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Ilea P, Ilea I. Administrative burden for patients in U.S. health care settings Post-Affordable Care Act: A scoping review. Soc Sci Med 2024; 345:116686. [PMID: 38368662 DOI: 10.1016/j.socscimed.2024.116686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 01/20/2024] [Accepted: 02/08/2024] [Indexed: 02/20/2024]
Abstract
Administrative burdens are the costs associated with receiving a service or accessing a program. Based on the Herd & Moynihan framework, they occur in three subcategories: learning costs, compliance costs, and psychological costs. Administrative burdens manifest inequitably, more significantly impacting vulnerable populations. Administrative burdens may impact the health of those trying to access services, and in some cases block access to health-promoting services entirely. This scoping review examined studies focused on the impact on patients of administrative burden administrative burden in health care settings in the U.S. following the passage of the Affordable Care Act. We queried databases for empirical literature capturing patient administrative burden, retrieving 1578 records, with 31 articles ultimately eligible for inclusion. Of the 31 included studies, 18 used quantitative methods, nine used qualitative methods, three used mixed methods, and one was a case study. In terms of administrative burden subcategories, most patient outcomes reported were learning (22 studies) and compliance costs (26 studies). Psychological costs were the most rarely reported; all four studies describing psychological costs were qualitative in nature. Only twelve studies connected patient demographic data with administrative burden data, despite previous research suggesting an inequitable burden impact. Additionally, twenty-eight studies assessed administrative burden and only three attempted to reduce it via an intervention, resulting in a lack of data on intervention design and efficacy.
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Affiliation(s)
- Passion Ilea
- Portland State University, School of Social Work, 1800 SW 6th Avenue, Portland, OR, 97201, 503.725.4040, USA.
| | - Ian Ilea
- The Center to Improve Veteran Involvement in Care, Portland VA Research Foundation, USA
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2
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Barrett TA, MacEwan SR, Melnyk H, Di Tosto G, Rush LJ, Shiu-Yee K, Volney J, Singer J, Benza R, McAlearney AS. The Role of Palliative Care in Heart Failure, Part 3: Facilitators and Barriers to Cardiac Palliative Care Clinic Development. J Palliat Med 2023; 26:1685-1690. [PMID: 37878332 DOI: 10.1089/jpm.2022.0597] [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: 10/26/2023] Open
Abstract
Background: Patients with heart failure frequently have significant disease burden and complex psychosocial needs. The integration of palliative care into the management of these patients can decrease symptom burden throughout their course of illness. Therefore, in 2009, we established a cardiac palliative care clinic colocated with heart failure providers in a large academic heart hospital. Objective: To better understand the facilitators and barriers to integrating palliative care into our heart failure management service. Design: Qualitative study using a semistructured interview guide. Setting, Subjects: Between October 2020 and January 2021, we invited all 25 primary cardiac providers at our academic medical center in the midwestern United States to participate in semistructured qualitative interviews to discuss their experiences with the cardiac palliative care clinic. Measurements: Interview transcripts were analyzed using a deductive-dominant thematic analysis approach to reveal emerging themes. Results: Providers noted that the integration of palliative care into the treatment of patients with heart failure was helped and hindered primarily by issues related to operations and communications. Operational themes about clinic proximity and the use of telehealth as well as communication themes around provider-provider communication and the understanding of palliative care were particularly salient. Conclusions: The facilitators and barriers identified have broad applicability that are independent of the etiological nature (e.g., cancer, pulmonary, neurological) of any specialty or palliative care clinic. Moreover, the strategies we used to implement improvements in our clinic may be of benefit to other practice models such as independent and embedded clinics.
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Affiliation(s)
- Todd A Barrett
- Division of Palliative Medicine, Department of Internal Medicine, Richard M. Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Sarah R MacEwan
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Division of General Internal Medicine, Department of Internal Medicine, and College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Halia Melnyk
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Gennaro Di Tosto
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Laura J Rush
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Karen Shiu-Yee
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jaclyn Volney
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jonathan Singer
- Department of Psychology, The Ohio State University, Columbus, Ohio, USA
| | - Raymond Benza
- Division of Cardiology, Heart, and Vascular Institute/Richard M. Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ann Scheck McAlearney
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, Ohio, USA
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3
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Stockman LS, Gundersen DA, Gikandi A, Akindele RN, Svoboda L, Pohl S, Drews MR, Lathan CS. The Colocation Model in Community Cancer Care: A Description of Patient Clinical and Demographic Attributes and Referral Pathways. JCO Oncol Pract 2023:OP2200487. [PMID: 36940391 DOI: 10.1200/op.22.00487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Abstract
PURPOSE Cancer disparities are well documented among Black, Indigenous, and People of Color, yet little is known about the characteristics of programs that serve these populations. Integrating specialized cancer care services within community settings is important for addressing the needs of historically marginalized populations. Our National Cancer Institute-Designated Cancer Center initiated a clinical outreach program incorporating cancer diagnostic services and patient navigation within a Federally Qualified Health Center (FQHC) to expedite evaluation and resolution of potential cancer diagnoses with the goal of collaboration between oncology specialists and primary care providers in a historically marginalized community in Boston, MA. MATERIALS AND METHODS Sociodemographic and clinical characteristics were analyzed from patients who were referred to the program for cancer-related care between January 2012 and July 2018. RESULTS The majority of patients self-identified as Black (non-Hispanic) followed by Hispanic (Black and White). Twenty-two percent of patients had a cancer diagnosis. Treatment and surveillance plans were established for those with and without cancer at a median time to diagnostic resolution of 12 and 28 days, respectively. The majority of patients presented with comorbid health conditions. There was a high prevalence of self-reported financial distress among patients seeking care through this program. CONCLUSION These findings highlight the wide spectrum of cancer care concerns in historically marginalized communities. This review of the program suggests that integrating cancer evaluation services within community-based primary health care settings offers promise for enhancing the coordination and delivery of cancer diagnostic services among historically marginalized populations and could be a method to address clinical access disparities.
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Affiliation(s)
- Leah S Stockman
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Daniel A Gundersen
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ajami Gikandi
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ruth N Akindele
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ludmila Svoboda
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Sarah Pohl
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Christopher S Lathan
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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Rosenblum RE, Ormond E, Smith CW, Bilderback AL, Altieri Dunn SC, Buchanan D, Geramita EM, Rossetti JM, Bhatnagar M, Arnold RM. Institution of Standardized Consultation Criteria to Increase Early Palliative Care Utilization in Older Patients With Acute Leukemia. JCO Oncol Pract 2023; 19:e161-e166. [PMID: 36170636 DOI: 10.1200/op.22.00269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Older patients with acute leukemia (AL) have a high symptom burden and poor prognosis. Although integration of palliative care (PC) with oncologic care has been shown to improve quality-of-life and end-of-life care in patients with AL, the malignant hematologists at our tertiary care hospital make limited use of PC services and do so late in the disease course. Using the Plan-Do-Study-Act (PDSA) methodology, we aimed to increase early PC utilization by older patients with newly diagnosed AL. METHODS We instituted the following standardized criteria to trigger inpatient PC consultation: (1) age 70 years and older and (2) new AL diagnosis within 8 weeks. PC consultations were tracked during sequential PDSA cycles in 2021 and compared with baseline rates in 2019. We also assessed the frequency of subsequent PC encounters in patients who received a triggered inpatient PC consult. RESULTS The baseline PC consultation rate before our intervention was 55%. This increased to 77% and 80% during PDSA cycles 1 and 2, respectively. The median time from diagnosis to first PC consult decreased from 49 days to 7 days. Among patients who received a triggered PC consult, 43% had no subsequent inpatient or outpatient PC encounter after discharge. CONCLUSION Although standardized PC consultation criteria led to earlier PC consultation in older patients with AL, it did not result in sustained PC follow-up throughout the disease trajectory. Future PDSA cycles will focus on identifying strategies to maintain the integration of PC with oncologic care over time, particularly in the ambulatory setting.
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Affiliation(s)
- Rachel E Rosenblum
- Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ellen Ormond
- Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Crystal W Smith
- The Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Dan Buchanan
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Emily M Geramita
- Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - James M Rossetti
- Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mamta Bhatnagar
- Palliative and Supportive Care Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Robert M Arnold
- Palliative and Supportive Care Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
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Islami F, Guerra CE, Minihan A, Yabroff KR, Fedewa SA, Sloan K, Wiedt TL, Thomson B, Siegel RL, Nargis N, Winn RA, Lacasse L, Makaroff L, Daniels EC, Patel AV, Cance WG, Jemal A. American Cancer Society's report on the status of cancer disparities in the United States, 2021. CA Cancer J Clin 2022; 72:112-143. [PMID: 34878180 DOI: 10.3322/caac.21703] [Citation(s) in RCA: 86] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 02/06/2023] Open
Abstract
In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.
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Affiliation(s)
- Farhad Islami
- Cancer Disparity Research, Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Carmen E Guerra
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adair Minihan
- Screening and Risk Factors Research, Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - K Robin Yabroff
- Health Services Research, Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Stacey A Fedewa
- Screening and Risk Factors Research, Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Kirsten Sloan
- Public Policy, American Cancer Society Cancer Action Network, Washington, District of Columbia
| | - Tracy L Wiedt
- Health Equity, Prevention and Early Detection, American Cancer Society, Atlanta, Georgia
| | - Blake Thomson
- Cancer Disparity Research, Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Rebecca L Siegel
- Surveillance Research, Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Nigar Nargis
- Tobacco Control Research, Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Robert A Winn
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - Lisa Lacasse
- American Cancer Society Cancer Action Network, Washington, District of Columbia
| | - Laura Makaroff
- Prevention and Early Detection, American Cancer Society, Atlanta, Georgia
| | - Elvan C Daniels
- Extramural Discovery Science, American Cancer Society, Atlanta, Georgia
| | - Alpa V Patel
- Department of Population Science, American Cancer Society, Atlanta, Georgia
| | - William G Cance
- Office of the Chief Medical and Scientific Officer, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
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van Steijn D, Pons Izquierdo JJ, Garralda Domezain E, Sánchez-Cárdenas MA, Centeno Cortés C. Population's Potential Accessibility to Specialized Palliative Care Services: A Comparative Study in Three European Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910345. [PMID: 34639645 PMCID: PMC8507925 DOI: 10.3390/ijerph181910345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/15/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Palliative care is a priority for health systems worldwide, yet equity in access remains unknown. To shed light on this issue, this study compares populations' driving time to specialized palliative care services in three countries: Ireland, Spain, and Switzerland. METHODS Network analysis of the population's driving time to services according to geolocated palliative care services using Geographical Information System (GIS). Percentage of the population living within a 30-min driving time, between 30 and 60 minutes, and over 60 min were calculated. RESULTS The percentage of the population living less than thirty minutes away from the nearest palliative care provider varies among Ireland (84%), Spain (79%), and Switzerland (95%). Percentages of the population over an hour away from services were 1.87% in Spain, 0.58% in Ireland, and 0.51% in Switzerland. CONCLUSION Inequities in access to specialized palliative care are noticeable amongst countries, with implications also at the sub-national level.
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Affiliation(s)
- Danny van Steijn
- ATLANTES Research Group, Institute for Culture and Society, University of Navarra, 31009 Pamplona, Navarra, Spain; (J.J.P.I.); (E.G.D.); (M.A.S.-C.); (C.C.C.)
- Navarra Institute for Health Research (IdiSNA), Recinto de Complejo Hospitalario de Navarra C/Irunlarrea, 3, 31008 Pamplona, Navarra, Spain
- Correspondence:
| | - Juan José Pons Izquierdo
- ATLANTES Research Group, Institute for Culture and Society, University of Navarra, 31009 Pamplona, Navarra, Spain; (J.J.P.I.); (E.G.D.); (M.A.S.-C.); (C.C.C.)
- School of Humanities and Social Sciences, University of Navarra, 31009 Pamplona, Navarra, Spain
| | - Eduardo Garralda Domezain
- ATLANTES Research Group, Institute for Culture and Society, University of Navarra, 31009 Pamplona, Navarra, Spain; (J.J.P.I.); (E.G.D.); (M.A.S.-C.); (C.C.C.)
- Navarra Institute for Health Research (IdiSNA), Recinto de Complejo Hospitalario de Navarra C/Irunlarrea, 3, 31008 Pamplona, Navarra, Spain
| | - Miguel Antonio Sánchez-Cárdenas
- ATLANTES Research Group, Institute for Culture and Society, University of Navarra, 31009 Pamplona, Navarra, Spain; (J.J.P.I.); (E.G.D.); (M.A.S.-C.); (C.C.C.)
- Navarra Institute for Health Research (IdiSNA), Recinto de Complejo Hospitalario de Navarra C/Irunlarrea, 3, 31008 Pamplona, Navarra, Spain
| | - Carlos Centeno Cortés
- ATLANTES Research Group, Institute for Culture and Society, University of Navarra, 31009 Pamplona, Navarra, Spain; (J.J.P.I.); (E.G.D.); (M.A.S.-C.); (C.C.C.)
- Navarra Institute for Health Research (IdiSNA), Recinto de Complejo Hospitalario de Navarra C/Irunlarrea, 3, 31008 Pamplona, Navarra, Spain
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Schenker Y, Hamm M, Bulls HW, Merlin JS, Wasilko R, Dawdani A, Kenkre B, Belin S, Sabik LM. This Is a Different Patient Population: Opioid Prescribing Challenges for Patients With Cancer-Related Pain. JCO Oncol Pract 2021; 17:e1030-e1037. [PMID: 33848194 DOI: 10.1200/op.20.01041] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Responses to the opioid epidemic in the United States, including efforts to monitor and limit prescriptions for noncancer pain, may be affecting patients with cancer. Oncologists' views on how the opioid epidemic may be influencing treatment of cancer-related pain are not well understood. METHODS We conducted a multisite qualitative interview study with 26 oncologists from a mix of urban and rural practices in Western Pennsylvania. The interview guide asked about oncologists' views of and experiences in treating cancer-related pain in the context of the opioid epidemic. A multidisciplinary team conducted thematic analysis of interview transcripts to identify and refine themes related to challenges to safe and effective opioid prescribing for cancer-related pain and recommendations for improvement. RESULTS Oncologists described three main challenges: (1) patients who receive opioids for cancer-related pain feel stigmatized by clinicians, pharmacists, and society; (2) patients with cancer-related pain fear becoming addicted, which affects their willingness to accept prescription opioids; and (3) guidelines for safe and effective opioid prescribing are often misinterpreted, leading to access issues. Suggested improvements included educational materials for patients and families, efforts to better inform prescribers and the public about safe and appropriate uses of opioids for cancer-related pain, and additional support from pain and/or palliative care specialists. CONCLUSION Challenges to safe and effective opioid prescribing for cancer-related pain include opioid stigma and access barriers. Interventions that address opioid stigma and provide additional resources for clinicians navigating complex opioid prescribing guidelines may help to optimize cancer pain treatment.
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Affiliation(s)
- Yael Schenker
- Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Megan Hamm
- Qualitative, Evaluation and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Hailey W Bulls
- Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jessica S Merlin
- Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rachel Wasilko
- Qualitative, Evaluation and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Alicia Dawdani
- Qualitative, Evaluation and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Balchandre Kenkre
- Qualitative, Evaluation and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Shane Belin
- Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lindsay M Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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Osarogiagbon RU, Sineshaw HM, Unger JM, Acuña-Villaorduña A, Goel S. Immune-Based Cancer Treatment: Addressing Disparities in Access and Outcomes. Am Soc Clin Oncol Educ Book 2021; 41:1-13. [PMID: 33830825 DOI: 10.1200/edbk_323523] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Avoidable differences in the care and outcomes of patients with cancer (i.e., cancer care disparities) emerge or worsen with discoveries of new, more effective approaches to cancer diagnosis and treatment. The rapidly expanding use of immunotherapy for many different cancers across the spectrum from late to early stages has, predictably, been followed by emerging evidence of disparities in access to these highly effective but expensive treatments. The danger that these new treatments will further widen preexisting cancer care and outcome disparities requires urgent corrective intervention. Using a multilevel etiologic framework that categorizes the targets of intervention at the individual, provider, health care system, and social policy levels, we discuss options for a comprehensive approach to prevent and, where necessary, eliminate disparities in access to the clinical trials that are defining the optimal use of immunotherapy for cancer, as well as its safe use in routine care among appropriately diverse populations. We make the case that, contrary to the traditional focus on the individual level in descriptive reports of health care disparities, there is sequentially greater leverage at the provider, health care system, and social policy levels to overcome the challenge of cancer care and outcomes disparities, including access to immunotherapy. We also cite examples of effective government-sponsored and policy-level interventions, such as the National Cancer Institute Minority-Underserved Community Oncology Research Program and the Affordable Care Act, that have expanded clinical trial access and access to high-quality cancer care in general.
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Affiliation(s)
| | | | - Joseph M Unger
- Health Services Research, Public Health Sciences Division, Fred Hutchinson Cancer Research Center Affiliate, University of Washington, Seattle, WA
| | | | - Sanjay Goel
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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9
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Berchuck JE, Meyer CS, Zhang N, Berchuck CM, Trivedi NN, Cohen B, Wang S. Association of Mental Health Treatment With Outcomes for US Veterans Diagnosed With Non-Small Cell Lung Cancer. JAMA Oncol 2021; 6:1055-1062. [PMID: 32496507 DOI: 10.1001/jamaoncol.2020.1466] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Preexisting mental health disorders (MHDs) are associated with increased mortality in people diagnosed with cancer, yet few data exist on the efficacy of interventions to mitigate this disparity. Objective To evaluate the association of participation in mental health treatment programs (MHTPs), housing support programs, or employment support programs with stage at cancer diagnosis, receipt of stage-appropriate treatment, and mortality among patients with a preexisting MHD. Design, Setting, and Participants This retrospective, population-based cohort study included 55 315 veterans in the Veterans Affairs Central Cancer Registry (VACCR) who had newly diagnosed non-small cell lung cancer (NSCLC) from September 30, 2000, to December 31, 2011. Data were analyzed from January 15, 2017, to March 17, 2020. Exposures Mental health disorders, including schizophrenia, bipolar disorder, depressive disorder, posttraumatic stress disorder, and substance use disorder. Main Outcomes and Measures Stage at cancer diagnosis, receipt of stage-appropriate cancer treatment, all-cause mortality, and lung cancer-specific mortality. Results Of 55 315 veterans with a new diagnosis of NSCLC included in the analysis (98.1% men; mean [SD] age, 68.1 [9.8] years), 18 229 had a preexisting MHD, among whom participation in MHTPs was associated with a lower likelihood of being diagnosed in a late stage (odds ratio [OR], 0.62; 95% CI, 0.58-0.66; P < .001), a higher likelihood of receiving stage-appropriate treatment (OR, 1.55; 95% CI, 1.26-1.89; P < .001), lower all-cause mortality (adjusted hazard ratio [AHR], 0.74; 95% CI, 0.72-0.77; P < .001), and lower lung cancer-specific mortality (AHR, 0.77; 95% CI, 0.74-0.80; P < .001). Likewise, participation in housing and employment support programs was associated with similar improvements in all outcomes described above. Conclusions and Relevance In veterans with preexisting MHDs diagnosed with NSCLC, participation in MHTPs and housing and employment support programs was associated with improved lung cancer-related outcomes. This study might be the first to demonstrate significant improvement in cancer mortality for patients with MHDs who participate in MHTPs, housing support programs, or employment support programs. This work supports substantial literature that investment in mental health and social needs can improve health outcomes and highlights the importance of further research to identify, evaluate, and implement interventions to improve outcomes for patients with MHDs who are diagnosed with cancer.
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Affiliation(s)
- Jacob E Berchuck
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Craig S Meyer
- Department of Medicine, School of Medicine, University of California, San Francisco
| | - Ning Zhang
- Department of Medicine, School of Medicine, University of California, San Francisco
| | | | - Neil N Trivedi
- Division of Pulmonary/Critical Care Medicine, San Francisco Veterans Affairs Medical Center and University of California, San Francisco
| | - Beth Cohen
- Department of Medicine, School of Medicine, University of California, San Francisco.,Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Sunny Wang
- Department of Medicine, School of Medicine, University of California, San Francisco.,Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Hematology/Oncology, San Francisco Veterans Affairs Medical Center, San Francisco, California
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10
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Dillon EC, Meehan A, Li J, Liang SY, Lai S, Colocci N, Roth J, Szwerinski NK, Luft H. How, when, and why individuals with stage IV cancer seen in an outpatient setting are referred to palliative care: a mixed methods study. Support Care Cancer 2020; 29:669-678. [PMID: 32430601 DOI: 10.1007/s00520-020-05492-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/20/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Early palliative care (PC) for individuals with advanced cancer improves patient and family outcomes and experience. However, it is unknown when, why, and how in an outpatient setting individuals with stage IV cancer are referred to PC. METHODS At a large multi-specialty group in the USA with outpatient PC implemented beginning in 2011, clinical records were used to identify adults diagnosed with stage IV cancer after January 1, 2012 and deceased by December 31, 2017 and their PC referrals and hospice use. In-depth interviews were also conducted with 25 members of medical oncology, gynecological oncology, and PC teams and thematically analyzed. RESULTS A total of 705 individuals were diagnosed and died between 2012 and 2017: of these, 332 (47%) were referred to PC, with 48.5% referred early (within 60 days of diagnosis). Among referred patients, 79% received hospice care, versus 55% among patients not referred. Oncologists varied dramatically in their rates of referral to PC. Interviews revealed four referral pathways: early referrals, referrals without active anti-cancer treatment, problem-based referrals, and late referrals (when stopping treatment). Participants described PC's benefits as enhancing pain/symptom management, advance care planning, transitions to hospice, end-of-life experiences, a larger team, and more flexible patient care. Challenges reported included variation in oncologist practices, patient fears and misconceptions, and access to PC teams. CONCLUSION We found high rates of use and appreciation of PC. However, interviews revealed that exclusively focusing on rates of referrals may obscure how referrals vary in timing, reason for referral, and usefulness to patients, families, and clinical teams.
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Affiliation(s)
- Ellis C Dillon
- Center for Health Systems Research, Sutter Health, Palo Alto, CA, USA. .,Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA.
| | - Amy Meehan
- Center for Health Systems Research, Sutter Health, Palo Alto, CA, USA.,Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - Jinnan Li
- Lilly Suzhou Pharmaceutical Co. Ltd, Shanghai, China.,formerly at Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Su-Ying Liang
- Center for Health Systems Research, Sutter Health, Palo Alto, CA, USA.,Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - Steve Lai
- Palo Alto Medical Foundation, Palo Alto, CA, USA
| | | | - Julie Roth
- Palo Alto Medical Foundation, Palo Alto, CA, USA
| | - Nina K Szwerinski
- Center for Health Systems Research, Sutter Health, Palo Alto, CA, USA.,Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - Hal Luft
- Center for Health Systems Research, Sutter Health, Palo Alto, CA, USA.,Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
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11
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Sedhom R, Gupta A, Shah M, Hsu M, Messmer M, Murray J, Browner I, Smith TJ, Marrone K. Oncology Fellow-Led Quality Improvement Project to Improve Rates of Palliative Care Utilization in Patients With Advanced Cancer. JCO Oncol Pract 2020; 16:e814-e822. [PMID: 32339469 DOI: 10.1200/jop.19.00714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. First-year oncology fellows at our institution identified low rates of PC utilization in their longitudinal clinic as a metric needing improvement. METHODS A fellow-led multidisciplinary team aimed to increase PC utilization for patients with advanced cancer followed in he first-year fellows' clinic from a baseline of 11.5% (5 of 43 patients, July to December of 2018) to 30% over a 6-month period. Utilization was defined as evaluation in the outpatient PC clinic hosted in the cancer center. The team identified the following barriers to referral: orders difficult to find in the electronic medical record (EMR), multiple consulting mechanisms (EMR, by phone, or in person), EMR request not activating formal consult, no centralized scheduler to contact or confirm appointment, and poor awareness of team structure. Plan-Do-Study-Act (PDSA) cycles were implemented based on identified opportunities. Data were obtained from the EMR. RESULTS The first PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and disseminating process changes. PDSA cycles were implemented from January to June of 2019. Rates of PC use increased from 11.5% before the intervention to 48.4% (48 of 99 patients) after the intervention. CONCLUSION A multidisciplinary approach and classic quality improvement methodology improved PC use in patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stakeholders, and institutional and leadership support. Straightforward EMR interventions and ancillary staff use are effective in addressing underreferrals.
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Affiliation(s)
- Ramy Sedhom
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Mirat Shah
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Melinda Hsu
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Marcus Messmer
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Joseph Murray
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Ilene Browner
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Thomas J Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Kristen Marrone
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
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12
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Fliedner MC, Hagemann M, Eychmüller S, King C, Lohrmann C, Halfens RJG, Schols JMGA. Does Time for (in)Direct Nursing Care Activities at the End of Life for Patients With or Without Specialized Palliative Care in a University Hospital Differ? A Retrospective Analysis. Am J Hosp Palliat Care 2020; 37:844-852. [PMID: 32180430 DOI: 10.1177/1049909120905779] [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: 11/16/2022] Open
Abstract
BACKGROUND Nurses' end of life (EoL) care focuses on direct (eg, physical) and indirect (e,g, coordination) care. Little is known about how much time nurses actually devote to these activities and if activities change due to support by specialized palliative care (SPC) in hospitalized patients. AIMS (1) Comparing care time for EoL patients receiving SPC to usual palliative care (UPC);(2) Comparing time spent for direct/indirect care in the SPC group before and after SPC. METHODS Retrospective observational study; nursing care time for EoL patients based on tacs® data using nonparametric and parametric tests. The Swiss data method tacs measures (in)direct nursing care time for monitoring and cost analyses. RESULTS Analysis of tacs® data (UPC, n = 642; SPC, n = 104) during hospitalization before death in 2015. Overall, SPC patients had higher tacs® than UPC patients by 40 direct (95% confidence interval [CI]: 5.7-75, P = .023) and 14 indirect tacs® (95% CI: 6.0-23, P < .001). No difference for tacs® by day, as SPC patients were treated for a longer time (mean number of days 7.2 vs 16, P < .001).Subanalysis for SPC patients showed increased direct care time on the day of and after SPC (P < .001), whereas indirect care time increased only on the day of SPC. CONCLUSIONS This study gives insight into nurses' time for (in)direct care activities with/without SPC before death. The higher (in)direct nursing care time in SPC patients compared to UPC may reflect higher complexity. Consensus-based measurements to monitor nurses' care activities may be helpful for benchmarking or reimbursement analysis.
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Affiliation(s)
- Monica C Fliedner
- Department of Oncology, University Center for Palliative Care, Inselspital, University Hospital, Bern, Switzerland.,Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Monika Hagemann
- Department of Oncology, University Center for Palliative Care, Inselspital, University Hospital, Bern, Switzerland
| | - Steffen Eychmüller
- Department of Oncology, University Center for Palliative Care, Inselspital, University Hospital, Bern, Switzerland
| | | | - Christa Lohrmann
- Institute of Nursing Science, Medical University Graz, Graz, Austria
| | - Ruud J G Halfens
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Jos M G A Schols
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands.,Department of Family Medicine; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
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13
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Berry LL, Crane J, Deming KA, Barach P. Using Evidence to Design Cancer Care Facilities. Am J Med Qual 2020; 35:397-404. [DOI: 10.1177/1062860619897406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The nuts and bolts of planning and designing cancer care facilities—the physical space, the social systems, the clinical and nonclinical workflows, and all of the patient-facing services—directly influence the quality of clinical care and the overall patient experience. Cancer facilities should be conceived and constructed on the basis of evidence-based design thinking and implementation, complemented by input from key stakeholders such as patients, families, and clinicians. Specifically, facilities should be designed to improve the patient experience, offer options for urgent care, maximize infection control, support and streamline the work of multidisciplinary teams, integrate research and teaching, incorporate palliative care, and look beyond mere diagnosis and treatment to patient wellness—all tailored to each cancer center’s patient population and logistical and financial constraints. From conception to completion to iterative reevaluation, motivated institutions can learn to make their own facilities reflect the excellence in cancer care that they aim to deliver to patients.
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Affiliation(s)
- Leonard L. Berry
- Texas A&M University, College Station, TX
- Institute for Healthcare Improvement, Boston, MA
| | | | | | - Paul Barach
- Wayne State University, Detroit, MI
- Jefferson College of Population Health, Philadelphia, PA
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14
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15
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Tasneem S, Kim A, Bagheri A, Lebret J. Telemedicine Video Visits for patients receiving palliative care: A qualitative study. Am J Hosp Palliat Care 2019; 36:789-794. [DOI: 10.1177/1049909119846843] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
In this needs assessment, gathered patient perceptions on how telemedicine video visits might influence their care. Patients in this study (n = 13) were all diagnosed with end-stage cancer and were receiving palliative care at an urban academic medical center. Interview themes addressed: 1. impact on patient's health management, 2. user experience, 3. technical issues and 4. cost and time. Ultimately, despite concerns over truncated physical exams and prescription limits, the majority of patients favored having the opportunity for telemedicine video visits, felt that the doctor-patient relationship would not suffer, had confidence in their or their surrogate's technical abilities to navigate the video visit, had privacy concerns on par with other technologies, had few cost concerns, and believed a video alternative to an in-person visit might increase access, save time as well as increase comfort and safety by avoiding a trip to the office. These results suggest potential for acceptance of video-based telemedicine by an urban population of oncology patients receiving palliative care.
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Affiliation(s)
- Sumaiya Tasneem
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - Arum Kim
- Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Ashley Bagheri
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - James Lebret
- Department of Medicine, NYU Langone Health, New York, NY, USA
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