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Teeple S, Chivers C, Linn KA, Halpern SD, Eneanya N, Draugelis M, Courtright K. Evaluating equity in performance of an electronic health record-based 6-month mortality risk model to trigger palliative care consultation: a retrospective model validation analysis. BMJ Qual Saf 2023; 32:503-516. [PMID: 37001995 PMCID: PMC10898860 DOI: 10.1136/bmjqs-2022-015173] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 03/08/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE Evaluate predictive performance of an electronic health record (EHR)-based, inpatient 6-month mortality risk model developed to trigger palliative care consultation among patient groups stratified by age, race, ethnicity, insurance and socioeconomic status (SES), which may vary due to social forces (eg, racism) that shape health, healthcare and health data. DESIGN Retrospective evaluation of prediction model. SETTING Three urban hospitals within a single health system. PARTICIPANTS All patients ≥18 years admitted between 1 January and 31 December 2017, excluding observation, obstetric, rehabilitation and hospice (n=58 464 encounters, 41 327 patients). MAIN OUTCOME MEASURES General performance metrics (c-statistic, integrated calibration index (ICI), Brier Score) and additional measures relevant to health equity (accuracy, false positive rate (FPR), false negative rate (FNR)). RESULTS For black versus non-Hispanic white patients, the model's accuracy was higher (0.051, 95% CI 0.044 to 0.059), FPR lower (-0.060, 95% CI -0.067 to -0.052) and FNR higher (0.049, 95% CI 0.023 to 0.078). A similar pattern was observed among patients who were Hispanic, younger, with Medicaid/missing insurance, or living in low SES zip codes. No consistent differences emerged in c-statistic, ICI or Brier Score. Younger age had the second-largest effect size in the mortality prediction model, and there were large standardised group differences in age (eg, 0.32 for non-Hispanic white versus black patients), suggesting age may contribute to systematic differences in the predicted probabilities between groups. CONCLUSIONS An EHR-based mortality risk model was less likely to identify some marginalised patients as potentially benefiting from palliative care, with younger age pinpointed as a possible mechanism. Evaluating predictive performance is a critical preliminary step in addressing algorithmic inequities in healthcare, which must also include evaluating clinical impact, and governance and regulatory structures for oversight, monitoring and accountability.
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Affiliation(s)
- Stephanie Teeple
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Kristin A Linn
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nwamaka Eneanya
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Katherine Courtright
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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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
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Alquati S, Peruselli C, Turrà C, Tanzi S. Lesson Learned From Hospital Palliative Care Service in a Cancer Research Center in Italy: Results of 5 Years of Experience. Front Oncol 2022; 12:936795. [PMID: 35832554 PMCID: PMC9271826 DOI: 10.3389/fonc.2022.936795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundInternational studies have documented that over a third of all hospital beds are occupied by patients with palliative care needs in their last year of life. Experiences of Palliative Care Services that take place prevalently or exclusively in hospital settings are very few in Italy.ObjectiveDescribe clinical, educational and research activities performed by a hospital PCS and discussing opportunities and critical issues encountered in an Italian Cancer Center.MethodRetrospective data regarding adults with advanced stage diseases referred from January 2015 to December 2019.ResultsClinical activity - The PCS performed 2422 initial consultations with an average of 484 initial consultations per year. A majority of patients had advanced cancer, from 85% to 72%, with an average of 2583 total consultations per year and an average of 4.63 consultations per patient. The penetrance has increased over time from 6.3% to 15.75%. Educational and research activity - Since 2015, PCS has provided training to health professionals (HPs) of different departments of our hospital. Most of the educational projects for HPs were part of research projects, for example the communication training program, management of pain and end-of-life symptoms and the training program for PC-based skills.ConclusionOur data suggests that a PCS able to provide palliative care to inpatients and outpatient and continuous training support to other hospital specialists can relatively quickly improve the level of its penetrance in hospital activities.
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Affiliation(s)
- Sara Alquati
- Palliative Care Unit, Azienda USL – IRCCS di Reggio Emilia, Reggio Emilia, Italy
- *Correspondence: Sara Alquati, ; orcid.org/0000-0001-8696-9602
| | | | - Caterina Turrà
- Department of Hospital Pharmacy, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Silvia Tanzi
- Palliative Care Unit, Azienda USL – IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Boddaert MS, Douma J, Dijxhoorn AFQ, Héman RACL, van der Rijt CCD, Teunissen SSCM, Huijgens PC, Vissers KCP. Development of a national quality framework for palliative care in a mixed generalist and specialist care model: A whole-sector approach and a modified Delphi technique. PLoS One 2022; 17:e0265726. [PMID: 35320315 PMCID: PMC8942240 DOI: 10.1371/journal.pone.0265726] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 03/07/2022] [Indexed: 11/19/2022] Open
Abstract
In a predominantly biomedical healthcare model focused on cure, providing optimal, person-centred palliative care is challenging. The general public, patients, and healthcare professionals are often unaware of palliative care’s benefits. Poor interdisciplinary teamwork and limited communication combined with a lack of early identification of patients with palliative care needs contribute to sub-optimal palliative care provision. We aimed to develop a national quality framework to improve availability and access to high-quality palliative care in a mixed generalist-specialist palliative care model. We hypothesised that a whole-sector approach and a modified Delphi technique would be suitable to reach this aim. Analogous to the international AGREE guideline criteria and employing a whole-sector approach, an expert panel comprising mandated representatives for patients and their families, various healthcare associations, and health insurers answered the main question: ‘What are the elements defining high-quality palliative care in the Netherlands?’. For constructing the quality framework, a bottleneck analysis of palliative care provision and a literature review were conducted. Six core documents were used in a modified Delphi technique to build the framework with the expert panel, while stakeholder organisations were involved and informed in round-table discussions. In the entire process, preparing and building relationships took one year and surveying, convening, discussing content, consulting peers, and obtaining final consent from all stakeholders took 18 months. A quality framework, including a glossary of terms, endorsed by organisations representing patients and their families, general practitioners, elderly care physicians, medical specialists, nurses, social workers, psychologists, spiritual caregivers, and health insurers was developed and annexed with a summary for patients and families. We successfully developed a national consensus-based patient-centred quality framework for high-quality palliative care in a mixed generalist-specialist palliative care model. A whole-sector approach and a modified Delphi technique are feasible structures to achieve this aim. The process we reported may guide other countries in their initiatives to enhance palliative care.
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Affiliation(s)
- Manon S. Boddaert
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
- Center of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
- * E-mail:
| | - Joep Douma
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
- Palliactief, Dutch Society for Professionals in Palliative Care, Delft, the Netherlands
| | - Anne-Floor Q. Dijxhoorn
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
- Center of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Carin C. D. van der Rijt
- Palliactief, Dutch Society for Professionals in Palliative Care, Delft, the Netherlands
- Department of Medical Oncology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | | | - Peter C. Huijgens
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Kris C. P. Vissers
- Palliactief, Dutch Society for Professionals in Palliative Care, Delft, the Netherlands
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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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.
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Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol. Ann Am Thorac Soc 2021; 18:336-346. [PMID: 32936675 DOI: 10.1513/annalsats.202002-088sd] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).
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Clinical Outcomes of Patients Hospitalized with Coronavirus Disease 2019 (COVID-19) in Boston. J Gen Intern Med 2021; 36:1285-1291. [PMID: 33629266 PMCID: PMC7904295 DOI: 10.1007/s11606-021-06622-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 01/14/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Outcomes of hospitalized patients with COVID-19 have been described in health systems overwhelmed with a surge of cases. However, studies examining outcomes of patients admitted to hospitals not in crisis are lacking. OBJECTIVE To describe clinical characteristic and outcomes of all patients with COVID-19 who are admitted to hospitals not in crisis, and factors associated with mortality in this population. DESIGN A retrospective analysis PARTICIPANTS: In total, 470 consecutive patients with COVID-19 requiring hospitalization in one health system in Boston from January 1, 2020 to April 15, 2020. MAIN MEASURES We collected clinical outcomes during hospitalization including intensive care unit (ICU) admission, receipt of mechanical ventilation, and vasopressors. We utilized multivariable logistic regression models to examine factors associated with mortality. KEY RESULTS A total of 470 patients (median age 66 [range 23-98], 54.0% male) were included. The most common comorbidities were diabetes (38.5%, 181/470) and obesity (41.3%, 194/470). On admission, 41.9% (197/470) of patients were febrile and 60.6% (285/470) required supplemental oxygen. During hospitalization, 37.9% (178/470) were admitted to the ICU, 33.6% (158/470) received mechanical ventilation, 29.4% (138/470) received vasopressors, 16.4% (77/470) reported limitations on their desire for life-sustaining therapies such as intubation and cardiopulmonary resuscitation, and 25.1% (118/470) died. Among those admitted to the ICU (N=178), the median number of days on the ventilator was 10 days (IQR 1-29), and 58.4% (104/178) were discharged alive. Older age (OR=1.04, P<0.001), male sex (OR=2.14, P=0.007), higher comorbidities (OR=1.20, P=0.001), higher lactate dehydrogenase on admission (2nd tertile: OR=4.07, P<0.001; 3rd tertile: OR=8.04, P<0.001), and the need for supplemental oxygen on admission (OR=2.17, P=0.014) were all associated with higher mortality. CONCLUSIONS The majority of hospitalized patients with COVID-19 and those who received mechanical ventilation survived. These data highlight the need to examine public health and system factors that contribute to improved outcomes for this population.
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Johnson LA, Melendez C, Larson K, Moye J, Schreier AM, Ellis C. Using Demographics to Predict Palliative Care Access in Inpatient Facilities in Rural North Carolina. J Rural Health 2020; 37:412-416. [PMID: 32808716 DOI: 10.1111/jrh.12507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE For individuals with cancer, palliative care improves quality of life, mood, and survival. Rural residents experience limited access to palliative care. In eastern North Carolina, a rural area, little is known about access to inpatient cancer-related palliative care. This study describes access to inpatient palliative care and developed a predictive model of who was most likely to be admitted to an inpatient facility without a palliative care provider. METHODS A descriptive, exploratory design was used to examine demographics, clinical variables, and inpatient admissions from 2017 and 2018, in a major regional teaching hospital system that included 8 hospitals (7 rural hospitals). Descriptive statistics and a binary logistic regression were used to analyze data. FINDINGS The mean age was 62.2 years (N = 2,161, range: 18-88, SD = 15.52): 49.4% were female, 54% lived in a rural county, and 44.4% were black. The outlying rural hospitals, with no palliative care providers on staff, had 388 admissions (18%). Only gender (P = .0128), county (P < .0001), and age (P < .05) contributed to the logistic model. The predicted probability of being admitted to an inpatient facility with a palliative care provider is higher for younger males living in urban counties. That probability decreases with age regardless of the gender or type of county. CONCLUSIONS These findings highlight the limited availability of inpatient palliative care for those with cancer. Women, older adults, and rural residents are more likely to be admitted to 1 of the 7 rural hospitals with no palliative care provider on staff.
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Affiliation(s)
- Lee Ann Johnson
- School of Nursing, University of Virginia, Charlottesville, Virginia
| | - Carlos Melendez
- Nursing Science Department, College of Nursing, East Carolina University, Greenville, North Carolina
| | - Kim Larson
- Nursing Science Department, College of Nursing, East Carolina University, Greenville, North Carolina
| | - Janet Moye
- Vidant Health, Greenville, North Carolina
| | - Ann M Schreier
- Nursing Science Department, College of Nursing, East Carolina University, Greenville, North Carolina
| | - Charles Ellis
- Center for Health Disparities, East Carolina University, Greenville, North Carolina
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Brinkman-Stoppelenburg A, Vergouwe Y, Booms M, Hendriks MP, Peters LA, Quarles van Ufford-Mannesse P, Terheggen F, Verhage S, van der Vorst MJDL, Willemen I, Polinder S, van der Heide A. The Impact of Palliative Care Team Consultation on Quality of Life of Patients with Advanced Cancer in Dutch Hospitals: An Observational Study. Oncol Res Treat 2020; 43:405-413. [PMID: 32580199 DOI: 10.1159/000508312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 04/28/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Experimental studies have shown that palliative care team (PCT) involvement can improve quality of life (QoL) and symptom burden of patients with advanced cancer. It is unclear to what extent this effect is sustained in daily practice of hospital care. OBJECTIVE This observational study aims to investigate the effect of PCT consultation on QoL and symptom burden of hospitalized patients with advanced cancer in daily practice. METHODS After admission to 1 of 9 participating hospitals, patients with advanced cancer for whom the attending physician answered "no" to the Surprise Question were invited to complete a questionnaire, including the EORTC QLQ-C15-PAL, at 6 points in time, until 3 months after admission. Outcomes were compared between patients who received PCT consultation and patients who did not, taking into account differences in baseline characteristics. RESULTS A total of 164 patients consented to participate, of whom 32 received PCT consultation. Of these patients, 108 were able to complete a questionnaire at day 14, of whom 19 after receiving PCT consultation. After adjusting for baseline differences, EORTC QLQ-C15-PAL scores for pain, appetite, and emotional functioning at day 14 were more favorable for patients who received a PCT consultation. CONCLUSION PCT consultation decreased patients' symptom burden and tends to have a positive effect on QoL of hospitalized patients with advanced cancer, even if the PCT is consulted late in the patient's disease trajectory.
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Affiliation(s)
| | - Yvonne Vergouwe
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Monique Booms
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Mathijs P Hendriks
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Liesbeth A Peters
- Department of Pulmonary Diseases, Northwest Clinics, Den Helder, The Netherlands
| | | | - Frederiek Terheggen
- Department of Internal Medicine, Bravis Hospital, Bergen op Zoom, The Netherlands
| | - Sylvia Verhage
- Breast Center, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Maurice J D L van der Vorst
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Ingrid Willemen
- Department of Internal Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Kamal AH, Bowman B, Ritchie CS. Identifying Palliative Care Champions to Promote High-Quality Care to Those with Serious Illness. J Am Geriatr Soc 2020; 67:S461-S467. [PMID: 31074852 DOI: 10.1111/jgs.15799] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/10/2018] [Accepted: 01/02/2019] [Indexed: 11/30/2022]
Abstract
Leading medical authorities advocate for routine integration of palliative care for all major causes of death in the United States. With rapid growth and acceptance, the field of palliative care is tasked with addressing a compelling question of its time: "Who will deliver timely, evidence-based palliative care to all who should benefit?" The current number of palliative care specialists will not suffice to meet the needs of persons with serious illness. In 2010, initial estimates quantified the shortage at 6000 to 18 000 additional palliative care physicians needed to fully staff existing programs. Unfortunately, the predicted number of specialty physicians in 2030 will likely not be larger than the workforce in existence today. These findings result in a physician-to-serious-illness-person ratio of about 1:28 000 in 2030.1 To address the workforce shortage, stronger alignment is needed between intensity of patient needs and provision of palliative care services. Such an alignment better harnesses the talents of those in a position to deliver core palliative care services (such as discussing goals of care with patients or managing their symptoms) while engaging palliative care specialists to address more complex issues. We introduce the concept of "Palliative Care Champions," who sit at the nexus between specialty palliative care and the larger clinical workforce. Acknowledging that the needs of most patients can be met by clinicians who have received basic palliative care training, and that specialty palliative care is not always available for those with more complex needs, there exists an important opportunity for those with additional interest to scale training and quality improvement to fill this void. J Am Geriatr Soc 67:S461-S467, 2019.
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Affiliation(s)
- Arif H Kamal
- Duke Cancer Institute and Duke Fuqua School of Business, Durham, North Carolina
| | - Brynn Bowman
- Center to Advance Palliative Care, New York, New York
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Hua M, Lu Y, Ma X, Morrison RS, Li G, Wunsch H. Association Between the Implementation of Hospital-Based Palliative Care and Use of Intensive Care During Terminal Hospitalizations. JAMA Netw Open 2020; 3:e1918675. [PMID: 31913493 PMCID: PMC6991248 DOI: 10.1001/jamanetworkopen.2019.18675] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/10/2019] [Indexed: 11/14/2022] Open
Abstract
Importance The use of intensive care at the end of life continues to be common. Although the provision of palliative care has been advocated as a way to mitigate the use of high-intensity care, it is unknown whether implementation of hospital-based palliative care services is associated with reduced use of intensive care at the end of life. Objective To determine whether implementation of hospital-based palliative care services is associated with decreased intensive care unit (ICU) use during terminal hospitalizations. Design, Setting, and Participants This cohort study included 51 hospitals in New York State that either did or did not implement a palliative care program between 2008 and 2014. Hospitals that consistently had a palliative care program during the study period were excluded. Participants were adult patients who died during hospitalization. Data analysis was performed between January 2018 and July 2019. Exposure Implementation of a palliative care program. Main Outcomes and Measures The primary outcome was ICU use. A difference-in-differences analysis was performed using multilevel regression to assess the association between implementing a palliative care program and ICU use during terminal hospitalizations while adjusting for patient and hospital characteristics and time trends. Results During the study period, 73 370 patients (mean [SD] age, 76.5 [14.1] years; 38 467 [52.4%] women) died during hospitalization, of whom 37 628 (51.3%) received care in hospitals that implemented palliative care services and 35 742 (48.7%) received care in a hospital without palliative care implementation. Patients who received care in hospitals after implementation of palliative care services were less likely to receive intensive care than patients admitted to the same hospitals before implementation (49.3% vs 52.8%; difference 3.5%; 95% CI, 2.5%-4.5%; P < .001). Compared with hospitals that never had a palliative care program, the implementation of palliative care was associated with a 10% reduction in ICU use during terminal hospitalizations (adjusted relative risk, 0.90; 95% CI, 0.85-0.95; P < .001). Conclusions and Relevance The implementation of hospital-based palliative care services in New York State was associated with a modest reduction in ICU use during terminal hospitalizations.
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Affiliation(s)
- May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Yewei Lu
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Xiaoyue Ma
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Guohua Li
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hannah Wunsch
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
- Department of Anesthesia and Interdisciplinary Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Brinkman-Stoppelenburg A, Polinder S, Meerum-Terwogt J, de Nijs E, van der Padt-Pruijsten A, Peters L, van der Vorst M, van Zuylen L, Lingsma H, van der Heide A. The COMPASS study: A descriptive study on the characteristics of palliative care team consultation for cancer patients in hospitals. Eur J Cancer Care (Engl) 2019; 29:e13172. [PMID: 31571338 DOI: 10.1111/ecc.13172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/03/2019] [Accepted: 09/04/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To describe the characteristics of palliative care team (PCT) consultation for patients with cancer who are admitted in hospital and to investigate when and why PCTs are consulted. METHODS In this descriptive study in ten Dutch hospitals, the COMPASS study, we compared characteristics of patients with cancer for whom a PCT was or was not consulted (substudy 1). We also collected information about the process of PCT consultations and the disciplines involved (substudy 2). RESULTS In substudy 1, we included 476 patients. A life expectancy <3 months, unplanned hospitalisation and lack of options for anti-cancer treatment increased the likelihood of PCT consultation. In substudy 2, 64% of 550 consultations concerned patients with a life expectancy of <3 months. The most frequently mentioned problems that were identified by the PCTS were complex pain problems (56%), issues around the organisation of care (31%), fatigue (27%) and dyspnoea (27%). There was much variance between hospitals in the disciplines that were involved in consultations. CONCLUSION Palliative care teams in Dutch hospitals are most often consulted for patients with a life expectancy of <3 months who have an unplanned hospital admission because of physical symptoms or problems. We found much variance between hospitals in the composition and activities of PCTs.
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Affiliation(s)
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jetske Meerum-Terwogt
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Ellen de Nijs
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Liesbeth Peters
- Department of Pulmonary Diseases, Northwest Clinics, Den Helder, The Netherlands
| | - Maurice van der Vorst
- Department of Medical Oncology, Cancer Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.,Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Hester Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Electronic Health Record Mortality Prediction Model for Targeted Palliative Care Among Hospitalized Medical Patients: a Pilot Quasi-experimental Study. J Gen Intern Med 2019; 34:1841-1847. [PMID: 31313110 PMCID: PMC6712114 DOI: 10.1007/s11606-019-05169-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/11/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Development of electronic health record (EHR) prediction models to improve palliative care delivery is on the rise, yet the clinical impact of such models has not been evaluated. OBJECTIVE To assess the clinical impact of triggering palliative care using an EHR prediction model. DESIGN Pilot prospective before-after study on the general medical wards at an urban academic medical center. PARTICIPANTS Adults with a predicted probability of 6-month mortality of ≥ 0.3. INTERVENTION Triggered (with opt-out) palliative care consult on hospital day 2. MAIN MEASURES Frequencies of consults, advance care planning (ACP) documentation, home palliative care and hospice referrals, code status changes, and pre-consult length of stay (LOS). KEY RESULTS The control and intervention periods included 8 weeks each and 138 admissions and 134 admissions, respectively. Characteristics between the groups were similar, with a mean (standard deviation) risk of 6-month mortality of 0.5 (0.2). Seventy-seven (57%) triggered consults were accepted by the primary team and 8 consults were requested per usual care during the intervention period. Compared to historical controls, consultation increased by 74% (22 [16%] vs 85 [63%], P < .001), median (interquartile range) pre-consult LOS decreased by 1.4 days (2.6 [1.1, 6.2] vs 1.2 [0.8, 2.7], P = .02), ACP documentation increased by 38% (23 [17%] vs 37 [28%], P = .03), and home palliative care referrals increased by 61% (9 [7%] vs 23 [17%], P = .01). There were no differences between the control and intervention groups in hospice referrals (14 [10] vs 22 [16], P = .13), code status changes (42 [30] vs 39 [29]; P = .81), or consult requests for lower risk (< 0.3) patients (48/1004 [5] vs 33/798 [4]; P = .48). CONCLUSIONS Targeting hospital-based palliative care using an EHR mortality prediction model is a clinically promising approach to improve the quality of care among seriously ill medical patients. More evidence is needed to determine the generalizability of this approach and its impact on patient- and caregiver-reported outcomes.
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Kamal AH, Wolf SP, Troy J, Leff V, Dahlin C, Rotella JD, Handzo G, Rodgers PE, Myers ER. Policy Changes Key To Promoting Sustainability And Growth Of The Specialty Palliative Care Workforce. Health Aff (Millwood) 2019; 38:910-918. [DOI: 10.1377/hlthaff.2019.00018] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Arif H. Kamal
- Arif H. Kamal is an associate professor of medicine at Duke Cancer Institute, in Durham, North Carolina
| | - Steven P. Wolf
- Steven P. Wolf is a biostatistician at the Duke University School of Medicine, in Durham
| | - Jesse Troy
- Jesse Troy is an assistant professor in the Department of Pediatrics, Duke University School of Medicine
| | - Victoria Leff
- Victoria Leff is a palliative care social worker in the Section of Palliative Care at Duke University Hospital, in Durham
| | - Constance Dahlin
- Constance Dahlin is director of professional practice at the Hospice and Palliative Nurses Association, in Boston, Massachusetts
| | - Joseph D. Rotella
- Joseph D. Rotella is chief medical officer at the American Academy of Hospice and Palliative Medicine, in Chicago, Illinois
| | - George Handzo
- George Handzo is director of health services research and quality at the Healthcare Chaplaincy Network, in New York City
| | - Phillip E. Rodgers
- Phillip E. Rodgers is an associate professor of family medicine at the University of Michigan Medical School, in Ann Arbor
| | - Evan R. Myers
- Evan R. Myers is a professor of obstetrics and gynecology at the Duke University School of Medicine
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15
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Kamal AH, Wolf SP, Troy J, Leff V, Dahlin C, Rotella JD, Handzo G, Rodgers PE, Myers ER. Policy Changes Key To Promoting Sustainability And Growth Of The Specialty Palliative Care Workforce. Health Aff (Millwood) 2019. [DOI: 10.10.1377/hlthaff.2019.00018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Arif H. Kamal
- Arif H. Kamal is an associate professor of medicine at Duke Cancer Institute, in Durham, North Carolina
| | - Steven P. Wolf
- Steven P. Wolf is a biostatistician at the Duke University School of Medicine, in Durham
| | - Jesse Troy
- Jesse Troy is an assistant professor in the Department of Pediatrics, Duke University School of Medicine
| | - Victoria Leff
- Victoria Leff is a palliative care social worker in the Section of Palliative Care at Duke University Hospital, in Durham
| | - Constance Dahlin
- Constance Dahlin is director of professional practice at the Hospice and Palliative Nurses Association, in Boston, Massachusetts
| | - Joseph D. Rotella
- Joseph D. Rotella is chief medical officer at the American Academy of Hospice and Palliative Medicine, in Chicago, Illinois
| | - George Handzo
- George Handzo is director of health services research and quality at the Healthcare Chaplaincy Network, in New York City
| | - Phillip E. Rodgers
- Phillip E. Rodgers is an associate professor of family medicine at the University of Michigan Medical School, in Ann Arbor
| | - Evan R. Myers
- Evan R. Myers is a professor of obstetrics and gynecology at the Duke University School of Medicine
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Hua M, Ma X, Morrison RS, Li G, Wunsch H. Association between the Availability of Hospital-based Palliative Care and Treatment Intensity for Critically Ill Patients. Ann Am Thorac Soc 2018; 15:1067-1074. [PMID: 29812967 PMCID: PMC6137683 DOI: 10.1513/annalsats.201711-872oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 05/29/2018] [Indexed: 11/20/2022] Open
Abstract
RATIONALE In the intensive care unit (ICU), studies involving specialized palliative care services have shown decreases in the use of nonbeneficial life-sustaining therapies and ICU length of stay for patients. However, whether widespread availability of hospital-based palliative care is associated with less frequent use of high intensity care is unknown. OBJECTIVES To determine whether availability of hospital-based palliative care is associated with decreased markers of treatment intensity for ICU patients. METHODS Retrospective cohort study of adult ICU patients in New York State hospitals, 2008-2014. Multilevel regression was used to assess the relationship between availability of hospital-based palliative care during the year of admission and hospital length of stay, use of mechanical ventilation, dialysis and artificial nutrition, placement of a tracheostomy or gastrostomy tube, days in ICU and discharge to hospice. RESULTS Of 1,025,503 ICU patients in 151 hospitals, 814,794 (79.5%) received care in a hospital with a palliative care program. Hospital length of stay was similar for patients in hospitals with and without palliative care programs (6 d [interquartile range, 3-12] vs. 6 d [interquartile range, 3-11]; adjusted rate ratio, 1.04 [95% confidence interval 1.03-1.05]; P < 0.001), as were other healthcare use outcomes. However, patients in hospitals with palliative care programs were 46% more likely to be discharged to hospice than those in hospitals without palliative care programs (1.7% vs. 1.4%; adjusted odds ratio, 1.46 [95% confidence interval 1.30-1.64]; P < 0.001). CONCLUSIONS The availability of hospital-based palliative care was not associated with differences in in-hospital treatment intensity, but it was associated with significantly increased hospice use for ICU patients. Currently, the measurable benefit of palliative care programs for critically ill patients may be the increased use of hospice facilities, as opposed to decreased healthcare use during an ICU-associated hospitalization.
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Affiliation(s)
- May Hua
- Department of Anesthesiology and
| | - Xiaoyue Ma
- Department of Anesthesiology and
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Guohua Li
- Department of Anesthesiology and
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Hannah Wunsch
- Department of Anesthesiology and
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; and
- Department of Anesthesia and
- Interdisciplinary Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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17
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Curtis JR, Downey L, Back AL, Nielsen EL, Paul S, Lahdya AZ, Treece PD, Armstrong P, Peck R, Engelberg RA. Effect of a Patient and Clinician Communication-Priming Intervention on Patient-Reported Goals-of-Care Discussions Between Patients With Serious Illness and Clinicians: A Randomized Clinical Trial. JAMA Intern Med 2018; 178:930-940. [PMID: 29802770 PMCID: PMC6145723 DOI: 10.1001/jamainternmed.2018.2317] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/07/2018] [Indexed: 12/20/2022]
Abstract
Importance Clinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication. Objective To evaluate the efficacy of a patient-specific preconversation communication-priming intervention (Jumpstart-Tips) targeting both patients and clinicians and designed to increase goals-of-care conversations compared with usual care. Design, Setting, and Participants Multicenter cluster-randomized trial in outpatient clinics with physicians or nurse practitioners and patients with serious illness. The study was conducted between 2012 and 2016. Interventions Clinicians were randomized to the bilateral, preconversation, communication-priming intervention (n = 65) or usual care (n = 67), with 249 patients assigned to the intervention and 288 to usual care. Main Outcomes and Measures The primary outcome was patient-reported occurrence of a goals-of-care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals-of-care conversation in the medical record and patient-reported quality of communication (Quality of Communication questionnaire [QOC]; 4-indicator latent construct) at 2 weeks, as well as patient assessments of goal-concordant care at 3 months and patient-reported symptoms of depression (8-item Patient Health Questionnaire; PHQ-8) and anxiety (7-item Generalized Anxiety Disorder survey; GAD-7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for confounders. Results We enrolled 132 of 485 potentially eligible clinicians (27% participation; 71 women [53.8%]; mean [SD] age, 47.1 [9.6] years) and 537 of 917 eligible patients (59% participation; 256 women [47.7%]; mean [SD] age, 73.4 [12.7] years). The intervention was associated with a significant increase in a goals-of-care discussion at the target visit (74% vs 31%; P < .001) and increased medical record documentation (62% vs 17%; P < .001), as well as increased patient-rated quality of communication (4.6 vs 2.1; P = .01). Patient-assessed goal-concordant care did not increase significantly overall (70% vs 57%; P = .08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = .03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months. Conclusions and Relevance This intervention increased the occurrence, documentation, and quality of goals-of-care communication during routine outpatient visits and increased goal-concordant care at 3 months among patients with stable goals, with no change in symptoms of anxiety or depression. Understanding the effect on subsequent health care delivery will require additional study. Trial Registration ClinicalTrials.gov identifier: NCT01933789.
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Affiliation(s)
- J. Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Anthony L. Back
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
| | - Elizabeth L. Nielsen
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Sudiptho Paul
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Alexandria Z. Lahdya
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Patsy D. Treece
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Priscilla Armstrong
- Community Advisory Board, Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ronald Peck
- Community Advisory Board, Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
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18
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Meier DE, Back AL, Berman A, Block SD, Corrigan JM, Morrison RS. A National Strategy For Palliative Care. Health Aff (Millwood) 2018; 36:1265-1273. [PMID: 28679814 DOI: 10.1377/hlthaff.2017.0164] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In 2014 the World Health Organization called for palliative care to be integrated as an essential element of the health care continuum. Yet in 2017 US palliative care services are found largely in hospitals, and hospice care, which is delivered primarily in the home, is limited to people who are dying soon. The majority of Americans with a serious illness are not dying; are living at home, in assisted living facilities, or in nursing homes; and have limited access to palliative care. Most health care providers lack knowledge about and skills in pain and symptom management, communication, and care coordination, and both the public and health professionals are only vaguely aware of the benefits of palliative care and how and when to access it. The lack of policy supports for palliative care contributes to preventable suffering and low-value care. In this article we outline the need for a national palliative care strategy to ensure reliable access to high-quality palliative care for Americans with serious medical illnesses. We review approaches employed by other countries, list the participants needed to develop and implement an actionable strategy, and identify analogous US national health initiatives to inform a process for implementing the strategy.
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Affiliation(s)
- Diane E Meier
- Diane E. Meier is director of the Center to Advance Palliative Care and a professor in the Department of Geriatrics and Palliative Medicine, both at the Icahn School of Medicine at Mount Sinai, in New York City
| | - Anthony L Back
- Anthony L. Back is a professor in the Department of Medicine and codirector of the Cambia Palliative Care Center of Excellence at the University of Washington, cofounder of Vitaltalk (a nonprofit communication skills training organization), and an affiliate member of the Fred Hutchinson Cancer Research Center, all in Seattle
| | - Amy Berman
- Amy Berman is a senior program officer at the John A. Hartford Foundation, in New York City
| | - Susan D Block
- Susan D. Block is director of the Serious Illness Care Program at Ariadne Labs and a professor of psychiatry and medicine at Harvard Medical School, both in Boston, Massachusetts
| | - Janet M Corrigan
- Janet M. Corrigan is chief program officer for patient care at the Gordon and Betty Moore Foundation, in Palo Alto, California
| | - R Sean Morrison
- R. Sean Morrison is director of the National Palliative Care Research Center and a professor in the Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, in New York City
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Gruhler H, Krutka A, Luetke-Stahlman H, Gardner E. Determining Palliative Care Penetration Rates in the Acute Care Setting. J Pain Symptom Manage 2018; 55:226-235. [PMID: 28935130 DOI: 10.1016/j.jpainsymman.2017.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 09/07/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT Intermountain Healthcare, in collaboration with Cerner Corporation, developed a hospital-based electronic palliative care algorithm. OBJECTIVES This study aims to improve identification of patients who would benefit from palliative care services, and calculate palliative care penetration rates. METHODS This study used a mixed-methods nonrandomized retrospective study design. Three 30-day iterations of clinical data were analyzed for patients identified by the electronic algorithm. During the second and third 30-day iterations, palliative care clinicians conducted chart reviews on a weekly basis for identified patients and determined whether the patients were appropriate for a palliative care consult. Positive predictive values (PPVs) were calculated. Based on the PPV, palliative care consult penetration rates were also calculated. RESULTS During the first iteration, the algorithm triggered 2995 times on 1384 unique patient encounters (69.3% of the total inpatient population). In the second iteration, the algorithm triggered 851 times on 477 unique patient encounters (26.4% of the total inpatient population). Eight hundred twenty-one chart reviews were completed on 420 unique patient encounters. The PPV was 68.3%. Based on the PPV, the projected palliative care penetration rate was 17.6%. During the third iteration, the algorithm triggered 1229 times on 539 unique patient encounters (33.3% of the total inpatient population). Nine hundred sixty-seven chart reviews were completed on 505 unique patient encounters. The PPV was 80.1%. Based on the PPV, the projected palliative care penetration rate was 26.4%. CONCLUSION This study successfully optimized an electronic palliative care identification algorithm with a PPV of 80.1% and indicates appropriate palliative care penetration rates may be as high as 26.4% of the total inpatient population.
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Affiliation(s)
| | - April Krutka
- Intermountain Healthcare, Salt Lake City, Utah, USA
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20
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Greer JA, Jacobs JM, El-Jawahri A, Nipp RD, Gallagher ER, Pirl WF, Park ER, Muzikansky A, Jacobsen JC, Jackson VA, Temel JS. Role of Patient Coping Strategies in Understanding the Effects of Early Palliative Care on Quality of Life and Mood. J Clin Oncol 2017; 36:53-60. [PMID: 29140772 DOI: 10.1200/jco.2017.73.7221] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose The early integration of oncology and palliative care (EIPC) improves quality of life (QOL) and mood for patients with advanced cancer. However, the mechanisms by which EIPC benefits these outcomes remain unclear. We therefore examined whether EIPC improved patients' coping strategies and if changes in coping accounted for intervention effects on QOL and depressive symptoms. Patients and Methods For this secondary analysis of an EIPC trial, we examined data from 350 patients with newly diagnosed incurable lung or GI cancer. Participants completed assessments of QOL (Functional Assessment of Cancer Therapy-General), depressive symptoms (Patient Health Questionnaire-9), and coping (Brief COPE) at baseline and 24 weeks. We used linear regression to test intervention effects on use of coping strategies and mediation regression models with bias-corrected bootstrapping to examine whether improvements in coping mediated the effects of early palliative care on patient-reported outcomes. Results Compared with usual oncology care, EIPC significantly increased patient use of approach-oriented coping strategies ( B = 1.09; SE = 0.44; P = .01) and slightly reduced use of avoidant strategies ( B = -0.44; SE = 0.23; P = .06) from baseline to 24 weeks. Also, the increased use of approach-oriented coping and reduction in avoidant coping were associated with higher QOL and lower depressive symptoms at 24 weeks. The positive changes in approach-oriented coping, but not avoidant coping, significantly mediated the effects of EIPC on QOL (indirect effect, 1.27; 95% CI, 0.33 to 2.86) and depressive symptoms (indirect effect, -0.39; 95% CI, -0.87 to -0.08). Conclusion Patients with incurable cancer who received EIPC showed increased use of approach-oriented coping, which was associated with higher QOL and reduced depressive symptoms. Palliative care may improve these outcomes by providing patients with the skills to cope effectively with life-threatening illness.
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Affiliation(s)
- Joseph A Greer
- Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Jamie M Jacobs
- Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Areej El-Jawahri
- Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Ryan D Nipp
- Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Emily R Gallagher
- Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - William F Pirl
- Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Elyse R Park
- Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Alona Muzikansky
- Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Juliet C Jacobsen
- Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Vicki A Jackson
- Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Jennifer S Temel
- Joseph A. Greer, Jamie M. Jacobs, Areej El-Jawahri, Ryan D. Nipp, Emily R. Gallagher, Elyse R. Park, Alona Muzikansky, Juliet C. Jacobsen, Vicki A. Jackson, and Jennifer S. Temel, Massachusetts General Hospital and Harvard Medical School, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
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Chuang E, Hope AA, Allyn K, Szalkiewicz E, Gary B, Gong MN. Gaps in Provision of Primary and Specialty Palliative Care in the Acute Care Setting by Race and Ethnicity. J Pain Symptom Manage 2017; 54:645-653.e1. [PMID: 28760524 PMCID: PMC5650940 DOI: 10.1016/j.jpainsymman.2017.05.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 03/27/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT Previous research has identified a large unmet need in provision of specialist-level palliative care services in the hospital. How much of this gap is filled by primary palliative care provided by generalists or nonpalliative specialists has not been quantified. Estimates of racial and ethnic disparities have been inconsistent. OBJECTIVES The objective of this study was to 1) estimate primary and specialty palliative care delivery and to measure unmet needs in the inpatient setting and 2) explore racial and ethnic disparities in palliative care delivery. METHODS This was a cross-sectional, retrospective study of 55,658 adult admissions to two acute care hospitals in the Bronx in 2013. Patients with palliative care needs were identified by criteria adapted from the literature. The primary outcomes were delivery of primary and specialist-level palliative care. RESULTS In all, 18.5% of admissions met criteria for needing palliative care. Of those, 18% received specialist-level palliative care, an estimated 30% received primary palliative care, and 37% had no evidence of palliative care or advance care planning. Black and Hispanic patients were not less likely to receive specialist-level palliative care (adjusted odds ratio [OR] black patients = 1.18, 95% CI 0.98, 1.42; adjusted OR Hispanic patients = 1.24, 95% CI 1.04, 1.48), but they were less likely to receive primary palliative care (adjusted OR black patients = 0.41, 95% CI 0.20, 0.84; adjusted OR Hispanic patients = 0.48, 95% CI 0.25, 0.94). CONCLUSION Even when considering primary and specialty palliative care, hospitalized patients have a high prevalence of unmet palliative care need. Further research is needed understand racial and ethnic disparities in palliative care delivery.
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Affiliation(s)
- Elizabeth Chuang
- Department of Family and Social Medicine, Palliative Care Service, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York.
| | - Aluko A Hope
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Katherine Allyn
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | | | - Brittany Gary
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Michelle N Gong
- Division of Critical Care Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; Department of Epidemiology and Population Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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22
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Mun E, Umbarger L, Ceria-Ulep C, Nakatsuka C. Palliative Care Processes Embedded in the ICU Workflow May Reserve Palliative Care Teams for Refractory Cases. Am J Hosp Palliat Care 2016; 35:60-65. [PMID: 28273756 DOI: 10.1177/1049909116684821] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
CONTEXT Palliative Care Teams have been shown to be instrumental in the early identification of multiple aspects of advanced care planning. Despite an increased number of services to meet the rising consultation demand, it is conceivable that the numbers of palliative care consultations generated from an ICU alone could become overwhelming for an existing palliative care team. OBJECTIVE Improve end-of-life care in the ICU by incorporating basic palliative care processes into the daily routine ICU workflow, thereby reserving the palliative care team for refractory situations. METHODS A structured, palliative care, quality-improvement program was implemented and evaluated in the ICU at Kaiser Permanente Medical Center in Hawaii. This included selecting trigger criteria, a care model, forming guidelines, and developing evaluation criteria. MAIN OUTCOME MEASURES These included the early identification of the multiple features of advanced care planning, numbers of proactive ICU and palliative care family meetings, and changes in code status and treatment upon completion of either meeting. RESULTS Early identification of Goals-of-Care, advance directives, and code status by the ICU staff led to a proactive ICU family meeting with resultant increases in changes in code status and treatment. The numbers of palliative care consultations also rose, but not significantly. CONCLUSIONS Palliative care processes could be incorporated into a daily ICU workflow allowing for integration of aspects of advanced care planning to be identified in a systematic and proactive manner. This reserved the palliative care team for situations when palliative care efforts performed by the ICU staff were ineffective.
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Affiliation(s)
- Eluned Mun
- 1 Department of Physician Services, The Rehabilitation Hospital of the Pacific, Honolulu, HI, USA
| | - Lillian Umbarger
- 2 Department of Intensive Care Unit, Kaiser Permanente Medical Center, Honolulu, HI, USA
| | - Clementina Ceria-Ulep
- 3 Department of School of Nursing and Dental Hygiene, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Craig Nakatsuka
- 4 Department of Palliative Care, Kaiser Permanente Medical Center, Honolulu, HI, USA
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23
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Thygeson NM, Wang M, O'Riordan D, Pantilat SZ. Self-Reported California Hospital Palliative Care Program Composition, Certification, and Staffing Level Are Associated with Lower End-of-Life Medicare Utilization. J Palliat Med 2016; 19:1281-1287. [DOI: 10.1089/jpm.2016.0176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- N. Marcus Thygeson
- Department of Healthcare Quality and Affordability, Blue Shield of California, San Francisco, California
| | - Meinong Wang
- School of Public Health, Yale University, New Haven, Connecticut
| | - David O'Riordan
- Department of Medicine, University of California, San Francisco, California
| | - Steven Z. Pantilat
- Department of Hospital Medicine, University of California, San Francisco, California
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24
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Parikh RB, Bowman B, Dahlin C, Twohig JS, Meier DE. Scalable principles of community-based high-value care for seriously ill individuals: Diamonds in the rough. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2016; 5:12-16. [PMID: 27687915 DOI: 10.1016/j.hjdsi.2016.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 07/20/2016] [Accepted: 08/01/2016] [Indexed: 11/26/2022]
Abstract
Early, integrated palliative care has been shown to improve quality of life and reduce utilization in both inpatient and outpatient settings. As health systems shift to risk-based payment structures, palliative care will play an increasing role in improving value of care outside of the hospital. Based on successful models of community-based palliative care, we identify six principles - interdisciplinary team-based care; 24/7 access and responsiveness; concurrent palliative care with disease-directed treatment; targeting services to high-risk patients; integrated medical and social supports; and caregiver support - that are widely implemented because of their impact on improving value for seriously ill individuals.
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Affiliation(s)
- Ravi B Parikh
- Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Brynn Bowman
- Center to Advance Palliative Care, New York, NY, United States
| | - Constance Dahlin
- Center to Advance Palliative Care, New York, NY, United States; Hospice and Palliative Nurses Association, Pittsburgh, PA, United States
| | - Jeanne S Twohig
- Center to Advance Palliative Care, New York, NY, United States
| | - Diane E Meier
- Center to Advance Palliative Care, New York, NY, United States; Icahn School of Medicine at Mount Sinai, New York, NY, United States
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25
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Brinkman-Stoppelenburg A, Boddaert M, Douma J, van der Heide A. Palliative care in Dutch hospitals: a rapid increase in the number of expert teams, a limited number of referrals. BMC Health Serv Res 2016; 16:518. [PMID: 27663961 PMCID: PMC5035474 DOI: 10.1186/s12913-016-1770-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/16/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Palliative care expert teams in hospitals have positive effects on the quality of life and satisfaction with care of patients with advanced disease. Involvement of these teams in medical care is also associated with substantial cost savings. In the Netherlands, professional standards state that each hospital should have a palliative care team by 2017. We studied the number of hospitals that have a palliative care team and the characteristics of these teams. METHODS In April 2015, questionnaires were mailed to key palliative care professionals in all general, teaching and academic hospitals in the Netherlands. Out of 92 hospitals, 74 responded (80 %). RESULTS Seventy-seven percent of all participating hospitals had a palliative care team. Other services, such as outpatient clinics (22 %), palliative care inpatient units (7 %), and palliative day care facilities (4 %) were relatively scarce. The mean number of disciplines that were represented in the teams was 6,5. The most common disciplines were nurses (72 %) and nurse practitioners (54 %), physicians specialized in internal medicine (90 %) or anaesthesiology (75 %), and spiritual caregivers (65 %). In most cases, the physicians did not have labeled hours available for their work as palliative care consultant, whereas nurses and nurse practitioners did. Most teams (77 %) were only available during office hours. Twenty-six percent of the teams could not only be consulted by healthcare professionals but also by patients or relatives. The annual number of consultations for inpatients per year ranged from 2 to 680 (median: 77). On average, teams were consulted for 0.6 % of all patients admitted to the hospitals. CONCLUSION The number of Dutch hospitals with a palliative care team is rapidly increasing. There are substantial differences between teams regarding the disciplines represented in the teams, the procedures and the number of consultations. The development of quality standards and adequate staffing of the teams could improve the quality and effectiveness of the teams.
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Affiliation(s)
- A Brinkman-Stoppelenburg
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, Room NA22-12, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands.
| | - M Boddaert
- Netherlands Comprehensive Cancer Organisation (IKNL), Godebaldkwartier 419, 3511DT, Utrecht, The Netherlands
| | - J Douma
- Netherlands Comprehensive Cancer Organisation (IKNL), Godebaldkwartier 419, 3511DT, Utrecht, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, Room NA22-12, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands
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26
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Spetz J, Dudley N, Trupin L, Rogers M, Meier DE, Dumanovsky T. Few Hospital Palliative Care Programs Meet National Staffing Recommendations. Health Aff (Millwood) 2016; 35:1690-7. [DOI: 10.1377/hlthaff.2016.0113] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Joanne Spetz
- Joanne Spetz ( ) is a professor of economics at the Philip R. Lee Institute for Health Policy Studies and the Healthforce Center at the University of California, San Francisco (UCSF)
| | - Nancy Dudley
- Nancy Dudley is a VA Quality Scholars fellow with the UCSF Department of Geriatrics and the San Francisco Veterans Affairs Medical Center
| | - Laura Trupin
- Laura Trupin is an epidemiologist in the Philip R. Lee Institute for Health Policy Studies at UCSF
| | - Maggie Rogers
- Maggie Rogers is senior research associate at the Center to Advance Palliative Care, in New York City
| | - Diane E. Meier
- Diane E. Meier is the director of the Center to Advance Palliative Care and a professor in the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, in New York City
| | - Tamara Dumanovsky
- Tamara Dumanovsky is a vice president for research and analytics at the Center to Advance Palliative Care
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