similar between PC and non-PC groups. Finally, intensity of PC services was similar for imaged and non-imaged patients in the final 3 months and 1 month of life. During these time periods, increased PC intensity was not associated with decreased MII. CONCLUSIONS PC involvement in end-of-life oncological care was not associated with decreased use of non-emergent, high-cost imaging. The role of advanced imaging in the PC setting requires further investigation.
Collapse
Affiliation(s)
- Kesav Raghavan
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Timothy P Copeland
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Michael Rabow
- Palliative Care Program, University of California San Francisco, San Francisco, California, USA
| | - Maya Ladenheim
- Palliative Care Program, University of California San Francisco, San Francisco, California, USA
| | - Angela Marks
- Palliative Care Program, University of California San Francisco, San Francisco, California, USA
| | - Steven Z Pantilat
- Palliative Care Program, University of California San Francisco, San Francisco, California, USA
| | - David O'Riordan
- Palliative Care Program, University of California San Francisco, San Francisco, California, USA
| | | | - Benjamin Franc
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
32
|
Utilization of palliative care resource remains low, consuming potentially avoidable hospital admissions in stage IV non-small cell lung cancer: a community-based retrospective review. Support Care Cancer 2022; 30:10117-10126. [PMID: 36374328 PMCID: PMC9661463 DOI: 10.1007/s00520-022-07364-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022]
Abstract
Purpose Early referral of patients with stage IV non-small cell lung cancer (NSCLC) to outpatient palliative care has been shown to increase survival and reduce unnecessary healthcare resource utilization. We aimed to determine outpatient palliative care referral rate and subsequent resource utilization in patients with stage IV NSCLC in a multistate, community-based hospital network and identify rates and reasons for admissions within a local healthcare system of Washington State. Methods A retrospective chart review of a multistate hospital network and a local healthcare system. Patients were identified using ICD billing codes. In the multistate network, 2844 patients diagnosed with stage IV NSCLC between January 1, 2013, and March 1, 2018, were reviewed. In the state healthcare system, 283 patients between August 2014 and June 2017 were reviewed. Results Referral for outpatient palliative care was low: 8% (217/2844) in the multistate network and 11% (32/283) in the local healthcare system. Early outpatient palliative care (6%, 10/156) was associated with a lower proportion of patients admitted into the intensive care unit in the last 30 days of life compared to no outpatient palliative care (15%, 399/2627; p = 0.003). Outpatient palliative care referral was associated with improved overall survival in Kaplan Meier survival analysis. Within the local system, 51% (104/204) of admissions could have been managed in outpatient setting, and of the patients admitted in the last 30 days of life, 59% (87/147) experienced in-hospital deaths. Conclusion We identified underutilization of outpatient palliative care services within stage IV NSCLC patients. Many patients with NSCLC experience hospitalization the last month of life and in-hospital death. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-022-07364-0.
Collapse
|
33
|
Finlay EE, Goodlev ER, Biewald MA, Skavinski KA, Sinclair CT. An Educational Needs Assessment for Outpatient Palliative Care Clinicians. J Palliat Med 2022; 26:464-471. [PMID: 36260354 DOI: 10.1089/jpm.2022.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: As the field of palliative medicine continues to grow in community-based settings, outpatient palliative care clinics have become an important site for providing upstream palliative care to patients and families. It is unclear whether current training models, focused predominantly on the inpatient setting, adequately prepare clinicians for outpatient palliative care practice. Methods: We performed an online educational needs assessment survey of physicians and advanced practice providers working in outpatient palliative care clinics. Survey questions focused on the importance of specific palliative care knowledge, skills, and attitudes in outpatient practice using the Accreditation Council of Graduate Medical Education Hospice and Palliative Medicine (HPM) curricular milestones to guide survey development. We also explored clinician perception of training adequacy and current educational needs relevant to outpatient practice. Results: One hundred sixty-four clinicians, including 122 (74.4%) physicians, 32 (19.5%) nurse practitioners, and 8 (4.9%) physician assistants, completed our survey. Clinicians had a median of 10 years of HPM experience and 6 years of outpatient experience. We identified two main areas of perceived knowledge or skill deficit: navigating insurance and prior authorizations and co-management of pain and opioid use disorder. Conclusion: Addressing gaps in education and preparedness for outpatient practice is essential to improve clinician competence and efficiency as well as patient care, safety, and care coordination. This study identifies practice management and opioid stewardship as potential targets for educational interventions. The development of curricula related to these outpatient skills may improve clinicians' ability to provide safe, patient-centered care with confidence.
Collapse
Affiliation(s)
- Esme E Finlay
- Department of Medicine, Division of Palliative Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Eric R Goodlev
- Department of Medicine, Division of Palliative Care, Einstein Healthcare Network (Einstein Medical Center Montgomery), Norristown, Pennsylvania, USA
| | - Mollie A Biewald
- Department of Medicine, Division of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York. USA
| | - Kira A Skavinski
- Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care, University of California, San Diego Health, La Jolla, California, USA
| | - Christian T Sinclair
- Department of Medicine, Division of Palliative Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
34
|
Bassette E, Salyer C, McCammon S, Brooks JV, Spoozak L. Hospice and Palliative Medicine Fellowship after Surgical Training: A Roadmap to the Future of Surgical Palliative Care. JOURNAL OF SURGICAL EDUCATION 2022; 79:1177-1187. [PMID: 35662536 DOI: 10.1016/j.jsurg.2022.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/17/2022] [Accepted: 05/07/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Surgeons comprise only 2% of Hospice and Palliative Medicine (HPM) board-certified physicians. Little is known about the motivations of individuals who pursue this combined training or the perceived benefits of this pathway. This study aimed to capture the pathways and experiences of HPM fellowship trained surgeons and to establish recommendations for surgical trainees who may benefit from HPM fellowship training. DESIGN A qualitative study was designed using semi-structured zoom interviews that elicited experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis. SETTING Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings. PARTICIPANTS Eligibility included completion of a 1-year HPM fellowship and training in general surgery, general obstetrics and gynecology, or affiliated subspecialties. RESULTS Seventeen interviews were conducted. All participants expressed satisfaction with their HPM fellowship training. Four themes emerged as recommendations for surgeons to pursue HPM fellowship training: 1) a commitment to joining the HPM workforce, 2) becoming ambassadors for HPM and surgical culture change, 3) desire for advanced communication and symptom management skills at the specialist level, and 4) specialist level HPM skills may enhance surgical career. CONCLUSIONS HPM fellowship training is achievable through multiple pathways for surgeons from a variety of training backgrounds.
Collapse
Affiliation(s)
- Emma Bassette
- University of Kansas School of Medicine, Kansas City, Kansas
| | - Chelsea Salyer
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Kansas School of Medicine, Kansas City, Kansas
| | - Susan McCammon
- Department of Otolaryngology, University of Alabama School of Medicine, Birmingham, Alabama; Department of Internal Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama School of Medicine, Birmingham, Alabama
| | - Joanna Veazey Brooks
- Department of Population Health, University of Kansas School of Medicine, Kansas City, Kansas; Department of Internal Medicine, Palliative Medicine Division, University of Kansas School of Medicine, Kansas City, Kansas
| | - Lori Spoozak
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Kansas School of Medicine, Kansas City, Kansas; Department of Internal Medicine, Palliative Medicine Division, University of Kansas School of Medicine, Kansas City, Kansas.
| |
Collapse
|
35
|
Sedhom R, Kamal AH. Is Improving the Penetration Rate of Palliative Care the Right Measure? JCO Oncol Pract 2022; 18:e1388-e1391. [DOI: 10.1200/op.22.00370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ramy Sedhom
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, PA
| | - Arif H. Kamal
- Duke Cancer Institute, Durham, NC
- American Cancer Society, Atlanta, GA
| |
Collapse
|
36
|
Ernecoff NC, Bell LF, Arnold RM, Shea CM, Switzer GE, Jhamb M, Schell JO, Kavalieratos D. Clinicians' Perceptions of Collaborative Palliative Care Delivery in Chronic Kidney Disease. J Pain Symptom Manage 2022; 64:168-177. [PMID: 35417752 PMCID: PMC9276626 DOI: 10.1016/j.jpainsymman.2022.04.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/20/2022]
Abstract
CONTEXT Guidelines recommend palliative care for patients with chronic kidney disease (CKD), who experience a high pain and symptom burden, and receive intensive treatments that often do not align with their values. A lack of scalable specialty palliative care services has prompted calls for attention to primary palliative care, delivered in primary care and nephrology settings. OBJECTIVES The objectives of this study were to 1) describe expectations for care to meet the palliative care needs of people living with CKD, and limitations to meeting those expectations in the current model, and 2) identify potential interventions to meet patients' palliative care needs. METHODS We conducted semi-structured interviews with clinicians from primary care, nephrology, and palliative care to assess 1) reasonable expectations for meeting palliative needs, 2) barriers to integrating primary palliative care, and 3) potential intervention points. RESULTS Clinicians discussed their expectations for high-quality communication (e.g., discussing disease understanding, assessing goals of care) and better integration of palliative care services. Clinicians expressed barriers to delivering that care, including poor inter-clinician communication. To address barriers, clinicians outlined potential intervention points, such as building collaborative models of care, and structural triggers to identify patients who may be appropriate for palliative care. CONCLUSION Interventions to address gaps in palliative care delivery for people living with CKD should incorporate systematic identification of patients with palliative care needs and structural mechanisms to meeting those needs via specialty and primary palliative care.
Collapse
Affiliation(s)
- Natalie C Ernecoff
- RAND Corporation (N.C.E.), Pittsburgh, Pennsylvania, USA; Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA.
| | - Lindsay F Bell
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Christopher M Shea
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (C.M.S.), Chapel Hill, North Carolina, USA
| | - Galen E Switzer
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Department of Psychiatry, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Department of Clinical and Translational Science, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System (G.E.S.), Pittsburgh, Pennsylvania, USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh (M.J.), Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine (D.K.), Atlanta, Georgia, USA
| |
Collapse
|
37
|
Boddaert MS, Pereira C, Adema J, Vissers KCP, van der Linden YM, Raijmakers NJH, Fransen HP. Inappropriate end-of-life cancer care in a generalist and specialist palliative care model: a nationwide retrospective population-based observational study. BMJ Support Palliat Care 2022; 12:e137-e145. [PMID: 33355176 PMCID: PMC9120402 DOI: 10.1136/bmjspcare-2020-002302] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 11/16/2020] [Accepted: 11/23/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To evaluate the impact of provision and timing of palliative care (PC) on potentially inappropriate end-of-life care to patients with cancer in a mixed generalist-specialist PC model. METHOD A retrospective population-based observational study using a national administrative health insurance database. All 43 067 adults in the Netherlands, who were diagnosed with or treated for cancer during the year preceding their death in 2017, were included. Main exposure was either generalist or specialist PC initiated >30 days before death (n=16 967). Outcomes were measured over the last 30 days of life, using quality indicators for potentially inappropriate end-of-life care. RESULTS In total, 14 504 patients (34%) experienced potentially inappropriate end-of-life care; 2732 were provided with PC >30 days before death (exposure group) and 11 772 received no PC or ≤30 days before death (non-exposure group) (16% vs 45%, p<0.001). Most patients received generalist PC (88%). Patients provided with PC >30 days before death were 5 times less likely to experience potentially inappropriate end-of-life care (adjusted OR (AOR) 0.20; (95% CI 0.15 to 0.26)) than those with no PC or PC in the last 30 days. Both early (>90 days) and late (>30 and≤90 days) PC initiation had lower odds for potentially inappropriate end-of-life care (AOR 0.23 and 0.19, respectively). CONCLUSION Timely access to PC in a mixed generalist-specialist PC model significantly decreases the likelihood of potentially inappropriate end-of-life care for patients with cancer. Generalist PC can play a substantial role.
Collapse
Affiliation(s)
- Manon S Boddaert
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
- Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, Netherlands
- Netherlands Association for Palliative Care, Utrecht, Netherlands
| | - Chantal Pereira
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
- Netherlands Association for Palliative Care, Utrecht, Netherlands
| | - Jeroen Adema
- Vektis, Business Intelligence Center for Healthcare, Zeist, Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, Netherlands
| | - Yvette M van der Linden
- Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, Netherlands
| | - Natasja J H Raijmakers
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
- Netherlands Association for Palliative Care, Utrecht, Netherlands
| | - Heidi P Fransen
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
- Netherlands Association for Palliative Care, Utrecht, Netherlands
| |
Collapse
|
38
|
Cook DA, Stephenson CR, Pankratz VS, Wilkinson JM, Maloney S, Prokop LJ, Foo J. Associations Between Physician Continuous Professional Development and Referral Patterns: A Systematic Review and Meta-Analysis. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:728-737. [PMID: 34985042 DOI: 10.1097/acm.0000000000004575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE Both overuse and underuse of clinician referrals can compromise high-value health care. The authors sought to systematically identify and synthesize published research examining associations between physician continuous professional development (CPD) and referral patterns. METHOD The authors searched MEDLINE, Embase, PsycInfo, and the Cochrane Database on April 23, 2020, for comparative studies evaluating CPD for practicing physicians and reporting physician referral outcomes. Two reviewers, working independently, screened all articles for inclusion. Two reviewers reviewed all included articles to extract information, including data on participants, educational interventions, study design, and outcomes (referral rate, intended direction of change, appropriateness of referral). Quantitative results were pooled using meta-analysis. RESULTS Of 3,338 articles screened, 31 were included. These studies enrolled at least 14,458 physicians and reported 381,165 referral events. Among studies comparing CPD with no intervention, 17 studies with intent to increase referrals had a pooled risk ratio of 1.91 (95% confidence interval: 1.50, 2.44; P < .001), and 7 studies with intent to decrease referrals had a pooled risk ratio of 0.68 (95% confidence interval: 0.55, 0.83; P < .001). Five studies did not indicate the intended direction of change. Subgroup analyses revealed similarly favorable effects for specific instructional approaches (including lectures, small groups, Internet-based instruction, and audit/feedback) and for activities of varying duration. Four studies reported head-to-head comparisons of alternate CPD approaches, revealing no clear superiority for any approach. Seven studies adjudicated the appropriateness of referral, and 9 studies counted referrals that were actually completed (versus merely requested). CONCLUSIONS Although between-study differences are large, CPD is associated with statistically significant changes in patient referral rates in the intended direction of impact. There are few head-to-head comparisons of alternate CPD interventions using referrals as outcomes.
Collapse
Affiliation(s)
- David A Cook
- D.A. Cook is professor of medicine and medical education, director, Section of Research and Data Analytics, School of Continuous Professional Development, and director of education science, Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science, and consultant, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-2383-4633
| | - Christopher R Stephenson
- C.R. Stephenson is assistant professor of medicine, Mayo Clinic College of Medicine and Science, associate program director, Mayo-Rochester Internal Medicine Residency Program, and consultant, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0001-8537-392X
| | - V Shane Pankratz
- V.S. Pankratz is professor of internal medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico; ORCID: https://orcid.org/0000-0002-3742-040X
| | - John M Wilkinson
- J.M. Wilkinson is associate professor of family medicine, Mayo Clinic College of Medicine and Science, and consultant, Department of Family Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-1156-8577
| | - Stephen Maloney
- S. Maloney is professor of health professions education and deputy head of school, Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia; ORCID: https://orcid.org/0000-0003-2612-5162
| | - Larry J Prokop
- L.J. Prokop is a reference librarian, Plummer Library, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0002-7197-7260
| | - Jonathan Foo
- J. Foo is a lecturer, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia; ORCID: https://orcid.org/0000-0003-4533-8307
| |
Collapse
|
39
|
Alonzi S, Perry LM, Lewson AB, Mossman B, Silverstein MW, Hoerger M. Fear of Palliative Care: Roles of Age and Depression Severity. J Palliat Med 2022; 25:768-773. [PMID: 34762507 PMCID: PMC9081062 DOI: 10.1089/jpm.2021.0359] [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] [Accepted: 10/21/2021] [Indexed: 11/12/2022] Open
Abstract
Background: Palliative care is underutilized due in part to fear and misunderstanding, and depression might explain variation in fear of palliative care. Objective: Informed by the socioemotional selectivity theory, we hypothesized that older adults with cancer would be less depressed than younger adults, and subsequently less fearful of utilizing palliative care. Setting/Subjects: Patients predominately located in the United States with heterogeneous cancer diagnoses (n = 1095) completed the Patient-Reported Outcomes Information System (PROMIS) Depression scale and rated their fear of palliative care using the Palliative Care Attitudes Scale (PCAS). We examined the hypothesized intercorrelations, followed by a bootstrapped analysis of indirect effects in the PROCESS macro for SPSS. Results: Participants ranged from 26 to 93 years old (mean [M] = 60.40, standard deviation = 11.45). The most common diagnoses were prostate (34.1%), breast (23.3%), colorectal (17.5%), skin (15.3%), and lung (13.5%) cancer. As hypothesized, older participants had lower depression severity (r = -0.20, p < 0.001) and were less fearful of palliative care (r = -0.11, p < 0.001). Participants who were more depressed were more fearful of palliative care (r = 0.21, p < 0.001). An indirect effect (β = -0.04, standard error = .01, 95% confidence interval: -0.06 to -0.02) suggested that depression severity may account for up to 40% of age-associated differences in fear of palliative care. Conclusions: Findings indicate that older adults with cancer are more likely to favor palliative care, with depression symptom severity accounting for age-related differences. Targeted interventions among younger patients with depressive symptoms may be helpful to reduce fear and misunderstanding and increase utilization of palliative care.
Collapse
Affiliation(s)
- Sarah Alonzi
- Department of Psychology, Tulane University, New Orleans, Louisiana, USA
| | - Laura M. Perry
- Department of Psychology, Tulane University, New Orleans, Louisiana, USA
| | - Ashley B. Lewson
- Department of Psychology, Indiana University—Purdue University Indianapolis, Indianapolis, Indiana, USA
| | - Brenna Mossman
- Department of Psychology, Tulane University, New Orleans, Louisiana, USA
| | | | - Michael Hoerger
- Department of Psychology, Tulane University, New Orleans, Louisiana, USA
- Department of Palliative Medicine and Supportive Care, University Medical Center, New Orleans, Louisiana, USA
- Departments of Psychiatry and Medicine, Tulane Cancer Center, and Freeman School of Business, Tulane University, New Orleans, Louisiana, USA
| |
Collapse
|
40
|
Bischoff KE, Lin J, Cohen E, O'Riordan DL, Meister S, Zapata C, Sicotte J, Lindenfeld P, Calton B, Pantilat SZ. Outpatient Palliative Care for Noncancer Illnesses: One Program's Experience with Implementation, Impact, and Lessons Learned. J Palliat Med 2022; 25:1468-1475. [PMID: 35442773 DOI: 10.1089/jpm.2022.0019] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Despite substantial palliative care (PC) needs in people with serious illnesses other than cancer, outpatient PC is less available to these populations. Objectives: Describe the experience, impact, and lessons learned from implementing an outpatient PC service (OPCS) for people with noncancer illnesses. Design: Observational cohort study. Setting/Subjects: Patients seen by an OPCS at a United States academic medical center October 2, 2017-March 31, 2021. Measurements: Patient demographics and clinical characteristics, care processes, rates of advance care planning (ACP), and health care utilization. Results: During the study period, 736 patients were seen. Mean age was 66.7 years, 47.7% were women, and 61.4% were White. Nearly half (44.9%) had a neurologic diagnosis, 19.2% pulmonary, and 11.0% cardiovascular. Patients were most often referred for symptoms other than pain (62.2%), ACP (60.2%), and support for patient/family (48.2%). Three-quarters (74.1%) of visits occurred by video. A PC physician, nurse, social worker, and spiritual care provider addressed nonpain symptoms (for 79.2%), family caregiver needs (70.0%), psychosocial distress (69.9%), ACP (68.8%), care coordination (66.8%), pain (38.2%), and spiritual concerns (27.8%). Rates of advance directives increased from 24.6% to 31.8% (p < 0.001) and Physician Orders for Life-Sustaining Treatment forms from 15.6% to 27.3% (p < 0.001). Of 214 patients who died, 61.7% used hospice, with median hospice length-of-stay >30 days. Comparing the six months before initiating PC to the six months after, hospitalizations decreased by 31.3% (p = 0.001) and hospital days decreased by 29.8% (p = 0.02). Conclusions: Outpatient PC for people with noncancer illnesses is feasible, addresses needs in multiple domains, and is associated with increased rates of ACP and decreased health care utilization. Controlled studies are warranted.
Collapse
Affiliation(s)
- Kara E Bischoff
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Joseph Lin
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Eve Cohen
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - David L O'Riordan
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sarah Meister
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Carly Zapata
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jeffrey Sicotte
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Paul Lindenfeld
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brook Calton
- Division of Palliative Medicine and Geriatrics, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
41
|
Schultz K, Howard S, Siegel T, Zonies D, Brasel K, Cook M, Moreno K. Supporting surgical residents learning clinical palliative care: Insights from multi-disciplinary focus groups. Am J Surg 2022; 224:676-680. [DOI: 10.1016/j.amjsurg.2022.02.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/26/2022] [Accepted: 02/25/2022] [Indexed: 12/18/2022]
|
42
|
Seow H, Barbera LC, McGrail K, Burge F, Guthrie DM, Lawson B, Chan KKW, Peacock SJ, Sutradhar R. Effect of Early Palliative Care on End-of-Life Health Care Costs: A Population-Based, Propensity Score-Matched Cohort Study. JCO Oncol Pract 2022; 18:e183-e192. [PMID: 34388021 PMCID: PMC8758090 DOI: 10.1200/op.21.00299] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE This study aimed to investigate the impact of early versus not-early palliative care among cancer decedents on end-of-life health care costs. METHODS Using linked administrative databases, we created a retrospective cohort of cancer decedents between 2004 and 2014 in Ontario, Canada. We identified those who received early palliative care (palliative care service used in the hospital or community 12 to 6 months before death [exposure]). We used propensity score matching to identify a control group of not-early palliative care, hard matched on age, sex, cancer type, and stage at diagnosis. We examined differences in average health system costs (including hospital, emergency department, physician, and home care costs) between groups in the last month of life. RESULTS We identified 144,306 cancer decedents, of which 37% received early palliative care. After matching, we created 36,238 pairs of decedents who received early and not-early (control) palliative care; there were balanced distributions of age, sex, cancer type (24% lung cancer), and stage (25% stage III and IV). Overall, 56.3% of early group versus 66.7% of control group used inpatient care in the last month (P < .001). Considering inpatient hospital costs in the last month of life, the early group used an average (±standard deviation) of $7,105 (±$10,710) versus the control group of $9,370 (±$13,685; P < .001). Overall average costs (±standard deviation) in the last month of life for patients in the early versus control group was $12,753 (±$10,868) versus $14,147 (±$14,288; P < .001). CONCLUSION Receiving early palliative care reduced average health system costs in the last month of life, especially via avoided hospitalizations.
Collapse
Affiliation(s)
- Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada,Hsien Seow, PhD, Department of Oncology, McMaster University, 699 Concession St, 4th Fl, Rm 4-229, Hamilton, ON L8V 5C2, Canada; e-mail:
| | - Lisa C. Barbera
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Kimberlyn McGrail
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
| | - Fred Burge
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Dawn M. Guthrie
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, ON, Canada
| | - Beverley Lawson
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
| | | | | | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| |
Collapse
|
43
|
Specialist palliative care teams and characteristics related to referral rate: a national cross-sectional survey among hospitals in the Netherlands. BMC Palliat Care 2021; 20:175. [PMID: 34758792 PMCID: PMC8582112 DOI: 10.1186/s12904-021-00875-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 10/18/2021] [Indexed: 11/18/2022] Open
Abstract
Background Specialist palliative care teams (SPCTs) in hospitals improve quality of life and satisfaction with care for patients with advanced disease. However, referrals to SPCTs are often limited. To identify areas for improvement of SPCTs’ service penetration, we explored the characteristics and level of integration of palliative care programmes and SPCTs in Dutch hospitals and we assessed the relation between these characteristics and specialist palliative care referral rates. Methods We performed a secondary analysis of a national cross-sectional survey conducted among hospitals in the Netherlands from March through May 2018. For this survey, a previously developed online questionnaire, containing 6 consensus-based integration indicators, was sent to palliative care programme leaders in all 78 hospitals. For referral rate we calculated the number of annual inpatient referrals to the SPCT as a percentage of the number of total annual hospital admissions. Referral rate was dichotomized into high (≥ third quartile) and low (< third quartile). Characteristics of SPCTs with high and low referral rate were compared using univariate analyses. P-values < 0.05 were considered significant. Results In total, 63 hospitals (81%) participated in the survey, of which 62 had an operational SPCT. The palliative care programmes of these hospitals consisted of inpatient consultation services (94%), interdisciplinary staffing (61%), outpatient clinics (45%), dedicated acute care beds (21%) and community-based palliative care (27%). The median referral rate was 0.56% (IQR 0.23–1.0%), ranging from 0 to 3.7%. Comparing SPCTs with high referral rate (≥1%, n = 17) and low referral rate (< 1%, n = 45) showed significant differences for SPCTs’ years of existence, staffing, their level of education, participation in other departments’ team meetings, provision of education and conducting research. With regard to integration, significant differences were found for the presence of outpatient clinics and timing of referrals. Conclusion In the Netherlands, palliative care programmes and specialist palliative care teams in hospitals vary in their level of integration and development, with more mature teams showing higher referral rates. Appropriate staffing, dedicated outpatient clinics, education and research appear means to improve service penetration and timing of referral for patients with advanced diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00875-3.
Collapse
|
44
|
Perry LM, Sartor O, Malhotra S, Alonzi S, Kim S, Voss HM, Rogers JL, Robinson W, Harris K, Shank J, Morrison DG, Lewson AB, Fuloria J, Miele L, Lewis B, Mossman B, Hoerger M. Increasing Readiness for Early Integrated Palliative Oncology Care: Development and Initial Evaluation of the EMPOWER 2 Intervention. J Pain Symptom Manage 2021; 62:987-996. [PMID: 33864847 PMCID: PMC8526633 DOI: 10.1016/j.jpainsymman.2021.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/23/2021] [Accepted: 03/27/2021] [Indexed: 11/28/2022]
Abstract
CONTEXT Early integrated palliative care improves quality of life, but palliative care programs are underutilized. Psychoeducational interventions explaining palliative care may increase patients' readiness for palliative care. OBJECTIVES To 1) collaborate with stakeholders to develop the EMPOWER 2 intervention explaining palliative care, 2) examine acceptability, 3) evaluate feasibility and preliminary efficacy. METHODS The research was conducted at a North American cancer center and involved 21 stakeholders and 10 patient-participants. Investigators and stakeholders iteratively developed the intervention. Stakeholders rated acceptability of the final intervention. Investigators implemented a pre-post trial to examine the feasibility of recruiting 10 patients with metastatic cancer within one month and with a ≥50% consent rate. Preliminary efficacy outcomes were changes in palliative care knowledge and attitudes. RESULTS Using feedback from four stakeholder meetings, we developed a multimedia intervention tailored to three levels of health-literacy. The intervention provides knowledge and reassurance about the purpose and nature of palliative care, addressing cognitive and emotional barriers to utilization. Stakeholders rated the intervention and design process highly acceptable (3.78/4.00). The pilot met a priori feasibility criteria (10 patients enrolled in 14 days; 83.3% consent rate). The intervention increased palliative care knowledge by 83.1% and improved attitudes by 18.9 points on a 0 to 51 scale (Ps < 0.00001). CONCLUSIONS This formative research outlines the development of a psychoeducational intervention about palliative care. The intervention is acceptable, feasible, and demonstrated promising pilot test results. This study will guide clinical teams in improving patients' readiness for palliative care and inform the forthcoming EMPOWER 3 randomized clinical trial.
Collapse
Affiliation(s)
| | | | - Sonia Malhotra
- Tulane University, New Orleans, Louisiana, USA; University Medical Center New Orleans, New Orleans, Louisiana, USA
| | | | - Seowoo Kim
- Tulane University, New Orleans, Louisiana, USA
| | | | | | - William Robinson
- University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | | | - David G Morrison
- The Oncology Institute of Hope and Innovation, New Orleans, Louisiana, USA
| | - Ashley B Lewson
- Indiana University-Purdue University, Indianapolis, Indiana, USA
| | - Jyotsna Fuloria
- University Medical Center New Orleans, New Orleans, Louisiana, USA
| | - Lucio Miele
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Brian Lewis
- Tulane University, New Orleans, Louisiana, USA
| | | | - Michael Hoerger
- Tulane University, New Orleans, Louisiana, USA; University Medical Center New Orleans, New Orleans, Louisiana, USA.
| |
Collapse
|
45
|
Schmitz RSJM, Geurts SME, Ibragimova KIE, Tilli DJP, Tjan-Heijnen VCG, de Boer M. Healthcare Use during the Last Six Months of Life in Patients with Advanced Breast Cancer. Cancers (Basel) 2021; 13:cancers13215271. [PMID: 34771434 PMCID: PMC8582356 DOI: 10.3390/cancers13215271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/14/2021] [Accepted: 10/19/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary In the last decades, new treatment options for advanced (breast) cancer have resulted in increased use of health care resources near the end of life. We assessed health care use near the end of life of patients with advanced breast cancer (ABC). In this study, we have shown that ICU admission, and CPR occurred rarely during the last six months of life of ABC patients. However, hospital admissions occurred often, especially in patients who received new chemotherapy within 30 days of end of life. Those patients were also more likely to die in the hospital. However, death was most often due to disease progression. To improve quality of life near the end of life of advanced breast cancer patients, it is vital to develop tools to help clinicians identify those patients who will benefit from chemotherapy at the end of life. Abstract New treatment options in cancer have resulted in increased use of health care resources near the end of life. We assessed health care use near the end of life of patients with advanced breast cancer (ABC). From the Southeast Netherlands Breast cancer (SONABRE) registry, we selected all deceased patients diagnosed with ABC in Maastricht University Medical Center between January 2007 and October 2017. Frequency of health care use in the last six months of life was described and predictors for health care use were assessed. Of 203 patients, 76% were admitted during the last six months, 6% to the intensive care unit (ICU) and 2% underwent cardiopulmonary resuscitation (CPR). Death in hospital occurred in 25%. Nine percent of patients received a new line of chemotherapy ≤30 days before death, which was associated with age <65 years and <1 year survival since diagnosis of metastases. In these patients, the hospital admission rate was 95%, of which 79% died in the hospital, mostly due to progressive disease (80%). In conclusion, the frequency of ICU-admission, CPR or a new line of chemotherapy ≤30 days before death was low. Most patients receiving a new line of chemotherapy ≤30 days before death, died in the hospital.
Collapse
|
46
|
Kaufmann TL, Getz KD, Hsu JY, Bennett AV, Takvorian SU, Kamal AH, DeMichele A. Identification of Patient-Reported Outcome Phenotypes Among Oncology Patients With Palliative Care Needs. JCO Oncol Pract 2021; 17:e1473-e1488. [PMID: 33760637 PMCID: PMC8791824 DOI: 10.1200/op.20.00849] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Despite evidence-based guidelines recommending early palliative care, it remains unclear how to identify and refer oncology patients, particularly in settings with constrained access to palliative care. We hypothesize that patient-reported outcome (PRO) data can be used to characterize patients with palliative care needs. To determine if PRO data can identify latent phenotypes that characterize indications for specialty palliative care referral. METHODS We conducted a retrospective study of self-reported symptoms on the Edmonton Symptom Assessment System collected from solid tumor oncology patients (n = 745) referred to outpatient palliative care. Data were collected as part of routine clinical care from October 2012 to March 2018 at eight community and academic sites. We applied latent profile analysis to identify PRO phenotypes and examined the association of phenotypes with clinical and demographic characteristics using multinomial logistic regression. RESULTS We identified four PRO phenotypes: (1) Low Symptoms (n = 295, 39.6%), (2) Moderate Pain/Fatigue + Mood (n = 180, 24.2%), (3) Moderate Pain/Fatigue + Appetite + Dyspnea (n = 201, 27.0%), and (4) High Symptoms (n = 69, 9.3%). In a secondary analysis of 421 patients, we found that two brief items assessing social and existential needs aligned with higher severity symptom and psychological distress phenotypes. CONCLUSION Oncology patients referred to outpatient palliative care in a real-world setting can be differentiated into clinically meaningful phenotypes using brief, routinely collected PRO measures. Latent modeling provides a mechanism to use patient-reported data on a population level to identify distinct subgroups of patients with unmet palliative needs.
Collapse
Affiliation(s)
- Tara L. Kaufmann
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA,Livestrong Cancer Institutes, Dell Medical School, The University of Texas at Austin, Austin, TX,Tara L. Kaufmann, MD, MSCE, The University of Texas at Austin, Livestrong Cancer Institutes, Dell Medical School, 1601 Trinity St, Bldg B, Stop Z1100, Austin, TX 78712; e-mail:
| | - Kelly D. Getz
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,University of Pennsylvania, Philadelphia, PA,The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Antonia V. Bennett
- Cancer Outcomes Research Program, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Samuel U. Takvorian
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | - Angela DeMichele
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
47
|
Mills S, Cioletti A, Gingell G, Ramani S. Training Residents in Virtual Advance Care Planning: A New Twist in Telehealth. J Pain Symptom Manage 2021; 62:691-698. [PMID: 33819515 DOI: 10.1016/j.jpainsymman.2021.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/26/2021] [Accepted: 03/23/2021] [Indexed: 11/22/2022]
Abstract
CONTEXT Advance care planning (ACP) conversations represent an important physician skill, a need further highlighted by the COVID-19 pandemic. Most resident ACP training occurs in inpatient, settings, often featuring goals of care (GOC) conversations during a crisis. Outpatient clinics are valuable but underutilized settings to provide skills training for residents, yet little research has been done in these spaces. OBJECTIVE We sought to 1) create an ACP curriculum harnessing the principles of a community of practice in a virtual format, and 2) obtain residents' perspectives regarding their skills and confidence in having early GOC conversations in the outpatient setting. METHODS We interviewed 48 internal medicine residents using questionnaires, reflective narratives, and transcripts of debriefing conversations. We created a virtual curriculum during the ambulatory week which included didactics, virtual role plays, ACP phone conversations with five patients, and group debriefings. Quantitative data were analyzed for changes in resident confidence. Qualitative data were coded using thematic analysis, guided by instructor field notes. RESULTS Residents reported decreased confidence in navigating advance directive conversations following training [Z=2.24, P=0.03, r = 0.33]. Resident reflections indicated that they felt more practiced at inpatient late GOC conversation skills, and that these skills were not fully transferable to the outpatient early GOC setting. Residents also endorsed the ambulatory environment as the best space for ACP conversations. CONCLUSION This study illustrates the feasibility of a virtual format for ACP curriculum. The virtual community of practice created space for a metacognitive unmasking of prior resident unconscious incompetence. Also, inpatient, crisis-oriented late GOC conversation skills may translate poorly to the outpatient setting requiring early and ongoing GOC skills. Residents need more training to navigate ACP conversations in ambulatory environments.
Collapse
Affiliation(s)
- Sarah Mills
- Dell Medical School, Department of Internal Medicine, Austin, Texas, USA.
| | - Anne Cioletti
- Dell Medical School, Department of Internal Medicine, Austin, Texas, USA; Dell Medical School, Department of Population Health, Austin, Texas, USA
| | - Gareth Gingell
- The University of Texas at Austin, STEM Education Doctoral Program, Department of Curriculum and Instruction, Austin, Texas, USA
| | - Subha Ramani
- Harvard Medical School and Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
48
|
Dalhammar K, Malmström M, Sandberg M, Falkenback D, Kristensson J. Health care utilization among patients with oesophageal and gastric cancer: the impact of initial treatment strategy and assignment of a contact nurse. BMC Health Serv Res 2021; 21:1019. [PMID: 34579714 PMCID: PMC8477461 DOI: 10.1186/s12913-021-07042-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 09/14/2021] [Indexed: 12/26/2022] Open
Abstract
Background Patients diagnosed with oesophageal and gastric cancer face a poor prognosis and numerous challenges of symptom management, lifestyle adjustments and complex treatment regimens. The multifaceted care needs and rapid disease progression reinforce the need for proactive and coherent health care. According to the national cancer strategy, providing coherent health care and palliative support is an area of priority. More knowledge is needed about health care utilization and the characteristics of the health care service in order to understand the readiness, accessibility and quality of current health care. The aim of this study was to describe individuals’ health care use from the time of treatment decision until death, and investigate the impact of the initial treatment strategy and assignment of a contact nurse (CN) on health care use among patients with oesophageal and gastric cancer. Methods This population-based cohort study included patients who died from oesophageal and gastric cancer in Sweden during 2014–2016. Through linking data from the National Register for Oesophageal and Gastric Cancer, the National Cause of Death Register, and the National Patient Register, 2614 individuals were identified. Associations between the initial treatment strategy and CN assignment, and health care use were investigated. Adjusted incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated using Poisson regression. Results Patients receiving palliative treatment and those receiving no tumour-directed treatment had a higher IRR for unplanned hospital stays and unplanned outpatient care visits compared with patients who received curative treatment. Patients receiving no tumour-directed treatment also had a lower IRR for planned hospital stays and planned outpatient care visits compared with patients given curative treatment. Compared with this latter group, patients with palliative treatment had a higher IRR for planned outpatient care visits. Patients assigned a CN had a higher IRR for unplanned hospital stays, unplanned outpatient care visits and planned outpatient care visits, compared with patients not assigned a CN. Conclusions A palliative treatment strategy and no tumour-directed treatment were associated with higher rates of unplanned health care compared with a curative treatment strategy, suggesting that a proactive approach is imperative to ensure quality palliative care.
Collapse
Affiliation(s)
- Karin Dalhammar
- Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden. .,Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
| | - Marlene Malmström
- Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden.,Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Magnus Sandberg
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Dan Falkenback
- Department of Surgery, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Jimmie Kristensson
- Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden.,Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| |
Collapse
|
49
|
May P, Normand C, Noreika D, Skoro N, Cassel JB. Using predicted length of stay to define treatment and model costs in hospitalized adults with serious illness: an evaluation of palliative care. HEALTH ECONOMICS REVIEW 2021; 11:38. [PMID: 34542719 PMCID: PMC8454145 DOI: 10.1186/s13561-021-00336-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 09/07/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Economic research on hospital palliative care faces major challenges. Observational studies using routine data encounter difficulties because treatment timing is not under investigator control and unobserved patient complexity is endemic. An individual's predicted LOS at admission offers potential advantages in this context. METHODS We conducted a retrospective cohort study on adults admitted to a large cancer center in the United States between 2009 and 2015. We defined a derivation sample to estimate predicted LOS using baseline factors (N = 16,425) and an analytic sample for our primary analyses (N = 2674) based on diagnosis of a terminal illness and high risk of hospital mortality. We modelled our treatment variable according to the timing of first palliative care interaction as a function of predicted LOS, and we employed predicted LOS as an additional covariate in regression as a proxy for complexity alongside diagnosis and comorbidity index. We evaluated models based on predictive accuracy in and out of sample, on Akaike and Bayesian Information Criteria, and precision of treatment effect estimate. RESULTS Our approach using an additional covariate yielded major improvement in model accuracy: R2 increased from 0.14 to 0.23, and model performance also improved on predictive accuracy and information criteria. Treatment effect estimates and conclusions were unaffected. Our approach with respect to treatment variable yielded no substantial improvements in model performance, but post hoc analyses show an association between treatment effect estimate and estimated LOS at baseline. CONCLUSION Allocation of scarce palliative care capacity and value-based reimbursement models should take into consideration when and for whom the intervention has the largest impact on treatment choices. An individual's predicted LOS at baseline is useful in this context for accurately predicting costs, and potentially has further benefits in modelling treatment effects.
Collapse
Affiliation(s)
- Peter May
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin, Ireland.
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Ireland.
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin, Ireland
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Danielle Noreika
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Nevena Skoro
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - J Brian Cassel
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
50
|
Ahmad TR, Kazberouk A, Santhosh L, Hsu G, Dhaliwal G. Tissue, Teamwork, and Timing: an Exercise in Clinical Reasoning. J Gen Intern Med 2021; 36:2839-2844. [PMID: 34244961 PMCID: PMC8390715 DOI: 10.1007/s11606-021-06817-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Tessnim R Ahmad
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA.
| | - Alexander Kazberouk
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Lekshmi Santhosh
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Division of Pulmonary/Critical Care Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Gerald Hsu
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Gurpreet Dhaliwal
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| |
Collapse
|