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Chung H, Hyatt A, Webber K, Kosmider S, Krishnasamy M. Value in care: The contribution of supportive care to value-based lung cancer services-A qualitative semistructured interview study. Health Expect 2024; 27:e14089. [PMID: 38769867 PMCID: PMC11106590 DOI: 10.1111/hex.14089] [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: 06/16/2023] [Revised: 04/01/2024] [Accepted: 05/12/2024] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Despite significant advances in the management of lung cancer, patients continue to experience a high burden of unmet need impacting quality of life and outcomes of care. Achieving value-based health care, where investment is targeted to services that deliver optimal experience and outcomes of care relative to the cost of delivering that care, requires attention to what people value most in meeting their needs. To date there has been little attention to what matters most to patients with lung cancer (i.e., what they value) as a component of achieving value-based cancer care. This qualitative study was undertaken to investigate components of care valued by people with lung cancer in Australia. METHODS This qualitative study used semistructured interviews with 23 people with lung cancer. Participants were recruited using a purposive sampling strategy from two metropolitan tertiary public health services. Data collected included demographic characteristics and patient perspectives regarding their priority concerns and components of care identified as most valuable in meeting their needs. Demographic characteristics of participants were analysed descriptively, and qualitative data were analysed thematically using Interpretive Description. RESULTS Data analysis generated three key themes: valued components of care; benefits of receiving valued care components and consequences of missed opportunities for care. The components of care valued by patients reflect the core dimensions of cancer supportive care, with particular emphasis on ongoing opportunities for consultation (screening for unmet needs) and provision of person-centred information. The facilitation of trust between patients and their treating team, as a consequence of having these valued components evident in their care, was identified as a key characteristic of value-based care. CONCLUSIONS This study has identified valued components of care described by people with lung cancer. Importantly, the care components identified have been proven to improve access to and coordination of care, and demonstrate the importance of integrating supportive care into care provision to achieve value-based cancer care. PATIENT OR PUBLIC CONTRIBUTION This study was informed by perspectives of lung cancer patients who participated in semistructured interviews. We acknowledge that this contribution does not meet the criteria for patient and public involvement in research as defined by Health Expectations, but this study forms part of a larger program of cancer supportive care work being undertaken by this team, where comprehensive consumer engagement and co-design approaches are embedded in our work.
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Affiliation(s)
- Holly Chung
- Academic Nursing UnitPeter MacCallum Cancer CentreParkvilleVictoriaAustralia
- Department of Health Services ResearchPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | - Amelia Hyatt
- Department of Health Services ResearchPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
- Department of NursingUniversity of MelbourneMelbourneVictoriaAustralia
| | - Kate Webber
- Oncology DepartmentMonash HealthClaytonVictoriaAustralia
- Faculty of Medicine, Nursing and Health Sciences, School of Clinical SciencesMonash UniversityClaytonVictoriaAustralia
| | - Suzanne Kosmider
- Cancer Services, Sunshine HospitalWestern HealthSt AlbansVictoriaAustralia
| | - Meinir Krishnasamy
- Academic Nursing UnitPeter MacCallum Cancer CentreParkvilleVictoriaAustralia
- Sir Peter MacCallum Department of OncologyUniversity of MelbourneMelbourneVictoriaAustralia
- Department of NursingUniversity of MelbourneMelbourneVictoriaAustralia
- Victorian Comprehensive Cancer Centre AllianceMelbourneVictoriaAustralia
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Steinfeldt J, Wild B, Buergel T, Pietzner M, Upmeier Zu Belzen J, Vauvelle A, Hegselmann S, Denaxas S, Hemingway H, Langenberg C, Landmesser U, Deanfield J, Eils R. Medical history predicts phenome-wide disease onset and enables the rapid response to emerging health threats. Nat Commun 2024; 15:4257. [PMID: 38763986 PMCID: PMC11102902 DOI: 10.1038/s41467-024-48568-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 05/03/2024] [Indexed: 05/21/2024] Open
Abstract
The COVID-19 pandemic exposed a global deficiency of systematic, data-driven guidance to identify high-risk individuals. Here, we illustrate the utility of routinely recorded medical history to predict the risk for 1883 diseases across clinical specialties and support the rapid response to emerging health threats such as COVID-19. We developed a neural network to learn from health records of 502,460 UK Biobank. Importantly, we observed discriminative improvements over basic demographic predictors for 1774 (94.3%) endpoints. After transferring the unmodified risk models to the All of US cohort, we replicated these improvements for 1347 (89.8%) of 1500 investigated endpoints, demonstrating generalizability across healthcare systems and historically underrepresented groups. Ultimately, we showed how this approach could have been used to identify individuals vulnerable to severe COVID-19. Our study demonstrates the potential of medical history to support guidance for emerging pandemics by systematically estimating risk for thousands of diseases at once at minimal cost.
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Affiliation(s)
- Jakob Steinfeldt
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Klinik/Centrum, Charitéplatz 1, 10117, Berlin, Germany
- Computational Medicine, Berlin Institute of Health (BIH), Charite - University Medicine Berlin, Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charite, Charite - University Medicine Berlin, Berlin, Germany
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - Benjamin Wild
- Center for Digital Health, Berlin Institute of Health (BIH), Charite - University Medicine Berlin, Berlin, Germany
| | - Thore Buergel
- Institute of Cardiovascular Sciences, University College London, London, UK
- Center for Digital Health, Berlin Institute of Health (BIH), Charite - University Medicine Berlin, Berlin, Germany
| | - Maik Pietzner
- Computational Medicine, Berlin Institute of Health (BIH), Charite - University Medicine Berlin, Berlin, Germany
- MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Precision Health University Research Institute, Queen Mary University of London and Barts NHS Trust, London, UK
| | - Julius Upmeier Zu Belzen
- Center for Digital Health, Berlin Institute of Health (BIH), Charite - University Medicine Berlin, Berlin, Germany
| | - Andre Vauvelle
- Institute of Health Informatics, University College London, London, UK
| | - Stefan Hegselmann
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Massachusetts, USA
- Pattern Recognition and Image Analysis Lab, University of Münster, Münster, Germany
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
- British Heart Foundation Data Science Centre, London, UK
- Health Data Research UK, London, UK
- National Institute for Health Research, Biomedical Research Centre at University College London Hospitals National Institute for Health Research, Biomedical Research Centre, London, UK
| | - Harry Hemingway
- Institute of Health Informatics, University College London, London, UK
- Health Data Research UK, London, UK
- National Institute for Health Research, Biomedical Research Centre at University College London Hospitals National Institute for Health Research, Biomedical Research Centre, London, UK
| | - Claudia Langenberg
- Computational Medicine, Berlin Institute of Health (BIH), Charite - University Medicine Berlin, Berlin, Germany
- MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Precision Health University Research Institute, Queen Mary University of London and Barts NHS Trust, London, UK
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Klinik/Centrum, Charitéplatz 1, 10117, Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charite, Charite - University Medicine Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Charite - University Medicine Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Berlin, Germany
| | - John Deanfield
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - Roland Eils
- Center for Digital Health, Berlin Institute of Health (BIH), Charite - University Medicine Berlin, Berlin, Germany.
- Health Data Science Unit, Heidelberg University Hospital and BioQuant, Heidelberg, Germany.
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Hua M, Guo L, Ing C, Lackraj D, Wang S, Morrison RS. Specialist Palliative Care Use and End-of-Life Care in Patients With Metastatic Cancer. J Pain Symptom Manage 2024; 67:357-365.e15. [PMID: 38278187 PMCID: PMC11032225 DOI: 10.1016/j.jpainsymman.2024.01.029] [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: 11/16/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 01/28/2024]
Abstract
CONTEXT For patients with advanced cancer, high intensity treatment at the end of life is measured as a reflection of the quality of care. Use of specialist palliative care has been promoted to improve care quality, but whether its use is associated with decreased treatment intensity on a population-level is unknown. OBJECTIVES To determine whether receipt of specialist palliative care use is associated with differences in end-of-life quality metrics in patients with metastatic cancer. METHODS Retrospective propensity-matched cohort of patients age ≥ 65 who died with metastatic cancer in U.S. hospitals with palliative care programs that participated in the National Palliative Care Registry in 2018-2019. Cox proportional hazards regression was used to assess the impact of specialist palliative care on use of chemotherapy in the last 14 days of life, use of intensive care unit (ICU) in the last 30 days of life, use of hospice, and hospice enrollment ≥ three days. RESULTS After 1:2 matching, our cohort consisted of 15,878 exposed and 31,756 unexposed patients. Receipt of specialist palliative care was associated with a decrease in use of chemotherapy (adjusted hazard ratio (aHR) 0.59 [0.50-0.70]) and ICU at the end of life (aHR 0.86 [0.80-0.92]), and an increase in hospice use (aHR 1.92 [1.85-1.99]) and hospice enrollment for ≥three days (aHR 2.00 [1.93-2.07]). CONCLUSION On a population-level, use of specialist palliative care was associated with improved metrics for quality end-of-life care for patients dying with metastatic cancer, underscoring the importance of its integration into cancer care.
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Affiliation(s)
- May Hua
- Department of Anesthesiology (M.H., C.I.), College of Physicians and Surgeons, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.
| | - Ling Guo
- Department of Anesthesiology (L.G.), College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Caleb Ing
- Department of Anesthesiology (M.H., C.I.), College of Physicians and Surgeons, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Deven Lackraj
- Department of Anesthesiology (D.L.), Columbia University College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Shuang Wang
- Department of Biostatistics (S.W.), Mailman School of Public Health, Columbia University, New York, New York, USA
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai and James J Peters VA (R.S.M.), Bronx, New York, USA
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Gerhardt S, Benthien KS, Herling S, Leerhøy B, Jarlbaek L, Krarup PM. Associations between health-related quality of life and subsequent need for specialized palliative care and hospital utilization in patients with gastrointestinal cancer-a prospective single-center cohort study. Support Care Cancer 2024; 32:311. [PMID: 38683444 PMCID: PMC11058934 DOI: 10.1007/s00520-024-08509-z] [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: 12/06/2023] [Accepted: 04/15/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND We lack knowledge of which factors are associated with the risk of developing complex palliative care needs. The aim of this study was to investigate the associations between patient-reported health-related quality of life and subsequent referral to specialized palliative care (SPC) and hospital utilization. METHODS This was a prospective single-center cohort study. Data on patient-reported outcomes were collected through the European Organization of Research and Treatment of Cancer Questionnaire-Core-15-Palliative Care (EORTC QLQ-C15-PAL) at the time of diagnosis. Covariates and hospital utilization outcomes were collected from medical records. Adjusted logistic and Poisson regression were applied in the analyses. Participants were newly diagnosed with incurable gastrointestinal cancer and affiliated with a palliative care case management intervention established in a gastroenterology department. RESULTS Out of 397 patients with incurable gastrointestinal cancer, 170 were included in the study. Patients newly diagnosed with incurable gastrointestinal cancer experienced a substantial burden of symptoms. Pain was significantly associated with subsequent referral to SPC (OR 1.015; 95% CI 1.001-1.029). Patients with lower education levels (OR 0.210; 95% CI 0.056-0.778) and a Charlson Comorbidity Index score of 2 or more (OR 0.173; 95% CI 0.041-0.733) were less likely to be referred to SPC. Pain (IRR 1.011; 95% CI 1.005-1.018), constipation (IRR 1.009; 95% CI 1.004-1.015), and impaired overall quality of life (IRR 0.991; 95% CI 0.983-0.999) were significantly associated with increased risk of hospital admissions. CONCLUSION The study indicates a need for interventions in hospital departments to identify and manage the substantial symptom burden experienced by patients, provide palliative care, and ensure timely referral to SPC.
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Affiliation(s)
- Stine Gerhardt
- Digestive Disease Center, Copenhagen University Hospital - Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark.
| | - Kirstine Skov Benthien
- Palliative Care Unit, Copenhagen University Hospital - Hvidovre, Hvidovre, Denmark
- REHPA - Danish Knowledge Centre for Rehabilitation and Palliative Care, University of Southern Denmark, Nyborg, Denmark
| | - Suzanne Herling
- The Neuroscience Center, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Bonna Leerhøy
- Digestive Disease Center, Copenhagen University Hospital - Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
- Centre for Translational Research, Copenhagen University Hospital - Bispebjerg, Copenhagen, Denmark
| | - Lene Jarlbaek
- REHPA - Danish Knowledge Centre for Rehabilitation and Palliative Care, University of Southern Denmark, Nyborg, Denmark
| | - Peter-Martin Krarup
- Digestive Disease Center, Copenhagen University Hospital - Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
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Ahmed S, Simon J, Biondo P, Slobogian V, Shirt L, King S, Paolucci A, Pabani A, Hao D, Bossio E, Cross R, Monds T, Nieuwenhuis J, Sinnarajah A. Acceptability of automatic referrals to supportive and palliative care by patients living with advanced lung cancer: qualitative interviews and a co-design process. RESEARCH INVOLVEMENT AND ENGAGEMENT 2024; 10:36. [PMID: 38566198 PMCID: PMC10985851 DOI: 10.1186/s40900-024-00568-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/21/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE Timely access to supportive and palliative care (PC) remains a challenge. A proposed solution is to trigger an automatic referral process to PC by pre-determined clinical criteria. This study sought to co-design with patients and providers an automatic PC referral process for patients newly diagnosed with stage IV lung cancer. METHODS In Step 1 of this work, nine one on one phone interviews were conducted with advanced lung cancer patients on their perspectives on the acceptability of phone contact by a specialist PC provider triggered by an automatic referral process. Interviews were thematically analysed. Step 2: Patient advisors, healthcare providers (oncologists, nurses from oncology and PC, clinical social worker, psychologist), and researchers were invited to join a working group to provide input on the development and implementation of the automatic referral process. The group met biweekly (virtually) over the course of six months. RESULTS From interviews, the concept of an automatic referral process was perceived to be acceptable and beneficial for patients. Participants emphasized the need for timely support, access to peer and community resources. Using these findings, the co-design working group identified eligibility criteria for identifying newly diagnosed stage IV lung cancer patients using the cancer centre electronic health record, co-developed a telephone script for specialist PC providers, handouts on supportive care, and interview and survey guides for evaluating the implemented automatic process. CONCLUSION A co-design process ensures stakeholders are involved in program development and implementation from the very beginning, to make outputs relevant and acceptable for stage IV lung cancer patients.
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Affiliation(s)
- Sadia Ahmed
- Alberta SPOR SUPPORT Unit, Patient Engagement Team, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.
| | - Jessica Simon
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine University of Calgary, Calgary, AB, Canada
| | - Patricia Biondo
- Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine University of Calgary, Calgary, AB, Canada
| | - Vanessa Slobogian
- Palliative and End of Life Care, Alberta Health Services, Calgary Zone, Calgary, Canada
| | - Lisa Shirt
- Palliative and End of Life Care, Alberta Health Services, Calgary Zone, Calgary, Canada
| | - Seema King
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Alessandra Paolucci
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Aliyah Pabani
- Department of Oncology, Cumming School of Medicine University of Calgary, Calgary, AB, Canada
| | - Desiree Hao
- Department of Oncology, Cumming School of Medicine University of Calgary, Calgary, AB, Canada
| | - Emi Bossio
- Patient and Family Advisor, Alberta Health Services, Calgary, AB, Canada
| | - Ralph Cross
- Patient and Family Advisor, Alberta Health Services, Calgary, AB, Canada
| | - Tim Monds
- Patient and Family Advisor, Alberta Health Services, Calgary, AB, Canada
| | - Jane Nieuwenhuis
- Patient and Family Advisor, Alberta Health Services, Calgary, AB, Canada
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine University of Calgary, Calgary, AB, Canada
- Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
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Müller E, Müller MJ, Boehlke C, Schäfer H, Quante M, Becker G. Screening for Palliative Care Need in Oncology: Validation of Patient-Reported Outcome Measures. J Pain Symptom Manage 2024; 67:279-289.e6. [PMID: 38154625 DOI: 10.1016/j.jpainsymman.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
CONTEXT Leading oncology societies recommend monitoring symptoms and support needs through patient-reported outcome measures (PROMs), but their use for assessing specialist palliative care (SPC) need has not yet been explored. Research on SPC integration has focused on staff-assessed screening tools, which are time-consuming. OBJECTIVES This study aimed to assess the diagnostic validity of the Integrated Palliative Outcome Scale (IPOS) and NCCN Distress Thermometer (NCCN DT) in identifying need for SPC in patients with incurable cancer. METHODS In a cross-sectional study, patients with incurable cancer (prognosis <2 years) completed PROMs. In an independent process, the palliative care consultation service (PCCS) assessed the need for SPC in each patient through multiprofessional case review, and this was used as the reference standard. ROC analyses were employed to determine diagnostic validity. RESULTS Of the 208 participants, 71 (34.1 %) were classified as having SPC need by the PCCS. Aiming for a minimum sensitivity of 80%, a cut-off of ≥2 items with high/very high burden in the IPOS resulted in a 90.2% sensitivity (specificity = 50; AUC = 0.791; CI 95%= 0.724-0.858). A cut-off of ≥5 resulted in a sensitivity of 80 % for NCCN DT (specificity = 49.5 %; AUC = 0.687; CI 95% = 0.596-0.777). CONCLUSION PROMs are useful for identifying SPC need in cancer patients. Their implementation might facilitate timely integration of SPC. Future research should focus on an integrated assessment approach with PROMs that combines the requirements of the different specialties to save patient and staff resources.
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Affiliation(s)
- Evelyn Müller
- Department of Palliative Medicine (E.M., M.J.M., G.B.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Josef Müller
- Department of Palliative Medicine (E.M., M.J.M., G.B.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Christopher Boehlke
- Department of Palliative Care (C.B.), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Henning Schäfer
- Department of Radiation Oncology (H.S.), Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ) Heidelberg, Freiburg, Germany
| | - Michael Quante
- Clinic for Internal Medicine II (M.Q.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gerhild Becker
- Department of Palliative Medicine (E.M., M.J.M., G.B.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Pointon S, Collins A, Philip J. Introducing palliative care in advanced cancer: a systematic review. BMJ Support Palliat Care 2024:spcare-2023-004442. [PMID: 38307704 DOI: 10.1136/spcare-2023-004442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 01/08/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Negative perceptions about palliative care (PC), held by patients with cancer and their families, are a barrier to early referral and the associated benefits. This review examines the approaches that support the task of introducing PC to patients and families and describes any evaluations of these approaches. METHODS A systematic review with a systematic search informed by the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines was performed on the online databases MEDLINE, PsychInfo and CINAHL from May 2022 to July 2022. Identified studies were screened by title and abstract, and included if they were empirical studies and described an approach that supported the introduction of PC services for adult patients. A narrative-synthesis approach was used to extract and present the findings. RESULTS Searches yielded 1193 unique manuscripts, which, following title and abstract screening, were reduced to 31 papers subject to full-text review, with a final 12 studies meeting eligibility criteria. A diverse range of included studies described approaches used to introduce palliative care, which may be broadly summarised by four categories: education, clinical communication, building trust and rapport and integrative system approaches. CONCLUSION While educational approaches were helpful, they were less likely to change behaviours, with focused communication tasks also necessary to facilitate PC introduction. An established relationship and trust between patient and clinician were foundational to effective PC discussions. A framework to assist clinicians in this task is likely to be multidimensional in nature, although more quantitative research is necessary to establish the most effective methods and how they may be incorporated into clinical practice.
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Affiliation(s)
- Samuel Pointon
- Department of Medicine, St Vincent's Hospital, The University of Melbourne, Fitzroy, Victoria, Australia
| | - Anna Collins
- Department of Medicine, St Vincent's Hospital, The University of Melbourne, Fitzroy, Victoria, Australia
| | - Jennifer Philip
- Department of Medicine, St Vincent's Hospital, The University of Melbourne, Fitzroy, Victoria, Australia
- Department of Palliative Care, Peter MacCallum Cancer Centre, and Royal Melbourne Hospital, Parkville, Victoria, Australia
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Lin M, Rholl E, Andescavage N, Ackerman O, Fisher D, Lanzel AF, Mahmood LA. Improving Prenatal Palliative Care Consultation Using Diagnostic Trigger Criteria. J Pain Symptom Manage 2024; 67:e137-e145. [PMID: 37858635 DOI: 10.1016/j.jpainsymman.2023.10.015] [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: 08/08/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Three percent of pregnancies are complicated by congenital anomalies. Prenatal integration of pediatric palliative care (PPC) may be hindered by non-standardized PPC referral processes. This quality improvement (QI) project aimed to improve prenatal PPC consultation using a diagnostic trigger list. MEASURES Main outcome measure was the percentage of prenatal PPC consults completed based on diagnostic trigger list eligibility. Balancing measures included stakeholder perspectives on PPC consults and products. INTERVENTION Interventions included creation and implementation of a diagnostic trigger list for prenatal PPC consultation, educational initiatives with stakeholders, and iterative modifications of our prenatal consultation process. OUTCOMES Interventions increased consultation rates ≥80% during the first six months of QI implementation (baseline vs. post-interventions) although this increase was not consistently sustained over a 12-month period. CONCLUSIONS/LESSONS LEARNED Diagnostic trigger lists improve initial rates of prenatal PPC consultation and additional interventions are likely needed to sustain this increase.
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Affiliation(s)
- Matthew Lin
- Division of Neonatology (M.L.), Department of Pediatrics, New York University School of Medicine, New York, New York, USA.
| | - Erin Rholl
- Division of Neonatology (E.R.), Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nickie Andescavage
- Division of Neonatology (N.A.), Children's National Hospital, Washington, District of Columbia, USA; School of Medicine and Health Sciences (N.A., D.F., A.F.L., L.A.M.), George Washington University, Washington, District of Columbia, USA
| | - Olivia Ackerman
- Prenatal Pediatrics Institute (O.A.), Children's National Hospital, Washington, District of Columbia, USA
| | - Deborah Fisher
- School of Medicine and Health Sciences (N.A., D.F., A.F.L., L.A.M.), George Washington University, Washington, District of Columbia, USA; Pediatric Palliative Care Program (D.F., A.F.L., L.A.M.), Children's National Hospital, Washington, District of Columbia, USA
| | - Ashley F Lanzel
- School of Medicine and Health Sciences (N.A., D.F., A.F.L., L.A.M.), George Washington University, Washington, District of Columbia, USA; Pediatric Palliative Care Program (D.F., A.F.L., L.A.M.), Children's National Hospital, Washington, District of Columbia, USA
| | - Laila A Mahmood
- School of Medicine and Health Sciences (N.A., D.F., A.F.L., L.A.M.), George Washington University, Washington, District of Columbia, USA; Pediatric Palliative Care Program (D.F., A.F.L., L.A.M.), Children's National Hospital, Washington, District of Columbia, USA
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9
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Prsic E, Morris JC, Adelson KB, Parker NA, Gombos EA, Kottarathara MJ, Novosel M, Castillo L, Gould Rothberg BE. Oncology hospitalist impact on hospice utilization. Cancer 2023; 129:3797-3804. [PMID: 37706601 DOI: 10.1002/cncr.35008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/02/2023] [Accepted: 07/15/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Unplanned hospitalizations among patients with advanced cancer are often sentinel events prompting goals of care discussions and hospice transitions. Late referrals to hospice, especially those at the end of life, are associated with decreased quality of life and higher total health care costs. Inpatient management of patients with solid tumor malignancies is increasingly shifting from oncologists to oncology hospitalists. However, little is known about the impact of oncology hospitalists on the timing of transition to hospice. OBJECTIVE To compare hospice discharge rate and time to hospice discharge on an inpatient oncology service led by internal medicine-trained hospitalists and a service led by oncologists. METHODS At Smilow Cancer Hospital, internal medicine-trained hospitalists were integrated into one of two inpatient medical oncology services allowing comparison between the new, hospitalist-led service (HS) and the traditional, oncologist-led service (TS). Discharges from July 26, 2021, through January 31, 2022, were identified from the electronic medical record. The odds ratio for discharge disposition by team was calculated by logistic regression using a multinomial distribution. Adjusted length of stay before discharge was assessed using multivariable linear regression. RESULTS The HS discharged 47/400 (11.8%) patients to inpatient hospice, whereas the TS service discharged 18/313 (5.8%), yielding an adjusted odds ratio of 1.94 (95% CI, 1.07-3.51; p = .03). Adjusted average length of stay before inpatient hospice disposition was 6.83 days (95% CI, 4.22-11.06) for the HS and 16.29 days (95% CI, 7.73-34.29) for the TS (p = .003). CONCLUSIONS Oncology hospitalists improve hospice utilization and time to inpatient hospice referral on an inpatient medical oncology service. PLAIN LANGUAGE SUMMARY Patients with advanced cancer are often admitted to the hospital near the end of life. These patients generally have a poor chance of long-term survival and may prefer comfort-focused care with hospice. In this study, oncology hospitalists discharged a higher proportion of patients to inpatient hospice with less time spent in the hospital before discharge.
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Affiliation(s)
- Elizabeth Prsic
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jensa C Morris
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Hospital Medicine Service, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Kerin B Adelson
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
- Yale University Yale Cancer Center, New Haven, Connecticut, USA
| | - Nathaniel A Parker
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
- Hospital Medicine Service, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Erin A Gombos
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
- Hospital Medicine Service, Yale New Haven Hospital, New Haven, Connecticut, USA
| | | | - Madison Novosel
- Yale University School of Public Health, New Haven, Connecticut, USA
| | - Lawrence Castillo
- Yale University School of Public Health, New Haven, Connecticut, USA
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10
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Müller E, Müller MJ, Seibel K, Boehlke C, Schäfer H, Klein C, Heckel M, Simon ST, Becker G. Interrater agreement of multi-professional case review as reference standard for specialist palliative care need: a mixed-methods study. BMC Palliat Care 2023; 22:181. [PMID: 37974104 PMCID: PMC10652431 DOI: 10.1186/s12904-023-01281-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/11/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND A wide variety of screening tools for the need for specialist palliative care (SPC) have been proposed for the use in oncology. However, as there is no established reference standard for SPC need to compare their results with, their sensitivity and specificity have not yet been determined. The aim of the study was to explore whether SPC need assessment by means of multi-professional case review has sufficient interrater agreement to be employed as a reference standard. METHODS Comprehensive case descriptions were prepared for 20 inpatients with advanced oncologic disease at the University Hospital Freiburg (Germany). All cases were presented to the palliative care teams of three different hospitals in independent, multi-professional case review sessions. The teams assessed whether patients had support needs in nine categories and subsequently concluded SPC need (yes / no). Interrater agreement regarding SPC need was determined by calculating Fleiss' Kappa. RESULTS In 17 out of 20 cases the three teams agreed regarding their appraisal of SPC need (substantial interrater agreement: Fleiss' Kappa κ = 0.80 (95% CI: 0.55-1.0; p < 0.001)). The number of support needs was significantly lower for patients who all teams agreed had no SPC need than for those with agreed SPC need. CONCLUSIONS The proposed expert case review process shows sufficient reliability to be used as a reference standard. Key elements of the case review process (e.g. clear definition of SPC need, standardized review of the patients' support needs) and possible modifications to simplify the process are discussed. TRIAL REGISTRATION German Clinical Trials Register, DRKS00021686, registered 17.12.2020.
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Affiliation(s)
- Evelyn Müller
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
| | - Michael Josef Müller
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany
| | - Katharina Seibel
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany
| | - Christopher Boehlke
- Department of Palliative Care, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Henning Schäfer
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Robert-Koch-Straße 3, 79106, Freiburg, Germany
| | - Carsten Klein
- Department of Palliative Medicine, University Hospital Erlangen-EMN, Comprehensive Cancer Center CCC Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Maria Heckel
- Department of Palliative Medicine, University Hospital Erlangen-EMN, Comprehensive Cancer Center CCC Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Steffen T Simon
- Department of Palliative Medicine and Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO ABCD), University Hospital of Cologne, Faculty of Medicine and University Hospital, Kerpener Str. 62, 50937, Cologne, Germany
| | - Gerhild Becker
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany
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11
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Crooms RC, Taylor JW, Jette N, Morgenstern R, Agarwal P, Goldstein NE, Vickrey BG. Palliative care referral across the disease trajectory in high-grade glioma. J Neurooncol 2023; 163:249-259. [PMID: 37209290 PMCID: PMC10546385 DOI: 10.1007/s11060-023-04338-y] [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: 03/31/2023] [Accepted: 05/06/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE Adults with high-grade glioma (HGG), WHO grade III or IV, have substantial palliative care needs. Our aim was to determine occurrence, timing, and factors associated with palliative care consultation (PCC) in HGG at one large academic institution. METHODS HGG patients receiving care between 08/1/2011 and 01/23/2020 were identified retrospectively from a multi-center healthcare system cancer registry. Patients were stratified by any PCC (yes/no), and timing of initial PCC by disease phase: diagnosis (before radiation), during initial treatment (first-line chemotherapy/radiation), second-line treatment(s), or end-of-life (after last chemotherapy). RESULTS Of 621 HGG patients, 134 (21.58%) received PCC with the vast majority occurring during hospital admission [111 (82.84%)]. Of the 134, 14 (10.45%) were referred during the diagnostic phase; 35 (26.12%) during initial treatment; 20 (14.93%) during second-line treatment; and 65 (48.51%) during end of life. In multivariable logistic regression, only higher Charlson Comorbidity Index was associated with greater odds of PCC [OR 1.3 (95% CI 1.2-1.4), p < 0.01]; but not age or histopathology. Patients who received PCC prior to end of life had longer survival from diagnosis than those referred during end of life [16.5 (8, 24) months vs. 11 (4, 17); p < 0.01]. CONCLUSION A minority of HGG patients ever received PCC, which primarily occurred in the inpatient setting, and nearly half during the end-of-life phase. Thus, only about one in ten patients in the entire cohort potentially received the benefits of earlier PCC despite earlier referral having an association with longer survival. Further studies should elucidate barriers and facilitators to early PCC in HGG.
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Affiliation(s)
- Rita C Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Jennie W Taylor
- Departments of Neurology and Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachelle Morgenstern
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parul Agarwal
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Barbara G Vickrey
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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12
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Association between inpatient palliative care encounter and 30-day all-cause readmissions after index hospitalization for chronic obstructive pulmonary disease. Heart Lung 2023; 58:69-73. [PMID: 36410155 DOI: 10.1016/j.hrtlng.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/26/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Studies exist on the association between inpatient Palliative Care Encounter (iPCE) and 30-day rehospitalization among cancer and several non-cancer conditions but limited in persons with Chronic Obstructive Pulmonary Disease (COPD). OBJECTIVE To assess the association between an iPCE with the risk of 30-day rehospitalization after an index hospitalization for COPD. METHODS We conducted a cross-sectional analysis of the Nationwide Readmissions Database (2010-2014). Index hospitalizations were defined as persons ≥ 18 years of age, discharge destinations of either Home/Routine, Home with Home Care, or a Facility, and an index hospitalization with Diagnosis Related Group of COPD. The International Classification of Diseases, 9th revision codes were used to extract comorbidities and a Palliative Care Encounter (V66.7). RESULTS There were 3,163,889 index hospitalizations and iPCE occurred in 21,330 (0.67%). There were 558,059 (17.63%) with a 30-day rehospitalization. An iPCE was associated with a significantly lower adjusted odds of 30-day readmission (Odds Ratio [OR], 0.50; 95% Confidence Interval [CI], 0.46 to 0.54). By discharge destination, the odds of 30-day rehospitalization were for a discharged to a facility (OR, 0.37; 95% CI, 0.32 to 0.42), to home with home health (OR, 0.42; 95% CI, 0.37 to 0.47), and to home (OR, 0.98; 95% CI, 0.85 to 1.12) for those with relative to without iPCE. CONCLUSION Inpatient PCE was associated with a 50% lower relative odds of 30-day rehospitalization after an index hospitalization for COPD. This association varied by discharge destination being statistically significant among those with a discharge destination of a facility (63%) and home with home care (58%).
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13
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Im JH, Chow R, Novosel M, Xiang J, Strait M, Rao V, Kapo J, Zimmermann C, Prsic E. Association of palliative care and hospital outcomes among solid tumour oncology inpatients. BMJ Support Palliat Care 2023:spcare-2023-004207. [PMID: 36849221 DOI: 10.1136/spcare-2023-004207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVES We aimed to explore the association between receiving an inpatient palliative care consultation and hospital outcomes, including in-hospital death, intensive care unit (ICU) use, discharge to hospice, 30-day readmissions and 30-day emergency department (ED) visits. METHODS We conducted a retrospective chart review of Yale New Haven Hospital medical oncology admissions from January 2018 through December 2021, with and without inpatient palliative care consultations. Hospital outcome data were extracted from medical records and operationalised as binary. Multivariable logistic regression was used to estimate ORs for the association between number of inpatient palliative care consultations and hospital outcomes. RESULTS Our sample included 19 422 patients. Age, Rothman Index, site of malignancy, length of stay, discharge to hospice, ICU admissions, hospital death and readmissions within 30 days differed significantly between patients who received versus did not receive a palliative care consultation. On multivariable analysis, receiving one additional palliative care consultation was significantly associated with higher odds of hospital death (adjusted OR=1.15, 95% CI 1.12 to 1.17) and discharge to hospice (adjusted OR = 1.23, 95% CI 1.20 to 1.26), and lower odds of ICU admission (adjusted OR=0.94, 95% CI 0.92 to 0.97). There was no significant association between palliative care consultations and readmission within 30 days or with ED visits within 30 days. CONCLUSION Inpatients receiving palliative care had increased likelihood of hospital death. However, when controlling for significant differences in patient presentation, patients had nearly 25% greater odds of discharge to hospice and less odds to transition to ICU level of care.
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Affiliation(s)
- James Hb Im
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Ronald Chow
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Madison Novosel
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Jenny Xiang
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Michael Strait
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Vinay Rao
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Jennifer Kapo
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Camilla Zimmermann
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Prsic
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
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14
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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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15
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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.
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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
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16
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Srinivasan VJ, Akhtar S, Huppertz JW, Sidhu M, Coates A, Knudsen N. Prospective Cohort Study on the Impact of Early Versus Late Inpatient Palliative Care on Length of Stay and Cost of Care. Am J Hosp Palliat Care 2023:10499091231152609. [PMID: 36688285 DOI: 10.1177/10499091231152609] [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: 01/24/2023] Open
Abstract
Aim: To evaluate the impact of early vs late palliative care on (1) length of stay (LOS) in the context of expected LOS measures and (2) total cost of care to the hospital for each patient. Methods: A prospective cohort study was performed at a single large academic medical center on patients who received an inpatient palliative care consultation. The two cohorts were early palliative care (within 3 days of admission) and late palliative care (after 3 days of admission). Comparisons were made between patients' actual LOS, expected LOS, and total hospital costs between both cohorts. Results: Compared to the late palliative care cohort (N = 126), patients who received early palliative care (N = 68) had a significantly shorter LOS (P < .001) and also performed better compared to CMS-Expected LOS standards (Observed/Expected 3.1 vs 1.5 respectively; P < .001). Early palliative care patients also saw an average decline of $1431 in total costs 1-day pre/post consult as opposed to a more modest $403 decline in the later palliative care cohort (P < .001). Similarly, patients who received early palliative care had a $5839 decline in aggregated total 3-day costs, as opposed to a $1478 decline in those who received late palliative care (P < .001). Conclusions: In the competitive and rapidly evolving healthcare system, the opportunity to suppress costs and lower patient LOS has increasing importance. Our study strongly supports the implementation of earlier palliative care intervention to assist hospitals in approaching LOS targets and reducing patient costs.
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Affiliation(s)
- Vamshek J Srinivasan
- 1092Albany Medical College, Albany, NY, USA.,University of Michigan Medicine, Ann Arbor, MI, USA
| | - Saad Akhtar
- 1092Albany Medical College, Albany, NY, USA.,Boston Medical Center, Boston, MA, USA
| | - John W Huppertz
- Clarkson University School of Business, Schenectady, NY, USA
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17
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Khan H, Cherla D, Mehari K, Tripathi M, Butler TW, Crook ED, Heslin MJ, Johnston FM, Fonseca AL. Palliative Therapies in Metastatic Pancreatic Cancer: Does Medicaid Expansion Make a Difference? Ann Surg Oncol 2023; 30:179-188. [PMID: 36169753 DOI: 10.1245/s10434-022-12563-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/28/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of medicaid expansion (ME) on receipt of palliative therapies in metastatic pancreatic cancer patients. PATIENTS AND METHODS A difference-in-differences (DID) approach was used to analyze patients with metastatic pancreatic cancer identified from the National Cancer Database diagnosed during two time periods: pre-expansion (2010-2012) and post-expansion (2014-2016). Patients diagnosed while residing in ME states were compared with those in non-ME states. Multivariable logistic regression was used to identify predictors of receipt of palliative therapies. RESULTS Of 87,738 patients overall, 7483(18.1%) received palliative therapies in the pre-expansion, while 10,211(21.5%) received palliative therapies in the post-expansion period. In the pre-expansion period, treatment at a high-volume facility (HVF) (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.02-1.18) and non-west geographic location were predictive of increased palliative therapies. In the post-expansion period, treatment at an HVF (OR 1.09, 95% CI 1.02-1.16), geographic location, and living in an ME state at the time of diagnosis (OR 1.14, 95% CI 1.06-1.22) were predictive of increased palliative therapies. Older age, highest quartile median income (zip-code based), and treatment at a nonacademic facility were independently associated with decreased palliative therapies in both periods. DID analysis demonstrated that patients with metastatic pancreatic cancer living in ME states had increased receipt of palliative therapies relative to those in non-ME states (DID = 2.68, p < 0.001). CONCLUSIONS The overall utilization of palliative therapies in metastatic pancreatic cancer is low. Multiple sociodemographic disparities exist in the receipt of palliative therapies. ME is associated with increased receipt of palliative therapies in patients with metastatic pancreatic cancer.
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Affiliation(s)
- Hamza Khan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Deepa Cherla
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Krista Mehari
- Department of Psychology, The University of South Alabama, Mobile, AL, USA
| | - Manish Tripathi
- Kellogg School of Management, Northwestern University, Chicago, IL, USA
| | - Thomas W Butler
- Department of Internal Medicine, The University of South Alabama, Mobile, AL, USA
| | - Errol D Crook
- Department of Internal Medicine, The University of South Alabama, Mobile, AL, USA
| | - Martin J Heslin
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Serum microRNAs as new criteria for referral to early palliative care services in treatment-naïve advanced cancer patients. Oncotarget 2022; 13:1341-1349. [PMID: 36528878 PMCID: PMC9760266 DOI: 10.18632/oncotarget.28327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
A major obstacle to the implementation of early palliative care (EPC) is the lack of objective criteria for referral to EPC. Circulating microRNAs (miRNAs) have been recognized as promising biomarkers. The present study investigated objective definitions for referral to EPC using microRNA. A total of 178 serum samples were obtained from patients with lung, gastrointestinal, colorectal, bile duct, pancreas and bladder cancers who were treatment-naïve and received chemotherapy between January 2011 and December 2013 at National Cancer Center Hospital East. We investigated expression levels of miRNAs using microarrays. The primary outcome was prediction of admission to a palliative care unit ≤6 months after first visit. Diagnostic models using clinical characteristics, miRNAs and combinations of both were constructed. The miRNA models were constructed using 6 miRNA levels. The best areas under the receiver operating characteristic curve (AUCs) of the clinical model was 0.741, while the average AUCs of miRNA-based models and combination models were 0.769 and 0.806, respectively. Combination models showed higher AUCs than the clinical model (p < 0.023). The present combination models might offer new objective definitions for referral to EPC and thus contribute to real-world implementation of EPC.
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Raghavan K, Copeland TP, Rabow M, Ladenheim M, Marks A, Pantilat SZ, O'Riordan D, Seidenwurm D, Franc B. Palliative care and imaging utilisation for patients with cancer. BMJ Support Palliat Care 2022; 12:e813-e820. [PMID: 30826736 PMCID: PMC6773516 DOI: 10.1136/bmjspcare-2018-001572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 01/01/2019] [Accepted: 01/16/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE This observational study explores the association between palliative care (PC) involvement and high-cost imaging utilisation for patients with cancer patients during the last 3 months of life. METHODS Adult patients with cancer who died between 1 January 2012 and 31 May 2015 were identified. Referral to PC, intensity of PC service use, and non-emergent oncological imaging utilisation were determined. Associations between PC utilisation and proportion of patients imaged and mean number of studies per patient (mean imaging intensity (MII)) were assessed for the last 3 months and the last month of life. Similar analyses were performed for randomly matched case-control pairs (n = 197). Finally, the association between intensity of PC involvement and imaging utilisation was assessed. RESULTS 3784 patients were included, with 3523 (93%) never referred to PC and 261 (7%) seen by PC, largely before the last month of life (61%). Similar proportions of patients with and without PC referral were imaged during the last 3 months, while a greater proportion of patients with PC referral were imaged in the last month of life. PC involvement was not associated with significantly different MII during either time frame. In the matched-pairs analysis, a greater proportion of patients previously referred to PC received imaging in the period between the first PC encounter and death, and in the last month of life. MII remained similar between PC and non-PC groups. Finally, intensity of PC services was similar for imaged and non-imaged patients in the final 3 months and 1 month of life. During these time periods, increased PC intensity was not associated with decreased MII. CONCLUSIONS PC involvement in end-of-life oncological care was not associated with decreased use of non-emergent, high-cost imaging. The role of advanced imaging in the PC setting requires further investigation.
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Affiliation(s)
- Kesav Raghavan
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Timothy P Copeland
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Michael Rabow
- Palliative Care Program, University of California San Francisco, San Francisco, California, USA
| | - Maya Ladenheim
- Palliative Care Program, University of California San Francisco, San Francisco, California, USA
| | - Angela Marks
- Palliative Care Program, University of California San Francisco, San Francisco, California, USA
| | - Steven Z Pantilat
- Palliative Care Program, University of California San Francisco, San Francisco, California, USA
| | - David O'Riordan
- Palliative Care Program, University of California San Francisco, San Francisco, California, USA
| | | | - Benjamin Franc
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
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20
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Worster B, Waldman L, Garber G, Zhan T, Lopez A, Trachtenberg O, Handley N, Rising KL, Csik V, Leader A. Increasing equitable access to telehealth oncology care in the COVID-19 National Emergency: Creation of a telehealth task force. Cancer Med 2022; 12:2842-2849. [PMID: 36210751 PMCID: PMC9874479 DOI: 10.1002/cam4.5176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 08/01/2022] [Accepted: 08/15/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Telehealth (TH) utilization in cancer care prior to COVID-19 was variable. Research highlights disparities in access determined by socioeconomic factors including education, income, race, and age. In response to COVID-19 and these disparities, we assessed the impact of a personalized digital support structure, the Telehealth Task Force (TTF), to reduce disparities in TH. METHODS We performed a retrospective review of cohorts between January 1, 2020 and August 30, 2020: Pre (TH use with basic telephone support), Intervention (TH access with TTF), and Post (TH access after TTF initiation and educational material dissemination). Data collected included successful TH access, health literacy (HL), and Area Deprivation Index, a ranking of neighborhoods by socioeconomic disadvantage (ADI). The data were analyzed in univariate ordinary least squares model and adjacent categories ratio model using statistical software R to understand the relationship between TTF, HL, ADI, and TH access. RESULTS We included 555 patients from January 1, 2020 to August 30, 2020 (90 preintervention, 194 intervention, and 271 postintervention), excluding patients without ADI/HL. TTF support successfully engaged older, racially, and socioeconomically diverse patients in TH; ADI is significantly higher in the postintervention group vs. preintervention (mean difference = 7.66, 95% CI 1.00-4.32, p = 0.024) and more patients had low HL during intervention compared with preintervention (adjacent categories ratio = 0.62, 95% CI 0.41-0.93, p = 0.021). DISCUSSION COVID-19 created an immediate need for TH. Implementation of the TTF helped close the digital divide, increasing TH access for vulnerable patients. Attention to digital readiness can mitigate disparities in access to care. Future research should explore the implementation of widespread routine digital support initiatives.
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Affiliation(s)
- Brooke Worster
- Sidney Kimmel Cancer CenterThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA,Jefferson Health New JerseySewellNew JerseyUSA,Department of Medical OncologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA,Center for Connected CareThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Lauren Waldman
- Sidney Kimmel Cancer CenterThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA,Jefferson Health New JerseySewellNew JerseyUSA
| | - Gregory Garber
- Sidney Kimmel Cancer CenterThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA,Jefferson Health New JerseySewellNew JerseyUSA
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology & Experimental TherapeuticsThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - AnaMaria Lopez
- Sidney Kimmel Cancer CenterThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA,Jefferson Health New JerseySewellNew JerseyUSA,Department of Medical OncologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Olivia Trachtenberg
- Sidney Kimmel Cancer CenterThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA,Jefferson Health New JerseySewellNew JerseyUSA
| | - Nathan Handley
- Sidney Kimmel Cancer CenterThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA,Jefferson Health New JerseySewellNew JerseyUSA,Department of Medical OncologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Kristin L. Rising
- Department of Medical OncologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA,Department of Emergency MedicineSidney Kimmel Medical College, Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA,College of Nursing, Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Valerie Csik
- Sidney Kimmel Cancer CenterThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA,Jefferson Health New JerseySewellNew JerseyUSA
| | - Amy Leader
- Sidney Kimmel Cancer CenterThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA,Jefferson Health New JerseySewellNew JerseyUSA,Department of Medical OncologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA,Center for Connected CareThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
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21
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Johnson AW, Byriel B, Rubeck J, Ghabril M, Orman ES. Standardized Criteria Increases Palliative Care Consultation Utilization in Patients With End-Stage Liver Disease: A Pilot Study. Am J Hosp Palliat Care 2022:10499091221127984. [PMID: 36167488 DOI: 10.1177/10499091221127984] [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: 11/17/2022] Open
Abstract
Context: Patients with end-stage liver disease have high symptom burden and high healthcare utilization, which may be improved by palliative care consultation. Objectives: We sought to determine if implementing standardized palliative care consultation criteria in hospitalized patients with end-stage liver disease would increase palliative care utilization and improve patient outcomes. Methods: We conducted a retrospective cohort study of hospitalized patients with end-stage liver disease. Patients under the age of 18, received a previous liver transplant, or admitted for liver transplantation were not included. Patients with end-stage liver disease meeting two or more of the following criteria were included: (i)Child Pugh C cirrhosis, (ii)2 or more liver related hospitalizations within 6 months, (iii) current alcohol use with alcoholic cirrhosis, and (iv) unsuitable for transplantation work up. We compared consults before and after implementation of the criteria, and we compared outcomes in patients who did and did not see palliative care. Results: With implementation, consults increased (2/25 (8%) vs 11/33 (33%), p = .020). Palliative care was associated with higher completion of health care representative documentation (66.7% vs 35.7%, P = .20) and physician orders for scope of treatment forms (16.7% vs 0%, P = 0.13). Patients seen by palliative care had a higher rate of discharges with hospice (30.8% vs 0, P = .002). Conclusions: Implementation of standardized palliative care consultation criteria for patients with end-stage liver disease increased palliative care utilization. Patients seen by palliative care had increased discharges with hospice services and a trend towards higher completion rates of advanced directives.
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Affiliation(s)
- Amy W Johnson
- Division of General Internal Medicine & Geriatrics, 12250Indiana University School of Medicine, Indianapolis. IN, USA
| | - Benjamin Byriel
- Gastroenterology Fellowship, Department of Medicine, 12250Indiana University School of Medicine, Indianapolis. IN, USA
| | | | - Marwan Ghabril
- Division of Gastroenterology & Hepatology, 12250Indiana University School of Medicine, Indianapolis. IN, USA
| | - Eric S Orman
- Division of Gastroenterology & Hepatology, 12250Indiana University School of Medicine, Indianapolis. IN, USA
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22
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Collins A, Sundararajan V, Le B, Mileshkin L, Hanson S, Emery J, Philip J. The feasibility of triggers for the integration of Standardised, Early Palliative (STEP) Care in advanced cancer: A phase II trial. Front Oncol 2022; 12:991843. [PMID: 36185312 PMCID: PMC9520487 DOI: 10.3389/fonc.2022.991843] [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: 07/12/2022] [Accepted: 08/26/2022] [Indexed: 12/03/2022] Open
Abstract
Background While multiple clinical trials have demonstrated benefits of early palliative care for people with cancer, access to these services is frequently very late if at all. Establishing evidence-based, disease-specific ‘triggers’ or times for the routine integration of early palliative care may address this evidence-practice gap. Aim To test the feasibility of using defined triggers for the integration of standardised, early palliative (STEP) care across three advanced cancers. Method Phase II, multi-site, open-label, parallel-arm, randomised trial of usual best practice cancer care +/- STEP Care conducted in four metropolitan tertiary cancer services in Melbourne, Australia in patients with advanced breast, prostate and brain cancer. The primary outcome was the feasibility of using triggers for times of integration of STEP Care, defined as enrolment of at least 30 patients per cancer in 24 months. Triggers were based on hospital admission with metastatic disease (for breast and prostate cancer), or development of disease recurrence (for brain tumour cohort). A mixed method study design was employed to understand issues of feasibility and acceptability underpinning trigger points. Results The triggers underpinning times for the integration of STEP care were shown to be feasible for brain but not breast or prostate cancers, with enrolment of 49, 6 and 10 patients across the three disease groups respectively. The varied feasibility across these cancer groups suggested some important characteristics of triggers which may aid their utility in future work. Conclusions Achieving the implementation of early palliative care as a standardized component of quality care for all oncology patients will require further attention to defining triggers. Triggers which are 1) linked to objective points within the illness course (not dependent on recognition by individual clinicians), 2) Identifiable and visible (heralded through established service-level activities) and 3) Not reliant upon additional screening measures may enhance their feasibility.
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Affiliation(s)
- Anna Collins
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Melbourne, VIC, Australia
- *Correspondence: Anna Collins,
| | - Vijaya Sundararajan
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Brian Le
- Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Linda Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | - Jon Emery
- Department of General Practice, University of Melbourne, Melbourne, VIC, Australia
| | - Jennifer Philip
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Melbourne, VIC, Australia
- Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Palliative Care Service, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
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23
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Yazdanyar A, Guthier D, Maitz T, Singh S, Parfianowicz D, Li S, Jarjous S. Inpatient palliative care encounter and 30-day readmission among hospitalizations for heart failure. Future Cardiol 2022; 18:809-816. [PMID: 36052818 DOI: 10.2217/fca-2022-0041] [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: 01/05/2023] Open
Abstract
Aim: To determine the association between inpatient palliative care encounter (PCE) and 30-day rehospitalization. Materials & methods: The Nationwide Readmission Database was used in a cross-sectional design study. Comorbidities and a palliative care encounter (PCE; V66.7) were defined using ICD-9 codes. Results: Overall, 21.28% of 3,534,480 index hospitalizations were readmitted. PCE occurred in 1.66% of index hospitalizations and was associated with a lower odds of 30-day rehospitalization (adjusted odds ratio, 0.38; 95% CI: 0.35-0.40). This association remained significant when assessed by discharge destination. Conclusion: PCE was associated with a lower relative odds of 30-day rehospitalization. A 73% decrease in the relative odds of 30-day rehospitalization among discharges to a facility, 64% for home with home health, and 22% for discharges to home.
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Affiliation(s)
- Ali Yazdanyar
- Department of Emergency & Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18103, USA.,Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Desire Guthier
- Department of Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18013, USA
| | - Theresa Maitz
- Department of Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18013, USA
| | - Satinder Singh
- Department of Emergency & Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18103, USA
| | - Dominic Parfianowicz
- Department of Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18013, USA
| | - Shuisen Li
- Department of Emergency & Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18103, USA.,Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Shadi Jarjous
- Department of Emergency & Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA 18103, USA.,Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
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24
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Müller E, Müller MJ, Boehlke C, Ramsenthaler C, Jäger H, Schäfer H, Ostgathe C, Klein C, Simon S, Becker G. Development of a screening tool for the need of specialist palliative care in oncologic inpatients: study protocol for the ScreeningPALL Study. BMJ Open 2022; 12:e059598. [PMID: 36581985 PMCID: PMC9438211 DOI: 10.1136/bmjopen-2021-059598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION A range of referral criteria and scores have been developed in recent years to help with screening for the need of specialist palliative care (SPC) in advanced, incurable cancer patients. However, referral criteria have not yet been widely implemented in oncology, as they usually need to be revised by physicians or nurses with limited time resources. To develop an easily applicable screening for the need for SPC in incurable cancer inpatients, we aim to (a) test inter-rater reliability of multiprofessional expert opinion as reference standard for SPC need (phase I) and (b) explore the diagnostic validity of selected patient-reported outcome measures (PROMs) and routine data for the need of SPC (phase II). METHODS AND ANALYSIS Inclusion criteria for patients are metastatic or locally advanced, incurable cancer, ≥18 years of age and informed consent by patient or proxy. (Exclusion criteria: malignant haematological disease as main diagnosis). In phase I, three palliative care consultation teams (PCTs) of three German university hospitals assess the SPC need of 20 patient cases. Fleiss' Kappa will be calculated for inter-rater reliability. In phase II, 208 patients are consecutively recruited in four inpatient oncology wards of Freiburg University Hospital. The PCT will provide assessment of SPC need. As potential referral criteria, patients complete PROMs and a selection of routine data on person, disease and treatment is documented. Logistic regression models and ROC analyses are employed to test their utility in screening for SPC need. ETHICS AND DISSEMINATION Our findings will be published in peer-reviewed journals and presented at national and international scientific meetings and congresses. Ethical approval was granted by the Ethics Committee of Albert-Ludwigs-University Freiburg, Germany (approval no. 20-1103). TRIAL REGISTRATION NUMBER German Clinical Trials Register, DRKS00021686, registered on 17 December 2020.
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Affiliation(s)
- Evelyn Müller
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Josef Müller
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christopher Boehlke
- Department of Palliative Care, University Hospital Basel, Basel, Switzerland
| | - Christina Ramsenthaler
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Helga Jäger
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Henning Schäfer
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, University Hospital Erlangen-EMN, Comprehensive Cancer Center CCC Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine, University Hospital Erlangen-EMN, Comprehensive Cancer Center CCC Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Steffen Simon
- Department of Palliative Medicine and Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Gerhild Becker
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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25
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Hahn W, Schütte K, Schultz K, Wolkenhauer O, Sedlmayr M, Schuler U, Eichler M, Bej S, Wolfien M. Contribution of Synthetic Data Generation towards an Improved Patient Stratification in Palliative Care. J Pers Med 2022; 12:1278. [PMID: 36013227 PMCID: PMC9409663 DOI: 10.3390/jpm12081278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 11/23/2022] Open
Abstract
AI model development for synthetic data generation to improve Machine Learning (ML) methodologies is an integral part of research in Computer Science and is currently being transferred to related medical fields, such as Systems Medicine and Medical Informatics. In general, the idea of personalized decision-making support based on patient data has driven the motivation of researchers in the medical domain for more than a decade, but the overall sparsity and scarcity of data are still major limitations. This is in contrast to currently applied technology that allows us to generate and analyze patient data in diverse forms, such as tabular data on health records, medical images, genomics data, or even audio and video. One solution arising to overcome these data limitations in relation to medical records is the synthetic generation of tabular data based on real world data. Consequently, ML-assisted decision-support can be interpreted more conveniently, using more relevant patient data at hand. At a methodological level, several state-of-the-art ML algorithms generate and derive decisions from such data. However, there remain key issues that hinder a broad practical implementation in real-life clinical settings. In this review, we will give for the first time insights towards current perspectives and potential impacts of using synthetic data generation in palliative care screening because it is a challenging prime example of highly individualized, sparsely available patient information. Taken together, the reader will obtain initial starting points and suitable solutions relevant for generating and using synthetic data for ML-based screenings in palliative care and beyond.
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Affiliation(s)
- Waldemar Hahn
- Institute for Medical Informatics and Biometry, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Katharina Schütte
- University Palliative Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Kristian Schultz
- Department of Systems Biology and Bioinformatics, University of Rostock, Universitätsplatz 1, 18051 Rostock, Germany
| | - Olaf Wolkenhauer
- Department of Systems Biology and Bioinformatics, University of Rostock, Universitätsplatz 1, 18051 Rostock, Germany
- Leibniz-Institute for Food Systems Biology, Technical University Munich, 85354 Freising, Germany
- Stellenbosch Institute of Advanced Study, Wallenberg Research Centre, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Martin Sedlmayr
- Institute for Medical Informatics and Biometry, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Ulrich Schuler
- University Palliative Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Martin Eichler
- National Center for Tumor Diseases Dresden (NCT/UCC), Fetscherstraße 74, 01307 Dresden, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Bautzner Landstraße 400, 01328 Dresden, Germany
| | - Saptarshi Bej
- Department of Systems Biology and Bioinformatics, University of Rostock, Universitätsplatz 1, 18051 Rostock, Germany
- Leibniz-Institute for Food Systems Biology, Technical University Munich, 85354 Freising, Germany
| | - Markus Wolfien
- Institute for Medical Informatics and Biometry, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
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Yeh JC, Urman AR, Besaw RJ, Dodge LE, Lee KA, Buss MK. Different Associations Between Inpatient or Outpatient Palliative Care and End-of-Life Outcomes for Hospitalized Patients With Cancer. JCO Oncol Pract 2022; 18:e516-e524. [PMID: 34914566 PMCID: PMC9810126 DOI: 10.1200/op.21.00546] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Palliative care (PC) improves outcomes in advanced cancer, and guidelines recommend early outpatient referral. However, many PC teams see more inpatient than outpatient consults. We conducted a retrospective study of hospitalized patients with cancer to quantify exposure to inpatient and outpatient PC and describe associations between PC and end-of-life (EOL) quality measures. METHODS We identified all decedents admitted to an inpatient oncology unit in 1 year (October 1, 2017-September 30, 2018) and abstracted hospitalization statistics, inpatient and outpatient PC visits, and EOL outcomes. Descriptive statistics, univariate tests, and multivariate analysis evaluated associations between PC and patient outcomes. RESULTS In total, 522 decedents were identified. 50% saw PC; only 21% had an outpatient PC visit. Decedents seen by PC were more likely to enroll in hospice (78% v 44%; P < .001), have do-not-resuscitate status (87% v 55%; P < .001), have advance care planning documents (53% v 31%; P < .001), and die at home or inpatient hospice instead of in hospital (67% v 40%; P < .01). Decedents seen by PC had longer hospital length-of-stay (LOS; 8.4 v 7.0 days; P = .03), but this association reversed for decedents seen by outpatient PC (6.3 v 8.3 days; P < .001), who also had longer hospice LOS (46.5 v 27.1 days; P < .01) and less EOL intensive care (6% v 15%; P < .05). CONCLUSION PC was associated with significantly more hospice utilization and advance care planning. Patients seen specifically by outpatient PC had shorter hospital LOS and longer hospice LOS. These findings suggest different effects of inpatient and outpatient PC, underscoring the importance of robust outpatient PC.
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Affiliation(s)
- Jonathan C. Yeh
- Section of Palliative Care, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA,Jonathan C. Yeh, MD, 330 Brookline Ave, Yamins 100, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215; e-mail:
| | - Arielle R. Urman
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Robert J. Besaw
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Laura E. Dodge
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Kathleen A. Lee
- Section of Palliative Care, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mary K. Buss
- Section of Palliative Care, Division of General Medicine and Primary Care, Division of Medical Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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27
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Money NM, Hall M, Quinonez RA, Coon ER, Tremoulet AH, Markham JL, Erdem G, Tamaskar N, Parikh K, Neubauer HC, Darby JB, Wallace SS. Association of Models of Care for Kawasaki Disease With Utilization and Cardiac Outcomes. Hosp Pediatr 2022:e2021006364. [PMID: 35194637 DOI: 10.1542/hpeds.2021-006364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Describe the prevalence of different care models for children with Kawasaki disease (KD) and evaluate utilization and cardiac outcomes by care model. METHODS Multicenter, retrospective cohort study of children aged 0 to 18 hospitalized with KD in US children's hospitals from 2017 to 2018. We classified hospital model of care via survey: hospitalist primary service with as-needed consultation (Model 1), hospitalist primary service with automatic consultation (Model 2), or subspecialist primary service (Model 3). Additional data sources included administrative data from the Pediatric Health Information System database supplemented by a 6-site chart review. Utilization outcomes included laboratory, medication and imaging usage, length of stay, and readmission rates. We measured the frequency of coronary artery aneurysms (CAAs) in the full cohort and new CAAs within 12 weeks in the 6-site chart review subset. RESULTS We included 2080 children from 44 children's hospitals; 21 hospitals (48%) identified as Model 1, 19 (43%) as Model 2, and 4 (9%) as Model 3. Model 1 institutions obtained more laboratory tests and had lower overall costs (P < .001), whereas echocardiogram (P < .001) and immune modulator use (P < .001) were more frequent in Model 3. Secondary outcomes, including length of stay, readmission rates, emergency department revisits, CAA frequency, receipt of anticoagulation, and postdischarge CAA development, did not differ among models. CONCLUSIONS Modest cost and utilization differences exist among different models of care for KD without significant differences in outcomes. Further research is needed to investigate primary service and consultation practices for KD to optimize health care value and outcomes.
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Affiliation(s)
- Nathan M Money
- Section of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | - Matthew Hall
- Department of Analytics, Children's Hospital Association, Lenexa, Kansas
| | - Ricardo A Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Eric R Coon
- Section of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | - Adriana H Tremoulet
- Department of Pediatrics, Rady Children's Hospital and University of California San Diego, San Diego, California
| | - Jessica L Markham
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Guliz Erdem
- Section of Infectious Diseases, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Nisha Tamaskar
- Division of Hospital Medicine, Children's National Hospital, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia
| | - Kavita Parikh
- Division of Hospital Medicine, Children's National Hospital, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia
| | - Hannah C Neubauer
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - John B Darby
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Sowdhamini S Wallace
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Timely Palliative Care: Personalizing the Process of Referral. Cancers (Basel) 2022; 14:cancers14041047. [PMID: 35205793 PMCID: PMC8870673 DOI: 10.3390/cancers14041047] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 02/01/2023] Open
Abstract
Timely palliative care is a systematic process to identify patients with high supportive care needs and to refer these individuals to specialist palliative care in a timely manner based on standardized referral criteria. It requires four components: (1) routine screening of supportive care needs at oncology clinics, (2) establishment of institution-specific consensual criteria for referral, (3) a system in place to trigger a referral when patients meet criteria, and (4) availability of outpatient palliative care resources to deliver personalized, timely patient-centered care aimed at improving patient and caregiver outcomes. In this review, we discuss the conceptual underpinnings, rationale, barriers and facilitators for timely palliative care referral. Timely palliative care provides a more rational use of the scarce palliative care resource and maximizes the impact on patients who are offered the intervention. Several sets of referral criteria have been proposed to date for outpatient palliative care referral. Studies examining the use of these referral criteria consistently found that timely palliative care can lead to a greater number of referrals and earlier palliative care access than routine referral. Implementation of timely palliative care at each institution requires oncology leadership support, adequate palliative care infrastructure, integration of electronic health record and customization of referral criteria.
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Abstract
Convergence of principles of palliative care and integrative medicine has led to the introduction of the new practice of integrative palliative care in which integrative therapies (including mind-body modalities, traditional Chinese medicine, Ayurveda, and dietary supplements) are used to provide symptom management for patients who are dying or experiencing the sequelae of serious illness and its treatment. We propose an East-West Integrative palliative care model using non-drug therapies, such as acupuncture, diet, exercise, and stress management that shift the paradigm from suppressing the symptoms of illness to addressing both the root cause of the symptoms and the imbalance and declining homeostatic reserve that perpetuate these symptoms. This whole-person model expands the reach of palliative care, prolonging a better quality of life and allowing the patient to maintain as many activities as possible by preventing symptoms and improving function. Through this approach we reframe the dialogue such that patients are “living better” rather than “dying better” when faced with serious illness or death. In this article, we provide an overview of the principles of palliative care, integrative medicine, and the novel area of integrative palliative care, and propose an East-West integrative palliative care model that incorporates and broadens the scope of these existing approaches.
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Kaufmann TL, Getz KD, Hsu JY, Bennett AV, Takvorian SU, Kamal AH, DeMichele A. Identification of Patient-Reported Outcome Phenotypes Among Oncology Patients With Palliative Care Needs. JCO Oncol Pract 2021; 17:e1473-e1488. [PMID: 33760637 PMCID: PMC8791824 DOI: 10.1200/op.20.00849] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Despite evidence-based guidelines recommending early palliative care, it remains unclear how to identify and refer oncology patients, particularly in settings with constrained access to palliative care. We hypothesize that patient-reported outcome (PRO) data can be used to characterize patients with palliative care needs. To determine if PRO data can identify latent phenotypes that characterize indications for specialty palliative care referral. METHODS We conducted a retrospective study of self-reported symptoms on the Edmonton Symptom Assessment System collected from solid tumor oncology patients (n = 745) referred to outpatient palliative care. Data were collected as part of routine clinical care from October 2012 to March 2018 at eight community and academic sites. We applied latent profile analysis to identify PRO phenotypes and examined the association of phenotypes with clinical and demographic characteristics using multinomial logistic regression. RESULTS We identified four PRO phenotypes: (1) Low Symptoms (n = 295, 39.6%), (2) Moderate Pain/Fatigue + Mood (n = 180, 24.2%), (3) Moderate Pain/Fatigue + Appetite + Dyspnea (n = 201, 27.0%), and (4) High Symptoms (n = 69, 9.3%). In a secondary analysis of 421 patients, we found that two brief items assessing social and existential needs aligned with higher severity symptom and psychological distress phenotypes. CONCLUSION Oncology patients referred to outpatient palliative care in a real-world setting can be differentiated into clinically meaningful phenotypes using brief, routinely collected PRO measures. Latent modeling provides a mechanism to use patient-reported data on a population level to identify distinct subgroups of patients with unmet palliative needs.
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Affiliation(s)
- Tara L. Kaufmann
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA,Livestrong Cancer Institutes, Dell Medical School, The University of Texas at Austin, Austin, TX,Tara L. Kaufmann, MD, MSCE, The University of Texas at Austin, Livestrong Cancer Institutes, Dell Medical School, 1601 Trinity St, Bldg B, Stop Z1100, Austin, TX 78712; e-mail:
| | - Kelly D. Getz
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,University of Pennsylvania, Philadelphia, PA,The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Antonia V. Bennett
- Cancer Outcomes Research Program, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Samuel U. Takvorian
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | - Angela DeMichele
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Prachanukool T, Yuksen C, Jintanavasan S, Jenpanitpong C, Watcharakitpaisan S, Kaninworapan P, Maijan K. Decision-Making by Emergency Medicine Personnel in Prehospital Treatment of Patients Receiving Palliative Care: A Questionnaire, Comparative Cohort Study. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2021; 12:1111-1118. [PMID: 34616196 PMCID: PMC8487797 DOI: 10.2147/amep.s323557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 09/21/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Palliative care is an approach to improve quality of life in patients with life-limiting diseases. The sudden nature of such conditions involves emergency providers as the first responders, who have roles in delivering appropriate care to meet patients' needs. In this study, we evaluated whether previous experience in palliative care among paramedic students could affect their decision-making skills in prehospital work. METHODS This questionnaire-based prospective cross-sectional study was conducted from October 2019 to November 2020. We compared two groups of paramedic students in a tertiary hospital in Bangkok, Thailand. The class of 2019 did not attend palliative care courses and the class of 2020 completed a 2-week course regarding in-hospital palliative care services. Questionnaires including rating scales and checklists and involving cases with and without malignancy were completed via a web-based data collection form. The reliability of the questionnaire was tested. Decision-making skills were categorized into seven domains comprising life-sustaining treatment, withholding or withdrawing life-sustaining treatment, advance care planning, self-autonomy, decision-making capacity and surrogate decision-makers, prehospital dyspnea management, and communication skills. RESULTS Among 57 paramedics, 52 (91%) completed the questionnaire. There was no significant difference in decision-making between the two groups in all seven domains (p>0.050). Overall, participants more often recognized patients who were eligible for palliative care and made more decisions to withhold or withdraw life-sustaining treatment when patients had advanced malignancy than in cases of non-malignancy (100% and 84.6% respectively, p=0.006). CONCLUSION Our findings showed that the decision-making process for patients regarding prehospital palliative care was not significantly different between two groups of emergency personnel with and without in-hospital palliative care experience.
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Affiliation(s)
- Thidathit Prachanukool
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chaiyaporn Yuksen
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sirada Jintanavasan
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chetsadakon Jenpanitpong
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sorawich Watcharakitpaisan
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Parama Kaninworapan
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Konwachira Maijan
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Fadol AP, Patel A, Shelton V, Krause KJ, Bruera E, Palaskas NL. Palliative care referral criteria and outcomes in cancer and heart failure: a systematic review of literature. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2021; 7:32. [PMID: 34556191 PMCID: PMC8459494 DOI: 10.1186/s40959-021-00117-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/09/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Cardiotoxicity resulting in heart failure (HF) is among the most dreaded complications of cancer therapy and can significantly impact morbidity and mortality. Leading professional societies in cardiology and oncology recommend improved access to hospice and palliative care (PC) for patients with cancer and advanced HF. However, there is a paucity of published literature on the use of PC in cardio-oncology, particularly in patients with HF and a concurrent diagnosis of cancer. AIMS To identify existing criteria for referral to and early integration of PC in the management of cases of patients with cancer and patients with HF, and to identify assessments of outcomes of PC intervention that overlap between patients with cancer and patients with HF. DESIGN Systematic literature review on PC in patients with HF and in patients with cancer. DATA SOURCES Databases including Ovid Medline, Ovid Embase, Cochrane Library, and Web of Science from January 2009 to September 2020. RESULTS Sixteen studies of PC in cancer and 14 studies of PC in HF were identified after screening of the 8647 retrieved citations. Cancer and HF share similarities in their patient-reported symptoms, quality of life, symptom burden, social support needs, readmission rates, and mortality. CONCLUSION The literature supports the integration of PC into oncology and cardiology practices, which has shown significant benefit to patients, caregivers, and the healthcare system alike. Incorporating PC in cardio-oncology, particularly in the management of HF in patients with cancer, as early as at diagnosis, will enable patients, family members, and healthcare professionals to make informed decisions about various treatments and end-of-life care and provide an opportunity for patients to participate in the decisions about how they will spend their final days.
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Affiliation(s)
- Anecita P Fadol
- Department of Nursing, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Ashley Patel
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Valerie Shelton
- Department of Nursing, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kate J Krause
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicolas L Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Hanson LC, Wessell KL, Hanspal J, Lin FC, Collichio FA, DeWalt D, Milowsky MI, Rosenstein DL, Winzelberg GS, Wood WA, Ernecoff NC. Pre-Post Evaluation of Collaborative Oncology Palliative Care for Patients With Stage IV Cancer. J Pain Symptom Manage 2021; 62:e56-e64. [PMID: 33652096 PMCID: PMC8390587 DOI: 10.1016/j.jpainsymman.2021.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/15/2021] [Accepted: 02/23/2021] [Indexed: 11/21/2022]
Abstract
CONTEXT The Collaborative Care Model improves care processes and outcomes but has never been tested for palliative care. OBJECTIVES To develop and evaluate a model of collaborative oncology palliative care for Stage IV cancer. METHODS We conducted a pre-post evaluation of Collaborative Oncology Palliative Care (CO-Pal), enrolling patients with Stage IV lung, breast or genitourinary cancers and acute illness hospitalization. CO-Pal has 4 components: 1) oncologist communication skills training; 2) patient tracking; 3) palliative care needs assessment; and 4) care coordination stratified by high vs. low palliative care need. Health record reviews from hospital admission through 60 days provided data on outcomes - goals-of-care discussions (primary outcome), advance care planning, symptom treatment, specialty palliative care and hospice use, and hospital transfers. RESULTS We enrolled 256 patients (n = 114 pre and n = 142 post-intervention); 60-day mortality was 32%. Comparing patients pre vs post-intervention, CO-Pal did not increase overall goals-of-care discussions, but did increase advance care planning (48% vs 63%, P = 0.021) and hospice use (19% vs 31%, P = 0.034). CO-Pal did not impact symptom treatment, overall treatment plans, or 60-day hospital transfers. During the intervention phase, high-need vs low-need patients had more goals-of-care discussions (60% vs. 15%, P < 0.001) and more use of specialty palliative care (64% vs 22%, P < 0.001) and hospice (44% vs 16%, P < 0.001). CONCLUSION Collaborative oncology palliative care is efficient and feasible. While it did not increase overall goals-of-care discussions, it was effective to increase overall advance care planning and hospice use for patients with Stage IV cancer.
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Affiliation(s)
- Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill (L.C.H., G.S.W.), Chapel Hill, North Carolina, USA; Palliative Care Program, University of North Carolina at Chapel Hill (L.C.H., J.H., G.S.W.), Chapel Hill, North Carolina, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill (L.C.H., K.L.W.), Chapel Hill, North Carolina, USA.
| | - Kathryn L Wessell
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill (L.C.H., K.L.W.), Chapel Hill, North Carolina, USA
| | - Jenny Hanspal
- Palliative Care Program, University of North Carolina at Chapel Hill (L.C.H., J.H., G.S.W.), Chapel Hill, North Carolina, USA
| | - Feng-Chang Lin
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (F.-C.L.), Chapel Hill, North Carolina, USA
| | - Frances A Collichio
- Division of Hematology and Oncology, University of North Carolina at Chapel Hill (F.A.C., M.I.M., W.A.W.), Chapel Hill, North Carolina, USA
| | - Darren DeWalt
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill (D.D.), Chapel Hill, North Carolina, USA
| | - Matthew I Milowsky
- Division of Hematology and Oncology, University of North Carolina at Chapel Hill (F.A.C., M.I.M., W.A.W.), Chapel Hill, North Carolina, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill (D.L.R.), Chapel Hill, North Carolina, USA
| | - Gary S Winzelberg
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill (L.C.H., G.S.W.), Chapel Hill, North Carolina, USA; Palliative Care Program, University of North Carolina at Chapel Hill (L.C.H., J.H., G.S.W.), Chapel Hill, North Carolina, USA
| | - William A Wood
- Division of Hematology and Oncology, University of North Carolina at Chapel Hill (F.A.C., M.I.M., W.A.W.), Chapel Hill, North Carolina, USA
| | - Natalie C Ernecoff
- Division of General Internal Medicine, University of Pittsburgh School of Medicine (N.C.E.), Pittsburgh, Pennsylvania, USA
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Yang GM, Zhou S, Xu Z, Goh SS, Zhu X, Chong DQ, Tan DS, Kanesvaran R, Yee AC, Neo PS, Cheung YB. Comparing the effect of a consult model versus an integrated palliative care and medical oncology co-rounding model on health care utilization in an acute hospital - an open-label stepped-wedge cluster-randomized trial. Palliat Med 2021; 35:1578-1589. [PMID: 34524044 DOI: 10.1177/02692163211022957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The benefit of specialist palliative care for cancer inpatients is established, but the best method to deliver specialist palliative care is unknown. AIM To compare a consult model versus a co-rounding model; both provide the same content of specialist palliative care to individual patients but differ in the level of integration between palliative care and oncology clinicians. DESIGN An open-label, cluster-randomized trial with stepped-wedge design. The primary outcome was hospital length of stay; secondary outcomes were 30-day readmissions and access to specialist palliative care. ClinicalTrials.gov number NCT03330509. SETTING/PARTICIPANTS Cancer patients admitted to the oncology inpatient service of an acute hospital in Singapore. RESULTS A total of 5681 admissions from December 2017 to July 2019 were included, of which 5295 involved stage 3-4 cancer and 1221 received specialist palliative care review. Admissions in the co-rounding model had a shorter hospital length of stay than those in the consult model by 0.70 days (95%CI -0.04 to 1.45, p = 0.065) for all admissions. In the sub-group of stage 3-4 cancer patients, the length of stay was 0.85 days shorter (95%CI 0.05-1.65, p = 0.038). In the sub-group of admissions that received specialist palliative care review, the length of stay was 2.62 days shorter (95%CI 0.63-4.61, p = 0.010). Hospital readmission within 30 days (OR1.03, 95%CI 0.79-1.35, p = 0.822) and access to specialist palliative care (OR1.19, 95%CI 0.90-1.58, p = 0.215) were similar between the consult and co-rounding models. CONCLUSIONS The co-rounding model was associated with a shorter hospital length of stay. Readmissions within 30 days and access to specialist palliative care were similar.
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Affiliation(s)
- Grace M Yang
- National Cancer Centre Singapore, Singapore.,Duke-NUS Medical School, Singapore.,Sengkang General Hospital, Singapore
| | - Siqin Zhou
- National Cancer Centre Singapore, Singapore
| | - Zhizhen Xu
- National Cancer Centre Singapore, Singapore
| | | | - Xia Zhu
- National Cancer Centre Singapore, Singapore
| | | | | | | | | | | | - Yin-Bun Cheung
- Duke-NUS Medical School, Singapore.,Tampere University, Finland
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Meghani SH, Levoy K, Magan KC, Starr LT, Yocavitch L, Barg FK. "I'm Dealing With That": Illness Concerns of African American and White Cancer Patients While Undergoing Active Cancer Treatments. Am J Hosp Palliat Care 2021; 38:830-841. [PMID: 33107324 PMCID: PMC8424597 DOI: 10.1177/1049909120969121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND National oncology guidelines recommend early integration of palliative care for patients with cancer. However, drivers for this integration remain understudied. Understanding illness concerns at the time of cancer treatment may help facilitate integration earlier in the cancer illness trajectory. OBJECTIVE To describe cancer patients' concerns while undergoing cancer treatment, and determine if concerns differ among African Americans and Whites. METHODS A 1-time, semi-structured qualitative interview was conducted with a purposive subsample of cancer patients participating in a larger study of illness concerns. Eligible patients were undergoing cancer treatments and had self-reported moderate-to-severe pain in the last week. Analysis encompassed a qualitative descriptive approach with inductive thematic analysis. RESULTS Participants (16 African American, 16 White) had a median age of 53 and were predominantly females (72%) with stage III/IV cancer (53%). Illness concerns were largely consistent across participants and converged on 3 themes: symptom experience (pain, options to manage pain), cancer care delivery (communication, care coordination and care transitions), and practical concerns (access to community and health system resources, financial toxicity). CONCLUSIONS The findings extend the scope of factors that could be utilized to integrate palliative care earlier in the cancer illness trajectory, moving beyond the symptoms- and prognosis-based triggers that typify current referrals to also consider diverse logistical concerns. Using this larger set of concerns aids anticipatory risk mitigation and planning (e.g. care transitions, financial toxicity), helps patients receive a larger complement of support services, and builds cancer patients' capacity toward a more patient-centered treatment and care experience.
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Affiliation(s)
- Salimah H. Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | - Kristin Levoy
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | | | - Lauren T. Starr
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | | | - Frances K. Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania
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Crooms RC, Lin HM, Neifert S, Deiner SG, Brallier JW, Goldstein NE, Gal JS, Gelfman LP. Palliative Care Consultation for Hospitalized Patients with Primary and Secondary Brain Tumors at a Single Academic Center. J Palliat Med 2021; 24:1550-1554. [PMID: 34166114 DOI: 10.1089/jpm.2021.0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Studies addressing palliative care delivery in neuro-oncology are limited. Objectives: To compare inpatients with brain tumors who received palliative care (through referral or trigger) with those receiving usual care. Design: Retrospective cohort study. Setting/Subjects: Inpatients with primary or secondary brain tumors who did or did not receive palliative care at a U.S. medical center. Measurements: Sociodemographic, clinical, and utilization characteristics were compared. Results: Of 1669 brain tumor patients, 386 (23.1%) received palliative care [nontrigger: 246 (14.7%); trigger: 140 (8.4%)] and 1283 (76.9%) received usual care. Nontrigger patients were oldest (mean age 65.0 years; trigger: 61.1 years; usual care: 55.5 years; p < 0.001); sickest at baseline (mean Elixhauser comorbidity index 3.76; trigger: 3.49; usual care: 1.84; p < 0.001); and had highest in-hospital death [34 (13.8%), trigger: 10 (7.1%), usual care: 7 (0.5%); p < 0.001] and hospice discharge [54 (22.0%), trigger: 18 (12.9%), usual care: 14 (1.1%); p < 0.001]. Conclusions: Trigger criteria may promote earlier palliative care referral, yet criteria tailored for neuro-oncology are undeveloped.
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Affiliation(s)
- Rita C Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hung-Mo Lin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean Neifert
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stacie G Deiner
- Dartmouth Hitchcock and Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Jess W Brallier
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Jonathan S Gal
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
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37
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Chan AS, Rout A, D 'Adamo CR, Lev I, Yu A, Miller K. Palliative Referrals in Advanced Cancer Patients: Utilizing the Supportive and Palliative Care Indicators Tool and Rothman Index. Am J Hosp Palliat Care 2021; 39:164-168. [PMID: 34002623 DOI: 10.1177/10499091211017873] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Timely identification of palliative care needs can reduce hospitalizations and improve quality of life. The Supportive & Palliative Care Indicators Tool (SPICT) identifies patients with advanced medical conditions who may need special care planning. The Rothman Index (RI) detects patients at high risk of acutely decompensating in the inpatient setting. SPICT and RI among cancer patients were utilized in this study to evaluate their potential roles in palliative care referrals. METHODS Advanced cancer patients admitted to an institution in Baltimore, Maryland in 2019 were retrospectively reviewed. Patient demographics, length of hospital stay (LOS), palliative care referrals, RI scores, and SPICT scores were obtained. Patients were divided into SPICT positive or negative and RI > 60 or RI < 60.Unpaired t-tests and chi-square tests were utilized to determine the associations between SPICT and RI and early palliative care needs and mortality. RESULTS 227 patients were included, with a mean age of 68 years, 63% Black, 59% female, with the majority having lung and GI malignancies. Sixty percent were SPICT +, 21% had RI < 60. SPICT + patients were more likely to have RI < 60 (p = 0.001). SPICT + and RI < 60 patients were more likely to have longer LOS, change in code status, more palliative/hospice referrals, and increased mortality (p <0.05). CONCLUSIONS SPICT and RI are valuable tools in predicting mortality and palliative/hospice care referrals. These can also be utilized to initiate early palliative and goals of care discussions in patients with advanced cancer.
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Affiliation(s)
- Abigail Sy Chan
- Department of Medicine, Sinai Hospital of Baltimore, MD, USA.,Department of Hematology/Oncology, University of Louisville, KY, USA
| | - Amit Rout
- Department of Medicine, Sinai Hospital of Baltimore, MD, USA
| | - Christopher R D 'Adamo
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Irina Lev
- Department of Medicine, Sinai Hospital of Baltimore, MD, USA
| | - Amy Yu
- Department of Medicine, Sinai Hospital of Baltimore, MD, USA
| | - Kenneth Miller
- Department of Hematology/Oncology, Sinai Hospital of Baltimore, Baltimore, MD, USA
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Balter DR, Bertram A, Stewart CM, Stewart RW. Examining black and white racial disparities in emergency department consultations by age and gender. Am J Emerg Med 2021; 45:65-70. [PMID: 33677264 DOI: 10.1016/j.ajem.2021.01.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND While significant racial inequities in health outcomes exist in the United States, these inequities may also exist in healthcare processes, including the Emergency Department (ED). Additionally, gender has emerged in assessing racial healthcare disparity research. This study seeks to determine the association between race and the number and type of ED consultations given to patients presenting at a safety-net, academic hospital, which includes a level-one trauma center. METHOD Retrospective data was collected on the first 2000 patients who arrived at the ED from 1/1/2015-1/7/2015, with 532 patients being excluded. Of the eligible patients, 77% (74.6% adults and 80.7% pediatric patients) were black and 23% (25.4% adults and 19.3% pediatric patients) were white. RESULTS White and black adult patients receive similar numbers of ED consultations and remained after gender stratification. White pediatric males have a 91% higher incidence of receiving an ED consultation in comparison to their white counterparts. No difference was found between black and white adult patients when assessing the risk of receiving consultations. White adult females have a 260% higher risk of receiving both types of consultations than their black counterparts. Black and white pediatric patients had the same risk of receiving consultations, however, white pediatric males have a 194% higher risk of receiving a specialty consultation as compared to their white counterparts. DISCUSSION Future work should focus on both healthcare practice improvements, as well as explanatory and preventive research practices. Healthcare practice improvements can encompass development of appropriate racial bias trainings and institutionalization of conversations about race in medicine.
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Affiliation(s)
| | - Amanda Bertram
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Price M, Howell EP, Dalton T, Ramirez L, Howell C, Williamson T, Fecci PE, Anders CK, Check DK, Kamal AH, Goodwin CR. Inpatient palliative care utilization for patients with brain metastases. Neurooncol Pract 2021; 8:441-450. [PMID: 34277022 DOI: 10.1093/nop/npab016] [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] [Indexed: 12/22/2022] Open
Abstract
Introduction Given the high symptom burden and complex clinical decision making associated with a diagnosis of brain metastases (BM), specialty palliative care (PC) can meaningfully improve patient quality of life. However, no prior study has formally evaluated patient-specific factors associated with PC consultation among BM patients. Methods We examined the rates of PC consults in a cohort of 1303 patients with BM admitted to three tertiary medical centers from October 2015 to December 2018. Patient demographics, surgical status, 30-day readmission, and death data were collected via retrospective chart review. PC utilization was assessed by identifying encounters for which an inpatient consult to PC was placed. Statistical analyses were performed to compare characteristics and outcomes between patients who did and did not receive PC consults. Results We analyzed 1303 patients admitted to the hospital with BM. The average overall rate of inpatient PC consultation was 19.6%. Rates of PC utilization differed significantly by patient race (17.5% in White/Caucasian vs 26.0% in Black/African American patients, P = .0014). Patients who received surgery during their admission had significantly lower rates of PC consultation (3.9% vs 22.4%, P < .0001). Patients who either died during their admission or were discharged to hospice had significantly higher rates of PC than those who were discharged home or to rehabilitation (P < .0001). Conclusions In our dataset, PC consultation rates varied by patient demographic, surgical status, discharging service, and practice setting. Further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.
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Affiliation(s)
- Meghan Price
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Elizabeth P Howell
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Tara Dalton
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Luis Ramirez
- Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, North Carolina, USA
| | - Claire Howell
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Theresa Williamson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Carey K Anders
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Devon K Check
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.,Fuqua School of Business, Duke University, Durham, North Carolina, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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Kadu M, Mondor L, Hsu A, Webber C, Howard M, Tanuseputro P. Does Inpatient Palliative Care Facilitate Home-Based Palliative Care Postdischarge? A Retrospective Cohort Study. Palliat Med Rep 2021; 2:25-33. [PMID: 34223500 PMCID: PMC8241378 DOI: 10.1089/pmr.2020.0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Evidence of the impact of inpatient palliative care on receiving home-based palliative care remains limited. Objectives: The objective of this study was to examine, at a population level, the association between receiving inpatient palliative care and home-based palliative care postdischarge. Design: We conducted a retrospective cohort study to examine the association between receiving inpatient palliative care and home-based palliative care within 21 days of hospital discharge among decedents in the last six months of life. Setting/Subjects: We captured all decedents who were discharged alive from an acute care hospital in their last 180 days of life between April 1, 2014, and March 31, 2017, in Ontario, Canada. The index event was the first hospital discharge furthest away from death (i.e., closest to 180 days before death). Results: Decedents who had inpatient palliative care were significantly more likely to receive home-based palliative care after discharge (80.0% vs. 20.1%; p < 0.001). After adjusting for sociodemographic and clinical covariates, the odds of receiving home-based palliative care were 11.3 times higher for those with inpatient palliative care (95% confidence interval [CI]: 9.4–13.5; p < 0.001). The strength of the association incrementally decreased as death approached. The odds of receiving home-based palliative care after a hospital discharge 60 days before death were 7.7 times greater for those who received inpatient palliative care (95% CI: 6.0–9.8). Conclusion: Inpatient palliative care offers a distinct opportunity to improve transitional care between hospital and home, through enhancing access to home-based palliative care.
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Affiliation(s)
- Mudathira Kadu
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Luke Mondor
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amy Hsu
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michelle Howard
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter Tanuseputro
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Huo J, Hong YR, Turner K, Diaby V, Chen C, Bian J, Grewal R, Wilkie DJ. Timing, Costs, and Survival Outcome of Specialty Palliative Care in Medicare Beneficiaries With Metastatic Non–Small-Cell Lung Cancer. JCO Oncol Pract 2020; 16:e1532-e1542. [DOI: 10.1200/op.20.00298] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: ASCO recommends early integration of palliative care in treating patients diagnosed with metastatic lung cancer. Our study sought to examine utilization of timely specialty palliative care (SPC) and its association with survival and cost outcomes in patients diagnosed with metastatic non–small-cell lung cancer (NSCLC). METHODS: The 2001-2015 SEER-Medicare data were used to determine the baseline characteristics and outcomes of 79,253 patients with metastatic NSCLC. The predictors of early SPC use were examined using logistic regression. Mean and adjusted total and SPC-related costs were calculated using generalized linear regression. We used Cox regression model to determine the survival outcomes by SPC service settings. All statistical tests were two sided. RESULTS: The time from cancer diagnosis to the first SPC use has reduced significantly, from 13.7 weeks in 2001 to 8.3 weeks in 2015 ( P < .001). SPC use was associated with lower health care costs compared with those who had no SPC, from −$3,180 in 2011 ( P < .001) to −$1,285 in 2015 ( P = .059). Outpatient SPC use was associated with improved survival compared with patients who received SPC in other settings (hazard ratio, 0.83; 95% CI, 0.79 to 0.88; P < .001). CONCLUSION: Patients diagnosed with metastatic NSCLC now have more timely SPC service utilization, which was demonstrated to be a cost-saving treatment. Strategies to improve outpatient palliative care use might be associated with longer survival in patients with metastatic NSCLC.
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Affiliation(s)
- Jinhai Huo
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL
| | - Young-Rock Hong
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Cheng Chen
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL
| | - Reetu Grewal
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Jacksonville, FL
| | - Diana J. Wilkie
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, FL
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Siemens W, Schönsteiner SS, Orellana-Rios CL, Schaekel U, Kessler J, Eschbach C, Viehrig M, Mayer-Steinacker R, Becker G, Gaertner J. Severe symptoms and very low quality-of-life among outpatients newly diagnosed with advanced cancer: data from a multicenter cohort study. Support Care Cancer 2020; 28:5547-5555. [PMID: 32185557 PMCID: PMC7547028 DOI: 10.1007/s00520-020-05388-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study was to identify symptoms of severe intensity or very low scores for quality of life (QoL) domains in newly diagnosed outpatients with advanced cancer. METHODS This multicenter cohort study from a state-wide palliative care network included adult outpatients with advanced cancer diagnosed within the preceding 8 weeks from four comprehensive cancer centers (DRKS00006162, registered on 19 May 2014). We used the Palliative Outcome Scale (POS), Hospital Anxiety and Depression Scale, and European Organization for Research and Treatment of Cancer QoL Questionnaire-C30. For each questionnaire, cut-off scores defined symptoms and QoL domains that were considered "severe" or "very low." RESULTS Of 3155 patients screened, 481/592 (81.3%) were analyzed (mean age 62.4; women n = 245, 50.9%). We identified 324/481 (67.4%) patients experiencing at least one severe symptom or a very low QoL domain (median 2; range 0 to 16). Role functioning (n = 180, 37.4%), fatigue (n = 162, 33.7%), and social functioning (n = 126, 26.2%) were most commonly affected. QoL was very low in 89 patients (18.5%). Women experienced more anxiety symptoms, fatigue, and had lower POS scores. Patients often mentioned physical symptoms and fears of adverse events resulting from disease-modifying therapies (e.g., chemotherapy) as most relevant problems. CONCLUSIONS Already within the first 8 weeks after diagnosis, the majority of patients reported at least one severe symptom or a very low QoL domain. Gender differences were evident. The findings illustrate the value of early routine assessment of patient burden and the development of multi-professional and interdisciplinary palliative care.
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Affiliation(s)
- Waldemar Siemens
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany.
| | | | - Claudia Lorena Orellana-Rios
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany
| | - Ulrike Schaekel
- Internal Medicine V, Hematology/Oncology/Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jens Kessler
- Department of Anesthesiology, Center of Pain Therapy and Palliative Care Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Corinna Eschbach
- Department of Thoracic Oncology, Member of the German Centre for Lung Research (DZL), University Hospital Heidelberg and Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany
| | - Marén Viehrig
- Department of Radiooncology, Palliative Care Unit, University Hospital of Tübingen, Tuebingen, Germany
| | | | - Gerhild Becker
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany
| | - Jan Gaertner
- Center for Palliative Care Hildegard, Basel, Switzerland
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Berglund K, Chai E, Moreno J, Reyna M, Gelfman LP. A Social Worker-Led Primary Palliative Care Model for Hospitalized Patients Admitted to the Hospital Medicine Service. Palliat Med Rep 2020; 1:234-241. [PMID: 33135010 PMCID: PMC7596876 DOI: 10.1089/pmr.2020.0093] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 01/03/2023] Open
Abstract
Objective: To increase earlier access to palliative care, and in turn increase documented goals of care and appropriate hospice referrals for seriously ill patients admitted to hospital medicine. Background: Due to the growing number of patients with serious illness and the specialty palliative care workforce shortage, innovative primary palliative care models are essential to meet this population's needs. Methods: Patients with serious illness admitted to hospital medicine at a quaternary urban academic medical center in New York City and received an embedded palliative care social worker consultation in 2017. We used univariate analyses of sociodemographic, clinical, and utilization data to describe the sample. Results: Overall, 232 patients received a primary palliative care consultation (mean age of 69 years, 44.8% female, 34% white, median Karnofsky Performance Status of 40%), and 159 (69%) had capacity to participate in a goals-of -are conversation. Referrals were from palliative care solid tumor oncology trigger program (113 [49%]), specialty palliative care consultation team (42[18%]), and hospital medicine (34[14.6%]). Before the consultation, 10(4.3%) had documented goals of care and 207 (89%) did after the consultation. The percentage of those referred to hospice was 24.1%. Of those transferred to specialty palliative care consultation service, nearly half required symptom management. Discussion: Patients who received a primary palliative care consultation were seen earlier in their illness trajectory, based on their higher functional impairment, and the majority had capacity to participate in goals-of-care discussions, compared with those who were seen by specialty palliative care. The consultation increased goals-of-care documentation and the hospice referral rate was comparable with that of the specialty palliative consultation team.
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Affiliation(s)
- Keisha Berglund
- Department of Social Work Services, Mount Sinai Medical Center, New York, New York, USA
| | - Emily Chai
- Brookdale Department of Geriatrics and Palliative Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maria Reyna
- Division of Hospital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
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García-Martín E, Escudero-Vilaplana V, Fox B, Collado-Borrell R, Marzal-Alfaro B, Sánchez-Isac M, Solano-Garzón ML, González Del Val R, Cano-González JM, Pérez de Lucas N, Bravo-Guillén AI, Valero-Salinas J, González-Haba E, Sanjurjo M, Martín M. Aggressiveness of end-of-life cancer care: what happens in clinical practice? Support Care Cancer 2020; 29:3121-3127. [PMID: 33067765 DOI: 10.1007/s00520-020-05828-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/13/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE End-of-life cancer care varies widely, and very few centers evaluate it systematically. Our objective was to assess indicators of the aggressiveness of end-of-life cancer care in clinical practice. METHODS An observational, longitudinal, and retrospective cohort study was conducted at a tertiary hospital. Eligible patients were at least 18 years old, had a solid tumor, were followed up by the Oncology Department, and had died because of cancer or associated complications during 2017. We used the criteria of Earle et al. (J Clin Oncol 21(6):1133-1138, 2003) to assess the aggressiveness of care. Multivariate logistic regression analyses were performed to characterize factors associated with aggressiveness of therapy. RESULTS The study population comprised 684 patients. Eighty-eight patients (12.9%) received anti-cancer treatment during the last 14 days of their lives, and 62 patients (9.1%) started a new treatment line in the last 30 days. During the last month of life, 102 patients (14.9%) visited the ER, 80 patients (11.7%) were hospitalized more than once, and 26 (3.8%) were admitted to the ICU. A total of 326 patients (47.7%) died in the acute care unit. A total of 417 patients (61.0%) were followed by the Palliative Care Unit, and in 54 cases (13.0%), this care started during the last 3 days of life. CONCLUSIONS The use of anti-cancer therapies and health care services in our clinical practice, except for the ICU, did not meet the Earle criteria for high-quality care. Concerning hospice care, more than half of the patients received hospice services before death, although in some cases, this care started close to the time of death.
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Affiliation(s)
- Estela García-Martín
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Vicente Escudero-Vilaplana
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain.
| | - Bárbara Fox
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Roberto Collado-Borrell
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Belén Marzal-Alfaro
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
| | - María Sánchez-Isac
- Palliative Department, Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - María Luisa Solano-Garzón
- Palliative Department, Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ricardo González Del Val
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | | | | | | | - Eva González-Haba
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
| | - María Sanjurjo
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Miguel Martín
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Khan CP, Parver S, Kennedy Lesch J, DiGioia K, Gaglio B, Daugherty S, Clauser SB, Arora NK. Comparative Clinical Effectiveness Research Focused on Community-Based Delivery of Palliative Care: Overview of the Patient-Centered Outcomes Research Institute's Funding Initiative. J Palliat Med 2020; 22:2-6. [PMID: 31486731 DOI: 10.1089/jpm.2019.0370] [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: 11/13/2022] Open
Abstract
Palliative care is a growing specialty that addresses the needs of individuals diagnosed with advanced illness and their caregivers. Although palliative care has been shown to improve a variety of patient- and caregiver-centered outcomes, access to comprehensive palliative care services for patients is often limited. There is a need to identify the most effective approaches to delivering palliative care to patients in community settings. In fiscal year 2017, based on extensive input from a diverse set of stakeholders, the Patient-Centered Outcomes Research Institute (PCORI) funded nine multisite comparative clinical effectiveness research (CER) trials focused on community-based delivery of palliative care for a total investment of $80 million. These studies, focusing on advance care planning and models of palliative care delivery, represent some of the largest most complex palliative care trials funded to date. Each study evaluates both patient and caregiver outcomes, and together, these trials include a broad range of health conditions, interventions, and settings of care. PCORI has also fostered a learning network of the funded awardees to facilitate the successful conduct of these CER studies and to support awardee efforts to develop collaborative products relevant to advancing the field of palliative care research and practice. The protocols of each of the nine trials, detailed in this issue, demonstrate the expansive reach of the investment PCORI has made in an effort to further the research agenda and provide substantive research evidence in stakeholder-identified areas of need in the field of palliative care.
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Affiliation(s)
- Carly P Khan
- Patient-Centered Outcomes Research Institute, Washington, DC
| | | | | | | | - Bridget Gaglio
- Patient-Centered Outcomes Research Institute, Washington, DC
| | - Sarah Daugherty
- Patient-Centered Outcomes Research Institute, Washington, DC
| | | | - Neeraj K Arora
- Patient-Centered Outcomes Research Institute, Washington, DC
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Kubi B, Istl AC, Lee KT, Conca-Cheng A, Johnston FM. Advance Care Planning in Cancer: Patient Preferences for Personnel and Timing. JCO Oncol Pract 2020; 16:e875-e883. [DOI: 10.1200/jop.19.00367] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE: Opportunities for advance care planning (ACP) discussions continue to be missed despite the demonstrated benefit of such conversations. This is in part because of a poor understanding of patient preferences. We aimed to determine oncology patients’ preferences surrounding ACP with a focus on the choice of which health care providers to have the conversation with and the timing of conversations. METHODS: A cross-sectional 19-question survey of surgical and medical oncology patients in a tertiary care hospital was conducted that assessed knowledge, experience, and preferences surrounding ACP. Quantitative variables were reported with descriptive statistics, and a coding structure was developed to analyze qualitative data. RESULTS: Two hundred patients were surveyed. Only 24% of patients reported previously having ACP discussions with their physicians despite 82.5% reporting a wish to do so. Patients felt that these discussions were a priority for them (to alleviate familial guilt, maintain control, and prevent others’ values from guiding end-of-life care), but they reported that previous experiences with ACP had been neither comprehensive nor effective. Most patients (43.5%) preferred to have ACP discussions with their primary care providers (PCPs) compared with 7% preferring their surgeon and 5.5% preferring their oncologist. Trust and familiarity with PCPs arose as the dominant theme underlying this selection. Most patients (94%) preferred to have ACP discussions early, with 45% wishing such a discussion had been initiated before their cancer diagnosis. CONCLUSION: Patients with cancer prefer to have ACP discussions with their PCPs and prefer to do so early in their disease course.
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Affiliation(s)
- Boateng Kubi
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Kimberley T. Lee
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
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Kim JY, Peters KB, Herndon JE, Affronti ML. Utilizing a Palliative Care Screening Tool in Patients With Glioblastoma. J Adv Pract Oncol 2020; 11:684-692. [PMID: 33575065 PMCID: PMC7646633 DOI: 10.6004/jadpro.2020.11.7.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patients with glioblastoma have poor overall survival and experience significant burden from neurologic decline and adverse treatment effects. Despite the well-known benefits of early palliative care integration with oncology care, utilization of palliative care is low. The purpose of this quality improvement (QI) project is to investigate the feasibility, value, and effectiveness of using an adapted palliative care screening tool to improve outpatient palliative care screening and referral of glioblastoma patients. This QI project was conducted over a 10-week period. A glioma palliative care screening tool was developed and integrated into outpatient visits. Providers were required to use the screening tool during each patient visit. Patients 18 years or older who were diagnosed with a World Health Organization grade IV glioma and returning to the neuro-oncology clinic for a brain MRI evaluation were targeted. Screening, palliative care discussion, and referral rates were evaluated. Among 530 eligible patients who returned to the clinic over a 10-week period, the tool was available for 433 patients. Fifty-six percent (n = 294/530) of the patients were screened. Nine percent (n = 27) of screened patients were identified as candidates for a palliative care referral (score ≥ 5 on the screening tool). Of these 27 patients, the proportion of patients who had a palliative care discussion was 63% (n = 17). Overall, 71% (n = 12) of patients who had a palliative care discussion were referred to a palliative care provider. Integrating a glioma palliative care screening tool with outpatient visits can draw attention to palliative care needs and lead to a referral to palliative care.
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Affiliation(s)
- Jung Young Kim
- From The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, North Carolina
| | - Katherine B. Peters
- From The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, North Carolina
| | - James E. Herndon
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Mary Lou Affronti
- From The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, North Carolina
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Kistler EA, Stevens E, Scott E, Philpotts LL, Greer JA, Greenwald JL. Triggered Palliative Care Consults: A Systematic Review of Interventions for Hospitalized and Emergency Department Patients. J Pain Symptom Manage 2020; 60:460-475. [PMID: 32061721 DOI: 10.1016/j.jpainsymman.2020.02.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 02/05/2023]
Abstract
CONTEXT Palliative care improves the quality of care and may reduce utilization, but delays or the absences of such services are common and costly in inpatient and emergency department settings. Triggered palliative care consults (PCCs) offer one way to identify patients who would benefit from palliative care and to connect them with services early in their course. Consensus reports recommend use of triggers to identify patients for PCC, but no standards exist to guide trigger design or implementation. OBJECTIVES To conduct a systematic review of published trigger tools for PCC. METHODS Studies included quality improvement and prospective analyses of triggers for PCC for adults in the emergency department and inpatient settings since 2008. Paired reviewers evaluated the studies for inclusion criteria and extracted data related to study demographics, trigger processes, trigger criteria, and study bias. RESULTS The search yielded 5773 citations. Twenty studies were included for final analysis with more than 17,000 patients represented. Trigger processes and composition were heterogeneous, although frequently used categories, such as cancer, dementia, and chronic comorbidities, were identified. Three-quarters of the studies were deemed to have moderate or high risk of bias. CONCLUSION We present a range of trigger tools spanning different hospital settings and patient populations. Common themes in implementation and content arose, but the limitations of these studies are notable, and further rigorous randomized comparisons are needed to generate standards of care. In addition, future studies should focus on developing triggers that identify patients requiring primary-level vs. specialty-level palliative care.
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Affiliation(s)
- Emmett A Kistler
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Erin Stevens
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erin Scott
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa L Philpotts
- Treadwell Library, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey L Greenwald
- Department of Medicine, Core Educator Faculty, Massachusetts General Hospital, Boston, Massachusetts, USA
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49
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Paiva CE, Paiva BSR, Menezes D, Zanini LE, Ciorlia JB, Miwa MU, Hui D. Development of a screening tool to improve the referral of patients with breast and gynecological cancer to outpatient palliative care. Gynecol Oncol 2020; 158:153-157. [DOI: 10.1016/j.ygyno.2020.04.701] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/24/2020] [Indexed: 12/25/2022]
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Bickell NA, Back AL, Adelson K, Gonsky JP, Egorova N, Pintova S, Lin JJ, Kozuch P, Bagiella E, Smith CB. Effects of a Communication Intervention Randomized Controlled Trial to Enable Goals-of-Care Discussions. JCO Oncol Pract 2020; 16:e1015-e1028. [PMID: 32374710 DOI: 10.1200/op.20.00040] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients with advanced cancer often have a poor understanding of cancer incurability, which correlates with more aggressive treatment near the end of life (EOL). We sought to determine whether training oncologists to elicit patient values for goals-of-care (GoC) discussions will increase and improve these discussions. We explored its impact on use of aggressive care at EOL. METHODS We enrolled and used block randomization to assign 92% of solid tumor oncologists to 2-hour communication skills training and four coaching sessions. We surveyed 265 patient with newly diagnosed advanced cancer with < 2-year life expectancy at baseline and 6 months. We assessed prevalence and quality of GoC communication, change in communication skills, and use of aggressive care in the last month of life. RESULTS Intervention (INT) oncologists' (n = 11) skill to elicit patient values increased (27%-55%), while usual care (UC) oncologists' (n = 11) skill did not (9%-0%; P = .01). Forty-eight percent (n = 74) INT v 51% (n = 56) UC patients reported a GoC discussion (P = .61). There was no difference in the prevalence or quality of GoC communication between groups (global odds ratio, 0.84; 95% CI, 0.57 to 1.23). Within 6 months, there was no difference in deaths (18 INT v 16 UC; P = .51), mean hospitalizations (0.47 INT v 0.42 UC; P = .63), intensive care unit admissions (5% INT v 9% UC; P = .65), or chemotherapy (26% INT v 16% UC; P = .39). CONCLUSION Use of a coaching model focused on teaching oncologists to elicit patient values improved that skill but did not increase prevalence or quality of GoC discussions among patients with advanced cancer. There was no impact on high care utilization at EOL.
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Affiliation(s)
- Nina A Bickell
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.,Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anthony L Back
- Center of Excellence in Palliative Care, University of Washington, Seattle, WA
| | | | | | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sofya Pintova
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jenny J Lin
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter Kozuch
- Mount Sinai Beth Israel Comprehensive Cancer Center West, New York, NY
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Cardinale B Smith
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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