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Jia Z, Kurahashi A, Sharma RK, Mahtani R, Zagorski BM, Sanders JJ, Yarnell C, Detsky M, Lindvall C, Teno JM, Bell CM, Quinn KL. A Comparison of Palliative Care Delivery between Ethnically Chinese and Non-Chinese Canadians in the Last Year of Life. J Gen Intern Med 2024:10.1007/s11606-024-08859-8. [PMID: 38926319 DOI: 10.1007/s11606-024-08859-8] [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: 01/24/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Ethnically Chinese adults in Canada and the United States face multiple barriers in accessing equitable, culturally respectful care at the end-of-life. Palliative care (PC) is committed to supporting patients and families in achieving goal-concordant, high-quality serious illness care. Yet, current PC delivery may be culturally misaligned. Therefore, understanding ethnically Chinese patients' use of palliative care may uncover modifiable factors to sustained inequities at the end-of-life. OBJECTIVE To compare the use and delivery of PC in the last year of life between ethnically Chinese and non-Chinese adults. DESIGN Population-based cohort study. PARTICIPANTS All Ontario adults who died between January 1st, 2012, and October 31st, 2022, in Ontario, Canada. EXPOSURES Chinese ethnicity. MAIN MEASURES Elements of physician-delivered PC, including model of care (generalist; specialist; mixed), timing and location of initiation, and type of palliative care physician at initial consultation. KEY RESULTS The final study cohort included 527,700 non-Chinese (50.8% female, 77.9 ± 13.0 mean age, 13.0% rural residence) and 13,587 ethnically Chinese (50.8% female, 79.2 ± 13.6 mean age, 0.6% rural residence) adults. Chinese ethnicity was associated with higher likelihoods of using specialist (adjusted odds ratio [aOR] 1.53, 95%CI 1.46-1.60) and mixed (aOR 1.32, 95%CI 1.26-1.38) over generalist models of PC, compared to non-Chinese patients. Chinese ethnicity was also associated with a higher likelihood of PC initiation in the last 30 days of life (aOR 1.07, 95%CI 1.03-1.11), in the hospital setting (aOR 1.24, 95%CI 1.18-1.30), and by specialist PC physicians (aOR 1.33, 95%CI 1.28-1.38). CONCLUSIONS Chinese ethnicity was associated with a higher likelihood of mixed and specialist models of PC delivery in the last year of life compared to adults who were non-Chinese. These observed differences may be due to later initiation of PC in hospital settings, and potential differences in unmeasured needs that suggest opportunities to initiate early, community-based PC to support ethnically Chinese patients with serious illness.
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Affiliation(s)
- Zhimeng Jia
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada.
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
- Program in Global Palliative Care, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Allison Kurahashi
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ramona Mahtani
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Justin J Sanders
- Department of Family Medicine, McGill University, Montreal, QC, Canada
- Ariadne Labs, Boston, MA, USA
| | - Christopher Yarnell
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine and Research Institute, Scarborough Health Network, Toronto, Canada
| | - Michael Detsky
- Interdepartmental Division of Critical Care Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Charlotta Lindvall
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Joan M Teno
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Chaim M Bell
- ICES, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto and Sinai Health, Toronto, Ontario, Canada
| | - Kieran L Quinn
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto and Sinai Health, Toronto, Ontario, Canada
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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.
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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
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Schlichte LM, Hildenbrand J, Wolf S, Herring KW, Troy JD, LeBlanc TW. Knowledge of Palliative Care and Barriers to Access Among Outpatients with Cancer. J Pain Symptom Manage 2024; 67:115-125. [PMID: 37848077 DOI: 10.1016/j.jpainsymman.2023.10.013] [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: 06/24/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/19/2023]
Abstract
CONTEXT Palliative Care (PC) is poorly understood by laypersons. However, little is known about what ambulatory patients with cancer understand about PC or what barriers to access exist. METHODS Outpatients undergoing cancer treatment completed a survey evaluating their familiarity and knowledge of PC, Palliative Care Knowledge Scale (PaCKS), feelings towards PC (before and after reading a definition of PC), barriers to PC, and prognostic understanding. We summarized responses descriptively and used logistic regression models to examine variables associated with familiarity and interest. RESULTS The survey response rate was 32%. Of 151 participants, 58.9% reported familiarity with PC. The average PaCKs score was 11.9 out of 13 (standard deviation, 1.4), with 46.4% receiving a perfect score, indicating high knowledge of PC. Patients diagnosed more than one year ago had significantly increased odds of being familiar with PC (OR 2.93; 95% CI 1.37-6.25). More participants reported future interest in PC compared to current interest (74.2% vs 44.4%, respectively). Patients with stage III or IV cancer had significantly increased odds of having a current interest in receiving PC compared to patients with stage I or II disease (OR 2.66; 95% CI: 1.05, 6.76). Participants reported feeling significantly less anxious and more reassured after reading a standardized definition of PC (P < 0.05). CONCLUSION Outpatients with cancer who are being treated at a large academic cancer center exhibit high awareness and knowledge of PC, but anxiety toward PC persists. Factors beyond knowledge may perpetuate the delayed or lack of involvement with PC. KEY MESSAGE In this cross-sectional study of outpatients with cancer, findings suggest that high knowledge of PC may co-exist with a lingering uneasiness towards the service. Additionally, factors beyond knowledge, such as logistic barriers, anxiety, and oncologists' preference may be perpetuating the delay or lack of involvement in PC.
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Affiliation(s)
| | - Jordan Hildenbrand
- Department of Psychiatry and Behavior Sciences (J.H.), Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Steven Wolf
- Department of Biostatistics and Bioinformatics (S.W., J.D.T.), Duke University, Durham, North Carolina
| | | | - Jesse D Troy
- Department of Biostatistics and Bioinformatics (S.W., J.D.T.), Duke University, Durham, North Carolina
| | - Thomas W LeBlanc
- Department of Hematologic Malignancies and Cellular Therapy (T.W.L.), Duke University School of Medicine, Durham, North Carolina.
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Giannitrapani KF, Sasnal M, McCaa M, Wu A, Morris AM, Connell NB, Aslakson RA, Schenker Y, Shreve S, Lorenz KA. Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans. J Pain Symptom Manage 2023; 66:621-629.e5. [PMID: 37643653 DOI: 10.1016/j.jpainsymman.2023.08.021] [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: 05/24/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
CONTEXT Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively. OBJECTIVES To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons. METHODS We conducted semistructured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8). RESULTS Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: 1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; 2) establish risk assessment processes to identify patients who may benefit from a PC consult; 3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; 4) provide sufficient resources to allow for an interdisciplinary sharing of care. CONCLUSION The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.
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Affiliation(s)
- Karleen F Giannitrapani
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California.
| | - Marzena Sasnal
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | - Matthew McCaa
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California
| | - Adela Wu
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Neurosurgery (A.W.), Stanford School of Medicine, Stanford, California
| | - Arden M Morris
- Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | | | - Rebecca A Aslakson
- Department of Anesthesiology (R.A.A.), University of Vermont, Burlington, Vermont
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics (Y.S.), Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott Shreve
- Department of Veterans Affairs (S.S.), VA Palliative Care, Lebanon, Pennsylvania
| | - Karl A Lorenz
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California
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Hooker ER, Chapa J, Vranas KC, Niederhausen M, Goodlin SJ, Slatore CG, Sullivan DR. Intersection of Palliative Care and Hospice Use Among Patients With Advanced Lung Cancer. J Palliat Med 2023; 26:1474-1481. [PMID: 37262128 PMCID: PMC10658737 DOI: 10.1089/jpm.2023.0040] [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: 04/27/2023] [Indexed: 06/03/2023] Open
Abstract
Background: Hospice and palliative care (PC) are important components of lung cancer care and independently provide benefits to patients and their families. Objective: To better understand the relationship between hospice and PC and factors that influence this relationship. Methods: A retrospective cohort study of patients diagnosed with advanced lung cancer (stage IIIB/IV) within the U.S. Veterans Health Administration (VA) from 2007 to 2013 with follow-up through 2017 (n = 22,907). Mixed logistic regression models with a random effect for site, adjustment for patient variables, and propensity score weighting were used to examine whether the association between PC and hospice use varied by U.S. region and PC team characteristics. Results: Overall, 57% of patients with lung cancer received PC, 69% received hospice, and 16% received neither. Of those who received hospice, 60% were already enrolled in PC. Patients who received PC had higher odds of hospice enrollment than patients who did not receive PC (adjusted odds ratio = 3.25, 95% confidence interval: 2.43-4.36). There were regional differences among patients who received PC; the predicted probability of hospice enrollment was 85% and 73% in the Southeast and Northeast, respectively. PC team and facility characteristics influenced hospice use in addition to PC; teams with the shortest duration of existence, with formal team training, and at lower hospital complexity were more likely to use hospice (all p < 0.05). Conclusions: Among patients with advanced lung cancer, PC was associated with hospice enrollment. However, this relationship varied by geographic region, and PC team and facility characteristics. Our findings suggest that regional PC resource availability may contribute to substitution effects between PC and hospice for end-of-life care.
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Affiliation(s)
- Elizabeth R. Hooker
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
| | - Joaquin Chapa
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Portland Veterans Affairs Medical Center, Divisions of Pulmonary Critical Care Medicine, Portland, Oregon, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Oregon Health and Science University—Portland State University School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Sarah J. Goodlin
- Geriatrics Section, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Donald R. Sullivan
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
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Feder SL, Zhan Y, Abel EA, Smith D, Ersek M, Fried T, Redeker NS, Akgün KM. Validation of Electronic Health Record-Based Algorithms to Identify Specialist Palliative Care Within the Department of Veterans Affairs. J Pain Symptom Manage 2023; 66:e475-e483. [PMID: 37364737 PMCID: PMC10527602 DOI: 10.1016/j.jpainsymman.2023.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND The measurement of specialist palliative care (SPC) across Department of Veterans Affairs (VA) facilities relies on algorithms applied to administrative databases. However, the validity of these algorithms has not been systematically assessed. MEASURES In a cohort of people with heart failure identified by ICD 9/10 codes, we validated the performance of algorithms to identify SPC consultation in administrative data and differentiate outpatient from inpatient encounters. INTERVENTION We derived separate samples of people by receipt of SPC using combinations of stop codes signifying specific clinics, current procedural terminology (CPT), a variable representing encounter location, and ICD-9/ICD-10 codes for SPC. We calculated sensitivity, specificity, and positive and negative predictive values (PPV, NPV) for each algorithm using chart review as the reference standard. OUTCOMES Among 200 people who did and did not receive SPC (mean age = 73.9 years (standard deviation [SD] = 11.5), 98% male, 73% White), the validity of the stop code plus CPT algorithm to identify any SPC consultation was: Sensitivity = 0.89 (95% Confidence Interval [CI] 0.82-0.94), Specificity = 1.0 [0.96-1.0], PPV = 1.0 [0.96-1.0], NPV = 0.93 [0.86-0.97]. The addition of ICD codes increased sensitivity but decreased specificity. Among 200 people who received SPC (mean age = 74.2 years [SD = 11.8], 99% male, 71% White), algorithm performance in differentiating outpatient from inpatient encounters was: Sensitivity = 0.95 (0.88-0.99), Specificity = 0.81 (0.72-0.87), PPV = 0.38 (0.29-0.49), and NPV = 0.99 (0.95-1.0). Adding encounter location improved the sensitivity and specificity of this algorithm. CONCLUSIONS VA algorithms are highly sensitive and specific in identifying SPC and in differentiating outpatient from inpatient encounters. These algorithms can be used with confidence to measure SPC in quality improvement and research across the VA.
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Affiliation(s)
- Shelli L Feder
- Yale School of Nursing (S.L.F., Y.Z.), Orange, Connecticut, USA; VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA.
| | - Yan Zhan
- Yale School of Nursing (S.L.F., Y.Z.), Orange, Connecticut, USA
| | - Erica A Abel
- VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA; Yale School of Medicine (E.A.C., T.F., K.M.A.), Orange, Connecticut, USA
| | - Dawn Smith
- Veterans Experience Center, Corporal Michael J. Crescenz VA Medical Center (D.S., M.E.), Philadelphia, Pennsylvania, USA
| | - Mary Ersek
- Veterans Experience Center, Corporal Michael J. Crescenz VA Medical Center (D.S., M.E.), Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing (M.E.), Philadelphia, Pennsylvania, USA
| | - Terri Fried
- VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA; Yale School of Medicine (E.A.C., T.F., K.M.A.), Orange, Connecticut, USA; Yale Program on Aging (T.F.), New Haven, Connecticut, USA
| | - Nancy S Redeker
- University of Connecticut School of Nursing (N.S.R.), Storrs, Connecticut, USA
| | - Kathleen M Akgün
- VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA; Yale School of Medicine (E.A.C., T.F., K.M.A.), Orange, Connecticut, USA
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Díez-Concha JF, Gómez-García DM, Agudelo JA, Lizarazo Herrera EA. Assessing the impact of palliative care admission of end-of-life cancer adults. Palliat Care Soc Pract 2023; 17:26323524231198545. [PMID: 37706168 PMCID: PMC10496487 DOI: 10.1177/26323524231198545] [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: 04/01/2023] [Accepted: 08/15/2023] [Indexed: 09/15/2023] Open
Abstract
Background There is evidence that early admission to the palliative care (PC) program in adult cancer patients improves symptoms management, reduces unplanned hospital admissions, minimizes aggressive cancer treatments, and enables patients to make decisions about their end-of-life (EOL) care. Objectives This retrospective cohort study aimed to determine whether late admission to a PC program is associated with aggressive treatment at the EOL in adult patients with oncological diseases from their admission until death. Design/Methods The study evaluated the aggressiveness in EOL management in patients with advanced stage oncological diseases who died between 2017 and 2019. The study population was divided into two groups based on the time of admission to the PC program. Aggressiveness at the EOL was measured using five criteria: treatment, hospital admission and duration, emergency department care, and/or intensive care unit utilization. Results The study found a significant difference in the rate of aggressive EOL treatments between late admission to PC care and early admission [adjusted EOL 79.6% versus 70.4%; relative risk (RR): 1.98, 90% CI: 1.08-3.59, p: 0.061]; In the analysis of secondary variables, a significant association was observed between early admission to PC and the suspension of active treatments at the EOL, leading to a decrease in aggressiveness (77% versus 55.8%; RR: 1.38, 95% CI: 1.14-1.67, p: 0.004). Conclusion Our findings suggest that early referral to PC services is associated with less aggressive treatment at the EOL, including suspension of active treatments.
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Affiliation(s)
- Jose F. Díez-Concha
- Faculty of Health, Department of Family Medicine, Universidad del Valle, Cra 119a #60b-75, Cali, Valle del Cauca 760035, Colombia
| | - Diego Mauricio Gómez-García
- Faculty of Health, Department of Family Medicine, Universidad del Valle, Calle 15a #69-85, Cali, Valle del Cauca 760033, Colombia
| | - Julián Alberto Agudelo
- Pain Medicine and Palliative Care, Clínica de Occidente S.A., Cali, Valle del Cauca, Colombia
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Bagheri S, Barkhordari-Sharifabad M. Translation and psychometric validation of the Persian version of palliative care attitudes scale in cancer patients. BMC Palliat Care 2023; 22:95. [PMID: 37460923 DOI: 10.1186/s12904-023-01223-3] [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: 03/27/2023] [Accepted: 07/12/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION To improve cancer patients' quality of life, palliative care is necessary. The growth of palliative care, along with the assistance of the government and the collaboration of specialists, also relies on the knowledge and attitude of people. In Iran, there is no tool available to gauge patient attitudes about palliative treatment. The Persian version of the Palliative Care Attitude Scale (PCAS-9) was translated and psychometrically validated in this research among cancer patients. METHODS This methodological study was conducted in two stages: translation stage and psychometric validation stage. The method of translation was based on that proposed by Polit and Yang. Utilizing a qualitative approach, the scale's face and content validity were investigated. 162 cancer patients who required palliative care based on expert diagnosis participated in the confirmatory factor analysis to establish construct validity. Stability and internal consistency provided evidence of reliability. The data was examined using SPSS18 and AMOS. RESULTS The "Palliative Care Attitudes Scale" translated well across cultures. Validity on both the face and the content was acceptable. Confirmatory factor analysis (CFA) revealed a good fit for the original three-factor structure. The intra-class correlation coefficient (ICC) was equal to 0.89, while the internal consistency (Cronbach's alpha) reliability of the whole scale was equal to 0.77. CONCLUSIONS Persian version of the "Palliative Care Attitudes Scale" was acceptable and adequate in cancer patients. Using this tool makes it easier to assess how patients feel about receiving palliative care and how well training sessions are working to change patients' views.
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Affiliation(s)
- Sajjad Bagheri
- Department of Nursing, School of Medical Sciences, Yazd Branch, Islamic Azad University, Yazd, Iran
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Wilson PM, Ramar P, Philpot LM, Soleimani J, Ebbert JO, Storlie CB, Morgan AA, Schaeferle GM, Asai SW, Herasevich V, Pickering BW, Tiong IC, Olson EA, Karow JC, Pinevich Y, Strand J. Effect of an Artificial Intelligence Decision Support Tool on Palliative Care Referral in Hospitalized Patients: A Randomized Clinical Trial. J Pain Symptom Manage 2023; 66:24-32. [PMID: 36842541 DOI: 10.1016/j.jpainsymman.2023.02.317] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/12/2023] [Accepted: 02/15/2023] [Indexed: 02/26/2023]
Abstract
CONTEXT Palliative care services are commonly provided to hospitalized patients, but accurately predicting who needs them remains a challenge. OBJECTIVES To assess the effectiveness on clinical outcomes of an artificial intelligence (AI)/machine learning (ML) decision support tool for predicting patient need for palliative care services in the hospital. METHODS The study design was a pragmatic, cluster-randomized, stepped-wedge clinical trial in 12 nursing units at two hospitals over a 15-month period between August 19, 2019, and November 17, 2020. Eligible patients were randomly assigned to either a medical service consultation recommendation triggered by an AI/ML tool predicting the need for palliative care services or usual care. The primary outcome was palliative care consultation note. Secondary outcomes included: hospital readmissions, length of stay, transfer to intensive care and palliative care consultation note by unit. RESULTS A total of 3183 patient hospitalizations were enrolled. Of eligible patients, A total of 2544 patients were randomized to the decision support tool (1212; 48%) and usual care (1332; 52%). Of these, 1717 patients (67%) were retained for analyses. Patients randomized to the intervention had a statistically significant higher incidence rate of palliative care consultation compared to the control group (IRR, 1.44 [95% CI, 1.11-1.92]). Exploratory evidence suggested that the decision support tool group reduced 60-day and 90-day hospital readmissions (OR, 0.75 [95% CI, 0.57, 0.97]) and (OR, 0.72 [95% CI, 0.55-0.93]) respectively. CONCLUSION A decision support tool integrated into palliative care practice and leveraging AI/ML demonstrated an increased palliative care consultation rate among hospitalized patients and reductions in hospitalizations.
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Affiliation(s)
- Patrick M Wilson
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (P.M.W, J.O.E., C.B.S., G.M.S.), Rochester, Minnesota, USA.
| | - Priya Ramar
- Department of Medicine (P.R., L.M.P.), Mayo Clinic, Rochester, Minnesota USA
| | - Lindsey M Philpot
- Department of Medicine (P.R., L.M.P.), Mayo Clinic, Rochester, Minnesota USA
| | - Jalal Soleimani
- Department of Anesthesiology (J.S., V.H., B.W.P., Y.P.), Mayo Clinic, Rochester, Minnesota USA
| | - Jon O Ebbert
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (P.M.W, J.O.E., C.B.S., G.M.S.), Rochester, Minnesota, USA; Division of Community Internal Medicine (J.O.E., A.A.M. E.A.O., J.C.K., J.S.), Geriatrics and Palliative Care Mayo Clinic, Rochester, Minnesota, USA
| | - Curtis B Storlie
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (P.M.W, J.O.E., C.B.S., G.M.S.), Rochester, Minnesota, USA; Department of Health Sciences Research (C.B.S.), Mayo Clinic, Rochester, Minnesota, USA
| | - Alisha A Morgan
- Division of Community Internal Medicine (J.O.E., A.A.M. E.A.O., J.C.K., J.S.), Geriatrics and Palliative Care Mayo Clinic, Rochester, Minnesota, USA
| | - Gavin M Schaeferle
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (P.M.W, J.O.E., C.B.S., G.M.S.), Rochester, Minnesota, USA
| | - Shusaku W Asai
- Health Analytics | Global Health and Wellbeing (S.W.A.), Delta Air Lines, Atlanta, Georgia, USA
| | - Vitaly Herasevich
- Department of Anesthesiology (J.S., V.H., B.W.P., Y.P.), Mayo Clinic, Rochester, Minnesota USA
| | - Brian W Pickering
- Department of Anesthesiology (J.S., V.H., B.W.P., Y.P.), Mayo Clinic, Rochester, Minnesota USA
| | - Ing C Tiong
- Department of Information Technology (I.C.T.), Mayo Clinic, Rochester, Minnesota, USA
| | - Emily A Olson
- Division of Community Internal Medicine (J.O.E., A.A.M. E.A.O., J.C.K., J.S.), Geriatrics and Palliative Care Mayo Clinic, Rochester, Minnesota, USA
| | - Jordan C Karow
- Division of Community Internal Medicine (J.O.E., A.A.M. E.A.O., J.C.K., J.S.), Geriatrics and Palliative Care Mayo Clinic, Rochester, Minnesota, USA
| | - Yuliya Pinevich
- Department of Anesthesiology (J.S., V.H., B.W.P., Y.P.), Mayo Clinic, Rochester, Minnesota USA
| | - Jacob Strand
- Division of Community Internal Medicine (J.O.E., A.A.M. E.A.O., J.C.K., J.S.), Geriatrics and Palliative Care Mayo Clinic, Rochester, Minnesota, USA
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10
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Sousa BR, Dias Moreira T, Pires P. Palliative Care in a Specialized Palliative Cancer Care Unit in Portugal: A Complex Reality. Cureus 2023; 15:e37930. [PMID: 37220447 PMCID: PMC10200128 DOI: 10.7759/cureus.37930] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2023] [Indexed: 05/25/2023] Open
Abstract
Introduction The goal of palliative care (PC) is to improve the quality of life of patients and their families through the involvement of a multidisciplinary team. PC improves symptom control and end-of-life care. Despite the fact that the benefits of PC have long been acknowledged, Portugal's demands are currently unmet. The majority of patients have been identified as having a high level of complexity and are referred for symptom management and end-of-life care. Study aim The study aimed to analyze the sociodemographic, disease and hospitalization characteristics of the patients admitted to a specialized PC unit. Materials and methods We conducted a retrospective, single-center study of palliative care patients admitted to a Portuguese oncology institute's acute palliative care unit during a three-month period. Patients' information such as social demographics, clinical data, patient and family member's psychological, social, nutritional and spiritual counseling and knowledge on diagnosis and therapy objectives were collected from physician's records and analyzed using SPSS Statistics for Windows, Version 23.0 (IBM SPSS Statistics for Windows). Results A total of 41 patients were included, with a mean age of 66.4 years. Spouses were the primary caregivers. There was no indication for targeted therapy in any of the patients. Prior to hospitalization, 58.5% did not receive follow-up by PC. The most frequently reported symptoms were pain (75.6%), tiredness (68.3%), anorexia (61%) and emotional distress (58.5%). Patients were referred to counseling for psychological (43.3%), spiritual (19.5%), nutritional (58.5%) and social services (34.1%). During hospitalization, 75% of patients died; out of which, 70.9% were not previously followed up on by the PC team. Conclusion PC patients are complex, with multiple clinical-psychological-social-spiritual issues, and their management in non-PC wards can be challenging. Since the use of a multidisciplinary approach can improve patients' and families' quality of life, it is critical to train, expand and integrate the PC teams into the existing teams, allowing patients a better quality of life until they pass.
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Affiliation(s)
- Beatriz R Sousa
- Internal Medicine, Centro Hospitalar Universitário de Lisboa Central, Lisbon, PRT
| | - Teresa Dias Moreira
- Palliative Care, Instituto Português de Oncologia do Porto Francisco Gentil, Oporto, PRT
| | - Pedro Pires
- Internal Medicine, Centro Hospitalar Universitário de Lisboa Central, Lisbon, PRT
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11
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Kalver E, Branch-Elliman W, Stolzmann K, Wachterman M, Shin MH, Schweizer ML, Mull HJ. Prevalence of One-Year Mortality after Implantable Cardioverter Defibrillator Placement: An Opportunity for Palliative Care? J Palliat Med 2023; 26:175-181. [PMID: 36067080 PMCID: PMC9894597 DOI: 10.1089/jpm.2022.0205] [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: 07/18/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Current guidelines recommend against placement of implantable cardioverter defibrillators in patients with a life expectancy less than one year. These patients may benefit from early palliative care services; however, identifying this population is challenging. Objective: Determine whether a validated prognostic tool, based on patient factors and health care utilization from electronic medical records, accurately predicts one-year mortality at the time of implantable cardioverter defibrillator placement. Design: We used the United States (U.S.) Veterans Administration's "Care Assessment Needs" one-Year Mortality Score to identify patients at high risk of mortality (score ≥95) before their procedure. Data were extracted from the Corporate Data Warehouse. Logistic regression was used to assess the odds of mortality at different score levels. Setting/Subjects: Patients undergoing a new implantable cardioverter defibrillator procedure between October 1, 2015 and September 30, 2017 in the U.S. Veterans Administration. Results: Of 3194 patients with a new implantable cardioverter defibrillator placed, 657 (21.8%) had a score ≥95. The mortality rate among these patients was 151/657 (22.9%) compared with 281/3194 (8.8%) for all patients undergoing a new implantable cardioverter defibrillator procedure. Patients with a score ≥95 had 14.0 (95% confidence interval 8.0-24.4) higher odds of death within one year of the procedure compared with those with a score ≤60. Conclusions: The "Care Assessment Needs" Score is a valid predictor of one-year mortality following implantable cardioverter defibrillator procedures. Integrating its use into the management of Veterans Administration (VA) patients considering implantable cardioverter defibrillators may improve shared decision making and engagement with palliative care.
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Affiliation(s)
- Emily Kalver
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychology, Montclair State University, Montclair, New Jersey, USA
| | - Westyn Branch-Elliman
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Infectious Disease, and General Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Melissa Wachterman
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, General Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Marlena H. Shin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Marin L. Schweizer
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Hillary J. Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
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12
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Neville TH, Taich Z, Walling AM, Bear D, Cook DJ, Tseng CH, Wenger NS. The 3 Wishes Program Improves Families' Experience of Emotional and Spiritual Support at the End of Life. J Gen Intern Med 2023; 38:115-121. [PMID: 35581456 PMCID: PMC9113739 DOI: 10.1007/s11606-022-07638-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 04/22/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND The end-of-life (EOL) experience in the intensive care unit (ICU) is emotionally challenging, and there are opportunities for improvement. The 3 Wishes Program (3WP) promotes the dignity of dying patients and their families by eliciting and implementing wishes at the EOL. AIM To assess whether the 3WP is associated with improved ratings of EOL care. PROGRAM DESCRIPTION In the 3WP, clinicians elicit and fulfill simple wishes for dying patients and their families. SETTING 2-hospital academic healthcare system. PARTICIPANTS Dying patients in the ICU and their families. PROGRAM EVALUATION A modified Bereaved Family Survey (BFS), a validated tool for measuring EOL care quality, was completed by families of ICU decedents approximately 3 months after death. We compared patients whose care involved the 3WP to those who did not using three BFS-derived measures: Respectful Care and Communication (5 questions), Emotional and Spiritual Support (3 questions), and the BFS-Performance Measure (BFS-PM, a single-item global measure of care). RESULTS Of 314 completed surveys, 117 were for patients whose care included the 3WP. Bereaved families of 3WP patients rated the Emotional and Spiritual Support factor significantly higher (7.5 vs. 6.0, p = 0.003, adjusted p = 0.001) than those who did not receive the 3WP. The Respectful Care and Communication factor and BFS-PM were no different between groups. DISCUSSION The 3WP is a low-cost intervention that may be a feasible strategy for improving the EOL experience.
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Affiliation(s)
- Thanh H Neville
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
| | - Zachary Taich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.,VA Greater Los Angeles Healthcare System, Veteran Affairs, Los Angeles, USA
| | - Danielle Bear
- UCLA Office of the Patient Experience, UCLA Health, Los Angeles, CA, USA
| | - Deborah J Cook
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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13
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Marra AR, Clore GS, Balkenende E, Goedken CC, Livorsi DJ, Goto M, Vaughan-Sarrazin MS, Broderick A, Perencevich EN. Association of entry into hospice or palliative care consultation during acute care hospitalization with subsequent antibiotic utilization. Clin Microbiol Infect 2023; 29:107.e1-107.e7. [PMID: 35931374 DOI: 10.1016/j.cmi.2022.07.018] [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: 05/09/2022] [Revised: 07/12/2022] [Accepted: 07/16/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We aimed to estimate antibiotic use during the last 6 months of life for hospitalized patients under hospice or palliative care and identify potential targets (i.e. time points) for antibiotic stewardship during the end-of-life period. METHODS We conducted a retrospective cohort study of nationwide Veterans Affairs (VA) patients who died between January 1, 2014 and December 31, 2019 and who had been hospitalized within 6 months prior to death. Data from the VA's integrated electronic medical record were collected, including demographics, comorbid conditions, and duration of inpatient antibiotics administered, along with outpatient antibiotics dispensed. A propensity score-matched cohort analysis was conducted to compare antibiotic use between hospitalized patients placed into palliative care or hospice matched to hospitalized patients not receiving palliative care or hospice. RESULTS There were 9808 and 40 796 propensity score-matched patient pairs in the hospice and palliative care groups, respectively. Within 14 days of placement or consultation, 41% (4040/9808) of hospice patients and 48% (19 735/40 796) of palliative care patients received at least one antibiotic, while 25% (2420/9808) matched nonhospice and 27% (10 991/40 796) matched nonpalliative care patients received antibiotics. Entry into hospice was independently associated with a 12% absolute increase in antibiotic prescribing, and entry into palliative care was associated with a 17% absolute increase during the 14 days post-entry vs. pre-entry period. DISCUSSION We observed that patients receiving end-of-life care had high levels of antibiotic exposure across this VA population, particularly during admissions when they received hospice or palliative care consultation.
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Affiliation(s)
- Alexandre R Marra
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA; Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Gosia S Clore
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Erin Balkenende
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Cassie Cunningham Goedken
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Daniel J Livorsi
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Mary S Vaughan-Sarrazin
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Ann Broderick
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Eli N Perencevich
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
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14
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Gula AL, Ramos J, Simpson JM, Jiang L, Martin E, Wice M, Erqou S, Wu WC, Rudolph JL. Utilization of Palliative Care in Veterans Admitted With Heart Failure Experiencing Homelessness. J Pain Symptom Manage 2022; 64:471-477. [PMID: 35901868 DOI: 10.1016/j.jpainsymman.2022.07.010] [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: 04/22/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 12/24/2022]
Abstract
CONTEXT Patients experiencing housing insecurity have numerous barriers affecting their utilization of medical care. OBJECTIVES Determine if housing insecurity is associated with palliative care (PC) encounters and hospice services in patients with heart failure who receive care in United States Veterans Affairs (VA) medical centers. METHODS This retrospective study included inpatients in VA hospitals with a primary diagnosis of congestive heart failure from 2010 to 2020. Housing stability was collected from coding and separated into three cohorts: at risk for homelessness, experiencing homelessness, and stably housed. The primary outcome was a PC encounter during admission and the stably housed cohort was used as the analytic reference. Inverse-probability-weighting (IPTW) was calculated to adjust the likelihood of receiving PC during the index admission. RESULTS Seventy thousand eight hundred fourty nine veterans were identified. Veterans were identified as at risk for homelessness (n=4039, 5.7%), experiencing homelessness (n=1967, 2.8%) and stably housed (n=64,843, 91.5%). PC was delivered to veterans at risk for homelessness (n=484, 12.0%), veterans experiencing homelessness, (n=161, 8.2%) and patients with stable housing (n=6249, 9.6%). Relative to the stably housed and adjusted for IPTW, those at risk for homelessness received PC services similarly (adjusted OR=1.06, 95% CI 0.94,1.19) and those experiencing homelessness were at lower odds of receiving PC services (adjusted OR=0.62, 95% CI 0.52,0.75). CONCLUSION Housing stability may be a factor in Veterans receiving PC during hospitalization for heart failure. While the logistical challenges of delivering PC and hospice to people experiencing homelessness are daunting, advocating for these services shows commitment to reducing suffering in life-limiting Illness.
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Affiliation(s)
- Annie Laurie Gula
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA
| | - Jacob Ramos
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA
| | - Jane M Simpson
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA
| | - Lan Jiang
- Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - Edward Martin
- Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA
| | - Mitchell Wice
- Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - Sebhat Erqou
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA; Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - Wen-Chih Wu
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA; Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - James L Rudolph
- Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA.
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15
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Kutney-Lee A, Khazanov GK, Carpenter JG, Griffin H, Kinder D, Shreve ST, Smith D, Thorpe JM, Ersek M. Palliative Care and Documented Suicide: Association Among Veterans With High Mortality Risk. J Pain Symptom Manage 2022; 64:e63-e69. [PMID: 35489665 DOI: 10.1016/j.jpainsymman.2022.04.179] [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: 02/04/2022] [Revised: 04/11/2022] [Accepted: 04/17/2022] [Indexed: 11/17/2022]
Abstract
CONTEXT Palliative care consultations (PCCs) are associated with reduced physical and psychological symptoms that are related to suicide risk. Little is known, however, about the association between PCCs and death from suicide among patients at high risk of short-term mortality. OBJECTIVE To examine the association between the number of PCCs and documentation of suicide in a cohort of Veterans at high risk of short-term mortality, before and after accounting for Veterans' sociodemographic characteristics and clinical conditions. METHODS An observational cohort study was conducted using linked Veterans Affairs clinical and administrative databases for 580,620 decedents with high risk of one-year mortality. Logistic regression models were used to examine the association between number of PCCs and documentation of suicide. RESULTS Higher percentages of Veterans who died by suicide were diagnosed with chronic pulmonary disease as well as mental health/substance use conditions compared with Veterans who died from other causes. In adjusted models, one PCC in the 90 days prior to death was significantly associated with a 71% decrease in the odds of suicide (OR = 0.29, 95% CI = 0.23-0.37, P < 0.001) and two or more PCCs were associated with a 78% decrease (OR = 0.22, 95% CI = 0.15-0.33, P < 0.001). Associated "number needed to be exposed" estimates suggest that 421 Veterans in this population would need to receive at least one PCC to prevent one suicide. CONCLUSION While acknowledging the importance of specialized mental health care in reducing suicide among high-risk patients, interventions delivered in the context of PCCs may also play a role.
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Affiliation(s)
- Ann Kutney-Lee
- Veteran Experience Center (A.K.L., J.G.C., H.G., D.K., D.S., J.M.T.,), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; Center for Health Equity Research and Promotion (A.K.L., M.E.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing (A.K.L., M.E.), Philadelphia, Pennsylvania, USA.
| | - Gabriela K Khazanov
- Mental Illness Research, Education, and Clinical Center of the Veterans Integrated Service Network 4 (G.K.K.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Joan G Carpenter
- Veteran Experience Center (A.K.L., J.G.C., H.G., D.K., D.S., J.M.T.,), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Maryland School of Nursing (J.G.C.), Baltimore, Maryland, USA
| | - Hilary Griffin
- Veteran Experience Center (A.K.L., J.G.C., H.G., D.K., D.S., J.M.T.,), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Daniel Kinder
- Veteran Experience Center (A.K.L., J.G.C., H.G., D.K., D.S., J.M.T.,), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Scott T Shreve
- Palliative and Hospice Care Program Office (S.T.S.), US Department of Veterans Affairs, Washington, District of Columbia, USA; Penn State College of Medicine (S.T.S.), Hershey, Pennsylvania, USA
| | - Dawn Smith
- Veteran Experience Center (A.K.L., J.G.C., H.G., D.K., D.S., J.M.T.,), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua M Thorpe
- Veteran Experience Center (A.K.L., J.G.C., H.G., D.K., D.S., J.M.T.,), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; Center for Health Equity Research and Promotion (J.M.T.), Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania, USA; University of North Carolina School of Pharmacy (J.M.T.), Chapel Hill, North Carolina, USA
| | - Mary Ersek
- Center for Health Equity Research and Promotion (A.K.L., M.E.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing (A.K.L., M.E.), Philadelphia, Pennsylvania, USA
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16
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Framework for Integrating Equity Into Machine Learning Models. Chest 2022; 161:1621-1627. [DOI: 10.1016/j.chest.2022.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 11/23/2022] Open
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17
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Sullivan DR, Teno JM, Reinke LF. Evolution of Palliative Care in the Department of Veterans Affairs: Lessons from an Integrated Health Care Model. J Palliat Med 2021; 25:15-20. [PMID: 34665652 DOI: 10.1089/jpm.2021.0246] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Palliative care (PC) is beneficial, however, in many settings it is under-resourced and unable to consistently meet the needs of patients and their families. A lack of national health policy support for PC contributes to underutilization and the low value care experienced by many patients with serious illness at the end of life. Through a series of transformative health care structure and process improvements including developing robust initiatives and promoting institutional culture change, the Department of Veterans Affairs (VA) has significantly improved the quality of PC among veterans. VA's strategic simultaneous top-down and bottom-up approach to develop programs, policies, and initiatives provides important perspectives and deserves attention toward advancing PC in the broader U.S. health care system. Although opportunities for improvement exist, the comprehensive framework within VA should help inform the future of program development and serve as a model for integrated and accountable care organizations to emulate.
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Affiliation(s)
- Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA.,Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon, USA
| | - Joan M Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, OHSU, Portland, Oregon, USA
| | - Lynn F Reinke
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington, USA.,Department of Biobehavioral Nursing and Health Systems, University of Washington, School of Medicine, Seattle, Washington, USA
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18
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Carpenter JG, Hanson LC, Hodgson N, Murray A, Hippe DS, Polissar NL, Ersek M. Implementing Primary Palliative Care in Post-acute nursing home care: Protocol for an embedded pilot pragmatic trial. Contemp Clin Trials Commun 2021; 23:100822. [PMID: 34381919 PMCID: PMC8340123 DOI: 10.1016/j.conctc.2021.100822] [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: 02/19/2021] [Revised: 07/10/2021] [Accepted: 07/24/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Older adults with serious illness frequently receive post-acute rehabilitative care in nursing homes (NH) under the Part A Medicare Skilled Nursing Facility (SNF) Benefit. Treatment is commonly focused on disease-modifying therapies with minimal consideration for goals of care, symptom relief, and other elements of palliative care. INTERVENTION The evidence-based Primary Palliative Care in Post-Acute Care (PPC-PAC) intervention for older adults is delivered by nurse practitioners (NP). PPC-PAC NPs assess and manage symptoms, conduct goals of care discussions and assist with decision making; they communicate findings with NH staff and providers. Implementation of PPC-PAC includes online and face-to-face training of NPs, ongoing facilitation, and a template embedded in the NH electronic health record to document PPC-PAC. OBJECTIVES The objectives of this pilot pragmatic clinical trial are to assess the feasibility, acceptability, and preliminary effectiveness of the PPC-PAC intervention and its implementation for 80 seriously ill older adults newly admitted to a NH for post-acute care. METHODS Design is a two-arm nonequivalent group multi-site pilot pragmatic clinical trial. The unit of assignment is at the NP and unit of analysis is NH patients. Recruitment occurs at NHs in Pennsylvania, New Jersey, Delaware, and Maryland. Effectiveness (patient quality of life) data are collected at two times points-baseline and 14-21 days. CONCLUSION This will be the first study to evaluate the implementation of an evidence-based primary palliative care intervention specifically designed for older adults with serious illness who are receiving post-acute NH care.
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Affiliation(s)
- Joan G. Carpenter
- University of Maryland School of Nursing, Baltimore, MD, USA
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Laura C. Hanson
- Division of Geriatric Medicine & Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nancy Hodgson
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Andrew Murray
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Daniel S. Hippe
- The Mountain Whisper Light Statistics $ Data Science, Seattle, WA, USA
| | - Nayak L. Polissar
- The Mountain Whisper Light Statistics $ Data Science, Seattle, WA, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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19
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Ersek M, Smith D, Griffin H, Carpenter JG, Feder SL, Shreve ST, Nelson FX, Kinder D, Thorpe JM, Kutney-Lee A. End-Of-Life Care in the Time of COVID-19: Communication Matters More Than Ever. J Pain Symptom Manage 2021; 62:213-222.e2. [PMID: 33412269 PMCID: PMC7784540 DOI: 10.1016/j.jpainsymman.2020.12.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/23/2020] [Accepted: 12/26/2020] [Indexed: 11/28/2022]
Abstract
CONTEXT The COVID-19 pandemic resulted in visitation restrictions across most health care settings, necessitating the use of remote communication to facilitate communication among families, patients and health care teams. OBJECTIVE To examine the impact of remote communication on families' evaluation of end-of-life care during the COVID-19 pandemic. METHODS Retrospective, cross-sectional, mixed methods study using data from an after-death survey administered from March 17-June 30, 2020. The primary outcome was the next of kin's global assessment of care during the Veteran's last month of life. RESULTS Data were obtained from the next-of-kin of 328 Veterans who died in an inpatient unit (i.e., acute care, intensive care, nursing home, hospice units) in one of 37 VA medical centers with the highest numbers of COVID-19 cases. The adjusted percentage of bereaved families reporting excellent overall end-of-life care was statistically significantly higher among those reporting Very Effective remote communication compared to those reporting that remote communication was Mostly, Somewhat, or Not at All Effective (69.5% vs. 35.7%). Similar differences were observed in evaluations of remote communication effectiveness with the health care team. Overall, 81.3% of family members who offered positive comments about communication with either the Veteran or the health care team reported excellent overall end-of-life care vs. 28.4% who made negative comments. CONCLUSIONS Effective remote communication with the patient and the health care team was associated with significantly better ratings of the overall experience of end-of-life care by bereaved family members. Our findings offer timely insights into the importance of remote communication strategies.
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Affiliation(s)
- Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Dawn Smith
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Hilary Griffin
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Joan G Carpenter
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Shelli L Feder
- Yale University School of Nursing, New Haven, Connecticut, USA; VA Connecticut Health Care System, West Haven, Connecticut, USA
| | - Scott T Shreve
- Palliative and Hospice Care Program, US Department of Veterans Affairs, Washington, District of Columbia, USA; Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Francis X Nelson
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Daniel Kinder
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania, USA; University of North Carolina School of Pharmacy, Chapel Hill, NC, USA
| | - Ann Kutney-Lee
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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20
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Comparison of Two Methods for Implementing Comfort Care Order Sets in the Inpatient Setting: a Cluster Randomized Trial. J Gen Intern Med 2021; 36:1928-1936. [PMID: 33547573 PMCID: PMC8298677 DOI: 10.1007/s11606-020-06482-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND There is an ongoing need for interventions to improve quality of end-of-life care for patients in inpatient settings. OBJECTIVE To compare two methods for implementing a Comfort Care Education Intervention for Palliative Care Consultation Teams (PCCT) in Veterans Affairs Medical Centers (VAMCs). DESIGN Cluster randomized implementation trial conducted March 2015-April 2019. PCCTs were assigned to a traditional implementation approach using a teleconference or to an in-person, train-the-champion workshop to prepare PCCTs to be clinical champions at their home sites. PARTICIPANTS One hundred thirty-two providers from PCCTs at 47 VAMCs. INTERVENTIONS Both training modalities involved review of educational materials, instruction on using an electronic Comfort Care Order Set, and coaching to deliver the intervention to other providers. MAIN MEASUREMENTS Several processes of care were identified a priori as quality endpoints for end-of-life care (last 7 days) and abstracted from medical records of veterans who died within 9 months before or after implementation (n = 6,491). The primary endpoint was the presence of an active order for opioid medication at time of death. Secondary endpoints were orders/administration of antipsychotics, benzodiazepines, and scopolamine, do-not-resuscitate orders, advance directives, locations of death, palliative care consultations, nasogastric tubes, intravenous lines, physical restraints, pastoral care visits, and family presence at/near time of death. Generalized estimating equations were conducted adjusting for potential covariates. KEY RESULTS Eighty-eight providers from 23 VAMCs received teleconference training; 44 providers from 23 VAMCs received in-person workshop training. Analyses found no significant differences between intervention groups in any process-of-care endpoints (primary endpoint AOR (CI) = 1.18 (0.74, 1.89). Furthermore, pre-post changes were not significant for any endpoints (primary endpoint AOR (CI) = 1.16 (0.92, 1.46). Analyses may have been limited by high baseline values on key endpoints with little room for improvement. CONCLUSION Findings suggest the clinical effectiveness of palliative care educational intervention was not dependent on which of the two implementation methods was used. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02383173.
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21
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Crooms RC, Lin HM, Neifert S, Deiner SG, Brallier JW, Goldstein NE, Gal JS, Gelfman LP. Palliative Care Consultation for Hospitalized Patients with Primary and Secondary Brain Tumors at a Single Academic Center. J Palliat Med 2021; 24:1550-1554. [PMID: 34166114 DOI: 10.1089/jpm.2021.0088] [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: 11/13/2022] Open
Abstract
Introduction: Studies addressing palliative care delivery in neuro-oncology are limited. Objectives: To compare inpatients with brain tumors who received palliative care (through referral or trigger) with those receiving usual care. Design: Retrospective cohort study. Setting/Subjects: Inpatients with primary or secondary brain tumors who did or did not receive palliative care at a U.S. medical center. Measurements: Sociodemographic, clinical, and utilization characteristics were compared. Results: Of 1669 brain tumor patients, 386 (23.1%) received palliative care [nontrigger: 246 (14.7%); trigger: 140 (8.4%)] and 1283 (76.9%) received usual care. Nontrigger patients were oldest (mean age 65.0 years; trigger: 61.1 years; usual care: 55.5 years; p < 0.001); sickest at baseline (mean Elixhauser comorbidity index 3.76; trigger: 3.49; usual care: 1.84; p < 0.001); and had highest in-hospital death [34 (13.8%), trigger: 10 (7.1%), usual care: 7 (0.5%); p < 0.001] and hospice discharge [54 (22.0%), trigger: 18 (12.9%), usual care: 14 (1.1%); p < 0.001]. Conclusions: Trigger criteria may promote earlier palliative care referral, yet criteria tailored for neuro-oncology are undeveloped.
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Affiliation(s)
- Rita C Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hung-Mo Lin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean Neifert
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stacie G Deiner
- Dartmouth Hitchcock and Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Jess W Brallier
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Jonathan S Gal
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
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22
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Feder SL, Tate J, Ersek M, Krishnan S, Chaudhry SI, Bastian LA, Rolnick J, Kutney-Lee A, Akgün KM. The Association Between Hospital End-of-Life Care Quality and the Care Received Among Patients With Heart Failure. J Pain Symptom Manage 2021; 61:713-722.e1. [PMID: 32931904 PMCID: PMC7952458 DOI: 10.1016/j.jpainsymman.2020.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 11/30/2022]
Abstract
CONTEXT Improving end-of-life care (EOLC) quality among heart failure patients is imperative. Data are limited as to the hospital processes of care that facilitate this goal. OBJECTIVES To determine associations between hospital-level EOLC quality ratings and the EOLC delivered to heart failure patients. METHODS Retrospective analysis of the Veterans Health Administration (VA) and the Bereaved Family Survey data of heart failure patients from 2013 to 2015 who died in 107 VA hospitals. We calculated hospital-level observed-to-expected casemix-adjusted ratios of family reported excellent EOLC, dividing hospitals into quintiles. Using logistic regression, we examined associations between quintiles and palliative care consultation, receipt of chaplain and bereavement services, inpatient hospice, and intensive care unit death. RESULTS Of 6256 patients, mean age was 77.4 (SD = 11.1), 98.3% were male, 75.7% were white, and 18.2% were black. Median hospital scores of "excellent" EOLC ranged from 41.3% (interquartile range 37.0%-44.8%) in the lowest quintile to 76.4% (interquartile range 72.9%-80.3%) in the highest quintile. Patients who died in hospitals in the highest quintile, relative to the lowest, were slightly although not significantly more likely to receive a palliative care consultation (adjusted proportions 57.6% vs. 51.2%; P = 0.32) but were more likely to receive chaplaincy (92.6% vs. 81.2%), bereavement (86.0% vs. 72.2%), and hospice (59.7% vs. 35.9%) and were less likely to die in the intensive care unit (15.9% vs. 31.0%; P < 0.05 for all). CONCLUSION Patients with heart failure who die in VA hospitals with higher overall EOLC quality receive more supportive EOLC. Research is needed that integrates care processes and develops scalable best practices in EOLC across health care systems.
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Affiliation(s)
- Shelli L Feder
- Yale University School of Nursing, West Haven, Connecticut, USA; VA Connecticut Healthcare System, West Haven, Connecticut, USA.
| | - Janet Tate
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Mary Ersek
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Lori A Bastian
- VA Connecticut Healthcare System, West Haven, Connecticut, USA; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Joshua Rolnick
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Ann Kutney-Lee
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Kathleen M Akgün
- VA Connecticut Healthcare System, West Haven, Connecticut, USA; Yale University School of Medicine, New Haven, Connecticut, USA
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23
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Varilek BM, Isaacson MJ. Female Veteran Use of Palliative and Hospice Care: A Scoping Review. Mil Med 2021; 186:1100-1105. [PMID: 33512462 DOI: 10.1093/milmed/usab005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/11/2020] [Accepted: 01/05/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The number of female veterans in the USA in the age range of 55-64 years increased 7-fold from 2000 to 2015. Female veterans are more likely to suffer from certain mental health disorders, respiratory diseases, neurologic diseases, and some forms of cancer when compared to their male counterparts. Veterans Affairs (VA) healthcare providers need to be prepared to care for this growth of female veterans with serious illness. These serious illnesses require appropriate medical management, which often includes palliative care. It is imperative to determine how VA healthcare providers integrate palliative and hospice care for this population. The purpose of our scoping review was to explore the palliative and hospice care literature specific to female veterans to learn: (1) what evidence is available regarding female veterans' use of palliative and hospice care? (2) To meet the needs of this growing population, what gaps exist specific to female veterans' use of palliative and hospice care? METHODS A scoping review methodology was employed following the nine-step process described by the Joanna Briggs Institute for conducting scoping reviews. RESULTS Nineteen articles met the inclusion criteria. Fourteen quantitative articles were included which comprised 10 retrospective chart reviews, one randomized controlled trial, one correlation, one quality improvement, and one cross-sectional. The remaining five were qualitative studies. The sample populations within the articles were overwhelmingly male and white. Content analysis of the articles revealed three themes: quality of end of life care, distress, and palliative care consult. CONCLUSIONS The female veteran population is increasing and becoming more ethnically diverse. Female veterans are not well represented in the literature. Our review also uncovered a significant gap in the study methodologies. We found that retrospective chart reviews dominated the palliative and hospice care literature specific to veterans. More prospective study designs are needed that explore the veteran and family experience while receiving end of life care. With the rising number of older female veterans and their risk for serious illness, it is imperative that research studies purposefully recruit, retain, analyze, and report female veteran statistics along with their male counterparts. We can no longer afford to disregard the value of the female veterans' perspective.
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Affiliation(s)
- Brandon M Varilek
- College of Nursing, Graduate Nursing, South Dakota State University, Sioux Falls, SD 57107, USA
| | - Mary J Isaacson
- College of Nursing, Graduate Nursing, South Dakota State University, Rapid City, SD 57701, USA
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24
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Yefimova M, Aslakson RA, Yang L, Garcia A, Boothroyd D, Gale RC, Giannitrapani K, Morris AM, Johanning JM, Shreve S, Wachterman MW, Lorenz KA. Palliative Care and End-of-Life Outcomes Following High-risk Surgery. JAMA Surg 2020; 155:138-146. [PMID: 31895424 DOI: 10.1001/jamasurg.2019.5083] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance Palliative care has the potential to improve care for patients and families undergoing high-risk surgery. Objective To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation. Design, Setting, and Participants This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included. Exposures Palliative-care consultation within 30 days before or 90 days after surgery. Main Outcomes and Measures The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes. Results A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery. Conclusions and Relevance Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.
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Affiliation(s)
- Maria Yefimova
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.,Office of Research, Patient Care Services, Stanford Healthcare, Stanford, California
| | - Rebecca A Aslakson
- Section of Palliative Care, Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California.,Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University, Stanford, California
| | - Lingyao Yang
- Quantitative Sciences Unit, Stanford University, Stanford, California
| | - Ariadna Garcia
- Quantitative Sciences Unit, Stanford University, Stanford, California
| | - Derek Boothroyd
- Quantitative Sciences Unit, Stanford University, Stanford, California
| | - Randall C Gale
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Karleen Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Arden M Morris
- Stanford-Surgery Policy, Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Jason M Johanning
- Department of Surgery, Quality and Compliance, University of Nebraska Medical Center, Omaha.,Veterans Integrated Service Network 23, Nebraska-Western Iowa VA Medical Center, Omaha
| | - Scott Shreve
- Hospice and Palliative Care Program, Hospice and Palliative Care Unit Department of Veteran Affairs, Lebanon VA Medical Center, Lebanon, Pennsylvania
| | - Melissa W Wachterman
- Section of General Internal Medicine, VA Boston Health Care System, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.,Section of Palliative Care, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
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25
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McMahan RD, Tellez I, Sudore RL. Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review. J Am Geriatr Soc 2020; 69:234-244. [PMID: 32894787 DOI: 10.1111/jgs.16801] [Citation(s) in RCA: 215] [Impact Index Per Article: 53.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND/OBJECTIVES Advance care planning (ACP) has shown benefit in some, but not all, studies. It is important to understand the utility of ACP. We conducted a scoping review to identify promising interventions and outcomes. DESIGN Scoping review. MEASUREMENTS We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for ACP randomized controlled trials from January 1, 2010, to March 3, 2020. We used standardized Preferred Reporting Items for Systematic Review and Meta-Analyses methods to chart study characteristics, including a standardized ACP Outcome Framework: Process (e.g., readiness), Action (e.g., communication), Quality of Care (e.g., satisfaction), Health Status (e.g., anxiety), and Healthcare Utilization. Differences between arms of P < .05 were deemed positive. RESULTS Of 1,464 articles, 69 met eligibility; 94% were rated high quality. There were variable definitions, age criteria (≥18 to ≥80 years), diseases (e.g., dementia and cancer), and settings (e.g., outpatient and inpatient). Interventions included facilitated discussions (42%), video only (20%), interactive, multimedia (17%), written only (12%), and clinician training (9%). For written only, 75% of primary outcomes were positive, as were 69% for multimedia programs; 67% for facilitated discussions, 59% for video only, and 57% for clinician training. Overall, 72% of Process and 86% of Action outcomes were positive. For Quality of Care, 88% of outcomes were positive for patient-surrogate/clinician congruence, 100% for patients/surrogate/clinician satisfaction with communication, and 75% for surrogate satisfaction with patients' care, but not for goal concordance. For Health Status outcomes, 100% were positive for reducing surrogate/clinician distress, but not for patient quality of life. Healthcare Utilization data were mixed. CONCLUSION ACP is complex, and trial characteristics were heterogeneous. Outcomes for all ACP interventions were predominantly positive, as were Process and Action outcomes. Although some Quality of Care and Health Status outcomes were mixed, increased patient/surrogate satisfaction with communication and care and decreased surrogate/clinician distress were positive. Further research is needed to appropriately tailor interventions and outcomes for local contexts, set appropriate expectations of ACP outcomes, and standardize across studies.
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Affiliation(s)
- Ryan D McMahan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Ismael Tellez
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
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26
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Kubi B, Enumah ZO, Lee KT, Freund KM, Smith TJ, Cooper LA, Owczarzak JT, Johnston FM. Theory-Based Development of an Implementation Intervention Using Community Health Workers to Increase Palliative Care Use. J Pain Symptom Manage 2020; 60:10-19. [PMID: 32092401 PMCID: PMC8787809 DOI: 10.1016/j.jpainsymman.2020.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 12/29/2022]
Abstract
CONTEXT Opportunities for the use of palliative care services are missed in African American (AA) communities, despite Level I evidence demonstrating their benefits. OBJECTIVES Single-institution and stakeholder-engaged study to design an intervention to increase palliative care use in AA communities. METHODS Two-phased qualitative research design guided by the Behavior Change Wheel and Theoretical Domains Framework models. In Phase 1, focus group sessions were conducted to identify barriers and facilitators of palliative care use and the viability of community health workers (CHWs) as a solution. After applying the Behavior Change Wheel and Theoretical Domains Framework to data gathered from Phase 1, Phase 2 consisted of a stakeholder meeting to select intervention content and prioritize modes of delivery. RESULTS A total of 15 stakeholders participated in our study. Target behaviors identified were for patients to gain knowledge about benefits of palliative care, physicians to begin palliative care discussions earlier in treatment, and to improve patient-physician interpersonal communication. The intervention was designed to improve patient capability, physician capability, patient motivation, physician motivation, and increase patient opportunities to use palliative care services. Strategies to change patient and physician behaviors were all facilitated by CHWs and included creation and dissemination of brochures about palliative care to patients, empowerment and activation of patients to initiate goals-of-care discussions, outreach to community churches, and expanding patient social support. CONCLUSION Use of a theory-based approach to facilitate the implementation of a multi-component strategy provided a comprehensive means of identifying relevant barriers and enablers of CHWs as an agent to increase palliative care use in AA communities.
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Affiliation(s)
- Boateng Kubi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zachary O Enumah
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kimberley T Lee
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen M Freund
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Thomas J Smith
- Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jill T Owczarzak
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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27
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Pawlow PC, Doherty CL, Blumenthal NP, Matura LA, Christie JD, Ersek M. An Integrative Review of the Role of Palliative Care in Lung Transplantation. Prog Transplant 2020; 30:147-154. [DOI: 10.1177/1526924820913512] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Lung transplant patients experience significant physical symptoms and psychological stress that affect their quality of life. Palliative care is an interdisciplinary specialty associated with improved symptom management and enhanced quality of life. Little, however, is known about the palliative care needs of lung transplant patients and the role it plays in their care. Aim: The aim of this integrative review was to synthesize the literature describing the palliative care needs, the current role, and factors influencing the integration of palliative care in the care of lung transplant patients. Design/Data Sources: We searched PubMed, Scopus, CINAHL, and Embase to identify English-language, primary studies focused on palliative care in adult lung transplantation. Study quality was evaluated using Strengthening the Report of Observational studies in Epidemiology and Consolidated Criteria for Reporting Qualitative Research criteria. Results: Seven articles were included in the review. Most were single-center, descriptive studies. Two studies used qualitative and 5 used quantitative methodologies. Collectively, these studies suggest that palliative care is typically consulted for physical and psychological symptom management, although consultation is uncommon and often occurs late in the lung transplant process. We found no studies that systematically assessed palliative needs. Misperceptions about palliative care, communication challenges, and unrealistic patient/family expectations are identified barriers to the integration. While limited, evidence suggests that palliative care can be successfully integrated into lung transplant patient management. Conclusions: Empirical literature about palliative care in lung transplantation is sparse. Further research is needed to define the needs and opportunities for integration into the care of these patients.
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Affiliation(s)
| | | | | | - Lea Ann Matura
- University of Pennsylvania School of Nursing Philadelphia, PA, USA
| | - Jason D. Christie
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Ersek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, PA, USA
- School of Nursing, Perelman School of Medicine, University of Pennsylvania, PA, USA
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28
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Milazzo S, Hansen E, Carozza D, Case AA. How Effective Is Palliative Care in Improving Patient Outcomes? Curr Treat Options Oncol 2020; 21:12. [PMID: 32025964 DOI: 10.1007/s11864-020-0702-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OPINION STATEMENT As palliative care (PC) continues its rapid growth, an emerging body of evidence is demonstrating that its approach of interdisciplinary supportive care benefits many patient populations, including in the oncology setting. As studies and data proliferate, however, questions persist about who, what, why, when, and how PC as well as the ideal time for a PC consult and length of involvement. When comparing outcomes from chemotherapy trials, it is important to consider the dosing regimens used in the various studies. In the same way, it is important to account for the "dose" of the PC interventions utilized across studies, and apples to apples comparisons are needed in order to draw accurate conclusions about PC's benefits. Studies which include a true interdisciplinary PC intervention consistently show improvements in patient quality of life, as well as cost savings, with further study needed for other outcomes. These benefits cannot be extrapolated to care which may be labeled "palliative care," but which does not meet the standard of true interdisciplinary PC. The ultimate question is: Does PC indeed improve outcomes?
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Affiliation(s)
- Sarah Milazzo
- Department of Pediatrics State University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Eric Hansen
- Department of Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Medicine, Division of Geriatrics and Palliative Medicine, State University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Desi Carozza
- Department of Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Medicine, Division of Geriatrics and Palliative Medicine, State University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Amy A Case
- Department of Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA. .,Department of Medicine, Division of Geriatrics and Palliative Medicine, State University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.
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29
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Perry LM, Hoerger M, Malhotra S, Gerhart JI, Mohile S, Duberstein PR. Development and Validation of the Palliative Care Attitudes Scale (PCAS-9): A Measure of Patient Attitudes Toward Palliative Care. J Pain Symptom Manage 2020; 59:293-301.e8. [PMID: 31539604 DOI: 10.1016/j.jpainsymman.2019.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 11/28/2022]
Abstract
CONTEXT Palliative Care is underutilized, and research has neglected patient-level factors including attitudes that could contribute to avoidance or acceptance of Palliative Care referrals. This may be due in part to a lack of existing measures for this purpose. OBJECTIVES The objective of this study was to develop and validate a nine-item scale measuring patient attitudes toward Palliative Care, comprised of three subscales spanning emotional, cognitive, and behavioral factors. METHODS Data were collected online in three separate waves, targeting individuals with cancer (Sample 1: N = 633; Sample 2: N = 462) or noncancer serious illnesses (Sample 3: N = 225). Participants were recruited using ResearchMatch.org and postings on the web sites, social media pages, and listservs of international health organizations. RESULTS Internal consistency was acceptable for the total scale (α = 0.84) and subscales: emotional (α = 0.84), cognitive (αs = 0.70), and behavioral (α = 0.90). The PCAS-9 was significantly associated with a separate measure of Palliative Care attitudes (ps < 0.001) and a measure of Palliative Care knowledge (ps < 0.004), supporting its construct validity in samples of cancer and noncancer serious illnesses. The scale's psychometric properties, including internal consistency and factor structure, generalized across patient subgroups based on diagnosis, other health characteristics, and demographics. CONCLUSION Findings support the overall reliability, validity, and generalizability of the PCAS-9 in serious illness samples and have implications for increasing Palliative Care utilization via clinical care and future research efforts.
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Affiliation(s)
- Laura M Perry
- Department of Psychology, Tulane University, New Orleans, Louisiana, USA.
| | - Michael Hoerger
- Department of Psychology, Tulane University, New Orleans, Louisiana, USA; Department of Medicine, Section of Hematology and Medical Oncology, Tulane University, New Orleans, Louisiana, USA
| | - Sonia Malhotra
- Department of General Internal Medicine & Geriatrics, Section of Palliative Medicine, Tulane University, New Orleans, Louisiana, USA
| | - James I Gerhart
- Department of Psychology, Central Michigan University, Mount Pleasant, Michigan, USA
| | - Supriya Mohile
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Paul R Duberstein
- Department of Health Behavior, Society and Policy, Rutgers University School of Public Health, Piscataway, New Jersey, USA
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30
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Carpenter JG, Ersek M, Nelson F, Kinder D, Wachterman M, Smith D, Murray A, Garrido MM. A National Study of End-of-Life Care among Older Veterans with Hearing and Vision Loss. J Am Geriatr Soc 2019; 68:817-825. [PMID: 31886557 DOI: 10.1111/jgs.16298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Hearing and visual sensory loss is prevalent among older adults and may impact the quality of healthcare they receive. Few studies have examined sensory loss and end-of-life (EOL) care quality. Our aim was to describe hearing and vision loss and their associations with the quality of EOL care and family perception of care in the last 30 days of life among a national sample of veteran decedents. DESIGN Retrospective medical record review and Bereaved Family Survey (BFS). SETTING Veterans Affairs (VA) Medical Centers (N = 145). PARTICIPANTS Medical record review of all veterans who died in an inpatient VA Medical Center between October 2012 and September 2017 (N = 96 424). Survey results included 42 428 individuals. MEASUREMENTS Three indicators of high-quality EOL care were measured: palliative consultation in the last 90 days of life, death in a non-acute setting, and contact with a chaplain. The BFS reflects a global evaluation of quality of EOL care; pain and posttraumatic stress disorder management; and three subscales characterizing perceptions regarding communication, emotional and spiritual support, and information about death benefits in the last month of life. RESULTS In adjusted models, EOL care quality indicators and BFS outcomes for veterans with hearing loss were similar to those for veterans without hearing loss; however, we noted slightly lower scores for pain management and less satisfaction with communication. Veterans with vision loss were less likely to have received a palliative care consult or contact with a chaplain than those without vision loss. Although BFS respondents for veterans with vision loss were less likely than respondents for veterans without vision loss to report excellent overall care and satisfaction with emotional support, other outcomes did not differ. CONCLUSION In general, the VA is meeting the EOL care needs of veterans with hearing and vision loss through palliative care practices. J Am Geriatr Soc 68:817-825, 2020.
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Affiliation(s)
- Joan G Carpenter
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.,University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.,University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis Nelson
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Daniel Kinder
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Melissa Wachterman
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Dawn Smith
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Andrew Murray
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Melissa M Garrido
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Boston University School of Public Health, Boston, Massachusetts
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31
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Ufere NN, O'Riordan DL, Bischoff KE, Marks AK, Eneanya N, Chung RT, Jackson V, Pantilat SZ, El-Jawahri A. Outcomes of Palliative Care Consultations for Hospitalized Patients With Liver Disease. J Pain Symptom Manage 2019; 58:766-773. [PMID: 31326503 PMCID: PMC6823143 DOI: 10.1016/j.jpainsymman.2019.07.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/10/2019] [Accepted: 07/12/2019] [Indexed: 12/17/2022]
Abstract
CONTEXT Although palliative care (PC) has been shown to improve symptoms and end-of-life (EOL) care for patients with cancer, data are lacking on the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease. OBJECTIVES We sought to characterize the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease compared with patients with cancer. METHODS We conducted an observational study using data from the Palliative Care Quality Network (PCQN). The PCQN contains prospectively collected data on 135,197 hospitalized patients receiving PC consultations at 88 PCQN sites between January 2013 and December 2017. The PCQN data set includes patient demographics, processes of care, and patient-level clinical outcomes. RESULTS The cohort included 44,933 patients, of whom 4402 (9.8%) had liver disease and 40,531 (90.2%) had cancer. Patients with liver disease were younger (58.9 years vs. 65.2 years, P < 0.0001) and had higher in-hospital mortality (28% vs. 16.8%, P < 0.0001). Patients with liver disease were more likely to receive PC consultations to address goals of care (81.7% vs. 67.9%, P < 0.0001) as opposed to pain management (10.9% vs. 34.9%, P < 0.0001). Both groups had similar rates of symptom improvement and change in resuscitation preferences after PC consultation. CONCLUSION Hospitalized patients with liver disease were more likely to have a PC referral to address goals of care compared with those with cancer and were more likely to die in the hospital. Despite late PC consultations, patients with liver disease experienced improvement in symptoms and clarification of their goals of care, similar to those with cancer.
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Affiliation(s)
- Nneka N Ufere
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - David L O'Riordan
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Kara E Bischoff
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Angela K Marks
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Nwamaka Eneanya
- Palliative and Advanced Illness Research Center, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raymond T Chung
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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32
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Richards CA, Liu CF, Hebert PL, Ersek M, Wachterman MW, Reinke LF, Taylor LL, O’Hare AM. Family Perceptions of Quality of End-of-Life Care for Veterans with Advanced CKD. Clin J Am Soc Nephrol 2019; 14:1324-1335. [PMID: 31466952 PMCID: PMC6730503 DOI: 10.2215/cjn.01560219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/24/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Little is known about the quality of end-of-life care for patients with advanced CKD. We describe the relationship between patterns of end-of-life care and dialysis treatment with family-reported quality of end-of-life care in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We designed a retrospective observational study among a national cohort of 9993 veterans with advanced CKD who died in Department of Veterans Affairs facilities between 2009 and 2015. We used logistic regression to evaluate associations between patterns of end-of-life care and receipt of dialysis (no dialysis, acute dialysis, maintenance dialysis) with family-reported quality of end-of-life care. RESULTS Overall, 52% of cohort members spent ≥2 weeks in the hospital in the last 90 days of life, 34% received an intensive procedure, and 47% were admitted to the intensive care unit, in the last 30 days, 31% died in the intensive care unit, 38% received a palliative care consultation in the last 90 days, and 36% were receiving hospice services at the time of death. Most (55%) did not receive dialysis, 12% received acute dialysis, and 34% received maintenance dialysis. Patients treated with acute or maintenance dialysis had more intensive patterns of end-of-life care than those not treated with dialysis. After adjustment for patient and facility characteristics, receipt of maintenance (but not acute) dialysis and more intensive patterns of end-of-life care were associated with lower overall family ratings of end-of-life care, whereas receipt of palliative care and hospice services were associated with higher overall ratings. The association between maintenance dialysis and overall quality of care was attenuated after additional adjustment for end-of-life treatment patterns. CONCLUSIONS Among patients with advanced CKD, care focused on life extension rather than comfort was associated with lower family ratings of end-of-life care regardless of whether patients had received dialysis.
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Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Chuan-Fen Liu
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Paul L. Hebert
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Mary Ersek
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa W. Wachterman
- Section of General Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lynn F. Reinke
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, and
| | - Leslie L. Taylor
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Ann M. O’Hare
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- School of Medicine, University of Washington, Seattle, Washington
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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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34
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Schlick CJR, Bentrem DJ. Timing of palliative care: When to call for a palliative care consult. J Surg Oncol 2019; 120:30-34. [DOI: 10.1002/jso.25499] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Cary Jo R. Schlick
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of MedicineNorthwestern UniversityEvanston Illinois
| | - David J. Bentrem
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of MedicineNorthwestern UniversityEvanston Illinois
- Surgery ServiceJesse Brown VA Medical CenterChicago Illinois
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35
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Chang S, Sigel K, Goldstein NE, Wisnivesky J, Dharmarajan KV. Trends of Earlier Palliative Care Consultation in Advanced Cancer Patients Receiving Palliative Radiation Therapy. J Pain Symptom Manage 2018; 56:379-384. [PMID: 29885456 DOI: 10.1016/j.jpainsymman.2018.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/25/2018] [Accepted: 05/30/2018] [Indexed: 12/19/2022]
Abstract
CONTEXT The American Society of Clinical Oncology recommends that all patients with metastatic disease receive dedicated palliative care (PC) services early in their illness, ideally via interdisciplinary care teams. OBJECTIVES We investigated the time trends of specialty palliative care consultations from the date of metastatic cancer diagnosis among patients receiving palliative radiation therapy (PRT). A shorter time interval between metastatic diagnosis and first PC consultation suggests earlier involvement of palliative care in a patient's life with metastatic cancer. METHODS In this IRB-approved retrospective analysis, patients treated with PRT for solid tumors (bone and brain) at a single tertiary care hospital between 2010 and 2016 were included. Cohorts were arbitrarily established by metastatic diagnosis within approximately two-year intervals: 1) 1/1/2010-3/27/2012, 2) 3/28/2012-5/21/2014, and 3) 5/22/2014-12/31/2016. Cox proportional hazards regression modeling was used to compare trends of PC consultation among cohorts. RESULTS Of 284 patients identified, 184 patients received PC consultation, whereas 15 patients died before receiving a PC consult. Median follow-up time until an event or censor was 257 days (range: 1900). Patients in the most recent cohort had a shorter median time to first PC consult (57 days) compared to those in the first (374 days) and second (186 days) cohorts. On multivariable analysis, patients in the third cohort were more likely to undergo a PC consultation earlier in their metastatic illness (hazard ratio: 1.8, 95% CI: 1.2-2.8). CONCLUSION Over a six-year period, palliative care consultation occurred earlier for metastatic patients treated with PRT at our institution.
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Affiliation(s)
- Sanders Chang
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Keith Sigel
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Department of Internal Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Nathan E Goldstein
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Juan Wisnivesky
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Department of Internal Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Kavita V Dharmarajan
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA; Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital, New York, New York, USA; Department of Radiation Oncology, Mount Sinai Hospital, New York, New York, USA.
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