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Mack JW, Cernik C, Uno H, Laurent CA, Fisher L, Xu L, Munneke J, Cannizzaro N, Casperson M, Schwartz CM, Lakin JR, Cooper RM, Altschuler A, Wiener L, Chao CR, Kushi L. Quality of End-of-Life Care Among Adolescents and Young Adults With Cancer. J Clin Oncol 2024; 42:621-629. [PMID: 37890132 DOI: 10.1200/jco.23.01272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/21/2023] [Accepted: 08/24/2023] [Indexed: 10/29/2023] Open
Abstract
Adolescents, young adults with cancer receive limited psychosocial and spiritual support near death.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Colin Cernik
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | | | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Nancy Cannizzaro
- Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
| | - Mallory Casperson
- Pediatric Oncology, Kaiser Permanente Southern California, Pasadena, CA
| | - Corey M Schwartz
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Joshua R Lakin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Robert M Cooper
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | | | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, MD
| | - Chun R Chao
- Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
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Mack JW, Fisher L, Khalaj A, Altschuler A, Chao CR, Kushi LH, Casperson M, Lakin JR, Lefebvre A, Schwartz CM, Shalman DM, Wall CB, Wiener L. Quality Indicators for Adolescents and Young Adults With Advanced Cancer: A Modified Delphi Process With Patients, Family Members, and Clinicians. J Pain Symptom Manage 2023; 66:54-61. [PMID: 36933749 PMCID: PMC10330073 DOI: 10.1016/j.jpainsymman.2023.03.005] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/18/2023]
Abstract
CONTEXT Quality measures have been devised for end-of-life care of older adults with cancer, but are lacking for adolescents and young adults (AYAs). OBJECTIVE We previously conducted interviews with AYAs, family caregivers, and clinicians to identify priority domains for high quality care of AYAs with advanced cancer. The goal of this study was to use a modified Delphi process to form consensus around the highest priority quality indicators. METHODS A modified Delphi process was conducted with 10 AYAs with recurrent or metastatic cancer, 11 family caregivers, and 29 multidisciplinary clinicians, using small group web conferences. Participants were asked to rate the importance of each of 41 potential quality indicators, rank the 10 most important, and engage in discussion to reconcile differences. RESULTS Of 41 initial indicators, 34 were rated as highly important (rating seven, eight, or nine on a nine-point scale) by >70% of participants. The panel was unable to reach consensus around the 10 most important indicators. Instead, participants recommended retaining a larger set of indicators to reflect potential for different priorities across the population, resulting in a final set of 32 indicators. Recommended indicators broadly encompassed attention to physical symptoms; quality of life; psychosocial, and spiritual care; communication and decision-making; relationships with clinicians; care and treatment; and independence. CONCLUSION A patient- and family-centered process for quality indicator development led to strong endorsement of multiple potential indicators by Delphi participants. Further validation and refinement will be performed using a survey of bereaved family members.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences (JWM, LF, AK), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S.; Department of Pediatric Oncology (JWM, AL, CBW), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S..
| | - Lauren Fisher
- Division of Population Sciences (JWM, LF, AK), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S
| | - Andrew Khalaj
- Division of Population Sciences (JWM, LF, AK), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S
| | - Andrea Altschuler
- Department of Pediatric Oncology (JWM, AL, CBW), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S.; Division of Research (LHK, AA), Kaiser Permanente Northern California, Oakland, California, U.S
| | - Chun R Chao
- Department of Research and Evaluation (CRC), Kaiser Permanente Southern California, Pasadena, California, U.S
| | - Lawrence H Kushi
- Division of Research (LHK, AA), Kaiser Permanente Northern California, Oakland, California, U.S
| | | | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care (JRL), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S
| | - Anna Lefebvre
- Department of Pediatric Oncology (JWM, AL, CBW), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S
| | - Corey M Schwartz
- Medical Oncology (CMS), Kaiser Permanente Northern California, Oakland, California, U.S
| | - Dov M Shalman
- Palliative Care (DMS), Kaiser Permanente Southern California, Pasadena, California, U.S
| | - Catherine B Wall
- Department of Pediatric Oncology (JWM, AL, CBW), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S
| | - Lori Wiener
- Psychosocial Support and Research Program (LW), National Cancer Institute, Bethesda, Maryland, U.S
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MacMartin MA, Barnato AE. Development of an Abstraction Tool to Assess Palliative Care Components. Am J Hosp Palliat Care 2021; 39:1418-1427. [PMID: 34894773 DOI: 10.1177/10499091211061724] [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: 11/16/2022] Open
Abstract
Background: Little is known regarding the fidelity of delivery of guideline-recommended components of palliative care in "real world" encounters. Objective: To develop a qualitative coding framework to identify components of clinical palliative care in clinical documentation across care settings. Design: Retrospective review of palliative care clinical documentation from medical providers, with directed qualitative content analysis to identify components of clinical care documented. Setting/Subjects: Purposively sampled deceased patients seen by palliative care at a US academic medical center between 7/1/2011-7/1/2018. Main Outcomes and Measures: The outcome of this work is a coding framework for use in future research. We assessed the robustness of the framework using Cohen's kappa. Results: We reviewed sixty-two encounters from twenty-six patients. We identified 7 major themes in documentation: (1) addressing physical symptoms, (2) addressing psychological symptoms, (3) establishing illness understanding, (4) supporting decision making, (5) end-of-life planning, (6) understanding psychosocial context, and (7) care coordination. Interrater reliability varied widely between components, with Cohen's kappa ranging from -.51 to 1. Conclusions: This pilot study provides a coding framework to measure documentation of clinical palliative care components. Several components could not be reliably identified using this framework, suggesting the need for additional measurement strategies.
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Affiliation(s)
- Meredith A MacMartin
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,22916Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Amber E Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,22916Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Mack JW, Fisher L, Kushi L, Chao CR, Vega B, Rodrigues G, Josephs I, Brock KE, Buchanan S, Casperson M, Cooper RM, Fasciano KM, Kolevska T, Lakin JR, Lefebvre A, Schwartz CM, Shalman DM, Wall CB, Wiener L, Altschuler A. Patient, Family, and Clinician Perspectives on End-of-Life Care Quality Domains and Candidate Indicators for Adolescents and Young Adults With Cancer. JAMA Netw Open 2021; 4:e2121888. [PMID: 34424305 PMCID: PMC8383130 DOI: 10.1001/jamanetworkopen.2021.21888] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/09/2021] [Indexed: 11/14/2022] Open
Abstract
Importance End-of-life care quality indicators specific to adolescents and young adults (AYAs) aged 12 to 39 years with cancer have not been developed. Objective To identify priority domains for end-of-life care from the perspectives of AYAs, family caregivers, and clinicians, and to propose candidate quality indicators reflecting priorities. Design, Setting, and Participants This qualitative study was conducted from December 6, 2018, to January 5, 2021, with no additional follow-up. In-depth interviews were conducted with patients, family caregivers, and clinicians and included a content analysis of resulting transcripts. A multidisciplinary advisory group translated priorities into proposed quality indicators. Interviews were conducted at the Dana-Farber Cancer Institute, Kaiser Permanente Northern California, Kaiser Permanente Southern California, and an AYA cancer support community (lacunaloft.org). Participants included 23 AYAs, 28 caregivers, and 29 clinicians. Exposure Stage IV or recurrent cancer. Main Outcomes and Measures Care priorities. Results Interviews were conducted with 23 patients (mean [SD] age, 29.3 [7.3] years; 12 men [52%]; 18 White participants [78%]), 28 family caregivers (23 women [82%]; 14 White participants [50%]), and 29 clinicians (20 women [69%]; 13 White participants [45%]). Caregivers included 22 parents (79%), 5 spouses or partners (18%), and 1 other family member (4%); the 29 clinicians included 15 physicians (52%), 6 nurses or nurse practitioners (21%), and 8 social workers or psychologists (28%). Interviews identified 7 end-of-life priority domains: attention to physical symptoms, attention to quality of life, psychosocial and spiritual care, communication and decision-making, relationships with clinicians, care and treatment, and independence. Themes were consistent across the AYA age range and participant type. Although some domains were represented in quality indicators developed for adults, unique domains were identified, as well as AYA-specific manifestations of existing domains. For example, quality of life included global quality of life; attainment of life goals, legacy, and meaning; support of personal relationships; and normalcy. Within communication and decision-making, domains included communication early in the disease course, addressing prognosis and what to expect at the end of life, and opportunity for AYAs to hold desired roles in decision-making. Care and treatment domains relevant to cancer therapy, use of life-prolonging measures, and location of death emphasized the need for preference sensitivity rather than a standard path. This finding differs from existing adult indicators that propose that late-life chemotherapy, intensive measures, and hospital death should be rare. Conclusions and Relevance The findings of this qualitative study suggest that AYAs with cancer have priorities for care at the end of life that are not fully encompassed in existing indicators for adults. Use of new indicators for this young population may better reflect patient- and family-centered experiences of quality care.
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Affiliation(s)
- Jennifer W. Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Larry Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Chun R. Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Brenda Vega
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gilda Rodrigues
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Katharine E. Brock
- Divisions of Pediatric Oncology and Palliative Care, Emory University and Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Susan Buchanan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Now with Agios Pharmaceuticals, Cambridge, Massachusetts
| | | | - Robert M. Cooper
- Department of Pediatric Oncology, Kaiser Permanente Southern California, Pasadena
| | - Karen M. Fasciano
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tatjana Kolevska
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland
| | - Joshua R. Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anna Lefebvre
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Corey M. Schwartz
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland
| | - Dov M. Shalman
- Department of Palliative Care, Kaiser Permanente Southern California, Pasadena
| | - Catherine B. Wall
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, Maryland
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland
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Validity and reliability of the Palliative Care Transition Measure for Caregivers (PCTM-C). Palliat Support Care 2018; 17:202-207. [PMID: 29352818 DOI: 10.1017/s1478951517001225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Patients suffering from advanced disease face different care transitions. The transition from acute to palliative care is challenging and may lead to the discontinuity of care. Family caregivers become important sources of information, as patients begin to experience difficulties in coping with emotional transition events. The Care Transition Measure was developed to evaluate care transitions as experienced by the elderly. It has never been used in palliative care. The aim of this study was to test the validity and reliability of a modified version of the Palliative Care Transition Measure, specifically the Palliative Care Transition Measure for Caregivers (PCTM-C). METHOD The study included two main phases. Phase I focused on the construction of a modified version of the Palliative Care Transition Measure through two focus groups and by computing the content validity index. Phase II focused on testing the psychometric properties of the PCTM-C on 272 family caregivers through confirmatory factor analysis. RESULT The content validity index for each of the items was higher than 0.80, whereas that for the scale was 0.95. The model tested with confirmatory factor analysis fitted the data well and confirmed that the transition measures referred to communication, integrated care and a trusting-relationship, and therefore the core dimensions of continuity according to existing conceptual models. The internal consistency was high (Cronbach's alpha = 0.94). SIGNIFICANCE OF RESULTS The PCTM-C proved to be a suitable measure of the quality of such transitions. It may be used in clinical practice as a continuity quality indicator and has the potential to guide interventions to enhance family caregivers' experience of care continuity.
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Aslakson RA, Dy SM, Wilson RF, Waldfogel J, Zhang A, Isenberg SR, Blair A, Sixon J, Lorenz KA, Robinson KA. Patient- and Caregiver-Reported Assessment Tools for Palliative Care: Summary of the 2017 Agency for Healthcare Research and Quality Technical Brief. J Pain Symptom Manage 2017; 54:961-972.e16. [PMID: 28818633 DOI: 10.1016/j.jpainsymman.2017.04.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/11/2017] [Accepted: 04/13/2017] [Indexed: 12/21/2022]
Abstract
CONTEXT Assessment tools are data collection instruments that are completed by or with patients or caregivers and which collect data at the individual patient or caregiver level. OBJECTIVES The objectives of this study are to 1) summarize palliative care assessment tools completed by or with patients or caregivers and 2) identify needs for future tool development and evaluation. METHODS We completed 1) a systematic review of systematic reviews; 2) a supplemental search of previous reviews and Web sites, and/or 3) a targeted search for primary articles when no tools existed in a domain. Paired investigators screened search results, assessed risk of bias, and abstracted data. We organized tools by domains from the National Consensus Project Clinical Practice Guidelines for Palliative Care and selected the most relevant, recent, and highest quality systematic review for each domain. RESULTS We included 10 systematic reviews and identified 152 tools (97 from systematic reviews and 55 from supplemental sources). Key gaps included no systematic review for pain and few tools assessing structural, cultural, spiritual, or ethical/legal domains, or patient-reported experience with end-of-life care. Psychometric information was available for many tools, but few studies evaluated responsiveness (sensitivity to change) and no studies compared tools. CONCLUSION Few to no tools address the spiritual, ethical, or cultural domains or patient-reported experience with end-of-life care. While some data exist on psychometric properties of tools, the responsiveness of different tools to change and/or comparisons between tools have not been evaluated. Future research should focus on developing or testing tools that address domains for which few tools exist, evaluating responsiveness, and comparing tools.
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Affiliation(s)
- Rebecca A Aslakson
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Oncology, Palliative Care Program, Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA.
| | - Sydney M Dy
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Renee F Wilson
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Julie Waldfogel
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Allen Zhang
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Sarina R Isenberg
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Alex Blair
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Joshua Sixon
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Karl A Lorenz
- VA Palo Alto Health Care System, Palo Alto, California; Stanford School of Medicine, Department of Medicine, Palo Alto, California
| | - Karen A Robinson
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA; Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Sacco P, Cagle JG, Moreland ML, Camlin EA. Screening and Assessment of Substance Use in Hospice Care: Examining Content from a National Sample of Psychosocial Assessments. J Palliat Med 2017; 20:850-856. [DOI: 10.1089/jpm.2016.0538] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Paul Sacco
- School of Social Work, University of Maryland-Baltimore, Baltimore, Maryland
| | - John G. Cagle
- School of Social Work, University of Maryland-Baltimore, Baltimore, Maryland
| | - Melissa L. Moreland
- School of Social Work, University of Maryland-Baltimore, Baltimore, Maryland
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Lamba S, Berlin A, Goett R, Ponce CB, Holland B, Walther S. Assessing Emotional Suffering in Palliative Care: Use of a Structured Note Template to Improve Documentation. J Pain Symptom Manage 2016; 52:1-7. [PMID: 27241439 DOI: 10.1016/j.jpainsymman.2016.01.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/04/2016] [Indexed: 11/28/2022]
Abstract
CONTEXT Documentation of the emotional or psychological needs of seriously ill patients receiving specialty palliative care is endorsed by the "Measuring What Matters" project as a quality performance metric and recommended for use by hospice and palliative care programs for program improvement. OBJECTIVES The aim of this study was to increase the proportion of inpatient palliative care team encounters in which emotional or psychological needs of patients and family members were documented and to qualitatively enrich the nature of this documentation. METHODS This is a mixed-methods retrospective study of 200 patient charts reviewed before and after implementation of a structured note template (SmartPhrase) for palliative care encounters. Patterns of documentation of emotional needs pre- and post-implementation were assessed quantitatively and qualitatively using thematic analysis. RESULTS A total of 158 of 200 pre-intervention charts and 185 of 200 post-intervention charts included at least one note from the palliative care team. Documentation of emotional assessment increased after SmartPhrase implementation (63.9% [101 of 158] vs. 74.6% [138 of 185]; P < 0.03). Qualitative analysis revealed a post-intervention reduction in the use of generic phrases ("emotional support provided") and an increase in the breadth and depth of emotion-related documentation. CONCLUSION A structured note template with a prompt for emotional assessment increases the overall quantity and richness of documentation related to patient and family emotions. However, this documentation remains mostly descriptive. Additional prompting for documentation of recommendations to address identified emotional needs, and the use of screening tools for depression and anxiety, when appropriate, may be necessary for clinically meaningful quality improvements in patient care.
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Affiliation(s)
- Sangeeta Lamba
- New Jersey Medical School/Rutgers University, Newark, New Jersey, USA.
| | - Ana Berlin
- New Jersey Medical School/Rutgers University, Newark, New Jersey, USA
| | - Rebecca Goett
- New Jersey Medical School/Rutgers University, Newark, New Jersey, USA
| | | | - Bart Holland
- New Jersey Medical School/Rutgers University, Newark, New Jersey, USA
| | - Susanne Walther
- New Jersey Medical School/Rutgers University, Newark, New Jersey, USA
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Kamal AH, Anderson WG, Boss RD, Brody AA, Campbell TC, Creutzfeldt CJ, Hurd CJ, Kinderman AL, Lindenberger EC, Reinke LF. The Cambia Sojourns Scholars Leadership Program: Project Summaries from the Inaugural Scholar Cohort. J Palliat Med 2016; 19:591-600. [DOI: 10.1089/jpm.2016.0086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Renee D. Boss
- Johns Hopkins School of Medicine, Baltimore, Maryland
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Tuffrey-Wijne I, Wicki M, Heslop P, McCarron M, Todd S, Oliver D, de Veer A, Ahlström G, Schäper S, Hynes G, O'Farrell J, Adler J, Riese F, Curfs L. Developing research priorities for palliative care of people with intellectual disabilities in Europe: a consultation process using nominal group technique. BMC Palliat Care 2016; 15:36. [PMID: 27009550 PMCID: PMC4806426 DOI: 10.1186/s12904-016-0108-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 03/17/2016] [Indexed: 11/20/2022] Open
Abstract
Background Empirical knowledge around palliative care provision and needs of people with intellectual disabilities is extremely limited, as is the availability of research resources, including expertise and funding. This paper describes a consultation process that sought to develop an agenda for research priorities for palliative care of people with intellectual disabilities in Europe. Methods A two-day workshop was convened, attended by 16 academics and clinicians in the field of palliative care and intellectual disability from six European countries. The first day consisted of round-table presentations and discussions about the current state of the art, research challenges and knowledge gaps. The second day was focused on developing consensus research priorities with 12 of the workshop participants using nominal group technique, a structured method which involved generating a list of research priorities and ranking them in order of importance. Results A total of 40 research priorities were proposed and collapsed into eleven research themes. The four most important research themes were: investigating issues around end of life decision making; mapping the scale and scope of the issue; investigating the quality of palliative care for people with intellectual disabilities, including the challenges in achieving best practice; and developing outcome measures and instruments for palliative care of people with intellectual disabilities. Conclusions The proposal of four major priority areas and a range of minor themes for future research in intellectual disability, death, dying and palliative care will help researchers to focus limited resources and research expertise on areas where it is most needed and support the building of collaborations. The next steps are to cross-validate these research priorities with people with intellectual disabilities, carers, clinicians, researchers and other stakeholders across Europe; to validate them with local and national policy makers to determine how they could best be incorporated in policy and programmes; and to translate them into actual research studies by setting up European collaborations for specific studies that require such collaboration, develop research proposals and attract research funding.
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Affiliation(s)
- I Tuffrey-Wijne
- Kingston University & St George's University of London, Faculty of Health, Social Care and Education, Cranmer Terrace, London, SW17 0RE, UK.
| | - M Wicki
- Internationale Hochschule für Heilpädagogik Zürich, Zürich, Switzerland
| | - P Heslop
- Norah Fry Research Centre, School for Policy Studies, University of Bristol, Bristol, UK
| | - M McCarron
- Trinity College, University of Dublin, Dublin, Ireland
| | - S Todd
- Faculty of Life Sciences and Education, University of South Wales, Cardiff, Newport, UK
| | - D Oliver
- Tizard Centre, University of Kent, Kent, UK
| | - A de Veer
- Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | | | - S Schäper
- Department Muenster, Catholic University of Applied Sciences, Muenster, Germany
| | - G Hynes
- Trinity College, University of Dublin, Dublin, Ireland
| | - J O'Farrell
- Trinity College, University of Dublin, Dublin, Ireland
| | - J Adler
- University of Applied Sciences of Special Needs Education, Zürich, Switzerland
| | - F Riese
- Division of Psychiatry Research and Psychogeriatric Medicine, Zurich, Switzerland
| | - L Curfs
- Maastricht University Medical Centre, Governor Kremers Centre, Maastricht, The Netherlands
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Dy SM, Herr K, Bernacki RE, Kamal AH, Walling AM, Ersek M, Norton SA. Methodological Research Priorities in Palliative Care and Hospice Quality Measurement. J Pain Symptom Manage 2016; 51:155-62. [PMID: 26596877 DOI: 10.1016/j.jpainsymman.2015.10.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/17/2015] [Accepted: 10/22/2015] [Indexed: 11/26/2022]
Abstract
Quality measurement is a critical tool for improving palliative care and hospice, but significant research is needed to improve the application of quality indicators. We defined methodological priorities for advancing the science of quality measurement in this field based on discussions of the Technical Advisory Panel of the Measuring What Matters consensus project of the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association and a subsequent strategy meeting to better clarify research challenges, priorities, and quality measurement implementation strategies. In this article, we describe three key priorities: 1) defining the denominator(s) (or the population of interest) for palliative care quality indicators, 2) developing methods to measure quality from different data sources, and 3) conducting research to advance the development of patient/family-reported indicators. We then apply these concepts to the key quality domain of advance care planning and address relevance to implementation of indicators in improving care. Developing the science of quality measurement in these key areas of palliative care and hospice will facilitate improved quality measurement across all populations with serious illness and care for patients and families.
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Affiliation(s)
- Sydney Morss Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Keela Herr
- University of Iowa College of Nursing, Iowa City, Iowa, USA
| | - Rachelle E Bernacki
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Ariadne Labs, Boston, Massachusetts, USA; Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard School of Public Health, Boston, Massachusetts, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Anne M Walling
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Mary Ersek
- Corporal Michael J. Crescenz VA Medical Center-Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA; School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sally A Norton
- University of Rochester School of Nursing, Rochester, New York, USA
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Wool C. Instrument Psychometrics: Parental Satisfaction and Quality Indicators of Perinatal Palliative Care. J Palliat Med 2015; 18:872-7. [DOI: 10.1089/jpm.2015.0135] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Charlotte Wool
- Stabler Department of Nursing, York College of Pennsylvania, York, Pennsylvania
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13
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Dy SM, Kiley KB, Ast K, Lupu D, Norton SA, McMillan SC, Herr K, Rotella JD, Casarett DJ. Measuring what matters: top-ranked quality indicators for hospice and palliative care from the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association. J Pain Symptom Manage 2015; 49:773-81. [PMID: 25697097 DOI: 10.1016/j.jpainsymman.2015.01.012] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 01/10/2015] [Accepted: 01/21/2015] [Indexed: 01/29/2023]
Abstract
CONTEXT Measuring quality of hospice and palliative care is critical for evaluating and improving care, but no standard U.S. quality indicator set exists. OBJECTIVES The Measuring What Matters (MWM) project aimed to recommend a concise portfolio of valid, clinically relevant, cross-cutting indicators for internal measurement of hospice and palliative care. METHODS The MWM process was a sequential consensus project of the American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA). We identified candidate indicators mapped to National Consensus Project (NCP) Palliative Care Guidelines domains. We narrowed the list through a modified Delphi rating process by a Technical Advisory Panel and Clinical User Panel and ratings from AAHPM and HPNA membership and key organizations. RESULTS We narrowed the initial 75 indicators to a final list of 10. These include one in the NCP domain Structure and Process (Comprehensive Assessment), three in Physical Aspects (Screening for Physical Symptoms, Pain Treatment, and Dyspnea Screening and Management), one in Psychological and Psychiatric Aspects (Discussion of Emotional or Psychological Needs), one in Spiritual and Existential Aspects (Discussion of Spiritual/Religious Concerns), and three in Ethical and Legal Aspects (Documentation of Surrogate, Treatment Preferences, and Care Consistency with Documented Care Preferences). The list also recommends a global indicator of patient/family perceptions of care, but does not endorse a specific survey instrument. CONCLUSION This consensus set of hospice and palliative care quality indicators is a foundation for standard, valid internal quality measurement for U.S. SETTINGS Further development will assemble implementation tools for quality measurement and benchmarking.
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Affiliation(s)
- Sydney Morss Dy
- Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA.
| | | | - Katherine Ast
- American Academy of Hospice and Palliative Medicine, Chicago, Illinois, USA
| | - Dale Lupu
- American Academy of Hospice and Palliative Medicine, Chicago, Illinois, USA
| | - Sally A Norton
- University of Rochester School of Nursing, Rochester, New York, USA
| | - Susan C McMillan
- University of South Florida College of Nursing, Tampa, Florida, USA
| | - Keela Herr
- University of Iowa College of Nursing, Iowa City, Iowa, USA
| | | | - David J Casarett
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Cagle JG, Munn JC, Hong S, Clifford M, Zimmerman S. Validation of the Quality of Dying-Hospice Scale. J Pain Symptom Manage 2015; 49:265-76. [PMID: 25057986 PMCID: PMC4303538 DOI: 10.1016/j.jpainsymman.2014.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 06/09/2014] [Accepted: 06/25/2014] [Indexed: 11/18/2022]
Abstract
CONTEXT Measuring the quality of dying (QOD) experience is important for hospice providers. However, few instruments exist that assess one's QOD; and those that do have not been well validated in hospice. OBJECTIVES This study tested the properties of the QOD-Hospice Scale (QOD-Hospice) to provide preliminary validation data on internal consistency, inter-rater reliability, convergent validity, and factorability in a hospice setting. Additionally, results of the factor analysis were used to create a brief version of the measure. METHODS Bereaved informal caregivers who had provided care for a hospice patient were recruited from a large nonprofit hospice. Participants completed post-death surveys, which included the QOD-Hospice and other study measures. Convergent validity was tested by exploring hypothesized associations with related instruments measuring negative emotional states (Depression Anxiety Stress Scale-21), emotional grief (Texas Revised Inventory of Grief-2), social support (Lubben Social Network Scale-6), and a single-item measure of satisfaction with hospice care. RESULTS A total of 70 caregivers participated in the survey (40 primary and 30 secondary caregivers), most of whom were female (67%) and white (81%). The QOD-Hospice produced an alpha of 0.86, an intraclass correlation of 0.49 between caregivers of the same decedent, and was correlated with all measures testing convergent validity (P<0.05; in the hypothesized direction) and most, but not all, subscales. An exploratory factor analysis elicited two factors, Preparation (seven items) and Security (six items), which were combined to create a 13-item version of the scale, the QOD-Hospice-Short Form. CONCLUSION Although further testing of the QOD-Hospice measures is needed, preliminary evidence suggests that the instruments are reliable and valid for use in hospice.
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Affiliation(s)
- John G Cagle
- University of Maryland, Baltimore, Maryland, USA.
| | - Jean C Munn
- Florida State University, Tallahassee, Florida, USA
| | - Seokho Hong
- University of Maryland, Baltimore, Maryland, USA
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Currow DC, Allingham S, Yates P, Johnson C, Clark K, Eagar K. Improving national hospice/palliative care service symptom outcomes systematically through point-of-care data collection, structured feedback and benchmarking. Support Care Cancer 2014; 23:307-15. [PMID: 25063272 PMCID: PMC4289012 DOI: 10.1007/s00520-014-2351-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 07/01/2014] [Indexed: 11/28/2022]
Abstract
Purpose Every health care sector including hospice/palliative care needs to systematically improve services using patient-defined outcomes. Data from the national Australian Palliative Care Outcomes Collaboration aims to define whether hospice/palliative care patients’ outcomes and the consistency of these outcomes have improved in the last 3 years. Methods Data were analysed by clinical phase (stable, unstable, deteriorating, terminal). Patient-level data included the Symptom Assessment Scale and the Palliative Care Problem Severity Score. Nationally collected point-of-care data were anchored for the period July–December 2008 and subsequently compared to this baseline in six 6-month reporting cycles for all services that submitted data in every time period (n = 30) using individual longitudinal multi-level random coefficient models. Results Data were analysed for 19,747 patients (46 % female; 85 % cancer; 27,928 episodes of care; 65,463 phases). There were significant improvements across all domains (symptom control, family care, psychological and spiritual care) except pain. Simultaneously, the interquartile ranges decreased, jointly indicating that better and more consistent patient outcomes were being achieved. Conclusion These are the first national hospice/palliative care symptom control performance data to demonstrate improvements in clinical outcomes at a service level as a result of routine data collection and systematic feedback.
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Affiliation(s)
- David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Sturt Road Bedford Park, Adelaide, SA, 5042, Australia,
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Dy SM, Walling AM, Mack JW, Malin JL, Pantoja P, Lorenz KA, Tisnado DM. Evaluating the quality of supportive oncology using patient-reported data. J Oncol Pract 2014; 10:e223-30. [PMID: 24618077 DOI: 10.1200/jop.2013.001237] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patient-reported data may provide valuable information for oncology quality measurement. We evaluated applying patient-reported data from the Cancer Care Outcomes Research and Surveillance Consortium national study to quality indicators addressing supportive oncology domains. METHODS We analyzed surveys including validated instruments for symptoms and care planning from 4,174 patients newly diagnosed with lung or colorectal cancer. We adapted existing supportive oncology indicators for use with patient-reported data from Cancer Quality-ASSIST and the American Society of Clinical Oncology Quality Oncology Practice Initiative. Where feasible, we examined indicators using medical record data for comparison purposes. RESULTS Using patient-reported data, the percentage of patients meeting indicator criteria for screening ranged from 74% (significant depressive symptoms) to 93% (pain, nausea/vomiting). The percentage meeting indicator criteria for symptom treatment ranged from 73% (significant depressive symptoms) to 99% (nausea/vomiting). Symptom severity did not affect the results. Using medical record data, the percentage meeting indicator criteria varied between 4% (significant depressive symptoms) and 23% (pain). For information and care planning, 44% met criteria for discussion about resuscitation and 32% for hospice discussion using survey data. Using medical record data, 11% met criteria for goals-of-care discussion in intensive care and 46% for hospice/pain management/palliative care referral before death. CONCLUSION Quality of care for symptoms measured using patient self-report was higher than when including medical record data. Use of patient-reported and medical record data allowed measurement of different perspectives on care planning indicators. Patient-reported data provide a complementary, patient-centered perspective on the quality of supportive oncology care.
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Affiliation(s)
- Sydney M Dy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Anne M Walling
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Jennifer W Mack
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Jennifer L Malin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Philip Pantoja
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Karl A Lorenz
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Diana M Tisnado
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of California, Los Angeles; Veterans Health Administration of Greater Los Angeles, Los Angeles, CA; and Dana-Farber Cancer Institute, Boston, MA
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Health care providers’ use and knowledge of the Edmonton Symptom Assessment System (ESAS): is there a need to improve information and training? Support Care Cancer 2013; 22:201-8. [DOI: 10.1007/s00520-013-1955-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 08/21/2013] [Indexed: 11/26/2022]
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Aldridge Carlson MD. Research methods priorities in geriatric palliative medicine. J Palliat Med 2013; 16:838-42. [PMID: 23777330 DOI: 10.1089/jpm.2013.9492] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Continuing the momentum of geriatric palliative medicine research achieved during the past decade requires a focus on research methods priorities that span the continuum of research from small pilot studies testing new interventions to large multisite studies evaluating implementation of proven interventions and models of care. Each phase of this continuum presents unique challenges for investigators who are designing, conducting, and reporting results of these scientific endeavors. The goal of this article is to describe the top priorities in research methods for the field of geriatric palliative medicine that will enable the field to rapidly respond to the changing landscape of health care policy and quality improvement initiatives.
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Weber M, Claus M, Zepf KI, Fischbeck S, Escobar Pinzon LC. Dying in Germany--unfulfilled needs of relatives in different care settings. J Pain Symptom Manage 2012; 44:542-51. [PMID: 22771131 DOI: 10.1016/j.jpainsymman.2011.10.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 10/05/2011] [Accepted: 10/10/2011] [Indexed: 10/28/2022]
Abstract
CONTEXT The integration of family members in the dying process and the recognition of their special needs are important factors for the development of high-quality palliative care. OBJECTIVES This study aimed to explore important needs and personal experiences of relatives at the end of life, and to detect differences in these needs and experiences for various care settings. METHODS Our cross-sectional survey was based on a random sampling of 5000 inhabitants of Rhineland-Palatinate (Germany) who died between May 25 and August 24, 2008. Relatives of these randomly drawn deceased persons were interviewed by a written survey. RESULTS A total of 1378 questionnaires were completed (response rate 36.0%), with 1337 eligible for our analyses; 81.5% of the bereaved totally/partially agreed that the information received from physicians was comprehensive and sufficient; 7.5% neither agreed nor disagreed; and 11.0% partially/totally disagreed. Of the respondents, 54.1% totally/partially agreed to having received emotional support by physicians, 14.2% neither agreed nor disagreed, and 31.7% partially/totally disagreed. Physicians in nursing homes and standard hospital wards were rated less favorably. Whereas the professionals' lack of time was strongly associated with the unfulfilled needs for emotional support, many relatives also lacked this type of care when physicians seemed to have enough time. CONCLUSION The high rates of unfulfilled needs of relatives across all care settings and all types of diseases reinforce the necessity of a comprehensive palliative care approach. An increased awareness of the psychological vulnerability of caregivers should lead to dedicated efforts to improve deficits in the German health care system.
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Affiliation(s)
- Martin Weber
- Interdisciplinary Palliative Care Unit, III, Department of Medicine, University Medical Center of the Johannes Gutenberg University of Mainz, ObereZahlbacher Strasse 67, Mainz, Germany
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Hanson LC, Rowe C, Wessell K, Caprio A, Winzelberg G, Beyea A, Bernard SA. Measuring Palliative Care Quality for Seriously Ill Hospitalized Patients. J Palliat Med 2012; 15:798-804. [DOI: 10.1089/jpm.2011.0471] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Laura C. Hanson
- Division of Geriatrics and Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina
| | - Charlotte Rowe
- Division of Hematology and Oncology, and Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina
| | - Kathryn Wessell
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Anthony Caprio
- Division of Geriatrics and Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina
| | - Gary Winzelberg
- Division of Geriatrics and Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina
| | - Annette Beyea
- Division of Geriatrics and Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina
| | - Stephen A. Bernard
- Division of Hematology and Oncology, and Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina
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Outcome assessment instruments in palliative and hospice care—a review of the literature. Support Care Cancer 2012; 20:2879-93. [DOI: 10.1007/s00520-012-1415-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 02/14/2012] [Indexed: 11/12/2022]
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Abstract
Collecting reliable and valid data is an increasing expectation within palliative care. Data remain the crux for demonstrating value and quality of care, which are the critical steps to program sustainability. Parallel goals of conducting research and performing quality assessment and improvement can also ensure program growth, financial health, and viability in an increasingly competitive environment. Mounting expectations by patients, hospitals, and payers and inevitable pay-for-performance paradigms have transitioned data collection procedures from novel projects to expected standard operation within usual palliative care delivery. We present types of data to collect, published guides for data collection, and how data can inform quality, value, and research within a palliative care organization. Our experiences with the Quality Data Collection Tool (QDACT) in the Carolinas Palliative Care Consortium to collect data on quality have led to valuable lessons learned in creating a data collection system. Suggested steps in forming data-sharing collaborations and building data collection procedures are shared.
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Schenck AP, Rokoske FS, Durham DD, Cagle JG, Hanson LC. The PEACE Project: Identification of Quality Measures for Hospice and Palliative Care. J Palliat Med 2010; 13:1451-9. [PMID: 21155640 DOI: 10.1089/jpm.2010.0238] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anna P. Schenck
- The Carolinas Center for Medical Excellence, Cary, North Carolina
- Public Health Leadership Program, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | | | | | - John G. Cagle
- Institute on Aging, University of North Carolina, Chapel Hill, North Carolina
| | - Laura C. Hanson
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill, North Carolina
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