1
|
Chen CC, Lien HY, Tsai CY, Woung LC, Ko MC. Differences in End-of-Life Care Between Patients Who Died of Cancer Diseases and Those Who Died of Noncancer Diseases. J Palliat Med 2024; 27:1191-1199. [PMID: 39023051 DOI: 10.1089/jpm.2023.0446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024] Open
Abstract
Background and Purpose: Patients with advanced noncancer diseases or advanced cancer diseases may experience similar symptom burdens during the end of their lives. This study aimed to evaluate the differences in receiving hospice care service and in receiving aggressive end-of-life care between patients who died of cancer diseases and those who died of noncancer diseases. Methods: This cross-sectional population-based study used data from the Taiwan National Health Insurance Research Database. Subjects who died of cancers or noncancer diseases from 2010 through 2019 were analyzed to identify the information on patient's characteristics, receipt of hospice care service, receipt of cardiopulmonary resuscitation (CPR) during the last hospitalization, and receipt of airway support interventions during the last hospitalization. The independent effects of various characteristics on the receipt of hospice care, CPR during the last hospitalization, and airway support interventions during the last hospitalization were evaluated using multivariate logistic regressions. Results: A total of 587,490 patients were included, of which 434,142 died of cancers and 153,348 died of noncancer diseases. There were significant trends of increase in receiving hospice care service and significant trends of decrease in receiving CPR or airway support interventions during the last hospitalization in both patients who died of cancers and those who died of noncancer diseases. Compared with patients who died of cancers, those who died of noncancer diseases were less likely to receive hospice care service (adjusted odds ratio [AOR]: 0.087; 95% confidence interval [CI]: 0.085-0.089) and had a higher risk of receiving CPR (AOR: 3.610; 95% CI: 3.521-3.704) or airway support interventions during the last hospitalization (AOR: 3.086; 95% CI: 3.021-3.165). Conclusions: Hospice care service should be promoted for all patients with end-stage diseases especially those with noncancer diseases.
Collapse
Affiliation(s)
- Chu-Chieh Chen
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan
| | - Hsin-Yi Lien
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan
- Taipei City Hospital, Taipei City, Taiwan
| | - Ching-Yao Tsai
- Taipei City Hospital, Taipei City, Taiwan
- School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
- School of Medicine, National Yang-Ming University, Taipei City, Taiwan
| | - Lin-Chung Woung
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan
- Taipei City Hospital, Taipei City, Taiwan
| | - Ming-Chung Ko
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan
- Taipei City Hospital, Taipei City, Taiwan
- School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| |
Collapse
|
2
|
Aldecoa KAT, Macaraeg CSL, Abougergi MS, Krishnamoorthy G, Arsene C. Palliative Care Utilization Among Hospitalized Patients With Hepatocellular Cancer: A Nationwide Study in the Pandemic Era (2019-2021). Am J Hosp Palliat Care 2024:10499091241271371. [PMID: 39138972 DOI: 10.1177/10499091241271371] [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: 08/15/2024] Open
Abstract
Background: Palliative care addresses a range of needs, from symptom management to providing support to patients with hepatocellular cancer (HCC) and their families throughout the illness. However, research on palliative care in HCC remains limited, particularly during the COVID-19 pandemic. This study investigates the healthcare utilization associated with palliative care referral among patients with HCC. Methods: This is a retrospective cross-sectional analysis conducted using the National Inpatient Sample (NIS) database from 2019 to 2021 among patients with HCC age ≥18 years. Results: Among the 35,220 hospitalizations with HCC as the principal diagnosis, 18.7% received inpatient palliative care referrals. Factors associated with increased palliative care referrals included age ≥65 years, Midwest region, Charlson Comorbidity Index (CCI) score ≥3, and end-of-life care, as reflected by discharge resulting in death. No racial or insurance disparities were observed. Palliative care consultations were associated with lower total hospital costs ($20,573 vs $26,035, <0.0001). A higher prevalence of "do-not-resuscitate" status was also found among patients with palliative care referrals. Conclusion: The study provides an understanding of palliative care utilization across pre-pandemic and pandemic periods. Factors such as advanced age, hospital region, and underlying comorbidities influenced the likelihood of referral, with no discernible racial or insurance disparities identified. Palliative care involvement has also been shown to provide cost-effective supportive care with lower hospital costs. These findings provide invaluable guidance for optimizing the integration of palliative care alongside HCC management.
Collapse
Affiliation(s)
- Kim Abbegail Tan Aldecoa
- Department of Internal Medicine, Trinity Health Oakland, Pontiac, MI, USA
- Wayne State University, Detroit, MI, USA
| | | | - Marwan S Abougergi
- Division of Gastroenterology, Department of Internal Medicine, INOVA Fairfax Medical Campus, Great Falls, VA
- Catalyst Medical Consulting, Huntington Valley, PA, USA
| | - Geetha Krishnamoorthy
- Department of Internal Medicine, Trinity Health Oakland, Pontiac, MI, USA
- Wayne State University, Detroit, MI, USA
| | - Camelia Arsene
- Department of Internal Medicine, Trinity Health Oakland, Pontiac, MI, USA
- Wayne State University, Detroit, MI, USA
| |
Collapse
|
3
|
Maduka RC, Canavan ME, Walters SL, Ermer T, Zhan PL, Kaminski MF, Li AX, Pichert MD, Salazar MC, Prsic EH, Boffa DJ. Association of patient socioeconomic status with outcomes after palliative treatment for disseminated cancer. Cancer Med 2024; 13:e7028. [PMID: 38711364 DOI: 10.1002/cam4.7028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Palliative treatment has been associated with improved quality of life and survival for a wide variety of metastatic cancers. However, it is unclear whether the benefits of palliative treatment are uniformly experienced across the US cancer population. We evaluated patterns and outcomes of palliative treatment based on socioeconomic, sociodemographic and treating facility characteristics. METHODS Patients diagnosed between 2008 and 2019 with Stage IV primary cancer of nine organ sites were analyzed in the National Cancer Database. The association between identified variables, and outcomes concerning the administration of palliative treatment were analyzed with multivariable logistic regression and Cox proportional hazard models. RESULTS Overall 238,995 (23.6%) of Stage IV patients received palliative treatment, which increased over time for all cancers (from 20.7% in 2008 to 25.6% in 2019). Palliative treatment utilization differed significantly by region (West less than Northeast, OR: 0.55 [0.54-0.56], p < 0.001) and insurance payer status (uninsured greater than private insurance, OR: 1.35 [1.32-1.39], p < 0.001). Black race and Hispanic ethnicity were also associated with lower rates of palliative treatment compared to White and non-Hispanics respectively (OR for Blacks: 0.91 [0.90-0.93], p < 0.001 and OR for Hispanics: 0.79 [0.77-0.81] p < 0.001). CONCLUSIONS There are important differences in the utilization of palliative treatment across different populations in the United States. A better understanding of variability in palliative treatment use and outcomes may identify opportunities to improve informed decision making and optimize quality of care at the end-of-life.
Collapse
Affiliation(s)
- Richard C Maduka
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Center Advanced Training Program for Physician Scientist, NIH T32 Fellowship, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Maureen E Canavan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
- Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Samantha L Walters
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Theresa Ermer
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
- Faculty of Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
- London School of Hygiene & Tropical Medicine, University of London, London, UK
| | - Peter L Zhan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael F Kaminski
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew X Li
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Matthew D Pichert
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michelle C Salazar
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Elizabeth H Prsic
- Palliative Care Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel J Boffa
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
4
|
Afessa N, Birhanu D, Negese B, Tefera M. Palliative care service utilization and associated factors among cancer patients at oncology units of public hospitals in Addis Ababa, Ethiopia. PLoS One 2024; 19:e0294230. [PMID: 38483983 PMCID: PMC10939243 DOI: 10.1371/journal.pone.0294230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 10/29/2023] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Palliative care helps patients and their families deal with the hardships that come with a life-threatening illness. However, patients were not fully utilizing the palliative care services provided by healthcare facilities for a number of reasons. In Ethiopia, there hasn't been any research done on the variables that influence the utilization of palliative care services. OBJECTIVE To assess palliative care service utilization & associated factors affecting cancer patients at public hospitals oncology units in Addis Ababa, Ethiopia. METHODS An institution-based cross-sectional study design was carried out. A structured and pre-tested questionnaire was administered to 404 participants at Tikur Anbesa Specialized Hospital and Saint Paul's Hospital Millennium Medical College from July 4 to August 2, 2022. A systematic random sampling technique was used to select the study participants. The data was collected by ODK-Collect version 3.5 software and exported to excel and then to SPSS version 25 for recoding, cleaning, and analysis. Logistic regression model was employed. P-values <0.05 were regarded as statistically significant. RESULT About 404 participants' responded questionnaire giving a 97.6% response rate. The extent of Palliative care service utilization was 35.4% [95% CI: 31.4, 40.3%]. College or university education were 2.3 times more likely and living in a distance of <23 km from PC service centers were 1.8 times more likely to use palliative care services. Factors hindering palliative care service utilization were inability to read & write, treatment side effects, long distance to a health institution, and low satisfaction with the health care service. CONCLUSION AND RECOMMENDATION The extent of palliative care service utilization which was low. Factors to palliative care service utilization were clients' education level, treatment side effects, distance to a health institution, and patients' satisfaction. Interventions to enhance health education and counseling of cancer patients, early detection and management of treatment side effects and accessibility of palliative care services for cancer patients should be emphasized and implemented by all concerned stakeholders.
Collapse
Affiliation(s)
- Nigus Afessa
- Department of Nursing, School of Nursing and Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Dagmawit Birhanu
- Department of Nursing, School of Nursing and Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Belete Negese
- Department of Nursing, School of Nursing and Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Mitiku Tefera
- Department of Midwifery, School of Nursing and Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| |
Collapse
|
5
|
Sohal A, Chaudhry H, Sharma R, Dhillon N, Kohli I, Singla P, Arora K, Dukovic D, Verma M, Roytman M. Recent Trends in Palliative Care Utilization in Patients With Decompensated Liver Disease: 2016-2020 National Analysis. J Palliat Med 2024; 27:335-344. [PMID: 37851991 DOI: 10.1089/jpm.2023.0367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
Background: Patients with end-stage liver disease (ESLD) have a poor quality of life, which often worsens as disease severity increases. Palliative care (PC) has emerged as a management option in ESLD patients, especially for those who are not candidates for a liver transplant. Objective: To assess the associated factors and trends in PC utilization in recent years. Design: We used the 2016-2020 National Inpatient Sample (NIS) database of the United States to identify patients with decompensated cirrhosis who suffered in-hospital mortality. Information regarding patient demographics, hospital characteristics, etiology and decompensations, Elixhauser comorbidities, and interventions was collected. The multivariate regression model was used to identify factors associated with PC use. Results: Out of 98,160 patients, 52,645 patients (53.6%) received PC consultations. PC utilization increased from 49.11% in 2016 to 56.85% in 2019, with a slight decrease to 54.47% in 2020. Patients with PC use had decreased incidence of blood transfusions (28.85% vs. 36.53%, p < 0.001), endoscopy (18% vs. 20.26%, p 0.0001), liver transplantation (0.28% vs. 0.69%, p < 0.001), and mechanical ventilation (46.22% vs. 56.37%, p < 0.001). African American, Hispanic, and Asian/Pacific Islander patients had 29%, 27%, and 23% lower odds of receiving PC than White patients. Patients in the two lowest income quartiles had 12% and 22% lower odds of receiving PC compared with the highest quartile. Conclusions: PC utilization in patients with ESLD is associated with decreased invasive procedures, shorter lengths of stay, and lower hospitalization charges. Minorities, as well as patients in the lower income quartiles, were less likely to receive PC.
Collapse
Affiliation(s)
- Aalam Sohal
- Department of Hepatology, Liver Institute Northwest, Seattle, Washington, USA
| | - Hunza Chaudhry
- Department of Internal Medicine, University of California, Fresno, Fresno, California, USA
| | - Ragini Sharma
- Department of Internal Medicine, Maullana Azad Medical College, New Delhi, India
| | - Nimrat Dhillon
- Department of Internal Medicine, Shri Guru Ram Das Medical College, Amritsar, India
| | - Isha Kohli
- Graduate Program in Public Health, Icahn School of Medicine, Mount Sinai, New York, USA
| | - Piyush Singla
- Department of Internal Medicine, Dayanand Medical College, and Hospital, Punjab, India
| | - Kirti Arora
- Department of Internal Medicine, Dayanand Medical College, and Hospital, Punjab, India
| | - Dino Dukovic
- Department of Internal Medicine, Ross University School of Medicine, Miramar, Florida, USA
| | - Manisha Verma
- Department of Gastroenterology and Hepatology, Einstein Healthcare Network, Philadelphia, USA
| | - Marina Roytman
- Department of Gastroenterology and Hepatology, University of California, Fresno, Fresno, California, USA
| |
Collapse
|
6
|
Kim S, Chervu N, Premji A, Mallick S, Verma A, Ali K, Benharash P, Donahue T. Association of Inpatient Palliative Care Consultation with Clinical and Financial Outcomes for Pancreatic Cancer. Ann Surg Oncol 2024; 31:1328-1335. [PMID: 37957512 DOI: 10.1245/s10434-023-14528-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/14/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Palliative care consultation (PCC) has been shown to improve quality of life and reduce costs for various chronic life-threatening diseases. Despite PCC incorporation into modern pancreatic cancer care guidelines, limited data regarding its specific utilization and impact on resource use is available. METHODS The 2016-2020 Nationwide Readmissions Database was used to identify all adult hospitalizations entailing pancreatic cancer. Only patients with at least one readmission within 90 days were included to account for uncaptured out-of-hospital mortality. Multivariable regression models were used to ascertain the relationship between inpatient PCC during initial hospitalization and index as well as cumulative costs, overall length of stay (LOS), readmission rate, and number of repeat hospitalizations. RESULTS Of an estimated 175,805 patients with pancreatic cancer, 11.1% had inpatient PCC during the index admission. PCC utilization significantly increased from 10.5% in 2016 to 11.6% in 2020 (nptrend < 0.001). After adjustment, PCC was associated with reduced index hospitalization costs [β: - $1100; 95% confidence interval (CI) - 1500, - 800; P < 0.001] and cumulative 90-day costs (β: - $11,700; 95% CI - 12,700, - 10,000; P < 0.001). PCC was associated with longer index LOS (β: + 1.12 days, 95% CI 0.92-1.31, P < 0.001) but significantly reduced cumulative LOS (β: - 3.16 days; 95% CI - 3.67, - 2.65; P < 0.001). Finally, PCC was linked with decreased odds of 30-day nonelective readmission (AOR: 0.48, 95% CI 0.45-0.50, P < 0.001). DISCUSSION PCC was associated with decreased costs, readmission rates, and number of hospitalizations among patients with pancreatic cancer. Directed strategies to increase utilization and reduce barriers to consultation should be implemented to encourage practitioners to maximize inpatient PCC referral rates.
Collapse
Affiliation(s)
- Shineui Kim
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Alykhan Premji
- Division of Surgical Oncology, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Timothy Donahue
- Division of Surgical Oncology, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA.
| |
Collapse
|
7
|
Dullea JT, Vasan V, Devarajan A, Ali M, Nichols N, Chaluts D, Henson P, Porras C, Lopez C, Luna D, Liou L, Bederson J, Shrivastava RK. Utilization of Palliative Care Services Among Patients With Malignant Brain Tumors: An Analysis of the National Inpatient Sample (2016-2019). Neurosurgery 2023; 93:419-426. [PMID: 36867460 DOI: 10.1227/neu.0000000000002428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 01/03/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Recent advances in treatment of malignant brain tumors have improved outcomes. However, patients continue to experience significant disability. Palliative care helps patients with advanced illnesses improve their quality of life. There is a paucity of clinical studies examining palliative care usage among patients with malignant brain tumors. OBJECTIVE To assess if there were any patterns in palliative care utilization among patients hospitalized with malignant brain tumors. METHODS A retrospective cohort representing hospitalizations for malignant brain tumors was created from The National Inpatient Sample (2016-2019). Palliative care utilization was identified by ICD-10 code. Univariable and multivariable logistic regression models, accounting for the sample design, were built to evaluate the demographic variables associated with palliative care consultation in all patients and fatal hospitalizations. RESULTS 375 010 patients admitted with a malignant brain tumor were included in this study. Over the whole cohort, 15.0% of patients used palliative care. In fatal hospitalizations, Black and Hispanic patients had 28% lower odds of receiving a palliative care consultation compared with White patients (odds ratio for both = 0.72; P = .02). For fatal hospitalizations, patients insured privately were 34% more likely to use palliative care services compared with patients insured with Medicare (odds ratio = 1.34, P = .006). CONCLUSION Palliative care is underutilized among all patients with malignant brain tumors. Within this population, disparities in utilization are exacerbated by sociodemographic factors. Prospective studies investigating utilization disparities across race and insurance status are necessary to improve access to palliative care services for this population.
Collapse
Affiliation(s)
- Jonathan T Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex Devarajan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Noah Nichols
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Danielle Chaluts
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Phil Henson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christian Porras
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christine Lopez
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Diego Luna
- Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lathan Liou
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
8
|
Kim SJ, Patel I, Park C, Shin DY, Chang J. Palliative care and healthcare utilization among metastatic breast cancer patients in U.S. Hospitals. Sci Rep 2023; 13:4358. [PMID: 36928807 PMCID: PMC10020145 DOI: 10.1038/s41598-023-31404-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 03/11/2023] [Indexed: 03/18/2023] Open
Abstract
There is a lack of research focused on understanding the different characteristics and healthcare utilization of metastatic breast cancer patients by palliative care use. This study aims to investigate trend of in-patient palliative care and its association with healthcare utilization among hospitalized metastatic breast cancer patients in the US. National Inpatient Sample (NIS) was used to identify nationwide metastatic breast cancer patients (n = 5209, weighted n = 25,961) from 2010 to 2014. We examined the characteristics of the study sample by palliative care and its association with healthcare utilization, measured by discounted hospital charges and length of stay. Multivariable survey regression models were used to identify predictors. Among 26,961 breast cancer patients, 19.0% had palliative care. Percentage of receiving palliative care during the period were gradually increased. Social factors including race, insurance types were also associated with a receipt of palliative care. Survey linear regression results showed that patients with palliative care were associated with 31% lower hospital charges, however, length of stays were not significantly associated. This study found evidence of who was associated with the receipt of palliative care and its relationship with healthcare utilization. This study also emphasizes the importance of receiving palliative care in patients with breast cancer, paving the way for future research into ways to improve palliative care in cancer patients. This study also found social differences and gave evidence of programs that could be used to help vulnerable groups in future health policy decisions.
Collapse
Affiliation(s)
- Sun Jung Kim
- Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan, Republic of Korea
- Center for Healthcare Management Science, Soonchunhyang University, Asan, Republic of Korea
- Department of Software Convergence, Soonchunhyang University, Asan, Republic of Korea
| | - Isha Patel
- Department of Health Care Management, Brad D. Smith School of Business, Marshall University, Huntington, WV, USA
| | - Chanhyun Park
- Health Outcomes and Pharmacy Practice, College of Pharmacy, University of Texas, Austin, TX, USA
| | - Dong Yeong Shin
- Department of Public Health Sciences, College of Health, Education and Social Transformation, New Mexico State University, Las Cruces, NM, USA
| | - Jongwha Chang
- Department of Pharmaceutical Sciences, Irma Lerma Rangel School of Pharmacy, Texas A&M University, College Station, TX, 77843, USA.
- Irma Lerma Rangel School of Pharmacy, Texas A&M University, College Station, TX, 77843, USA.
| |
Collapse
|
9
|
Han HJ, Yeh JC, McNichol M, Buss MK. Delivering Palliative Care to Hospitalized Oncology Patients: A Scoping Review. J Pain Symptom Manage 2023; 65:e137-e153. [PMID: 36243248 DOI: 10.1016/j.jpainsymman.2022.09.016] [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: 07/07/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT Early, longitudinal integration of palliative care (PC) is recommended for patients with advanced cancer, in both inpatient and outpatient settings. Despite the growth of specialty PC teams in the last decade, the majority of PC is still delivered in the inpatient setting using a traditional referral-based consult delivery model. However, traditional consultation can lead to significant variation or delay in inpatient PC utilization. New care delivery models and strategies are emerging to deliver PC to hospitalized oncology patients who would most benefit from their services and to better align with professional society recommendations. OBJECTIVES To identify different care models to deliver PC to ho`spitalized oncology patients and summarize their impact on patient and health system-related outcomes. METHODS We conducted a scoping review of peer-reviewed articles from 2006 to 2021 evaluating delivery of PC to oncology patients in acute inpatient care. We abstracted study characteristics, the study's intervention and comparison arms, and outcomes related to specialty PC intervention. RESULTS We identified four delivery models that have been reported to deliver PC: 1) traditional referral-based consultation, 2) criterion-based or "triggered" consultation, 3) co-rounding with primary inpatient team, and 4) PC clinicians serving as the primary team. We summarize the known outcomes data from each model, and compare the benefits and limitations of each model. CONCLUSION Our findings provide guidance to health systems about care delivery models to deploy and implement inpatient PC resources to best serve their unique populations.
Collapse
Affiliation(s)
- Harry J Han
- Section of Palliative Care, Division of General Medicine and Primary Care (H.J.H., J.C.Y.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Jonathan C Yeh
- Section of Palliative Care, Division of General Medicine and Primary Care (H.J.H., J.C.Y.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Megan McNichol
- Division of Knowledge Services, Department of Information Services (M.M.), Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mary K Buss
- Division of Palliative Care, Department of Medicine (M.K.B.), Tufts University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
10
|
Kim DJ, Kim SJ. Is Hospital Hospice Service Associated with Efficient Healthcare Utilization in Deceased Lung Cancer Patients? Hospital Charges at Their End of Life. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15331. [PMID: 36430054 PMCID: PMC9690857 DOI: 10.3390/ijerph192215331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 06/16/2023]
Abstract
In July 2015, South Korea began applying National Health Insurance reimbursement to inpatient hospice service. It is now appropriate and relevant to evaluate how hospice care is associated with healthcare utilization in terminal lung cancer patients. We used nationwide NHI claims data of lung cancer patients from 2008-2018 and identified a sample of patients deceased after July 2016. We transposed the dataset into a retrospective cohort design where a unit of analysis was each lung cancer patients' healthcare utilization. The differences in hospital charges per day were investigated depending on the patient's use of hospice service before death with the Generalized Linear Model (GLM) analysis. Additionally, subgroup analysis and the propensity score matching method were used to validate the model using the claims information of 25,099 patients. About 17.0% of patients used hospice services (N = 4260). With other variables adjusted, hospice service utilization by deceased lung cancer patients was associated with statistically significant lower hospital charges per day at the end of life (1 month, 3 months, and 6 months before death) compared to non-users. A similar trend was found in the propensity score matching model analysis. We found lower end-of-life hospital charges per day among lung cancer patients who received hospice services near death. The ever-expanding aging population requires health policymakers and the National Health Insurance program to expand hospice services for terminal cancer patients in underserved regions and hospitals that do not provide hospice.
Collapse
Affiliation(s)
- Dong Jun Kim
- Division of Cancer Control and Policy, National Cancer Center, Goyang 10408, Republic of Korea
| | - Sun Jung Kim
- Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan 31538, Republic of Korea
- Center for Healthcare Management Science, Soonchunhyang University, Asan 31538, Republic of Korea
- Department of Software Convergence, Soonchunhyang University, Asan 31538, Republic of Korea
| |
Collapse
|
11
|
Lam MB, Friend TH, Erfani P, Orav EJ, Jha AK, Figueroa JF. ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study. J Gen Intern Med 2022; 37:3275-3282. [PMID: 35022958 PMCID: PMC9550919 DOI: 10.1007/s11606-021-07183-9] [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: 06/18/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending. OBJECTIVE To examine whether practices that became ACOs altered spending and utilization at the EOL. DESIGN Retrospective analysis of Medicare claims. PATIENTS We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients. MAIN MEASURES Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation. KEY RESULTS The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death. CONCLUSIONS With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.
Collapse
Affiliation(s)
- Miranda B Lam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Department of Radiation Oncology, Brigham and Women's Hospital / Dana Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, MA, Boston, USA.
| | - Tynan H Friend
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - E John Orav
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ashish K Jha
- School of Public Health, Brown University, Providence, RI, USA
| | - Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, MA, Boston, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
12
|
Kim SJ, Medina M, Delgado R, Miller A, Chang J. Healthcare Utilization Disparities Among Lung Cancer Patients in US Hospitals During 2010–2014: Evidence from the US Hispanic Population’s Hospital Charges and Length of Stay. Int J Gen Med 2022; 15:1329-1339. [PMID: 35173471 PMCID: PMC8841460 DOI: 10.2147/ijgm.s348159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/26/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose There is a lack of research focused on understanding the differences in the healthcare utilization of lung cancer patients between ethnic groups. This study aims to characterize disparities in healthcare utilization for Hispanic lung cancer patients compared to non-Hispanic patients. Methods National Inpatient Sample was used to identify nationwide lung cancer patients (n=141,675, weighted n=702,878) from 2010 to 2014. We examined the characteristics of the study sample by race (Hispanic vs non-Hispanic) and its association with healthcare utilization, measured by discounted hospital charges and length of stay. Multivariate survey regression models were used to identify predictors by racial groups. Results Among 702,878 lung cancer patients, 5.1% were Hispanic. Descriptive statistics showed that Hispanics have higher hospital charges and length of stay. Survey regression results also suggested that Hispanic lung cancer patients were associated with higher hospital charges (26.6%) and length of stay (3.5%) than non-Hispanic lung cancer patients. Subgroup analysis displayed a similar trend to the full model. Conclusion Healthcare utilization disparities may exist for lung cancer Hispanic patients due to insurance status and early detection. Thus, our findings support providing financial assistance and targeted programs for minority patients. Future health policy consideration should be given to those vulnerable populations where limited healthcare resources are available.
Collapse
Affiliation(s)
- Sun Jung Kim
- Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan, Republic of Korea
- Center for Healthcare Management Science, Soonchunhyang University, Asan, Republic of Korea
- Department of Software Convergence, Soonchunhyang University, Asan, Republic of Korea
| | - Mar Medina
- School of Pharmacy, University of Texas at El Paso, El Paso, TX, USA
| | - Rigoberto Delgado
- Department of Healthcare Administration, College of Business, Texas Woman’s University, Denton, TX, USA
| | - Anastasia Miller
- Department of Healthcare Administration, College of Business, Texas Woman’s University, Denton, TX, USA
| | - Jongwha Chang
- Department of Healthcare Administration, College of Business, Texas Woman’s University, Denton, TX, USA
- Correspondence: Jongwha Chang, Tel +1940-898-2899, Email
| |
Collapse
|
13
|
Cobert J, Cook AC, Lin JA, O'Riordan DL, Pantilat SZ. Trends in Palliative Care Consultations in Critically Ill Patient Populations, 2013-2019. J Pain Symptom Manage 2022; 63:e176-e181. [PMID: 34348177 DOI: 10.1016/j.jpainsymman.2021.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/19/2021] [Accepted: 07/26/2021] [Indexed: 11/15/2022]
Abstract
CONTEXT Critically ill patients have important palliative care (PC) needs in the intensive care unit (ICU), but specialty PC is often underutilized. OBJECTIVE To evaluate changes in utilization and reasons for PC consultation over time. METHODS Data from a national multi-site network of inpatient PC visits were used to identify patients age ≥18 years admitted to an ICU between 2013 and 2019. Year of ICU admission was the exposure. Primary diagnosis and reason for referral were identified by standardized process measures within the dataset at the time of referral. Trends in primary diagnosis and reason for referral were modeled as a function of year of ICU admission. RESULTS Across 39,515 ICU patients seen by a PC team, overall numbers of consultations from the ICU increased each year. Referrals for patients with cancer decreased from 17.6% (95% CI 13.7%-21.5%) to 14.3% (95% CI 13.2%-14.7%) and for patients with cardiovascular disease increased from 16.8% in (95% CI 16.8%-16.9%) to 18.8% (95% CI 18.8%-18.9%). Reasons for referrals were primarily for goals of care and advance care planning and increased from 74.0% (95% CI 70.0%-78.0%) in 2013 to 80.0% (95% CI 79.4%-80.0%) in 2019 (P < 0.0001 for all trends). CONCLUSION PC referrals in ICU patients with cancer are decreasing, while those for cardiovascular disease are increasing. Reasons for referrals in the ICU are commonly for goals of care; other reasons, like pain control are uncommon. Early goals of care conversations and further training in advance care planning should be emphasized in the ICU setting.
Collapse
Affiliation(s)
- Julien Cobert
- Anesthesia Service (J.C.), San Francisco VA Health Care System, San Francisco, CA, USA; Department of Anesthesiology (J.C.), University of California San Francisco, San Francisco, CA, USA.
| | - Allyson C Cook
- Division of Palliative Medicine (A.C.C., J.A.L., D.L.O., S.Z.P.), Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Surgery (A.C.C., J.A.L.), University of California San Francisco, San Francisco, CA, USA; Critical Care Medicine (A.C.C.), Department of Anesthesia, University of California San Francisco
| | - Joseph A Lin
- Division of Palliative Medicine (A.C.C., J.A.L., D.L.O., S.Z.P.), Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Surgery (A.C.C., J.A.L.), University of California San Francisco, San Francisco, CA, USA
| | - David L O'Riordan
- Division of Palliative Medicine (A.C.C., J.A.L., D.L.O., S.Z.P.), Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine (A.C.C., J.A.L., D.L.O., S.Z.P.), Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
14
|
Ferrario A, Zhang F, Ross-Degnan D, Wharam JF, Twaddle ML, Wagner AK. Use of Palliative Care Among Commercially Insured Patients With Metastatic Cancer Between 2001 and 2016. JCO Oncol Pract 2022; 18:e677-e687. [PMID: 34986008 DOI: 10.1200/op.21.00516] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Early palliative care, concomitant with disease-directed treatments, is recommended for all patients with advanced cancer. This study assesses population-level trends in palliative care use among a large cohort of commercially insured patients with metastatic cancer, applying an expanded definition of palliative care services based on claims data. METHODS Using nationally representative commercial insurance claims data, we identified patients with metastatic breast, colorectal, lung, bronchus, trachea, ovarian, esophageal, pancreatic, and liver cancers and melanoma between 2001 and 2016. We assessed the annual proportions of these patients who received services specified as, or indicative of, palliative care. Using Cox proportional hazard models, we assessed whether the time from diagnosis of metastatic cancer to first encounter of palliative care differed by demographic characteristics, socioeconomic factors, or region. RESULTS In 2016, 36% of patients with very poor prognosis cancers received a service specified as, or indicative of, palliative care versus 18% of those with poor prognosis cancers. Being diagnosed in more recent years (2009-2016 v 2001-2008: hazard ratio [HR], 1.8; P < .001); a diagnosis of metastatic esophagus, liver, lung, or pancreatic cancer, or melanoma (v breast cancer, eg, esophagus HR, 1.89; P < .001); a greater number of comorbidities (American Hospital Formulary Service classes > 10 v 0: HR, 1.71; P < .001); and living in the Northeast (HR, 1.43; P < .001) or Midwest (v South: HR, 1.39; P < .001) were the strongest predictors of shorter time from diagnosis to palliative care. CONCLUSION Use of palliative care among commercially insured patients with advanced cancers has increased since 2001. However, even with an expanded definition of services specified as, or indicative of, palliative care, < 40% of patients with advanced cancers received palliative care in 2016.
Collapse
Affiliation(s)
- Alessandra Ferrario
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Fang Zhang
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Dennis Ross-Degnan
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - J Frank Wharam
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | | | - Anita K Wagner
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| |
Collapse
|
15
|
Joo MK, Yoo JW, Mojtahedi Z, Kim P, Hwang J, Koo JS, Kang HT, Shen JJ. Ten-year trends of utilizing palliative care and palliative procedures in patients with gastric Cancer in the United States from 2009 to 2018 - a nationwide database study. BMC Health Serv Res 2022; 22:20. [PMID: 34980097 PMCID: PMC8725552 DOI: 10.1186/s12913-021-07404-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/13/2021] [Indexed: 12/19/2022] Open
Abstract
Objectives Little is known about the current status and the changing trends of hospitalization and palliative care consultation of patients with gastric cancer in the United States. The aim of this study was to evaluate the changing trend in the number of hospitalization, palliative care consultation, and palliative procedures in the US during a recent 10-year period using a nationwide database. Methods This was a retrospective study that analyzed the National Inpatient Sample (NIS) database of 2009–2018. Patients aged more than 18 years who were diagnosed with a gastric cancer using International Classification of Diseases (ICD)-9 and 10 codes were included. Palliative care consultation included palliative care (ICD-9, V66.7; ICD-10, Z51.5) and advanced care planning (ICD-9, V69.89; ICD-10, Z71.89). Palliative procedures included percutaneous or endoscopic bypass, gastrostomy or enterostomy, dilation, drainage, nutrition, and irrigation for palliative purpose. Results and discussion A total of 86,430 patients were selected and analyzed in this study. Using a compound annual growth rate (CAGR) approach, the annual number of hospitalizations of gastric cancer patients was found to be decreased during 2009–2018 (CAGR: -0.8%, P = 0.0084), while utilization rates of palliative care and palliative procedures increased (CAGR: 9.3 and 1.6%, respectively; P < 0.0001). Multivariable regression analysis revealed that palliative care consultation was associated with reduced total hospital charges (−$34,188, P < 0.0001). Conclusion Utilization of palliative care consultation to patients with gastric cancer may reduce use of medical resources and hospital costs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07404-1.
Collapse
Affiliation(s)
- Moon Kyung Joo
- School of Public Health, University of Nevada Las Vegas, Las Vegas, NV, USA. .,Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, 08308, Republic of Korea.
| | - Ji Won Yoo
- Department of Internal Medicine, School of Medicine, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Zahra Mojtahedi
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, NV, 89119, USA
| | - Pearl Kim
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, NV, 89119, USA
| | - Jinwook Hwang
- School of Public Health, University of Nevada Las Vegas, Las Vegas, NV, USA.,Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospita, Korea University College of Medicine, Ansan, Republic of Korea
| | - Ja Seol Koo
- School of Public Health, University of Nevada Las Vegas, Las Vegas, NV, USA.,Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospita, Korea University College of Medicine, Ansan, Republic of Korea
| | - Hee-Taik Kang
- Department of Family Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Jay J Shen
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, NV, 89119, USA.
| |
Collapse
|
16
|
Gajra A, Zettler ME, Miller KA, Frownfelter JG, Showalter J, Valley AW, Sharma S, Sridharan S, Kish JK, Blau S. Impact of Augmented Intelligence on Utilization of Palliative Care Services in a Real-World Oncology Setting. JCO Oncol Pract 2022; 18:e80-e88. [PMID: 34506215 PMCID: PMC8758123 DOI: 10.1200/op.21.00179] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/12/2021] [Accepted: 08/06/2021] [Indexed: 01/03/2023] Open
Abstract
PURPOSE For patients with advanced cancer, timely referral to palliative care (PC) services can ensure that end-of-life care aligns with their preferences and goals. Overestimation of life expectancy may result in underutilization of PC services, counterproductive treatment measures, and reduced quality of life for patients. We assessed the impact of a commercially available augmented intelligence (AI) tool to predict 30-day mortality risk on PC service utilization in a real-world setting. METHODS Patients within a large hematology-oncology practice were scored weekly between June 2018 and October 2019 with an AI tool to generate insights into short-term mortality risk. Patients identified by the tool as being at high or medium risk were assessed for a supportive care visit and further referred as appropriate. Average monthly rates of PC and hospice referrals were calculated 5 months predeployment and 17 months postdeployment of the tool in the practice. RESULTS The mean rate of PC consults increased from 17.3 to 29.1 per 1,000 patients per month (PPM) pre- and postdeployment, whereas the mean rate of hospice referrals increased from 0.2 to 1.6 per 1,000 PPM. Eliminating the first 6 months following deployment to account for user learning curve, the mean rate of PC consults nearly doubled over baseline to 33.0 and hospice referrals increased 12-fold to 2.4 PPM. CONCLUSION Deployment of an AI tool at a hematology-oncology practice was found to be feasible for identifying patients at high or medium risk for short-term mortality. Insights generated by the tool drove clinical practice changes, resulting in significant increases in PC and hospice referrals.
Collapse
Affiliation(s)
- Ajeet Gajra
- Cardinal Health Specialty Solutions, Dublin, OH
| | | | | | | | | | | | | | | | | | - Sibel Blau
- Rainier Hematology Oncology/Northwest Medical Specialties, Seattle, WA
| |
Collapse
|
17
|
Mojtahedi Z, Koo JS, Yoo J, Kim P, Kang HT, Hwang J, Joo MK, Shen JJ. Palliative Care and Life-Sustaining/Local Procedures in Colorectal Cancer in the United States Hospitals: A Ten-Year Perspective. Cancer Manag Res 2021; 13:7569-7577. [PMID: 34629903 PMCID: PMC8496534 DOI: 10.2147/cmar.s330448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/11/2021] [Indexed: 01/03/2023] Open
Abstract
Background In recent years, palliative care utilization has been increasing while life-sustaining/local procedures have been declining at the end of life. Palliative care utilization widely varies based on tumor type. Limited information is available on inpatient palliative care in colorectal cancer. Aims This study investigated inpatient palliative care utilization and its association with patient demographics, hospital charges, and procedures among colorectal cancer patients admitted to US hospitals between 2008 and 2017. Receipt of life-sustaining and local procedures and surgeries were also investigated during the ten years. Methods Data were extracted from the National inpatient sample (NIS) database containing de-identified information from each hospitalization. Codes V66.7 for ICD-9-CM or Z51.5 for ICD-10-CM were used to find palliative care utilization. Data were analyzed using generalized regression with adjustment for variations in predictors. The Compound Annual Growth Rate (CAGR) was calculated for palliative care and procedures over time. Results Of the 487,027 colorectal cancer hospitalizations, only 6.04% utilized palliative care. This percentage significantly increased over time from 2.3% in 2008 to 9.3% in 2017 (P<0.0001). Palliative care utilization sizably decreased hospital charges by $18,010 per hospitalization (P<0.0001) and was positively associated with female gender, severe disease, and age over 80 years (P≤ 0.05). Palliative care utilization was inversely associated with using life-sustaining and local procedures and surgeries (P<0.0001). Life-sustaining procedures (intubation, infusion of concentrate nutrients, dialysis, and blood transfusion) and surgeries were decreased over time (P<0.001). Conclusions Palliative care utilization increased over time and was inversely associated with hospital charges and performing procedures among colorectal cancer patients. Our findings warrant further research and interventions to increase palliative care utilization in colorectal cancer.
Collapse
Affiliation(s)
- Zahra Mojtahedi
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, NV, 89119, USA
| | - Ja Seol Koo
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, NV, 89119, USA.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, South Korea
| | - Ji Yoo
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Pearl Kim
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, NV, 89119, USA
| | - Hee-Taik Kang
- Department of Family Medicine, Chungbuk National University Hospital, Cheongju, South Korea
| | - Jinwook Hwang
- Department of Cardiovascular and Thoracic Surgery, Korea University Ansan Hospital, Ansan, South Korea
| | - Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Jay J Shen
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, NV, 89119, USA
| |
Collapse
|
18
|
Inpatient Palliative Care Is Less Utilized in Rare, Fatal Extrahepatic Cholangiocarcinoma: A Ten-Year National Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910004. [PMID: 34639305 PMCID: PMC8508271 DOI: 10.3390/ijerph181910004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 02/08/2023]
Abstract
Background—Extrahepatic cholangiocarcinoma (ECC) is a rare, morbid, fatal cancer with distressing symptoms. Maintaining a high quality of life while reducing hospital charges and length of stay (LOS) for the end-of-life period remains a major challenge for the healthcare system. Palliative care utilization has been shown to address these challenges; moreover, its use has increased in recent years among cancer patients. However, the utilization of palliative care in rare cancers, such as ECC, has not yet been explored. Objectives—To investigate palliative care utilization among ECC patients admitted to US hospitals between 2007 and 2016 and its association with patient demographics, clinical characteristics, hospital charges, and LOS. Methods—De-identified patient data of each hospitalization were retrieved from the National Inpatient Sample (NIS) database. Codes V66.7 (ICD-9-CM) or Z51.5 (ICD-10-CM) were used to find palliative care utilization. Multivariate adjusted logistic regression analyses were conducted to assess factors associated with palliative care use, LOS, hospital charges, and in-hospital death. Results—Of 4426 hospitalizations, only 6.7% received palliative care services. Palliative care utilization did not significantly increase over time (p = 0.06); it reduced hospital charges by USD 25,937 (p < 0.0001) and LOS by 1.3 days (p = 0.0004) per hospitalization. Palliative care was positively associated with female gender, severe disease, and age group ≥80 (p ≤ 0.05). The average LOS was 8.5 days for each admission. Conclusions—Hospital admissions with palliative care utilization had lower hospital charges and LOS in ECC. However, ECC patients received less palliative care compared with more common cancers sharing similar symptoms (e.g., pancreatic cancer). ECC patients also had longer LOS compared with the national average. Further research is warranted to develop interventions to increase palliative care utilization among ECC hospital patients.
Collapse
|
19
|
Abril MK, Berkowitz DM, Chen Y, Waller LA, Martin GS, Kempker JA. The Epidemiology of Adult Tracheostomy in the United States 2002-2017: A Serial Cross-Sectional Study. Crit Care Explor 2021; 3:e0523. [PMID: 34589711 PMCID: PMC8437212 DOI: 10.1097/cce.0000000000000523] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Describe the longitudinal national epidemiology of tracheostomies performed in acute care hospitals and describe the annual rate of tracheostomy performed for patients with respiratory failure with invasive mechanical ventilation. DESIGN Serial cross-sectional study. SETTING The 2002-2014 and 2016-2017 Healthcare Utilization Project's National Inpatient Sample datasets. PATIENTS Discharges greater than or equal to 18 years old, excluding those with head and neck cancer or transferred from another hospital. We used diagnostic and procedure codes from the International Classification of Diseases, 9th and 10th revisions to define cases of respiratory failure, invasive mechanical ventilation, and tracheostomy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were an estimated 80,612 tracheostomies performed in 2002, a peak of 89,545 tracheostomies in 2008, and a nadir of 58,840 tracheostomies in 2017. The annual occurrence rate was 37.5 (95% CI, 34.7-40.4) tracheostomies per 100,000 U.S. adults in 2002, with a peak of 39.7 (95% CI, 36.5-42.9) in 2003, and with a nadir of 28.4 (95% CI, 27.2-29.6) in 2017. Specifically, among the subgroup of hospital discharges with respiratory failure with invasive mechanical ventilation, an annual average of 9.6% received tracheostomy in the hospital. This changed over the study period from 10.4% in 2002, with a peak of 10.9% in 2004, and with a nadir of 7.4% in 2017. Among respiratory failure with invasive mechanical ventilation discharges with tracheostomy, the annual proportion of patients 50-59 and 60-69 years old increased, whereas patients from 70 to 79 and greater than or equal to 80 years old decreased. The mean hospital length of stay decreased, and in-hospital mortality decreased, whereas discharge to intermediate care facilities increased. CONCLUSIONS Over the study period, there were decreases in the annual total case volume and adult occurrence rate of tracheostomy as well as decreases in the rate of tracheostomy among the subgroup with respiratory failure with invasive mechanical ventilation. There is some evidence of changing patterns of patient selection for in-hospital tracheostomy among those with respiratory failure with invasive mechanical ventilation with decreasing proportions of patients with advanced age.
Collapse
Affiliation(s)
- Maria K Abril
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| | - David M Berkowitz
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| | - Yunyun Chen
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Lance A Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jordan A Kempker
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
20
|
Kubendran S, Schockett E, Jackson E, Huynh-Le MP, Roberti F, Rao YJ, Ojong-Ntui M, Goyal S. Trends in inpatient palliative care use for primary brain malignancies. Support Care Cancer 2021; 29:6625-6632. [PMID: 33945016 DOI: 10.1007/s00520-021-06255-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/26/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Primary brain malignancies (PBMs) pose significant morbidity and poor prognosis. Despite NCCN recommendations that palliative care should be integrated into general oncologic care plans, it has been historically underused in patients with PBM. We sought to examine trends and factors associated with inpatient palliative care use in patients with PBM. METHODS Data from the 2007-2016 National (Nationwide) Inpatient Sample was analyzed for descriptive statistics and trends. Multivariable logistic regression was used to identify factors associated with inpatient palliative care in patients with PBMs. RESULTS Of the 510,238 observed hospitalizations of adults with PBM in a 10-year period, 37,365 (7.3%) had an associated inpatient palliative care consult. Rates of inpatient palliative care have increased significantly over the 10-year period, from 2.3 in 2007 to 11.9% in 2011. Patients receiving inpatient palliative care were less likely to receive inpatient oncologic treatment such as brain surgery, chemotherapy, or radiation compared to those without palliative care (14.6% with palliative care vs. 42.4% without, p < 0.001). They were more likely to receive life-sustaining treatments such as intubation, mechanical ventilation, tracheostomy, nutritional support, hemodialysis, or CPR (21.0% with palliative care vs. 10.4% without, p < 0.001). Palliative care was associated with decreased cost of admission ($18,602 with palliative care vs. $20,077 without). In a multiple variable logistic regression, age, non-elective admission, comorbidities, history of chemotherapy and radiation, and mechanical ventilation were associated with significantly increased odds of receiving palliative care. CONCLUSIONS Inpatient palliative care utilization for patients hospitalized with PBM significantly increased between 2007 and 2016, though the service is still underutilized in the context of the severe symptoms and poor prognosis associated with PBM.
Collapse
Affiliation(s)
- Sindhu Kubendran
- George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue, NW, DC Level, Washington, DC, 20037, USA
| | - Erica Schockett
- George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue, NW, DC Level, Washington, DC, 20037, USA
| | - Erin Jackson
- George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue, NW, DC Level, Washington, DC, 20037, USA
| | - Minh Phuong Huynh-Le
- George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue, NW, DC Level, Washington, DC, 20037, USA
| | - Fabio Roberti
- George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue, NW, DC Level, Washington, DC, 20037, USA
| | - Yuan James Rao
- George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue, NW, DC Level, Washington, DC, 20037, USA
| | - Martin Ojong-Ntui
- George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue, NW, DC Level, Washington, DC, 20037, USA
| | - Sharad Goyal
- George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Avenue, NW, DC Level, Washington, DC, 20037, USA.
| |
Collapse
|
21
|
Chou CP, Lai WA, Pan BL, Yang YH, Huang KS. Effects of Hospice Care for Terminal Head and Neck Cancer Patients: A Nationwide Population-Based Matched Cohort Study. J Palliat Med 2021; 24:1299-1306. [PMID: 33434098 DOI: 10.1089/jpm.2020.0375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Background: Head and neck cancer was the fourth-most common cause of cancer death among Taiwanese men in 2018. Hospice care has been proven to reduce the use of invasive medical interventions and expenditures in caring for cancer patients. Aim: This study examined the effects of hospice care for terminal head and neck cancer patients. Design: A matched cohort study was used to compare the use of invasive interventions and expenditures among hospice care and nonhospice care patients. Setting/Participants: The investigated patients consisted of patients who died of head and neck cancer in Taiwan from 2004 to 2013 and were included in the Registry for Catastrophic Illness Patients in Taiwan and the Taiwan National Health Research Insurance Database. Results: A total of 45,948 terminal head and neck cancer patients were identified, and 9883 patients remained in each group after matching for comorbidities. After that matching, the rates of intensive care unit admission (23.9% vs. 38.94%, p < 0.0001), endotracheal intubation (10.05% vs. 31.32%, p < 0.0001), cardiopulmonary resuscitation (2.93% vs. 20.18%, p < 0.0001), defibrillation (0.51% vs. 4.36%. p < 0.0001), ventilator use (21.92% vs. 46.47%, p < 0.0001), blood transfusion (71.25% vs. 73.45%, p = 0.006), and hemodialysis (1.06% vs. 3.26%. p < 0.0001) were significantly lower in the hospice group than the nonhospice group, although the rates of parenteral nutrition for the two groups were similar (7.74% vs. 7.97%, p = 0.5432). The mean medical expenditure per person in the six months before death was 460,531 New Taiwan Dollar (NTD) for the nonhospice group and 389,079 NTD for those provided hospice care for more than three months, which was the lowest amount among various hospice enrollment durations. Conclusions: Hospice care can effectively reduce the use of invasive medical interventions in caring for terminal head and neck cancer patients and may improve their quality of death. Moreover, hospice care enrollment for more than three months can save on unnecessary medical expenditures for terminal head and neck cancer patients.
Collapse
Affiliation(s)
- Chia-Pei Chou
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-An Lai
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Bo-Lin Pan
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yao-Hsu Yang
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kun-Siang Huang
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| |
Collapse
|
22
|
Ko YT, Ko MC, Huang CM, Lien HY, Woung LC, Huang SJ. Trends of Utilization of Palliative Care and Aggressive End-of-Life Care for Patients Who Died of Cancers and Those Who Died of Noncancer Diseases in Hospitals. J Pain Symptom Manage 2020; 60:1136-1143. [PMID: 32619671 DOI: 10.1016/j.jpainsymman.2020.06.037] [Citation(s) in RCA: 2] [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: 04/24/2020] [Revised: 06/20/2020] [Accepted: 06/23/2020] [Indexed: 01/31/2023]
Abstract
CONTEXT Patients who died of cancers and those who died of noncancer diseases may receive different end-of-life care. OBJECTIVES This study aimed to evaluate the trends of utilization of palliative care and aggressive end-of-life care for patients who died of cancers and those who died of noncancer diseases in hospitals. METHODS The medical records of patients who died in a public hospital because of cancer or other diseases were reviewed. The proportion of those who received palliative care, admitted to intensive care unit (ICU) within 30 days of death, died in ICU, and received cardiopulmonary resuscitation (CPR) within three days of death in 2013-2014, 2015-2016, and 2017-2018, respectively, was investigated. Multivariate logistic regression was applied to evaluate the independent effects of various factors on the risk of receiving aggressive end-of-life care. RESULTS Significant trends of increase in receiving palliative care were found. The proportion of patients who died of noncancer diseases and received palliative care was lower than that of those who died of cancers. Palliative care was associated with a reduced risk of ICU admission within 30 days of death (adjusted odds ratio [AOR] 0.361), death in ICU (AOR 0.208), and receiving CPR within three days of death (AOR 0.057). Patients who died of noncancer diseases had a higher risk of ICU admission within 30 days of death (AOR 5.016), death in ICU (AOR 5.086), and receiving CPR within three days of death (AOR 3.274). CONCLUSION Utilization of palliative care is increasing. Patients who died of noncancer diseases received less palliative care but more aggressive end-of-life care than those who died of cancers.
Collapse
Affiliation(s)
- Yen-Ting Ko
- School of Medicine, Tzu Chi University, Hualien, Taiwan; Department of Medical Education, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Ming-Chung Ko
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan; Taipei City Hospital, Taipei City, Taiwan
| | | | - Hsin-Yi Lien
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan; Taipei City Hospital, Taipei City, Taiwan
| | - Lin-Chung Woung
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan; Taipei City Hospital, Taipei City, Taiwan; School of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Sheng-Jean Huang
- Taipei City Hospital, Taipei City, Taiwan; School of Medicine, National Taiwan University, Taipei City, Taiwan.
| |
Collapse
|
23
|
Pottash M, McCamey D, Groninger H, Aulisi EF, Chang JJ. Palliative Care Consultation and Effect on Length of Stay in a Tertiary-Level Neurological Intensive Care Unit. Palliat Med Rep 2020; 1:161-165. [PMID: 34223471 PMCID: PMC8241345 DOI: 10.1089/pmr.2020.0051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Patients admitted to an acute care setting with a devastating brain injury are at high risk for morbidity and mortality. These patients and their families can benefit from the psychosocial and decision-making support of a palliative care consultation. Objective: We aim to investigate the characteristics and impact of palliative care consultation for patients under the management of neurosurgical and critical care services with a devastating brain injury in a neurological intensive care unit (ICU) at a large tertiary-care hospital. Design: Data were collected by retrospective review of the electronic medical record and metrics collected by the palliative care service. Data were analyzed using descriptive statistics. Linear regression analysis was performed to assess effect of timing of palliative care consultation. Results: Fifty-five patients admitted to the neurological ICU under the management of the neurosurgical service received a palliative care consultation for the following: hemorrhagic stroke (49%), metastatic cancer (22%), and traumatic brain injury (18%). Of these, 73% had at least one neurosurgical intervention. Palliative care was most frequently consulted for assistance in defining a patient's goals of care (88%). When compared with late consultation, early palliative care consultation was significantly associated with shorter mean length of stay (LOS) and positively correlated in linear regression analysis without an effect on mortality. Conclusions: When compared with a late consultation, early palliative care consultation corresponded to shorter LOS without increasing mortality. One reason for this effect may be that palliative care can help to clarify and document goals of care earlier and more concretely.
Collapse
Affiliation(s)
- Michael Pottash
- Division of Palliative Medicine, Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Danielle McCamey
- Department of Critical Care and Preanesthesia, MedStar Washington Hospital Center, Washington, DC, USA
| | - Hunter Groninger
- Division of Palliative Medicine, Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Edward F Aulisi
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Neurology, Georgetown University School of Medicine, Washington, DC, USA
| |
Collapse
|