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Wood GJ, Clepp RK, Lee J, Twaddle ML, Ogunseitan A, Neagle J, Szmuilowicz E. Outcomes of a Multisite Mentored Implementation Approach to Promoting Goals of Care Conversations. J Pain Symptom Manage 2024:S0885-3924(24)00744-9. [PMID: 38697406 DOI: 10.1016/j.jpainsymman.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 04/20/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
CONTEXT The Preference-Aligned Communication and Treatment (PACT) Project is a multisite quality improvement effort that has been shown to increase the frequency of goals of care (GOC) conversations in hospitalized patients with serious illness. OBJECTIVES To evaluate the effect of PACT on goal-discordant care and resource utilization. METHODS Hospitals enrolled in a multiyear mentored implementation quality improvement initiative to facilitate GOC conversations for seriously ill hospitalized patients. The primary outcome was the percentage of patients with care discordant with stated preferences, assessed by comparing documented wishes to Medicare claims data for patients who were admitted to intervention units and died over the study period. Secondary outcomes evaluated end-of-life resource utilization by comparing Medicare claims data for intervention patients with propensity score-matched controls. RESULTS In the 9 hospitals included in the study, 1347 intervention group patients were compared to 4019 in the control group. Rates of discordance between wishes and care were generally low in the intervention group. Compared to the control group, patients in the intervention group had lower costs (-976.05 dollars, P = 0.010), were less likely to be admitted to the ICU (OR 0.9, P = 0.005), less likely to be on a ventilator or undergo CPR or cardioversion, more likely to enroll in hospice (OR 1.81, P < 0.001) and had a longer hospice stay (3.35 more days, P = 0.041). CONCLUSION A multisite mentored implementation quality improvement intervention for seriously ill hospitalized patients resulted in care aligned with goals and decreased resource utilization at the end of life.
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Affiliation(s)
- Gordon J Wood
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Medical Education (G.J.W.), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Rebecca K Clepp
- Division of Pulmonary and Critical Care (R.K.C.), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jungwha Lee
- Department of Preventive Medicine (J.L.), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Martha L Twaddle
- Northwestern Lake Forest Hospital (M.L.T), Palliative Medicine and Supportive Care, Lake Forest, Illinois, USA
| | - Adeboye Ogunseitan
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jayson Neagle
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Eytan Szmuilowicz
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Hui D, Huang YT, Andersen C, Cassel B, Nortje N, George M, Bruera E. Cost of Hospitalization Associated with Inpatient Goals-of-Care Program Implementation at a Comprehensive Cancer Center: A Propensity Score Analysis. Cancers (Basel) 2024; 16:1316. [PMID: 38610994 PMCID: PMC11010830 DOI: 10.3390/cancers16071316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
The impact of goals-of-care programs on acute hospitalization costs is unclear. We compared the hospitalization cost in an 8-month period before implementation of a multimodal interdisciplinary goals-of-care program (1 May 2019 to 31 December 2019) to an 8-month period after program implementation (1 May 2020 to 31 December 2020). Propensity score weighting was used to adjust for differences in potential covariates. The primary outcome was total direct cost during the hospital stay for each index hospitalization. This analysis included 6977 patients in 2019 and 5964 patients in 2020. The total direct cost decreased by 3% in 2020 but was not statistically significant (ratio 0.97, 95% CI 0.92, 1.03). Under individual categories, there was a significant decrease in medical oncology (ratio 0.58, 95% CI 0.50, 0.68) and pharmacy costs (ratio 0.86, 95% CI 0.79, 0.96), and an increase in room and board (ratio 1.06, 95% CI 1.01, 1.10). In subgroup analysis, ICU patients had a significant reduction in total direct cost after program implementation (ratio 0.83, 95% CI 0.72, 0.94). After accounting for the length of ICU admission, we found that the total direct cost per hospital day was no longer different between 2019 and 2020 (ratio 0.986, 95% CI 0.92, 1.05), suggesting that shorter ICU admissions likely explained much of the observed cost savings. This study provides real-world data on how "in-the-moment" GOC conversations may contribute to reduced hospitalization costs among ICU patients.
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Affiliation(s)
- David Hui
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Yu-Ting Huang
- Cost Management and Decision Support, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Clark Andersen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Brian Cassel
- Hematology/Oncology & Palliative Care, Virginia Commonwealth University, Richmond, VA 22043, USA;
| | - Nico Nortje
- Section of Integrated Ethics, Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
- Department of Dietetics and Nutrition, University of the Western Cape, Bellville 7535, South Africa
| | - Marina George
- Department of Hospital Medicine, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
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Gupta E, Ng AH, de Moraes AR, Fu JB, Tennison JM, Ahmed M, Fellman BM, Bruera E. Changes in Patterns of Referral for Inpatient Rehabilitation Cancer Patients Due to COVID-19: A Retrospective Study. Am J Phys Med Rehabil 2024; 103:62-65. [PMID: 37602564 PMCID: PMC10840623 DOI: 10.1097/phm.0000000000002331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
ABSTRACT There is a paucity of literature on the effect of COVID-19 on hospital processes. We hypothesized that COVID-19 was associated with decreased cancer physiatry referrals in 2020. This is a retrospective cohort study of consecutive patients from April to July 2019 and 2020 admitted at an academic quaternary cancer center. The main outcomes were number of hospital admissions, rate, and characteristics of inpatient rehabilitation admissions and change in percentage of physiatry referrals as the primary endpoint. Results showed that in 2019, there were 387 referrals from 10,274 inpatient admissions (3.8%; 95% confidence interval, 2.4-4.2), compared with 337 referrals from 7051 admissions in 2020 (4.8%; 95% confidence interval, 4.3-5.3, P = 0.001). Hematology services referred more patients than neurosurgery in 2020 (20.4% vs. 31.4%; 48.2% vs. 26.5%, P = 0.01). Discharge disposition reflected an increased frequency of return to acute care service in 2020 (10.2% vs. 21.8%, P = 0.03). In conclusion, there was an increase in the rate of physiatry referrals despite a decrease in hospital admissions. There was an increase in referrals by hematology, likely due to emphasis on safe discharge and the populations hospitalized.
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Affiliation(s)
- Ekta Gupta
- University of Texas MD Anderson Cancer Center, Section of Physical Medicine and Rehabilitation, Department of Palliative, Rehabilitation and Integrative Medicine, 1515 Holcombe Blvd, Unit 1414, Houston, TX 77030-4009. Phone #: 713-745-2327. Fax #: 713-892-6092
| | - Amy H. Ng
- University of Texas MD Anderson Cancer Center, Section of Physical Medicine and Rehabilitation, Department of Palliative, Rehabilitation and Integrative Medicine, 1515 Holcombe Blvd, Unit 1414, Houston, TX 77030-4009. Phone #: 713-745-2327. Fax #: 713-892-6092
| | - Aline Rozman de Moraes
- University of Texas MD Anderson Cancer Center, Section of Physical Medicine and Rehabilitation, Department of Palliative, Rehabilitation and Integrative Medicine, 1515 Holcombe Blvd, Unit 1414, Houston, TX 77030-4009. Phone #: 713-745-2327. Fax #: 713-892-6092
| | - Jack B. Fu
- University of Texas MD Anderson Cancer Center, Section of Physical Medicine and Rehabilitation, Department of Palliative, Rehabilitation and Integrative Medicine, 1515 Holcombe Blvd, Unit 1414, Houston, TX 77030-4009. Phone #: 713-745-2327. Fax #: 713-892-6092
| | - Jegy M Tennison
- University of Texas MD Anderson Cancer Center, Section of Physical Medicine and Rehabilitation, Department of Palliative, Rehabilitation and Integrative Medicine, 1515 Holcombe Blvd, Unit 1414, Houston, TX 77030-4009. Phone #: 713-745-2327. Fax #: 713-892-6092
| | - Maaheen Ahmed
- Baylor College of Medicine, Department of Physical Medicine and Rehabilitation, 7200 Cambridge, Suite 10B, Houston, TX 77030. Phone # 713-798-3518. Present address: University of Michigan, Department of Physical Medicine and Rehabilitation, 325 E. Eisenhower Parkway, Suite 100, Ann Arbor, Michigan 48108-5744. Phone # 734-936-7175. Fax # 734-764-9439
| | - Bryan M. Fellman
- University of Texas MD Anderson Cancer Center, Department of Biostatistics, 1515 Holcombe Blvd, Unit 1411, Houston, TX 77030. Phone #713-745-2341
| | - Eduardo Bruera
- University of Texas MD Anderson Cancer Center, Section of Palliative Medicine, Department of Palliative, Rehabilitation and Integrative Medicine, 1515 Holcombe Blvd, Unit 1414, Houston, TX 77030-4009. Phone #: 713-745-2327. Fax #: 713-892-6092
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Leung C, Andersen CR, Wilson K, Nortje N, George M, Flowers C, Bruera E, Hui D. The impact of a multidisciplinary goals-of-care program on unplanned readmission rates at a comprehensive cancer center. Support Care Cancer 2023; 32:66. [PMID: 38150077 DOI: 10.1007/s00520-023-08265-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/17/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE This study examined the 30-day unplanned readmission rate in the medical oncology population before and after the implementation of an institution-wide multicomponent interdisciplinary goals of care (myGOC) program. METHODS This retrospective study compared the 30-day unplanned readmission rates in consecutive medical patients during the pre-implementation period (May 1, 2019, to December 31, 2019) and the post-implementation period (May 1, 2020, to December 31, 2020). Secondary outcomes included 7-day unplanned readmission rates, inpatient do-not-resuscitate (DNR) orders, and palliative care consults. We randomly selected a hospitalization encounter for each unique patient during each study period for statistical analysis. A multivariate analysis model was used to examine the association between 30-day unplanned readmission rates and implementation of the myGOC program. RESULTS There were 7028 and 5982 unique medical patients during the pre- and post-implementation period, respectively. The overall 30-day unplanned readmission rate decreased from 24.0 to 21.3% after implementation of the myGOC program. After adjusting for covariates, the myGOC program implementation remained significantly associated with a reduction in 30-day unplanned readmission rates (OR [95% CI] 0.85 [0.77, 0.95], p = 0.003). Other factors significantly associated with a decreased likelihood of a 30-day unplanned readmission were an inpatient DNR order, advanced care planning documentation, and an emergent admission type. We also observed a significant decrease in 7-day unplanned readmission rates (OR [95% CI] 0.75 [0.64, 0.89]) after implementation of the myGOC program. CONCLUSION The 30-day and 7-day unplanned readmission rates decreased in our hospital after implementation of a system-wide multicomponent GOC intervention.
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Affiliation(s)
- Cerena Leung
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Clark R Andersen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kaycee Wilson
- Department of Inpatient Analytics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nico Nortje
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina George
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher Flowers
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Schell JO, Schenker Y, Piscitello G, Belin SC, Chiu EJ, Zapf RL, Kip PL, Marroquin OC, Donahoe MP, Holder-Murray J, Arnold RM. Implementing a Serious Illness Risk Prediction Model: Impact on Goals of Care Documentation. J Pain Symptom Manage 2023; 66:603-610.e3. [PMID: 37532159 PMCID: PMC10828667 DOI: 10.1016/j.jpainsymman.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 08/04/2023]
Abstract
CONTEXT Goals of care conversations can promote high value care for patients with serious illness, yet documented discussions infrequently occur in hospital settings. OBJECTIVES We sought to develop a quality improvement initiative to improve goals of care documentation for hospitalized patients. METHODS Implementation occurred at an academic medical center in Pittsburgh, Pennsylvania. Intervention included integration of a 90-day mortality prediction model grouping patients into low, intermediate, and high risk; a centralized goals of care note; and automated notifications and targeted palliative consults. We compared documented goals of care discussions by risk score before and after implementation. RESULTS Of the 12,571 patients hospitalized preimplementation and 10,761 postimplementation, 1% were designated high risk and 11% intermediate risk of mortality. Postimplementation, goals of care documentation increased for high (17.6%-70.8%, P< 0.0001) and intermediate risk patients (9.6%-28.0%, P < 0.0001). For intermediate risk patients, the percentage of goals of care documentation performed by palliative medicine specialists increased from pre- to postimplementation (52.3%-71.2%, P = 0.0002). For high-risk patients, the percentage of goals of care documentation completed by the primary service increased from pre-to postimplementation (36.8%-47.1%, P = 0.5898, with documentation performed by palliative medicine specialists slightly decreasing from pre- to postimplementation (63.2%-52.9%, P = 0.5898). CONCLUSIONS Implementation of a goals of care initiative using a mortality prediction model significantly increased goals of care documentation especially among high-risk patients. Further study to assess strategies to increase goals of care documentation for intermediate risk patients is needed especially by nonspecialty palliative care.
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Affiliation(s)
- Jane O Schell
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Renal-Electrolyte Division (J.O.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gina Piscitello
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shane C Belin
- Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eric J Chiu
- Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel L Zapf
- Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
| | - Paula L Kip
- Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
| | | | - Michael P Donahoe
- Division of Pulmonary, Allergy, and Critical Care Medicine (M.P.D.), Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Holder-Murray
- Departments of Surgery and Anesthesiology and Perioperative Medicine (J.H.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Wolff Center (R.L.Z., P.L.K., R.M.A.), UPMC, Pittsburgh, Pennsylvania
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Reddy A, González JB, Rizvi A, Nortje N, Dalal S, Haider A, Amaram-Davila JS, Bramati P, Chen M, Hui D, Bruera E. Impact of an Institution-Wide Goals of Care Program on the Timing of Referrals to Outpatient Palliative Care. J Pain Symptom Manage 2023; 66:e666-e671. [PMID: 37643654 DOI: 10.1016/j.jpainsymman.2023.08.019] [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: 06/15/2023] [Revised: 08/10/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
CONTEXT Palliative care has received increased interest since the COVID-19 pandemic due to its role in guiding goals of care (GOC) discussions. OBJECTIVES We assessed the change in the timing of outpatient palliative care referrals before and after implementing an institution-wide multicomponent interdisciplinary GOC (myGOC) program. METHODS We reviewed 200 random supportive care center (SCC) consult visits each from June to November 2019 (before myGOC) and June to November 2020 (after myGOC). Data regarding Edmonton Symptom Assessment Scale (ESAS) scores, time from hospital registration to SCC visit, SCC visit until death/last follow-up, and advance care planning (ACP) notes were collected. Kaplan-Meier curves were used to evaluate overall survival (OS). RESULTS The median OS from the SCC consult visit was 15.2 months (95% CI:11.7-19.7) before and 14.0 months (95% CI:10.8-17.9) after the myGOC program (P = 0.646). There were no significant differences in the median time between the SCC consult visit to death/last follow-up (11.95 vs. 12.0 months after myGOC; P = 0.841) and the first visits to our cancer center and SCC (6.1 vs. 5.29 months after myGOC; P = 0.689). Patients seen after myGOC had significantly lower ESAS symptom scores, better performance status (2 [1-2] vs. 2 [1-3]; P = 0.018], and more ACP notes composed by medical oncology teams (25.5% vs. 4.5%; P < 0.001). CONCLUSION There were no significant differences in OS among patients seen in the SCC before and after myGOC, likely related to a ceiling effect. More oncologists had ACP discussions with patients, and patients had lower symptom scores on ESAS after myGOC, likely indicating that more patients were referred for GOC discussions and ACP rather than for symptom distress.
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Affiliation(s)
- Akhila Reddy
- Departments of Palliative, Rehabilitation, and Integrative Medicine, Critical Care Medicine, (A.R., J.B.G., A.R., S.D., A.H., J.S.A.D., P.B., D.H., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Joannis Baez González
- Departments of Palliative, Rehabilitation, and Integrative Medicine, Critical Care Medicine, (A.R., J.B.G., A.R., S.D., A.H., J.S.A.D., P.B., D.H., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ali Rizvi
- Departments of Palliative, Rehabilitation, and Integrative Medicine, Critical Care Medicine, (A.R., J.B.G., A.R., S.D., A.H., J.S.A.D., P.B., D.H., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nico Nortje
- Section of Integrated Ethics (N.N.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shalini Dalal
- Departments of Palliative, Rehabilitation, and Integrative Medicine, Critical Care Medicine, (A.R., J.B.G., A.R., S.D., A.H., J.S.A.D., P.B., D.H., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ali Haider
- Departments of Palliative, Rehabilitation, and Integrative Medicine, Critical Care Medicine, (A.R., J.B.G., A.R., S.D., A.H., J.S.A.D., P.B., D.H., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaya Sheela Amaram-Davila
- Departments of Palliative, Rehabilitation, and Integrative Medicine, Critical Care Medicine, (A.R., J.B.G., A.R., S.D., A.H., J.S.A.D., P.B., D.H., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patricia Bramati
- Departments of Palliative, Rehabilitation, and Integrative Medicine, Critical Care Medicine, (A.R., J.B.G., A.R., S.D., A.H., J.S.A.D., P.B., D.H., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Minxing Chen
- Department of Biostatistics (M.C.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Departments of Palliative, Rehabilitation, and Integrative Medicine, Critical Care Medicine, (A.R., J.B.G., A.R., S.D., A.H., J.S.A.D., P.B., D.H., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Departments of Palliative, Rehabilitation, and Integrative Medicine, Critical Care Medicine, (A.R., J.B.G., A.R., S.D., A.H., J.S.A.D., P.B., D.H., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Nortje N, Zachariah F, Reddy A. Advance Care Planning conversations: What constitutes best practice and the way forward: Advance Care Planning-Gespräche: Was Best Practice ausmacht und wie es weitergehen kann. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:8-15. [PMID: 37438167 DOI: 10.1016/j.zefq.2023.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/07/2023] [Accepted: 05/08/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Advance Care Planning (ACP) conversations are a cornerstone of modern health care and need to be supported. However, research indicates that the uptake thereof is limited, regardless of various campaigns. ACP conversations are complex and specific elements thereof should be discussed at various timepoints during the illness trajectory. OBJECTIVE This narrative review delineates what ACP conversation should entail, and a way forward. METHODS A PEO (Population, Exposure, Outcome) search was performed using relevant keywords, and 615 articles were identified. Through screening and coding, this number was reduced to 24 articles. All the authors were involved in the final selection of the articles. RESULTS Various themes developed throughout the review which include timing early on in the disease trajectory; incorporating beliefs and culturally relevant contexts; conversations needing to be iterative and short; involving surrogates and family; applying various media formats. DISCUSSION ACP conversations are relevant. ACP is not static and needs to be dynamic as patients' illness trajectories and goals change. The care team needs to guard themselves against having ACP conversations to satisfy a metric and should instead be guided by the patient's expressed values and wishes. A system-wide operational plan will help alleviate common barriers in having appropriate ACP conversations.
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Affiliation(s)
- Nico Nortje
- Section of Integrated Ethics, Department of Critical Care Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX, USA; Department of Dietetics and Nutrition, University of the Western Cape, Bellville, South Africa.
| | - Finly Zachariah
- Department of Supportive Care Medicine, City of Hope, CA, USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Manz CR, Rocque GB, Patel MI. Leveraging Goals of Care Interventions to Deliver Personalized Care Near the End of Life. JAMA Oncol 2023; 9:1029-1030. [PMID: 37382970 DOI: 10.1001/jamaoncol.2023.1981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
This Viewpoint discusses barriers to and opportunities for incorporating goal of care communications into end-of-life care.
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Affiliation(s)
- Christopher R Manz
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gabrielle B Rocque
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Manali I Patel
- Division of Oncology, Department of Medicine, Stanford University, Stanford, California
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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Differential Impact of a Multicomponent Goals-of-Care Program in Patients with Hematologic and Solid Malignancies. Cancers (Basel) 2023; 15:cancers15051507. [PMID: 36900298 PMCID: PMC10001115 DOI: 10.3390/cancers15051507] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/24/2023] [Accepted: 02/25/2023] [Indexed: 03/08/2023] Open
Abstract
We recently reported that an interdisciplinary multicomponent goals-of-care (myGOC) program was associated with an improvement in goals-of-care (GOC) documentation and hospital outcomes; however, it is unclear if the benefit was uniform between patients with hematologic malignancies and solid tumors. In this retrospective cohort study, we compared the change in hospital outcomes and GOC documentation before and after myGOC program implementation between patients with hematologic malignancies and solid tumors. We examined the change in outcomes in consecutive medical inpatients before (May 2019-December 2019) and after (May 2020-December 2020) implementation of the myGOC program. The primary outcome was intensive care unit (ICU) mortality. Secondary outcomes included GOC documentation. In total, 5036 (43.4%) patients with hematologic malignancies and 6563 (56.6%) with solid tumors were included. Patients with hematologic malignancies had no significant change in ICU mortality between 2019 and 2020 (26.4% vs. 28.3%), while patients with solid tumors had a significant reduction (32.6% vs. 18.8%) with a significant between-group difference (OR 2.29, 95% CI 1.35, 3.88; p = 0.004). GOC documentation improved significantly in both groups, with greater changes observed in the hematologic group. Despite greater GOC documentation in the hematologic group, ICU mortality only improved in patients with solid tumors.
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Maharat M, Sajjadi SF, Moosavian SP. Changes in dietary habits and weight status during the COVID-19 pandemic and its association with socioeconomic status among Iranians adults. Front Public Health 2023; 10:1080589. [PMID: 36711378 PMCID: PMC9877516 DOI: 10.3389/fpubh.2022.1080589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/21/2022] [Indexed: 01/15/2023] Open
Abstract
Background COVID-19 pandemic has impacted human health through sudden lifestyle changes, including isolation at home, and social distancing. Therefore, the current study aimed to investigate the effect of the COVID-19 pandemic on eating habits, weight status, and their associations with socioeconomic status. Methods This cross-sectional study was conducted using an online structured questionnaire that inquired demographic, anthropometric (reported weight and height); dietary habits (weekly intake of certain foods); and dietary supplement intake information. Results A total of 1,187 participants completed the questionnaire, and after validation of the data, 1,106 respondents were included in the study, with a mean age of 34.5 ± 9.4 years. Our findings showed that the body mass index (BMI) of the participants significantly increased during COVID-19 (P < 0.001). Also, there were significant changes in the intake of a variety of food and beverage during the COVID-19, including less consumption of milk, yogurt, red meat, fish, canned fish, homemade fast foods, take out fast foods, carbonated drinks, and more consumption of whole bread, legumes (chickpeas, lentil, peas, kidney beans, black beans, pinto beans, and navy beans), soy bean, nuts, seeds, high vitamin C vegetables, high vitamin C fruits, green-yellow fruits and vegetables, onion/garlic, dried fruits, natural fruit juices, and water (P < 0.001; for all). It is informed that individuals consumed more vitamin and mineral supplements (P < 0.001). Also, before and during COVID-19 pandemic weekly intakes of dairy, red meat, poultry, high vitamin C fruits, and whole bread were positively associated with socioeconomic status (P < 0.001). Conclusion Overall, this study indicates changes in body weight, dietary habits and supplement intake during the pandemic. Therefore, the findings of this study are valuable for, health professionals and politicians to better public health practice and policy making.
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Affiliation(s)
| | | | - Seyedeh Parisa Moosavian
- Department of Community Nutrition, Vice-Chancellery for Health, Shiraz University of Medical Sciences, Shiraz, Iran
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Hui D, Paiva BSR, Paiva CE. Personalizing the Setting of Palliative Care Delivery for Patients with Advanced Cancer: "Care Anywhere, Anytime". Curr Treat Options Oncol 2023; 24:1-11. [PMID: 36576706 PMCID: PMC9795143 DOI: 10.1007/s11864-022-01044-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 12/29/2022]
Abstract
OPINION STATEMENT The specialty of palliative care has evolved over time to provide symptom management, psychosocial support, and care planning for patients with cancer throughout the disease continuum and in multiple care settings. This review examines the delivery and impact of palliative care in the outpatient, inpatient, and community-based settings. The article will discuss how these 3 palliative care settings can work together to optimize patient outcomes under a unifying model of palliative care "anywhere, anytime" and how to prioritize palliative care services when resources are limited. Many patients with advanced cancer receive care from each of the 3 branches of palliative care-outpatient, inpatient, and community-based settings-at some point along their disease trajectory. Early on, outpatient clinics provide longitudinal supportive care concurrent with active disease-modifying treatments. Telemedicine appointments can serve patients remotely to minimize their need to travel. When patients experience functional decline, community-based palliative care services can provide support and monitoring for patients at home. When patients develop acute symptomatic complications requiring admission, inpatient care consultation teams are essential for symptom management and goals-of-care discussions. For patients in severe distress, receiving care in a palliative care unit that provides intensive symptom control and facilitates complex discharge planning is ideal. Under a unifying model of palliative care designed to offer care "anywhere, anytime," the 3 branches of palliative care could work in unison to support each other, minimize gaps in care, and optimize patient outcomes.
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Affiliation(s)
- David Hui
- Department of Palliative, Rehabilitation and Integrative Medicine, Unit 1414, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030 USA
| | - Bianca Sakamoto Ribeiro Paiva
- Palliative Care and Quality of Life Research Group (GPQual), Learning and Research Institute, Barretos Cancer Hospital, Barretos, SP 14784-400 Brazil
| | - Carlos Eduardo Paiva
- Palliative Care and Quality of Life Research Group (GPQual), Learning and Research Institute, Barretos Cancer Hospital, Barretos, SP 14784-400 Brazil
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