Co-created Mobile Apps for Palliative Care Using Community-Partnered Participatory Research: Development and Usability Study

Background

Open design formats for mobile apps help clinicians and stakeholders bring their needs to direct, co-creative solutions. Palliative care for patients with advanced cancers requires intensive monitoring and support and remains an area in high need for innovation.

Objective

This study aims to use community-partnered participatory research to co-design and pretest a mobile app that focuses on palliative care priorities of clinicians and patients with advanced cancer.

Methods

In-person and teleconference workshops were held with patient and family stakeholders, researchers, and clinicians in palliative care and oncology. Question prompts, written feedback, semistructured interviews, and facilitated group discussions identified the core palliative care needs. Using Chorus, a no-code app-building platform, a mobile app was co-designed with the stakeholders. A pretest with 11 patients was conducted, with semistructured interviews of clinician and patient users for feedback.

Results

Key themes identified from the focus groups included needs for patient advocacy and encouragement, access to vetted information, patient-clinician communication support, and symptom management. The initial prototype, My Wellness App, contained a weekly wellness journal to track patient-reported symptoms, goals, and medication use; information on self-management of symptoms; community resources; and patient and caregiver testimonial videos. Initial pretesting identified value in app-based communication for clinicians, patients, and caregivers, with suggestions for improving user interface, feedback and presentation of symptom reports, and gamification and staff coordinators to support patient app engagement.

Conclusions

The development of a mobile app using community-partnered participatory research is a low-technology and feasible intervention for palliative care. Iterative redesign and user interface expertise may improve implementation.

Update in palliative care in gynecologic oncology

PURPOSE OF REVIEW

This review summarizes research advances in quality of life, symptom management, and end-of-life practices within palliative care that can benefit patients with gynecologic cancers.

RECENT FINDINGS

Addressing fertility issues, sexual side effects, and possible disease recurrence can promote quality of life in gynecologic cancer survivors. Cannabis can provide some benefit for nausea and neuropathic pain, yet for nonneuropathic pain presentations, it does not appear to provide significant benefit in reducing opioid usage. Lastly, palliative care outcomes, such as reduced aggressive care at the end of life and higher rates of hospice enrollment are augmented by the presence of an outpatient palliative care clinic.

SUMMARY

Ongoing advances in palliative care research hold potential for improvement in systems delivery of palliative care as well as symptom management and psychosocial support.

Impact of a Palliative Care Nurse Practitioner in an Oncology Clinic: A Quality Improvement Effort

PURPOSE

Guidelines support early integration of palliative care (PC) into standard oncology practice; however, little is known as to whether outcomes can be improved by modifying health care delivery in a real-world setting.

METHODS

We report our 6-year experience of embedding a nurse practitioner in an oncology clinic (March 2014-March 2020) to integrate early, concurrent advance care planning and PC.

RESULTS

Compared with patients with advanced cancer not enrolled in the palliative care nurse practitioner program, in March 2020, patients who are enrolled are more likely to have higher quality of PC (eg, goals of care note documentation [82% v 15%; P < .01], referral to the psychosocial oncology program [67% v 37%; P < .01], and referral to hospice [61% v 34%; P < .01]) and less inpatient utilization in the last 6 months of life (eg, hospital days [12 v 18; P < .01] and intensive care unit days [1.2 v 2.3; P < .01]). The program expanded over time with the support of faculty skills training for advance care planning and PC, supporting a shared mental model of PC delivery within the oncology clinic.

CONCLUSION

Embedding a trained palliative care nurse practitioner in oncology clinics to deliver early integrated PC can lead to improved quality of care for patients with advanced cancer.

Implementation and dissemination of a shared mental model of palliative oncology

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Background: American Society of Clinical Oncology guidelines support early integration of palliative care (PC) into standard oncology practice; however, little is known as to whether improved outcomes can be achieved by modifying health care delivery and training oncology providers. Methods: We report our five year experience of embedding a nurse practitioner (NP) in an oncology clinic (March 2014-March 2019) to develop a shared mental model (SMM) of early, concurrent advance care planning (ACP) and PC as well as the collaborative effort to further disseminate this SMM throughout the Division of Hematology-Oncology using communication training, quality measurement, audit and feedback, leadership support, and monthly collaborative meetings. We developed PC quality metrics (process measures and end of life utilization measures) using a validated advanced cancer denominator. We used these measures to evaluate the impact of the PC-NP program (2014-2019) and provide individualized metric packets to each oncologist in the context of an annual half-day interactive communication training sessions (1-hr didactic, 3-hr small group role-play) each spring and monthly implementation team meetings from 2017-2019. Results: Compared to patients with advanced cancer not seen by the PC-NP program, patients who are enrolled in the program have higher rates of goals of care note documentation (80% vs. 17%, p < 0.01), higher rates of Physician Orders for Life Sustaining Treatment (POLST) completion (19% vs. 5%, p < 0.01), higher referral rates to the psychosocial oncology program (51% vs. 25%, p < 0.01), and higher referral rates to hospice (60% vs. 33%, p < 0.01). Among decedents, there was less hospital use (12 vs. 18 days) and ICU use (1.5 vs. 2.6 days) in the last 6 months of life. Since spring 2017, 19/21 NP’s, 64/68 physicians, and 17/20 fellows have participated in communication training. Among all patients with advanced cancer, goals of care note documentation has improved from 3% in March 2014 to 21% in March 2019. Conclusions: Embedding a trained PC-NP in oncology clinics to deliver upstream PC to patients on active treatment can lead to opportunities for development and dissemination of a SMM that translates into better primary and specialist PC.

Prognostication Accuracy, Confidence, and Decisional Conflict Across Training Levels of Internal Medicine Providers

CONTEXT

Providing patient care at the end of a patient's life is a humbling and sacred experience for both patient and provider. Without a truthful and meaningful conversation about end-of-life care preferences, the care that is delivered may not be the care that the patient prefers.

OBJECTIVES

Determine if there is a relationship between level of training, confidence, and presence of decisional conflict in making an accurate prognosis for 2 standardized cases. Additionally, we evaluated the correctness of the prognosis as measured against survival outcomes for patients with similar diagnoses.

METHODS

Decisional conflict was measured with the SURE tool, a validated 4-item tool that has been used in assessing for the presence of decisional conflict.

RESULTS

Following analysis of data, it was found that providers with no decisional conflict were much more likely to be attendings with more than 5 years' experience. Providers were more conflicted overall when confronted with a case with a more grave prognosis. It was determined that providers with a lower level of training were more likely to have decisional conflict.

CONCLUSIONS

Provider confidence increases and decisional conflict decreases as one increases their level of training. However, the degree in which the provider is correct in their prognosis does not change as one increases their level of training. These findings have broad implications on patients, providers, and the health-care system.

Engaging oncologists toward integrating a shared mental model for palliative oncology within a large academic oncology practice

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Background: We aimed to engage oncologists to disseminate a successful pilot-tested shared mental model (SMM) for the integration of early advance care planning (ACP) and identification of palliative care (PC) needs across a health system’s oncologic practice. Methods: Our Oncology Communication Collaborative Team (OCCT) had oncology leadership support and included a multidisciplinary team representing leaders in oncology, ACP, PC, psycho-social oncology and quality. To communicate the SMM developed by our team, the OCCT developed an interactive Saturday session (1-hr didactic, 3-hr small group role-play) that focused on early ACP and the cognitive and emotional aspects of communication. Before and after the training, we asked participants to rate their ability to communicate with patients as well as their readiness, self-efficacy, and need for help to improve communication regarding prognosis, ACP, end of life care and symptom management using a previously validated survey. We computed means and compared matched pairs of pre and post surveys using a paired t-test. We also surveyed participants about whether they would recommend the course to others and planned changes to practice. Results: All but one oncologist (52/53), 3/4 invited fellows, and 12/14 oncology nurse practitioners participated and 90% of attendees completed pre and post surveys. Participants rated their communication ability higher (6.7 v. 7.6, p < 0.01) on a 10-point scale after the training. Readiness to improve communication in this domain (9.1 v. 9.2, p = 0.35) was similar before and after the training. Self-efficacy (1.5 v. 1.5, p = 0.70) and needing help to improve (1.6 v. 1.7, p = 0.37) were rated highly (1 = A lot and 4 = Not at all) but did not change with training. All but one participant reported they would recommend the course to others and free text responses about changes they planned to make to their practice based on the training included: having earlier ACP discussions, focusing on patient goals/priorities and asking open-ended questions. Conclusions: Conducting a training to disseminate a SMM of oncology and PC is feasible, valuable, and can be the first step for partnered continuous quality improvement.

Evaluation of an NP-based model of palliative care delivery within an oncology clinic

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Background: We initiated a nurse practitioner (NP)-based model of palliative care delivery embedded within an oncology clinic guided by a shared mental model (SMM) between palliative care, oncology, and psychosocial oncology clinicians in order to foster best practice collaboration and closed-loop communication between teams. These data represent processes and outcomes three years after initial implementation of the program. Methods: We evaluated program growth as well as advance care planning, hospice use, and utilization in patients with advanced cancer seen by the palliative care NP compared to patients receiving usual care from March 2014 to March 2017 at University-based oncology clinics. We developed a palliative care quality improvement tool integrating administrative and clinical data from multiple sources, including the electronic health record (EHR) and external hospices, using progressive methods of pulling data, such as natural language processing, in order to identify patients with advanced cancer and key process and end of life utilization measures. We used chi square tests to compare care received by the two groups. Results: There was good adoption of the intervention. The number of participating oncologists increased from 2 to 5 and the palliative care NP shifted from part-time to full-time after the first 1.5 years of implementation. Patients enrolled in the NP-based model of palliative care delivery were more likely to have a documented goals of care conversation (74.6% v. 9%, p < 0.01), to be referred for additional psychosocial support (52.5% v. 30.9%, p < 0.01), and to complete physician orders for life sustaining treatment (POLST) (20.3% v. 4.5%, p < 0.01). There was no statistically significant difference in advance directive completion (28.8% v. 23.5%). Among decedents, patients enrolled in the NP-based model were more likely to be enrolled in hospice (50.5% v. 29.1%, p < 0.01). There were non-statistically significant trends toward less hospital (4.6 days v. 5.6 days) and ICU use (1.0 day vs. 1.3 days) in the last 30 days of life. Conclusions: An NP-model of palliative care delivery within an oncology clinic led to important improvements in key palliative care processes and outcomes.

Palliative Care Professional Development for Critical Care Nurses: A Multicenter Program

BACKGROUND

Integrating palliative care into intensive care units (ICUs) requires involvement of bedside nurses, who report inadequate education in palliative care.

OBJECTIVE

To implement and evaluate a palliative care professional development program for ICU bedside nurses.

METHODS

From May 2013 to January 2015, palliative care advanced practice nurses and nurse educators in 5 academic medical centers completed a 3-day train-the-trainer program followed by 2 years of mentoring to implement the initiative. The program consisted of 8-hour communication workshops for bedside nurses and structured rounds in ICUs, where nurse leaders coached bedside nurses in identifying and addressing palliative care needs. Primary outcomes were nurses' ratings of their palliative care communication skills in surveys, and nurses' identification of palliative care needs during coaching rounds.

RESULTS

Each center held at least 6 workshops, training 428 bedside nurses. Nurses rated their skill level higher after the workshop for 15 tasks (eg, responding to family distress, ensuring families understand information in family meetings, all P < .01 vs preworkshop). Coaching rounds in each ICU took a mean of 3 hours per month. For 82% of 1110 patients discussed in rounds, bedside nurses identified palliative care needs and created plans to address them.

CONCLUSIONS

Communication skills training workshops increased nurses' ratings of their palliative care communication skills. Coaching rounds supported nurses in identifying and addressing palliative care needs.

Effect and Efficiency of an Embedded Palliative Care Nurse Practitioner in an Oncology Clinic

PURPOSE

To test a simultaneous care model for palliative care for patients with advanced cancer by embedding a palliative care nurse practitioner (NP) in an oncology clinic.

METHODS

We evaluated the effect of the intervention in two oncologists' clinics beginning March 2014 by using implementation strategies, including use of a structured referral mechanism, routine symptom screening, integration of a psychology-based cancer supportive care center, implementation team meetings, team training, and a metrics dashboard for continuous quality improvement. After 1 year of implementation, we evaluated key process and outcome measures for supportive oncology and efficiency of the model by documenting tasks completed by the NP during a subset of patient visits and time-motion studies.

RESULTS

Of approximately 10,000 patients with active cancer treated in the health system, 2,829 patients had advanced cancer and were treated by 42 oncologists. Documentation of advance care planning increased for patients of the two intervention oncologists compared with patients of the other oncologists. Hospice referral before death was not different at baseline, but was significantly higher for patients of intervention oncologists compared with patients of control oncologists (53% v 23%; P = .02) over the intervention period. Efficiency evaluation revealed that approximately half the time spent by the embedded NP potentially could have been completed by other staff (eg, a nurse, a social worker, or administrative staff).

CONCLUSION

An embedded palliative care NP model using scalable implementation strategies can improve advance care planning and hospice use among patients with advanced cancer.

Use of a Shared Mental Model by a Team Composed of Oncology, Palliative Care, and Supportive Care Clinicians to Facilitate Shared Decision Making in a Patient With Advanced Cancer

Our case describes the efforts of team members drawn from oncology, palliative care, supportive care, and primary care to assist a woman with advanced cancer in accepting care for her psychosocial distress, integrating prognostic information so that she could share in decisions about treatment planning, involving family in her care, and ultimately transitioning to hospice. Team members in our setting included a medical oncologist, oncology nurse practitioner, palliative care nurse practitioner, oncology social worker, and primary care physician. The core members were the patient and her sister. Our team grew organically as a result of patient need and, in doing so, operationalized an explicitly shared understanding of care priorities. We refer to this shared understanding as a shared mental model for care delivery, which enabled our team to jointly set priorities for care through a series of warm handoffs enabled by the team's close proximity within the same clinic. When care providers outside our integrated team became involved in the case, significant communication gaps exposed the difficulty in extending our shared mental model outside the integrated team framework, leading to inefficiencies in care. Integration of this shared understanding for care and close proximity of team members proved to be key components in facilitating treatment of our patient's burdensome cancer-related distress so that she could more effectively participate in treatment decision making that reflected her goals of care.

Use of the Edmonton Symptom Assessment Scale in patients with advanced cancer referred to an embedded palliative care clinician

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Background: Physical and emotional symptoms are highly prevalent in patients with advanced cancers and contribute to overall distress level and decreased self-reported quality of life. Oncology organizations and accrediting bodies now routinely recommend universal distress screening among patients with advanced cancers. Palliative and supportive care clinicians play an important role in implementing symptom and distress screening in cancer centers. Methods: As part of an embedded palliative care nurse practitioner (PC-NP) intervention within a large ambulatory oncology clinic, patients with advanced breast, GU, GI and lung cancer were screened for physical and emotional symptoms using the Edmonton Symptom Assessment Scale (ESAS) and treated appropriately including referral to psychology-based supportive care clinic for moderate to severe anxiety and depression or clinician-identified need. We used pre-test post-test methods to see if symptoms improved after enrollment in an embedded palliative oncology program. Results: Sixty-eight patients were screened at initial visit and 41 had follow-up screening during the first 13 months of the program with a part-time PC-NP. Only the 41 patients who had both an initial and a follow-up visit were included in the analysis. Patients were assessed using the ESAS at initial visit and at a follow-up visit an average of 5.9 weeks later (RANGE 1.0-30.6), and significant reductions were found in self-reported pain (4.0 v. 3.0), shortness of breath (3.0 v. 2.1), lack of appetite (2.8 v. 2.1), and overall well-being (4.7 v 3.8) (p < 0.05). Emotional symptoms (anxiety and depression) also decreased but were not statistically significant. Aggregate scores (emotional symptoms plus physical symptoms plus well-being) demonstrated a 6 point reduction in severity (26.2 baseline to 20.3 at follow-up, p = 0.17). Conclusions: These findings are suggestive of improvement in cancer-related symptoms and distress after enrollment in an embedded palliative oncology program. More rigorous study designs are needed to better understand the impact of the intervention on symptom management.

Evaluation of the efficiency of an embedded palliative nurse practitioner in an oncology clinic

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Background: We embedded a palliative nurse practitioner in 2 oncologists’ clinics in March 2014 using a reproducible training program. After one year, patients with advanced cancer receiving care in the embedded model clinics, compared to other oncologists’ clinics, were more likely to have advance care planning performed and to die receiving hospice. In order to expand the intervention to other oncologists, we evaluated the efficiency in our model of care delivery. Methods: We reviewed overall caseload and a subset of patient encounters in depth to understand how much of the NP's practice could be conducted by other staff to inform alternate clinical models of palliative care delivery in an oncology clinic. Overall time spent and time spent per task (Symptom Assessment Basic (SAB), Symptom Assessment Medical (SAM), Symptom Assessment Psychosocial (SAP), Communication Basic (CB), Communication Complex (CC)) was recorded for 16 patient encounters. We also completed 3 days of time motion study in which a trained observer tracked the NP's daily activities from minute to minute. Results: After part-time clinical participation over the first year of the program, the NP had seen 68 initial consults and 141 follow-up consults, which were potentially billable. She also had 120 encounters where she met a patient with an oncologist and 158 email or phone encounters that were not billable. Mean duration of a visit was 56 minutes (range 40-70 minutes) and about half of this time was spent on symptom assessment and communication topics requiring an MD or NP (SAM and CC), whereas half of the time was spent on topics that potentially could be covered by an RN (SAB or CB) or an MSW (SAB, SAP, CB). Time motion study revealed that a significant amount of time was spent with email correspondence and talking with other providers for care coordination. Conclusions: Palliative care is time consuming and much of the work is not reimbursed by a traditional fee for service model. Approximately half of the time spent by the NP in our embedded program potentially could have been completed by an RN or other interdisciplinary staff with training in palliative care under supervision of a physician. We plan to add an RN case management component to our model of care delivery.

Pattern of malaria-specific T-cell responses in a cohort of Ugandan children

Malaria is the leading cause of morbidity and mortality in children in Uganda. The mechanisms whereby malaria parasites are eliminated, or how they may avoid the immune response remain poorly understood. We examined malaria-specific T-cell responses in a well-characterized cohort of African children in an endemic area where malaria transmission occurs throughout the year. In studies of asymptomatic children, we found a low frequency of malaria-specific T-cell responses (15/117), and these appeared to be clustered in older children (> or =4 years old). Both CD4- and CD8-mediated T-cell responses were detected against circumsporozoite surface protein (CSP) and merozoite surface protein-1 (MSP-1). The presence of these T cells did not correlate with the frequency of prior episodes of parasitemia and 5 out of the 15 responders had no documented parasitemia within 8-12 months prior to immunologic evaluation. Our data supports focusing on high-risk children in future preventive vaccination efforts to ensure the generation and maintenance of effective anti-malarial cellular immune responses.