Inpatients With Dementia Referred for Palliative Care Consultation: A Multicenter Analysis

Background and Objectives:

Specialty palliative care (PC) may benefit patients with dementia by aligning treatment with goals and relieving symptoms. We aimed to compare demographics and processes and outcomes of PC for inpatients with dementia to those with systemic illnesses or cancer.

Methods:

This multicenter cohort study included standardized data for hospitalized patients with a primary diagnosis of dementia, systemic illnesses (cardiovascular, pulmonary, hepatic, renal disease) or cancer among the 98 PC teams submitting data to the Palliative Care Quality Network from 2013-2019.

Results:

Out of 155,356 patients, 4.5% (n= 6,925) had a primary diagnosis of dementia, 32.5% (n=50,501) systemic illness, and 29.2% (n=45,386) cancer. Patients with dementia were older (mean 85.5 years, 95%CI 85.3-85.6) than those with systemic illnesses (mean 73.2, 95%CI 73.0-73.3) or cancer (mean 66.6, 95%CI 66.4-66.7; p<0.0001). Patients with dementia were more likely to receive a PC consult within 24 hours of admission (52.3% vs. systemic illnesses 37.4%; cancer 45.3%; p<0.0001), more likely to be bed-bound (vs. systemic illnesses OR 2.23, 95%CI 2.09-2.39, p<0.0001; vs. cancer OR 3.45, 95%CI 3.21-3.72, p<0.0001) and more likely to be discharged alive (vs. systemic illnesses OR 2.22, 95%CI 2.03-2.43, p<0.0001; vs. cancer OR 1.51, 95%CI 1.36-1.67, p<0.0001). Advance care planning / Goals of care (GOC) was the primary reason for consultation for all groups. Few patients overall had advance directives or Physician Orders for Life-Sustaining Treatment (POLSTs) prior to consultation. At the time of referral and at discharge, patients with dementia were more likely to have a code status of DNR/DNI (62.6% and 81.0% vs. 38.7 and 64.2% for patients with systemic illnesses, and 33.4% and 60.5% for patients with cancer; p<0.0001). Among the minority of patients with dementia that could self-report, moderate-to-severe symptoms were uncommon (pain 6.4%, anxiety 5.8%, nausea 0.4%, dyspnea 3.5%).

Discussion:

Inpatients with a primary diagnosis of dementia receiving PC consultation were older and more functionally impaired than those with other illnesses. They were more likely to have a code status of DNR/DNI at discharge. Few reported distressing symptoms. These results highlight the need for routine clarification of GOC for patients with dementia.

Generalist versus Specialist Palliative Medicine

The issue of generalist versus specialist palliative care is on the minds of healthcare leaders everywhere. We are amid changing demographics of physicians. The industrialization of medicine is well underway in the US and around the developing world. Is it important to identify patients who benefit the most from specialist palliative care, given that it is currently a limited resource? Should we step out of standard practice and redesign palliative care using principles of population management? The COVID pandemic rapidly introduced virtual palliative care consults. Is it a better way to promote wide access to specialty palliative care? Looking forward, should we promote ways to advance primary palliative care and reserve specialty palliative care to patients who will benefit most from this level of care? These questions, and others, are considered in this transcribed discussion between leading physicians in the field.

Characteristics and Outcomes of In-Hospital Palliative Care Consultation among Patients with Renal Disease Versus Other Serious Illnesses

BACKGROUND AND OBJECTIVES

Despite significant morbidity and mortality associated with ESRD, these patients receive palliative care services much less often than patients with other serious illnesses, perhaps because they are perceived as having less need for such services. We compared characteristics and outcomes of hospitalized patients in the United States who had a palliative care consultation for renal disease versus other serious illnesses.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this observational study, we used data collected by the Palliative Care Quality Network, a national palliative care quality improvement collaborative. The 23-item Palliative Care Quality Network core dataset includes demographics, processes of care, and clinical outcomes of all hospitalized patients who received a palliative care consultation between December of 2012 and March of 2016.

RESULTS

The cohort included 33,183 patients, of whom 1057 (3.2%) had renal disease as the primary reason for palliative care consultation. Mean age was 71.9 (SD=16.8) or 72.8 (SD=15.2) years old for those with renal disease or other illnesses, respectively. At the time of consultation, patients with renal disease or other illnesses had similarly low mean Palliative Performance Scale scores (36.0% versus 34.9%, respectively; P=0.08) and reported similar moderate to severe anxiety (14.9% versus 15.3%, respectively; P=0.90) and nausea (5.9% versus 5.9%, respectively; P>0.99). Symptoms improved similarly after consultation regardless of diagnosis (P≥0.50), except anxiety, which improved more often among those with renal disease (92.0% versus 66.0%, respectively; P=0.002). Although change in code status was similar among patients with renal disease versus other illnesses, from over 60% full code initially to 30% full code after palliative care consultation, fewer patients with renal disease were referred to hospice than those with other illnesses (30.7% versus 37.6%, respectively; P<0.001).

CONCLUSIONS

Hospitalized patients with renal disease referred for palliative care consultation had similar palliative care needs, improved symptom management, and clarification of goals of care as those with other serious illnesses.

Acute pain management in radiation oncology: Quality of care and the impact of an integrated palliative oncology service

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Background: Radiotherapy (RT) effectively palliates bone metastases, but relief may take weeks, frequently necessitating acute pain management (APM). NCCN Guidelines for Adult Cancer Pain (V2.2015) recommend initiation/titration of analgesics for patients with pain scale value (PSV) ≥ 4. We sought to evaluate how often symptomatic patients have analgesic regimens assessed and intervened upon at radiation oncology (RO) consult for bone metastases, and the impact of a dedicated palliative RO service on APM. Methods: We reviewed consult notes for 217 bone metastases patients treated with RT at Dana Farber Cancer Institute/Brigham & Women’s Hospital (DFCI/BWH) and University of California, San Francisco (UCSF) during June-July 2008, Jan-Feb 2010, Jan-Feb 2013, and June-July 2014, time periods before and after implementation in 2011 of a dedicated palliative RO service at DFCI/BWH. For symptomatic patients, rate of assessment of analgesic regimen was recorded. Among patients with PSV ≥ 4, rate of pain intervention was recorded. The impact of a palliative RO service on these rates was evaluated. Results: Median age was 63 and median KPS was 70. Median PSV for painful bone metastases was 5 (IQR 2-7); 51% had PSV ≥ 4. Among symptomatic patients, analgesic regimen was assessed for 44.5% (51.7% at DFCI/BWH and 28.1% at UCSF). Among patients with PSV ≥ 4, pain intervention occurred for 17.2% (20.5% for DFCI/BWH, 0% for UCSF). At DFCI/BWH, consultation by a dedicated palliative RO provider was associated with higher rate of assessment of analgesic regimen (82.4% vs 47.7%, p = 0.007). At DFCI/BWH, consultation by a palliative RO provider was associated with higher rate of pain intervention (31.2% vs 7.9%, p = 0.012). There was no difference in analgesic regimen assessment or intervention between non-dedicated palliative RO providers at DFCI/BWH and UCSF (p = 0.07 and 0.09, respectively). Conclusions: At two cancer centers, half of bone metastases patients seen for RT have PSV ≥ 4, yet a minority have analgesic assessment and intervention, indicating need for APM quality improvement in RO. An integrated palliative RO service was associated with improved assessment and management of acute pain per NCCN guidelines.

A strategy to advance the evidence base in palliative medicine: formation of a palliative care research cooperative group

BACKGROUND

Palliative medicine has made rapid progress in establishing its scientific and clinical legitimacy, yet the evidence base to support clinical practice remains deficient in both the quantity and quality of published studies. Historically, the conduct of research in palliative care populations has been impeded by multiple barriers including health care system fragmentation, small number and size of potential sites for recruitment, vulnerability of the population, perceptions of inappropriateness, ethical concerns, and gate-keeping.

METHODS

A group of experienced investigators with backgrounds in palliative care research convened to consider developing a research cooperative group as a mechanism for generating high-quality evidence on prioritized, clinically relevant topics in palliative care.

RESULTS

The resulting Palliative Care Research Cooperative (PCRC) agreed on a set of core principles: active, interdisciplinary membership; commitment to shared research purposes; heterogeneity of participating sites; development of research capacity in participating sites; standardization of methodologies, such as consenting and data collection/management; agile response to research requests from government, industry, and investigators; focus on translation; education and training of future palliative care researchers; actionable results that can inform clinical practice and policy. Consensus was achieved on a first collaborative study, a randomized clinical trial of statin discontinuation versus continuation in patients with a prognosis of less than 6 months who are taking statins for primary or secondary prevention. This article describes the formation of the PCRC, highlighting processes and decisions taken to optimize the cooperative group's success.

Survey of palliative care programs in United States teaching hospitals

In order to estimate the prevalence of palliative care programs in academic hospitals in the United States, we surveyed a random sample of 100 hospitals in the Council of Teaching Hospitals and Health Systems directory. Sixty percent of hospitals provided information. At least 26% of hospitals had either a palliative care consultation service or inpatient unit and 7% had both. Eighteen percent of hospitals had a palliative care consultation service alone, 19% had an inpatient palliative care unit, 22% reported a hospice affiliation, and 17% had a hospice inpatient contract. Additionally, at least 20% of the remaining hospitals were planning a palliative care program. The consultation services had an average daily census of 6; the inpatient units had an average of 12 beds. Palliative care consultation programs were largely affiliated with departments of medicine or hematology/oncology, and were typically staffed by a physician and a nurse. Only half had a dedicated social worker, one third had a chaplain, one third had a pharmacist, and a few included a bereavement coordinator or volunteer director, suggesting that the hospice model of interdisciplinary care is not being adopted regularly in palliative care programs. In comparison, almost half of hospitals noted established pain services. In conclusion, palliative care programs, although found in a minority of surveyed hospitals, are becoming an established feature of academic medical centers in the United States. More detailed information is needed about the type and quality of care they provide.

When asked, patients tell: disclosure of sensitive health-risk behaviors

OBJECTIVES

National health care organizations recommend routinely screening patients for behavioral health risks, the effectiveness of which depends on patients' willingness to disclose risky behaviors. This study aimed to determine if primary care patients' disclosures of potentially stigmatizing behaviors would be affected by (1) their expectation about whether or not their physician would see their disclosures and (2) the assessment method.

METHODS

One thousand nine hundred fifty-two primary care patients completed a questionnaire assessing human immunodeficiency virus (HIV), alcohol, drug, domestic violence, tobacco, oral health, and seat belt risks; half were told their responses would be seen by the researcher and their physician and half were told that their responses would be seen by the researcher only. Patients were randomly assigned to one of five assessment methods: written, face-to-face, audio-based, computer-based, or video-based.

RESULTS

Across all risk areas, patients did not disclose differently whether or not they believed their physician would see their disclosures. Technologically advanced assessment methods (audio, computer, and video) produced greater risk disclosure (4%-8% greater) than traditional methods in three of seven risk areas.

CONCLUSIONS

These findings suggest patients are not less willing to disclose health risks to a research assistant knowing that this information would be shared with their physician and that a number of assessment methods can effectively elicit patient disclosure. Potentially small increases in risk disclosure must be weighed against other factors, such as cost and convenience, in determining which method(s) to use in different health care settings.

Development and testing of an HIV-risk screening instrument for use in health care settings

OBJECTIVE

To develop and test a brief, reliable, and valid HIV-risk screening instrument for use in primary health care settings.

DESIGN

A two-phase study: (1) developing a self-administered HIV-risk screening instrument, and (2) testing it with a primary care population, including testing the effect of confidentiality on disclosure of HIV-risk behaviors.

SETTING

Phase 1: 3 types of sites (a blood donor center, a methadone clinic, and 2 STD clinics) representing low and high HIV-seroprevalence rates. Phase 2: 4 primary care sites.

PARTICIPANTS

Phase 1: 293 consecutively recruited participants. Phase 2: 459 randomly recruited primary care patients.

MAIN OUTCOME MEASURE

Phase 1: comparison of the responses of participants from low and high HIV-seroprevalence sites. Phase 2: primary care patients' rates of disclosure of HIV-risk behaviors and ratings of acceptability.

RESULTS

Phase 1: through examining item-confirmation rates, item-total correlations, and comparison of responses from low and high HIV-seroprevalence sites, we developed a final 10-item HIV-risk Screening Instrument (HSI) with an internal consistency coefficient of .73. Phase 2: 76% of primary care patients disclosed at least 1 risky behavior and 52% disclosed 2 or more risky behaviors. Patients were willing to disclose HIV-risk behaviors even knowing that their physician would see this information. Ninety-five percent of our patient participants were comfortable with the questions on the HSI, 78% felt it was important that their doctor know their answers, and 52% wished to discuss their answers with their physician.

CONCLUSION

Our brief, self-administered HSI is a reliable and valid measure. The HSI can be used in health care settings to identify individuals at risk for HIV and to initiate HIV testing, early care, and risk-reduction counseling, necessary goals for effective HIV prevention efforts.

Improving primary care residents' proficiency in the diagnosis of skin cancer

OBJECTIVE

To determine whether a brief, multicomponent intervention could improve the skin cancer diagnosis and evaluation planning performance of primary care residents to a level equivalent to that of dermatologists.

PARTICIPANTS

Fifty-two primary care residents (26 in the control group and 26 in the intervention group) and 13 dermatologists completed a pretest and posttest.

DESIGN

A randomized, controlled trial with pretest and posttest measurements of residents' ability to diagnose and make evaluation plans for lesions indicative of skin cancer.

INTERVENTION

The intervention included face-to-face feedback sessions focusing on residents' performance deficiencies; an interactive seminar including slide presentations, case examples, and live demonstrations; and the Melanoma Prevention Kit including a booklet, magnifying tool, measuring tool, and skin color guide.

MEASUREMENTS AND MAIN RESULTS

We compared the abilities of a control and an intervention group of primary care residents, and a group of dermatologists to diagnose and make evaluation plans for six categories of skin lesions including three types of skin cancer-malignant melanoma, squamous cell carcinoma, and basal cell carcinoma. At posttest, both the intervention and control group demonstrated improved performance, with the intervention group revealing significantly larger gains. The intervention group showed greater improvement than the control group across all six diagnostic categories (a gain of 13 percentage points vs 5, p < .05), and in evaluation planning for malignant melanoma (a gain of 46 percentage points vs 36, p < .05) and squamous cell carcinoma (a gain of 42 percentage points vs 21, p < .01). The intervention group performed as well as the dermatologists on five of the six skin cancer diagnosis and evaluation planning scores with the exception of the diagnosis of basal cell carcinoma.

CONCLUSIONS

Primary care residents can diagnose and make evaluation plans for cancerous skin lesions, including malignant melanoma, at a level equivalent to that of dermatologists if they receive relevant, targeted education.

Primary care physicians as gatekeepers in managed care. Primary care physicians' and dermatologists' skills at secondary prevention of skin cancer

BACKGROUND AND DESIGN

This study determines (1) the readiness of primary care physicians (PCPs) to triage optimally lesions suspicious for skin cancer, (2) the difference in their abilities from those of dermatologists, and (3) whether accurate diagnosis after viewing slide images transfers to accurate diagnosis after viewing lesions on patients. Seventy-one primary care residents and 15 dermatologists and resident dermatologists diagnosed and selected a treatment/diagnostic plan for skin lesions suspicious for cancer. The lesions were shown on slides, computer images, and patients. Participants' performance was compared with biopsy results of all lesions.

RESULTS

Dermatologists' scores were almost double those of primary care residents, and primary care residents' performance was positively associated with previous experience in dermatology. Primary care residents failed 50% of the time to diagnose correctly nonmelanoma skin cancer and malignant melanomas, and 33% of the time they failed to recommend biopsies for cancerous lesions. Primary care residents failed to diagnose malignant melanomas 40% of the time; dermatologists failed to do so 26% of the time. Both groups performed better using slide images compared with patients.

CONCLUSIONS

Primary care residents may not be ready to assume a gatekeeper role for lesions suspicious for skin cancer. Because of the seriousness of missed diagnoses, especially of malignant melanomas, we need to improve the triage skills of PCPs. Future studies should evaluate whether primary care training allows sufficient time for PCPs to learn the necessary skills. Until we can show that PCPs are prepared to triage optimally, managed care plans should reduce the threshold for referrals to dermatologists of potential skin cancers.