Comparing Unmet Needs to Optimize Quality: Characterizing Inpatient and Outpatient Palliative Care Populations

Shared decision-making needs, barriers, and facilitators of patients with newly diagnosed advanced cancer in the hospital: a multi-level, mixed-methods study

PURPOSE

Little is known about the shared decision-making (SDM) needs, barriers, and facilitators of patients with newly diagnosed advanced cancer in the hospital. Understanding this may improve SDM and cancer care quality in this vulnerable population.

METHODS

A single-site, mixed-methods study of hospitalized patients with newly diagnosed advanced cancer, caregivers, and oncologists was conducted. After discharge, patient ± caregiver semi-structured interviews exploring SDM needs, barriers, and facilitators regarding their most important upcoming cancer-related decision were conducted. Oncologists were surveyed about patient knowledge and SDM needs using closed- and open-ended questions, respectively. Thematic analysis was performed for qualitative data with a focus on themes unique to or amplified by hospitalization. Descriptive statistics and the Chi-squared test were performed for quantitative data.

RESULTS

Patients and caregivers reported high SDM needs surrounding treatment and prognostic information, leading to decisional conflict. Eight themes emerged: anticipated cancer treatment decisions, variable control preferences in decision-making, high cancer-related information needs and uncertainty, barriers and facilitators to information gathering during and post hospitalization, and decision-making facilitators. Among 32 oncologists, most (56%) reported patients were poorly informed about treatment and prognosis. Oncologists reported variable expectations about patient knowledge after hospitalization, facilitators to patient decision-making, and patient uncertainty while awaiting an outpatient oncologist appointment.

CONCLUSION

Patients newly diagnosed with advanced cancer in the hospital have high SDM needs and experience decisional conflict. This may be due to barriers unique to or exacerbated by hospitalization. Further research is needed to develop strategies to address these barriers and enhance the facilitators identified in this study.

Fatigue in patients with inflammatory bowel disease-strongly influenced by depression and not identifiable through laboratory testing: a cross-sectional survey study

BACKGROUND

Fatigue is a debilitating and highly relevant symptom in patients with inflammatory bowel disease (IBD). However, awareness of fatigue and treatment options remains limited. This study was aimed at elucidating the influence of disease activity and common complications (pain, anemia, depression, anxiety and quality of life) on fatigue in patients with IBD to identify potential interventional targets for treating physicians.

METHODS

A cross-sectional survey including five questionnaires (HADS, Fatigue Assessment Scale, McGill Pain Questionnaire, IBDQ and general well-being) was performed on patients with IBD (n = 250) at a university IBD clinic. Additionally, demographic data, laboratory data, IBD history, treatment and current disease activity (Harvey-Bradshaw Index, partial Mayo Score, calprotectin and CRP) were recorded.

RESULTS

A total of 189 patients were analyzed (59.8% with Crohn's disease (CD) and 40.2% with ulcerative colitis (UC)). A total of 51.3% were fatigued, and 12.2% were extremely fatigued. Multiple factors showed significant correlations in univariate analysis. Multivariate analysis revealed that fatigue was correlated with depression (CD, p = 0.002; UC, p = 0.02), diminished quality of life (CD, p = 0.015), female sex (CD, p = 0.015) and younger age (UC, p = 0.024), whereas the influence of anemia or disease activity was non-significant.

CONCLUSIONS

Fatigue is burdensome and highly prevalent in patients with active and inactive IBD. Considerations for fatigue treatment, beyond targeting inflammation and anemia, should include investigation of underlying sub-clinical depression.

Basic Human Needs in the Elderly Receiving Palliative Care: A Scoping Review

Purpose

This scoping review identified scientific evidence on basic human needs (BHNs) in the elderly receiving palliative care.

Methods

Systematic searches were conducted using six electronic databases (PubMed, CINAHL, Scopus, Lilacs, IBECS, and Web of Science). The initial search resulted in 1,227 articles, of which 104 were identified as potentially relevant. Fifty-three articles that met the inclusion criteria were identified and included in the final analysis.

Results

Using the three hierarchical dimensions of the BHN model, 17 needs were organised, with five in the psychobiological dimension, 10 in the psychosocial dimension, and two in the psychospiritual dimension. These needs reflect the importance of care with dignity and relief from suffering for the elderly in palliative care.

Conclusion

Recognising impaired BHNs in elderly people receiving palliative care will contribute to better care plans for the elderly, considering the multiple bio-psycho-social-spiritual dimensions of BHNs. This review points to a predominance of psychosocial needs.

Utilization of palliative care resource remains low, consuming potentially avoidable hospital admissions in stage IV non-small cell lung cancer: a community-based retrospective review

Purpose

Early referral of patients with stage IV non-small cell lung cancer (NSCLC) to outpatient palliative care has been shown to increase survival and reduce unnecessary healthcare resource utilization. We aimed to determine outpatient palliative care referral rate and subsequent resource utilization in patients with stage IV NSCLC in a multistate, community-based hospital network and identify rates and reasons for admissions within a local healthcare system of Washington State.

Methods

A retrospective chart review of a multistate hospital network and a local healthcare system. Patients were identified using ICD billing codes. In the multistate network, 2844 patients diagnosed with stage IV NSCLC between January 1, 2013, and March 1, 2018, were reviewed. In the state healthcare system, 283 patients between August 2014 and June 2017 were reviewed.

Results

Referral for outpatient palliative care was low: 8% (217/2844) in the multistate network and 11% (32/283) in the local healthcare system. Early outpatient palliative care (6%, 10/156) was associated with a lower proportion of patients admitted into the intensive care unit in the last 30 days of life compared to no outpatient palliative care (15%, 399/2627; p = 0.003). Outpatient palliative care referral was associated with improved overall survival in Kaplan Meier survival analysis. Within the local system, 51% (104/204) of admissions could have been managed in outpatient setting, and of the patients admitted in the last 30 days of life, 59% (87/147) experienced in-hospital deaths.

Conclusion

We identified underutilization of outpatient palliative care services within stage IV NSCLC patients. Many patients with NSCLC experience hospitalization the last month of life and in-hospital death.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07364-0.

Integrating patient- and caregiver-reported outcome measures into the daily care routines of specialised outpatient palliative care: a qualitative study (ELSAH) on feasibility, acceptability and appropriateness

Background

The use of patient-reported outcome measures (PROM) and caregiver-reported outcome measures can raise the patient centeredness of treatment and improve the quality of palliative care. Nevertheless, the everyday implementation of self-report in patients and caregivers is complex, and should be adapted for use in specific settings. We aimed to implement a set of outcome measures that included patient and caregiver self- and proxy-reported outcome measures in specialised outpatient palliative care (SOPC). In this study, we explore how the Integrated Palliative Outcome Scale (IPOS), IPOS Views on Care (IPOS VoC) and the Short-form Zarit Caregiver Burden Interview (ZBI-7) can be feasibly, acceptably and appropriately implemented in the daily care routines of SOPC.

Methods

Five SOPC teams were trained, and used the outcome measures in daily practice. Team members were mainly nurses and physicians. To investigate their feedback, we used a multi-method qualitative design consisting of focus groups with SOPC-team members (n = 14), field notes of meetings and conversations with the SOPC teams. In an iterative process, we analysed the findings using qualitative content analysis and refined use of the outcome measures.

Results

We found that integrating patient and caregiver outcome measures into daily care routines in SOPC is feasible. To improve feasibility, acceptability and appropriateness, the resulting burden on patients and relatives should be kept to a minimum, the usefulness of the measures must be understood, they should be used considerately, and administration must be manageable. We removed ZBI-7 from the set of measures as a result of feedback on its content and wording.

Conclusions

SOPC-team members have reservations about the implementation of PROM in SOPC, but with appropriate adjustments, its application in daily care is feasible, accepted and perceived as appropriate. Previous to use, SOPC-team members should be trained in how to apply the measures, in the design of manageable processes that include integration into electronic documentation systems, and in ongoing evaluation and support. They should also be taught how useful the measures can be.

Trial registration

May 19th, 2017, German Clinical Trials Register DRKS-ID: DRKS00012421.

Characteristics and Trends Among Patients With Cardiovascular Disease Referred to Palliative Care

IMPORTANCE

Use of palliative care (PC) for patients with cardiovascular disease (CVD) has increased recently. However, it is unknown if patients are receiving earlier referrals to PC.

OBJECTIVE

To assess characteristics and trends of patients with CVD referred to PC.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study in which analysis of data from the multicenter Quality Data Collection Tool for Palliative Care registry from January 2, 2015, through December 29, 2017, included patients with CVD 18 years or older referred to initial PC consultation who had a documented palliative performance score (PPS) .

EXPOSURES

Patients with CVD who presented for an initial PC visit.

MAIN OUTCOMES AND MEASURES

The primary outcome was PPS. Secondary outcomes included symptoms and end-of-life documentation.

RESULTS

Among 1801 patients (mean [SD] age, 77.7 [13.7] years) from 16 sites in the analysis, 875 (48.6%) were women and 1339 (74.3%) were white. A low PPS score (0%-30%), consistent with bedbound status, was recorded for 521 patients (28.9%), with no change through time. The most common moderate to severe symptoms were poor well-being, tiredness, anorexia, and dyspnea. Year of encounter was associated with improved symptoms of pain (odds ratio, 1.25; 95% CI, 1.05-1.50) and with constipation (odds ratio, 1.32; 95% CI, 1.03-1.69). No change through time was noted in other symptoms or end-of-life documentation. Although the proportion of referrals from general medicine increased from 43.2% (167 of 387) in 2015 to 52.9% (410 of 775) in 2017, the proportion of referrals from cardiologists decreased from 16.5% (64 of 387) in 2015 to 10.5% (81 of 775) in 2017. The proportion of patients referred to PC who were black decreased from 11.9% (46 of 387) in 2015 to 6.3% (49 of 775) in 2017. While 69.5% of all patients with CVD (1252 of 1801) had a primary diagnosis of heart failure, the proportion of non-heart failure CVD diagnoses, such as coronary artery disease and valvular heart disease, increased from 25.6% (99 of 387) in 2015 to 30.1% (233 of 775) in 2017.

CONCLUSIONS AND RELEVANCE

Patients with CVD demonstrated significant symptom burden, and there was no evidence in the registry of change in the PPSs of patients with CVD referred to PC through time. Cardiologists provided comparatively fewer referrals to PC for patients with CVD, and this proportion decreased through time. The proportion of racial and ethnic minorities referred to PC was small and decreased through time. These findings reinforce the need for cardiologists to be more engaged with PC and consider referring appropriate patients with CVD sooner.

Development of the Quality Data Collection Tool for Prospective Quality Assessment and Reporting in Palliative Care

BACKGROUND

Assessing and reporting the quality of care provided are increasingly important in palliative care, but we currently lack practical, efficient approaches for collection and reporting.

OBJECTIVE

In response, the Global Palliative Care Quality Alliance ("Alliance") sought to create a Quality Data Collection Tool for Palliative Care (QDACT-PC).

METHODS

We collaboratively and iteratively developed QDACT-PC, an electronic, point-of-care quality monitoring system for palliative care that supports prospective quality assessment and reporting in any clinical setting. QDACT-PC is the web-based data collection and reporting interface. Quality measures selected to be used in QDACT-PC were derived from a systematic review summarizing all published palliative care quality measure sets; Alliance clinical providers prioritized measures to be included in QDACT-PC to ensure maximal clinical relevance. Data elements and variables required to ascertain conformance to all selected quality measures were included in the QDACT-PC data dictionary. Whenever possible, variables collected in QDACT-PC align with validated surveys and/or nationally recognized common data elements. QDACT-PC data elements and software programmed business rules inform real-time assessments of conformance to selected quality measures. Data are deposited into a centralized registry for future analyses.

RESULTS

QDACT-PC can be used to report on >80% of all published palliative care quality measures and 100% of high-priority measure.

CONCLUSION

Electronic methods for collecting point-of-care quality monitoring data can be developed using collaborative partnerships between community and academic palliative care providers. Feasibility testing and creation of feedback reports are ongoing.