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van Merendonk LN, Peters BJM, Möhlmann JE, Hunting CB, Kastelijn EA, van den Broek MPH. The potential for deprescribing in a palliative oncology patient population: a cross-sectional study. Eur J Hosp Pharm 2023; 31:10-15. [PMID: 35197277 PMCID: PMC10800274 DOI: 10.1136/ejhpharm-2021-003143] [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: 11/07/2021] [Accepted: 02/08/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The use of preventive medication in palliative oncology patients may be inappropriate due to limited life expectancy. Deprescribing tools are available but time-consuming and not always tailored to this specific population. Our primary goal was to identify potentially inappropriate medications (PIMs) in palliative oncology patients with a life expectancy of up to 2 years using an adapted deprescribing tool. Our secondary aim was to identify patient characteristics associated with the presence of PIMs. METHODS Oncology patients with a life expectancy of up to 2 years were included cross-sectionally. An adapted deprescribing tool was developed to identify PIMs. Logistic regression was used to identify factors associated with having PIMs. RESULTS A total of 218 patients were included in this study of which 56% had at least one PIM with a population mean of 1.1 PIM per patient. Most frequently defined PIMs were antihypertensive drugs and gastric acid inhibitors. Identification of PIMs by review took an estimated 5-10 min per patient. Polypharmacy, age >65 years and inpatient/outpatient status were found to be associated with having at least one PIM. CONCLUSIONS Deprescribing is possible in more than half of palliative oncology patients with a life expectancy of up to 2 years. The adapted deprescribing tool used is non-time consuming and suitable for palliative oncology patients, regardless of age.
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Affiliation(s)
| | - Bas J M Peters
- Clinical Pharmacy, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Julia E Möhlmann
- Clinical Pharmacy, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Cornelis B Hunting
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Elisabeth A Kastelijn
- Department of Pulmonary Diseases, Sint Antonius Hospital, Nieuwegein, The Netherlands
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2
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Prsic E, Morris JC, Adelson KB, Parker NA, Gombos EA, Kottarathara MJ, Novosel M, Castillo L, Gould Rothberg BE. Oncology hospitalist impact on hospice utilization. Cancer 2023; 129:3797-3804. [PMID: 37706601 DOI: 10.1002/cncr.35008] [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: 03/01/2023] [Revised: 07/02/2023] [Accepted: 07/15/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Unplanned hospitalizations among patients with advanced cancer are often sentinel events prompting goals of care discussions and hospice transitions. Late referrals to hospice, especially those at the end of life, are associated with decreased quality of life and higher total health care costs. Inpatient management of patients with solid tumor malignancies is increasingly shifting from oncologists to oncology hospitalists. However, little is known about the impact of oncology hospitalists on the timing of transition to hospice. OBJECTIVE To compare hospice discharge rate and time to hospice discharge on an inpatient oncology service led by internal medicine-trained hospitalists and a service led by oncologists. METHODS At Smilow Cancer Hospital, internal medicine-trained hospitalists were integrated into one of two inpatient medical oncology services allowing comparison between the new, hospitalist-led service (HS) and the traditional, oncologist-led service (TS). Discharges from July 26, 2021, through January 31, 2022, were identified from the electronic medical record. The odds ratio for discharge disposition by team was calculated by logistic regression using a multinomial distribution. Adjusted length of stay before discharge was assessed using multivariable linear regression. RESULTS The HS discharged 47/400 (11.8%) patients to inpatient hospice, whereas the TS service discharged 18/313 (5.8%), yielding an adjusted odds ratio of 1.94 (95% CI, 1.07-3.51; p = .03). Adjusted average length of stay before inpatient hospice disposition was 6.83 days (95% CI, 4.22-11.06) for the HS and 16.29 days (95% CI, 7.73-34.29) for the TS (p = .003). CONCLUSIONS Oncology hospitalists improve hospice utilization and time to inpatient hospice referral on an inpatient medical oncology service. PLAIN LANGUAGE SUMMARY Patients with advanced cancer are often admitted to the hospital near the end of life. These patients generally have a poor chance of long-term survival and may prefer comfort-focused care with hospice. In this study, oncology hospitalists discharged a higher proportion of patients to inpatient hospice with less time spent in the hospital before discharge.
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Affiliation(s)
- Elizabeth Prsic
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jensa C Morris
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Hospital Medicine Service, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Kerin B Adelson
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
- Yale University Yale Cancer Center, New Haven, Connecticut, USA
| | - Nathaniel A Parker
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
- Hospital Medicine Service, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Erin A Gombos
- Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut, USA
- Hospital Medicine Service, Yale New Haven Hospital, New Haven, Connecticut, USA
| | | | - Madison Novosel
- Yale University School of Public Health, New Haven, Connecticut, USA
| | - Lawrence Castillo
- Yale University School of Public Health, New Haven, Connecticut, USA
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3
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Numico G, Ferrua R, Fea E, Giamello J, Colantonio I, Occelli M, Vandone AM, Vanella P, Aimar G, Pisano C, Parlagreco E, Persano I, Milanesio M, Ippoliti R. Patients with cancer and hospital admissions: disease trajectory and strategic choices. BMJ Support Palliat Care 2023:spcare-2023-004574. [PMID: 37704262 DOI: 10.1136/spcare-2023-004574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVES Hospital admission (HA) in cancer history is a common, repeated and frequently unplanned event. The emergency departments (EDs) and the oncological outpatient service (OOS) are the ordinary way of entry. We studied the reasons of admission, pathways of access and discharge and prognostic factors in a population of admitted patients with cancer. METHODS The health records of the admitted patients in the oncological ward of a referral hospital in a 6-month period were retrieved and analysed. The characteristics of those admitted in the last 3 months of life were compared with the other group. RESULTS Among the 147 HA, 79.5% were unplanned, 48.9% passing through the ED and 30.6% through the OOS; 56.5% were due to cancer-related symptoms; 50.3% occurred in the last 3 months of life. Median overall survival was 90 days (95% IC 53.1-126.9). Independent prognostic factors for survival were: being admitted for symptoms, referral through the ED and not being discharged at home. CONCLUSIONS Hospital is a turning point in the cancer care pathway. Patients needing HA have a dismal prognosis, half of them being in the last 3 months of life. This group can be identified using universally available variables.
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Affiliation(s)
| | | | - Elena Fea
- Medical Oncology, AO S.Croce e Carle, Cuneo, Italy
| | | | | | | | | | | | | | | | | | | | | | - Roberto Ippoliti
- Department of Jurisprudence and Political Economic and Social Sciences, University of Eastern Piedmont Amedeo Avogadro, Alessandria, Piemonte, Italy
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4
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Im JH, Chow R, Novosel M, Xiang J, Strait M, Rao V, Kapo J, Zimmermann C, Prsic E. Association of palliative care and hospital outcomes among solid tumour oncology inpatients. BMJ Support Palliat Care 2023:spcare-2023-004207. [PMID: 36849221 DOI: 10.1136/spcare-2023-004207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVES We aimed to explore the association between receiving an inpatient palliative care consultation and hospital outcomes, including in-hospital death, intensive care unit (ICU) use, discharge to hospice, 30-day readmissions and 30-day emergency department (ED) visits. METHODS We conducted a retrospective chart review of Yale New Haven Hospital medical oncology admissions from January 2018 through December 2021, with and without inpatient palliative care consultations. Hospital outcome data were extracted from medical records and operationalised as binary. Multivariable logistic regression was used to estimate ORs for the association between number of inpatient palliative care consultations and hospital outcomes. RESULTS Our sample included 19 422 patients. Age, Rothman Index, site of malignancy, length of stay, discharge to hospice, ICU admissions, hospital death and readmissions within 30 days differed significantly between patients who received versus did not receive a palliative care consultation. On multivariable analysis, receiving one additional palliative care consultation was significantly associated with higher odds of hospital death (adjusted OR=1.15, 95% CI 1.12 to 1.17) and discharge to hospice (adjusted OR = 1.23, 95% CI 1.20 to 1.26), and lower odds of ICU admission (adjusted OR=0.94, 95% CI 0.92 to 0.97). There was no significant association between palliative care consultations and readmission within 30 days or with ED visits within 30 days. CONCLUSION Inpatients receiving palliative care had increased likelihood of hospital death. However, when controlling for significant differences in patient presentation, patients had nearly 25% greater odds of discharge to hospice and less odds to transition to ICU level of care.
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Affiliation(s)
- James Hb Im
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Ronald Chow
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Madison Novosel
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Jenny Xiang
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Michael Strait
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Vinay Rao
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Jennifer Kapo
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Camilla Zimmermann
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Prsic
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
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5
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Han HJ, Yeh JC, McNichol M, Buss MK. Delivering Palliative Care to Hospitalized Oncology Patients: A Scoping Review. J Pain Symptom Manage 2023; 65:e137-e153. [PMID: 36243248 DOI: 10.1016/j.jpainsymman.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT Early, longitudinal integration of palliative care (PC) is recommended for patients with advanced cancer, in both inpatient and outpatient settings. Despite the growth of specialty PC teams in the last decade, the majority of PC is still delivered in the inpatient setting using a traditional referral-based consult delivery model. However, traditional consultation can lead to significant variation or delay in inpatient PC utilization. New care delivery models and strategies are emerging to deliver PC to hospitalized oncology patients who would most benefit from their services and to better align with professional society recommendations. OBJECTIVES To identify different care models to deliver PC to ho`spitalized oncology patients and summarize their impact on patient and health system-related outcomes. METHODS We conducted a scoping review of peer-reviewed articles from 2006 to 2021 evaluating delivery of PC to oncology patients in acute inpatient care. We abstracted study characteristics, the study's intervention and comparison arms, and outcomes related to specialty PC intervention. RESULTS We identified four delivery models that have been reported to deliver PC: 1) traditional referral-based consultation, 2) criterion-based or "triggered" consultation, 3) co-rounding with primary inpatient team, and 4) PC clinicians serving as the primary team. We summarize the known outcomes data from each model, and compare the benefits and limitations of each model. CONCLUSION Our findings provide guidance to health systems about care delivery models to deploy and implement inpatient PC resources to best serve their unique populations.
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Affiliation(s)
- Harry J Han
- Section of Palliative Care, Division of General Medicine and Primary Care (H.J.H., J.C.Y.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Jonathan C Yeh
- Section of Palliative Care, Division of General Medicine and Primary Care (H.J.H., J.C.Y.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Megan McNichol
- Division of Knowledge Services, Department of Information Services (M.M.), Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mary K Buss
- Division of Palliative Care, Department of Medicine (M.K.B.), Tufts University School of Medicine, Boston, Massachusetts, USA
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6
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Van de Castle B, Lukkahatai N, Billing BSNL, Huang X, Wu H, Zhang J, Abdi S, Kameoka J, Smith TJ. Nurse-Administered Auricular Point Acupressure for Cancer-Related Pain. Integr Cancer Ther 2023; 22:15347354231198086. [PMID: 37706457 PMCID: PMC10503282 DOI: 10.1177/15347354231198086] [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] [Received: 11/18/2022] [Revised: 07/21/2023] [Accepted: 08/14/2023] [Indexed: 09/15/2023] Open
Abstract
PURPOSE The study aimed to (1) examine the feasibility of providing a training course on auricular point acupressure (APA) for clinical oncology nurses to integrate APA into real-world nursing care settings, and (2) examine the effectiveness of APA on cancer-related pain (CRP) under usual inpatient oncology ward conditions. METHODS This was a 2-phase feasibility study. Phase 1, an in-person, 8 hour training program was provided to oncology nurses. Phase 2, a prospective and feasibility study was conducted to evaluate the integration of APA into nursing care activities to manage CRP. Oncology patients were included if their pain was rated at ≥4 on a 0 to 10 numeric rating scale in the past 24 hours. Patients received 1 APA treatment administered by the nurses and were instructed to stimulate the points for 3 days. Study outcomes (pain intensity, fatigue, and sleep disturbance), pain medication use, and APA practice were measured by a phone survey daily. RESULTS Ten oncology nurses received APA training in phase 1. APA had been added to the hospital's electronic health records (EHRs) as a pain treatment. In phase 2, 33 oncology patients received APA treatment with a 100% adherence rate (pressing the seeds 3 times per day, 3 minutes per time based on the suggestion). The side effects of APA were minimal (~8%-12% felt tenderness on the ear). After 3 days of APA, patients reported 38% pain relief, 39% less fatigue, and 45% improvement in sleep disturbance; 24% reduced any type of pain medication use and 19% reduced opioid use (10 mg opioids using milligram morphine equivalent). The major barrier to integrating APA into routine nursing practice was time management (how to include APA in a daily workflow). CONCLUSION It is feasible to provide 8-hour training to oncology nurses for mastering APA skill and then integrating APA into their daily nursing care for patients with CRP. Based on the promising findings (decreased pain, improved fatigue and sleep disturbance, and less opioid use), the next step is to conduct a randomized clinical trial with a larger sample to confirm the efficacy of APA for oncology nurses to treat CRP in real-world practice.ClinicalTrial.gov identifier number: NCT04040140.
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Affiliation(s)
| | - Nada Lukkahatai
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | | | - Xinran Huang
- The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Hulin Wu
- The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Jingyu Zhang
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Salahadin Abdi
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Thomas J. Smith
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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7
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Hohl SD, Matulewicz RS, Salloum RG, Ostroff JS, Baker TB, Schnoll R, Warren G, Bernstein SL, Minion M, Lenhoff K, Dahl N, Juon HS, Tsosie U, Fleisher L, D'Angelo H, Ramsey AT, Ashing KT, Rolland B, Nolan MB, Bird JE, Nguyen CVT, Pauk D, Adsit RT, Tindle HA, Shoenbill K, Yeung S, Presant CA, Wiseman KP, Wen KY, Chichester LA, Chen LS. Integrating Tobacco Treatment Into Oncology Care: Reach and Effectiveness of Evidence-Based Tobacco Treatment Across National Cancer Institute-Designated Cancer Centers. J Clin Oncol 2022; 41:2756-2766. [PMID: 36473135 DOI: 10.1200/jco.22.00936] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Quitting smoking improves patients' clinical outcomes, yet smoking is not commonly addressed as part of cancer care. The Cancer Center Cessation Initiative (C3I) supports National Cancer Institute-designated cancer centers to integrate tobacco treatment programs (TTPs) into routine cancer care. C3I centers vary in size, implementation strategies used, and treatment approaches. We examined associations of these contextual factors with treatment reach and smoking cessation effectiveness. METHODS This cross-sectional study used survey data from 28 C3I centers that reported tobacco treatment data during the first 6 months of 2021. Primary outcomes of interest were treatment reach (reach)-the proportion of patients identified as currently smoking who received at least one evidence-based tobacco treatment component (eg, counseling and pharmacotherapy)-and smoking cessation effectiveness (effectiveness)-the proportion of patients reporting 7-day point prevalence abstinence at 6-month follow-up. Center-level differences in reach and effectiveness were examined by center characteristics, implementation strategies, and tobacco treatment components. RESULTS Of the total 692,662 unique patients seen, 44,437 reported current smoking. Across centers, a median of 96% of patients were screened for tobacco use, median smoking prevalence was 7.4%, median reach was 15.4%, and median effectiveness was 18.4%. Center-level characteristics associated with higher reach included higher smoking prevalence, use of center-wide TTP, and lower patient-to-tobacco treatment specialist ratio. Higher effectiveness was observed at centers that served a larger overall population and population of patients who smoke, reported a higher smoking prevalence, and/or offered electronic health record referrals via a closed-loop system. CONCLUSION Whole-center TTP implementation among inpatients and outpatients, and increasing staff-to-patient ratios may improve TTP reach. Designating personnel with tobacco treatment expertise and resources to increase tobacco treatment dose or intensity may improve smoking cessation effectiveness.
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Affiliation(s)
- Sarah D Hohl
- Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI.,Department of Family Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Richard S Matulewicz
- Memorial Sloan Kettering Cancer Center, Department of Surgery, Urology Service, New York, NY
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, and University of Florida Health Cancer Center, Gainesville, FL
| | - Jamie S Ostroff
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Timothy B Baker
- Center for Tobacco Research and Intervention, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Robert Schnoll
- Department of Psychiatry and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Graham Warren
- Department of Radiation Oncology, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Steven L Bernstein
- Department of Emergency Medicine, C. Everett Koop Institute, Norris Cotton Cancer Center, Geisel School of Medicine, Dartmouth College, Hanover, NH
| | - Mara Minion
- Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Katie Lenhoff
- Dartmouth-Hitchcock Norris Cotton Cancer Center, Geisel School of Medicine, Dartmouth College, Hanover, NH
| | - Neely Dahl
- University of Virginia Cancer Center, Charlottesville, VA
| | - Hee Soon Juon
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA
| | | | | | - Heather D'Angelo
- Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Alex T Ramsey
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO.,Department of Psychiatry, Washington University School of Medicine, St Louis, MO
| | - Kimlin T Ashing
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA
| | - Betsy Rolland
- Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI.,Institute for Clinical and Translational Research, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Margaret B Nolan
- Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI.,Center for Tobacco Research and Intervention, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Jennifer E Bird
- Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Claire V T Nguyen
- Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Danielle Pauk
- Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Robert T Adsit
- Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI.,Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Hilary A Tindle
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.,Geriatric Research Education and Clinical Centers (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Kimberly Shoenbill
- Department of Family Medicine, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Sophia Yeung
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, CA
| | - Cary A Presant
- Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, Duarte, CA
| | - Kara P Wiseman
- Department of Public Health Science, University of Virginia School of Medicine, Charlottesville, VA
| | - Kuang-Yi Wen
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA
| | - Lou-Anne Chichester
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Li-Shiun Chen
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, MO.,Department of Psychiatry, Washington University School of Medicine, St Louis, MO
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8
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Chi NC, Fu YK, Nakad L, Barani E, Gilbertson-White S, Tripp-Reimer T, Herr K. Family Caregiver Challenges in Pain Management for Patients with Advanced Illnesses: A Systematic Review. J Palliat Med 2022; 25:1865-1876. [PMID: 36178473 PMCID: PMC9784612 DOI: 10.1089/jpm.2020.0806] [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] [Accepted: 05/29/2022] [Indexed: 01/04/2023] Open
Abstract
Although pain management is integral to the caregiving role, there is a paucity of evidence synthesizing specific challenges family caregivers (FCs) face when managing pain for their care partners. This review comprehensively identified and summarized such challenges in the setting of advanced illnesses. Electronic databases (PubMed, CINAHL, PsycINFO, Scopus, and Health and Psychosocial Instruments) were searched using index and keyword methods for all articles published before April 2021. Fifty-five studies were included in this review. Most articles were published within the last 10 years (54%) in community settings, with home hospice care comprising the majority (50%). Most studies included patients with an advanced cancer diagnosis (84%), and 16% of the studies included patients with a noncancer diagnosis. Four major categories of challenges were identified: (1) caregiver-related issues (e.g., fears, beliefs, function), (2) caregivers' limited knowledge and skills in pain management (e.g., verbal and nonverbal pain assessment skills, pharmacological knowledge, documentation, safe management of medication), (3) communication challenges with health care providers, and (4) patient-related issues (e.g., inability to report pain). Many of these challenges have not been fully addressed in prior literature. Thus, this review provides a framework for needed future research to develop interventions that target FCs' specific challenges in providing pain management. The results also highlight a significant lack of research surrounding challenges faced by caregivers of care partners having a noncancer, dementia, or multimorbidity diagnosis.
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Affiliation(s)
- Nai-Ching Chi
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
| | - Ying-Kai Fu
- College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Lynn Nakad
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
| | - Emelia Barani
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington, USA
| | | | | | - Keela Herr
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
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9
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Bayesian Network Analysis for Prediction of Unplanned Hospital Readmissions of Cancer Patients with Breakthrough Cancer Pain and Complex Care Needs. Healthcare (Basel) 2022; 10:healthcare10101853. [PMID: 36292299 PMCID: PMC9601725 DOI: 10.3390/healthcare10101853] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Unplanned hospital readmissions (HRAs) are very common in cancer patients. These events can potentially impair the patients’ health-related quality of life and increase cancer care costs. In this study, data-driven prediction models were developed for identifying patients at a higher risk for HRA. Methods: A large dataset on cancer pain and additional data from clinical registries were used for conducting a Bayesian network analysis. A cohort of gastrointestinal cancer patients was selected. Logical and clinical relationships were a priori established to define and associate the considered variables including cancer type, body mass index (BMI), bone metastasis, serum albumin, nutritional support, breakthrough cancer pain (BTcP), and radiotherapy. Results: The best model (Bayesian Information Criterion) demonstrated that, in the investigated setting, unplanned HRAs are directly related to nutritional support (p = 0.05) and radiotherapy. On the contrary, BTcP did not significantly affect HRAs. Nevertheless, the correlation between variables showed that when BMI ≥ 25 kg/m2, the spontaneous BTcP is more predictive for HRAs. Conclusions: Whilst not without limitations, a Bayesian model, combined with a careful selection of clinical variables, can represent a valid strategy for predicting unexpected HRA events in cancer patients. These findings could be useful for calibrating care interventions and implementing processes of resource allocation.
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10
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Nipp RD, Horick NK, Qian CL, Knight HP, Kaslow-Zieve ER, Azoba CC, Elyze M, Landay SL, Kay PS, Ryan DP, Jackson VA, Greer JA, El-Jawahri A, Temel JS. Effect of a Symptom Monitoring Intervention for Patients Hospitalized With Advanced Cancer: A Randomized Clinical Trial. JAMA Oncol 2022; 8:571-578. [PMID: 35142814 PMCID: PMC8832303 DOI: 10.1001/jamaoncol.2021.7643] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Symptom monitoring interventions are increasingly becoming the standard of care in oncology, but studies assessing these interventions in the hospital setting are lacking. OBJECTIVE To evaluate the effect of a symptom monitoring intervention on symptom burden and health care use among hospitalized patients with advanced cancer. DESIGN, SETTING, AND PARTICIPANTS This nonblinded randomized clinical trial conducted from February 12, 2018, to October 30, 2019, assessed 321 hospitalized adult patients with advanced cancer and admitted to the inpatient oncology services of an academic hospital. Data obtained through November 13, 2020, were included in analyses, and all analyses assessed the intent-to-treat population. INTERVENTIONS Patients in both the intervention and usual care groups reported their symptoms using the Edmonton Symptom Assessment System (ESAS) and the 4-item Patient Health Questionnaire-4 (PHQ-4) daily via tablet computers. Patients assigned to the intervention had their symptom reports displayed during daily oncology rounds, with alerts for moderate, severe, or worsening symptoms. Patients assigned to usual care did not have their symptom reports displayed to their clinical teams. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of days with improved symptoms, and the secondary outcomes were hospital length of stay and readmission rates. Linear regression was used to evaluate differences in hospital length of stay. Competing-risk regression (with death treated as a competing event) was used to compare differences in time to first unplanned readmission within 30 days. RESULTS From February 12, 2018, to October 30, 2019, 390 patients (76.2% enrollment rate) were randomized. Study analyses to assess change in symptom burden included 321 of 390 patients (82.3%) who had 2 or more days of symptom reports completed (usual care, 161 of 193; intervention, 160 of 197). Participants had a mean (SD) age of 63.6 (12.8) years and were mostly male (180; 56.1%), self-reported as White (291; 90.7%), and married (230; 71.7%). The most common cancer type was gastrointestinal (118 patients; 36.8%), followed by lung (60 patients; 18.7%), genitourinary (39 patients; 12.1%), and breast (29 patients; 9.0%). No significant differences were detected between the intervention and usual care for the proportion of days with improved ESAS-physical (unstandardized coefficient [B] = -0.02; 95% CI, -0.10 to 0.05; P = .56), ESAS-total (B = -0.05; 95% CI, -0.12 to 0.02; P = .17), PHQ-4-depression (B = -0.02; 95% CI, -0.08 to 0.04; P = .55), and PHQ-4-anxiety (B = -0.04; 95% CI, -0.10 to 0.03; P = .29) symptoms. Intervention patients also did not differ significantly from patients receiving usual care for the secondary end points of hospital length of stay (7.59 vs 7.47 days; B = 0.13; 95% CI, -1.04 to 1.29; P = .83) and 30-day readmission rates (26.5% vs 33.8%; hazard ratio, 0.73; 95% CI, 0.48-1.09; P = .12). CONCLUSIONS AND RELEVANCE This randomized clinical trial found that for hospitalized patients with advanced cancer, the assessed symptom monitoring intervention did not have a significant effect on patients' symptom burden or health care use. These findings do not support the routine integration of this type of symptom monitoring intervention for hospitalized patients with advanced cancer. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03396510.
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Affiliation(s)
- Ryan D. Nipp
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
| | - Nora K. Horick
- Biostatistics Center, Massachusetts General Hospital, Boston
| | - Carolyn L. Qian
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
| | - Helen P. Knight
- Department of Medicine, Brigham and Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Emilia R. Kaslow-Zieve
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
| | - Chinenye C. Azoba
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
| | - Madeleine Elyze
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
| | - Sophia L. Landay
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
| | - Paul S. Kay
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
| | - David P. Ryan
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
| | - Vicki A. Jackson
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
| | - Joseph A. Greer
- Department of Psychiatry, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
| | - Jennifer S. Temel
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts
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11
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Chiec L, Szmuilowicz E, Neagle J, Clepp K, Wood GJ. Identifying Patients in Need of Goals of Care Conversations: Reliability, Acceptability, and Prognostic Significance of the Preference-Aligned Communication and Treatment Conversation Trigger Tool for Patients with Cancer. J Palliat Med 2022; 25:1249-1253. [PMID: 35363050 DOI: 10.1089/jpm.2021.0401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Simple methods to help teams identify patients with goals of care (GOC) conversation needs are lacking. Objectives: To develop a tool to identify hospitalized patients who may benefit from GOC conversations. Methods: The Preference-Aligned Communication and Treatment (PACT) Conversation Trigger Tool was implemented as part of a quality improvement initiative in 10 Illinois hospitals and validated in a cohort of patients admitted to the coordinating site's oncology unit (n = 135). Results: The tool was reliable and acceptable to clinicians using it across sites. Thirty percent (n = 40) of patients screened at the coordinating site's oncology unit triggered positive. These patients were more likely to have a do-not-resuscitate order (43% vs. 11%) and palliative care consult (53% vs. 20%) and had lower mean survival time (125 vs. 248 days) than those who did not trigger (p < 0.001). Conclusions: The tool is reliable, acceptable, and can identify hospitalized oncology patients who may benefit from GOC conversations.
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Affiliation(s)
- Lauren Chiec
- Division of Hematology-Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Eytan Szmuilowicz
- Division of Hospital Medicine (Palliative Care), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jayson Neagle
- Division of Hospital Medicine (Palliative Care), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katie Clepp
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gordon J Wood
- Division of Hospital Medicine (Palliative Care), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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12
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Martinez-Recio S, Perez-Wert JP, Martinez-Fdez S, Jimenez-Bou D, Ruiz-Gutierrez I, Peña J, Pertejo A, Espinosa E, Pinto A. COMPARISON OF 2-WEEKLY AND 3-WEEKLY DOSING OF DOCETAXEL IN METASTATIC PROSTATE CANCER. Clin Genitourin Cancer 2022; 20:363-370. [DOI: 10.1016/j.clgc.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/14/2022] [Accepted: 02/19/2022] [Indexed: 12/20/2022]
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13
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Quality of End-of-Life Cancer Care in Canada: A 12-Year Retrospective Analysis of Three Provinces' Administrative Health Care Data Evaluating Changes over Time. Curr Oncol 2021; 28:4673-4685. [PMID: 34898554 PMCID: PMC8628746 DOI: 10.3390/curroncol28060394] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
This retrospective cohort study of cancer decedents during 2004-2015 examined end-of-life cancer care quality indicators (QIs) in the provinces of British Columbia (BC), Ontario, and Nova Scotia (NS). These included: emergency department use, in-patient hospitalization, intensive care unit admissions, physician house calls, home care visits, and death experienced in hospital. Ontario saw the greatest 12-year decrease in in-hospital deaths from 52.8% to 41.1%. Hospitalization rates within 30 days of death decreased in Ontario, increased in NS, and remained the same in BC. Ontario's usage of aggressive end-of-life measures changed very little, while BC increased their utilization rates. Supportive care use increased in both NS and Ontario. Those who were male or living in a lower income/smaller community (in Ontario) were associated with a decreased likelihood of receiving supportive care. Despite the shift in focus to providing hospice and home care services, approximately 50% of oncology patients are still dying in hospital and 11.7% of patients overall are subject to aggressive care measures that may be out of line with their desire for comfort care. Supportive care use is increasing, but providers must ensure that Canadians are connected to palliative services, as its utilization improves a wide variety of outcomes.
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14
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Shirane S, Michihata N, Yoshiuchi K, Ariyoshi K, Iwase S, Morita K, Matsui H, Fushimi K, Yasunaga H. Evaluation of quality indicators near death in older adult cancer decedents in Japan: A nationwide retrospective cohort study. Jpn J Clin Oncol 2021; 51:1643-1648. [PMID: 34530454 DOI: 10.1093/jjco/hyab145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/30/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES End-of-life cancer care is important; however, data on hospitalization and costs for older patients have been lacking. We aimed to examine quality indicators and costs for older patients in Japan. METHODS Using the Diagnosis Procedure Combination database, a national database of acute-care hospitals in Japan, we retrospectively collected data on cancer decedents aged ≥65 years. We evaluated the quality indicators (hospitalizations, length of stay in the hospital, emergency hospitalizations, emergency hospitalizations using an ambulance, intensive care unit [ICU] admissions, length of stay in the ICU, interval between last chemotherapy use and death, and chemotherapy within 14 days before death) and hospitalization costs at 30, 90 and 180 days before death. We compared the outcomes across age groups (65-74, 75-84 and ≥ 85 years). RESULTS Between January 2011 and March 2015, we identified 369 616 cancer decedents. From 180 to 30 days before death, there were increases in emergency hospitalizations, emergency hospitalizations using an ambulance, and the mean costs per hospital day. Overall, 16.7% of patients receiving chemotherapy last received this treatment on the day before death or the day of death. Costs decreased with increasing age. The group aged ≥85 years had the shortest hospital and ICU stays and the lowest multiple hospitalizations, ICU admissions, chemotherapy within 14 days before death, and costs. CONCLUSIONS Many older adult patients had emergency hospitalizations and received chemotherapy just prior to death, and there is room for improvement in appropriate end-of-life care. Oldest old patients consumed relatively few medical resources.
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Affiliation(s)
- Sachie Shirane
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiro Yoshiuchi
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keisuke Ariyoshi
- Department of Data Management, Japanese Organisation for Research and Treatment of Cancer Data Center, Tokyo, Japan
| | - Satoru Iwase
- Department of Emergency and Palliative Medicine, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Kojiro Morita
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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15
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Yang GM, Zhou S, Xu Z, Goh SS, Zhu X, Chong DQ, Tan DS, Kanesvaran R, Yee AC, Neo PS, Cheung YB. Comparing the effect of a consult model versus an integrated palliative care and medical oncology co-rounding model on health care utilization in an acute hospital - an open-label stepped-wedge cluster-randomized trial. Palliat Med 2021; 35:1578-1589. [PMID: 34524044 DOI: 10.1177/02692163211022957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The benefit of specialist palliative care for cancer inpatients is established, but the best method to deliver specialist palliative care is unknown. AIM To compare a consult model versus a co-rounding model; both provide the same content of specialist palliative care to individual patients but differ in the level of integration between palliative care and oncology clinicians. DESIGN An open-label, cluster-randomized trial with stepped-wedge design. The primary outcome was hospital length of stay; secondary outcomes were 30-day readmissions and access to specialist palliative care. ClinicalTrials.gov number NCT03330509. SETTING/PARTICIPANTS Cancer patients admitted to the oncology inpatient service of an acute hospital in Singapore. RESULTS A total of 5681 admissions from December 2017 to July 2019 were included, of which 5295 involved stage 3-4 cancer and 1221 received specialist palliative care review. Admissions in the co-rounding model had a shorter hospital length of stay than those in the consult model by 0.70 days (95%CI -0.04 to 1.45, p = 0.065) for all admissions. In the sub-group of stage 3-4 cancer patients, the length of stay was 0.85 days shorter (95%CI 0.05-1.65, p = 0.038). In the sub-group of admissions that received specialist palliative care review, the length of stay was 2.62 days shorter (95%CI 0.63-4.61, p = 0.010). Hospital readmission within 30 days (OR1.03, 95%CI 0.79-1.35, p = 0.822) and access to specialist palliative care (OR1.19, 95%CI 0.90-1.58, p = 0.215) were similar between the consult and co-rounding models. CONCLUSIONS The co-rounding model was associated with a shorter hospital length of stay. Readmissions within 30 days and access to specialist palliative care were similar.
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Affiliation(s)
- Grace M Yang
- National Cancer Centre Singapore, Singapore.,Duke-NUS Medical School, Singapore.,Sengkang General Hospital, Singapore
| | - Siqin Zhou
- National Cancer Centre Singapore, Singapore
| | - Zhizhen Xu
- National Cancer Centre Singapore, Singapore
| | | | - Xia Zhu
- National Cancer Centre Singapore, Singapore
| | | | | | | | | | | | - Yin-Bun Cheung
- Duke-NUS Medical School, Singapore.,Tampere University, Finland
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16
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Wong CW, Chen C, Rossi LA, Abila M, Munu J, Nakamura R, Eftekhari Z. Explainable Tree-Based Predictions for Unplanned 30-Day Readmission of Patients With Cancer Using Clinical Embeddings. JCO Clin Cancer Inform 2021; 5:155-167. [PMID: 33539176 PMCID: PMC8140786 DOI: 10.1200/cci.20.00127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Thirty-day unplanned readmission is one of the key components in measuring quality in patient care. Risk of readmission in oncology patients may be associated with a wide variety of specific factors including laboratory results and diagnoses, and it is hard to include all such features using traditional approaches such as one-hot encoding in predictive models.
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Affiliation(s)
- Chi Wah Wong
- Department of Applied AI and Data Science, City of Hope National Medical Center, Duarte, CA
| | - Chen Chen
- Department of Applied AI and Data Science, City of Hope National Medical Center, Duarte, CA
| | - Lorenzo A Rossi
- Department of Applied AI and Data Science, City of Hope National Medical Center, Duarte, CA
| | - Monga Abila
- Department of Clinical Informatics, City of Hope National Medical Center, Duarte, CA
| | - Janet Munu
- Department of Clinical Informatics, City of Hope National Medical Center, Duarte, CA
| | - Ryotaro Nakamura
- Department of Hematology and HCT, City of Hope National Medical Center, Duarte, CA
| | - Zahra Eftekhari
- Department of Applied AI and Data Science, City of Hope National Medical Center, Duarte, CA
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17
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Lage DE, El-Jawahri A, Fuh CX, Newcomb RA, Jackson VA, Ryan DP, Greer JA, Temel JS, Nipp RD. Functional Impairment, Symptom Burden, and Clinical Outcomes Among Hospitalized Patients With Advanced Cancer. J Natl Compr Canc Netw 2021; 18:747-754. [PMID: 32502982 DOI: 10.6004/jnccn.2019.7385] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/04/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND National guidelines recommend regular measurement of functional status among patients with cancer, particularly those who are elderly or high-risk, but little is known about how functional status relates to clinical outcomes among hospitalized patients with advanced cancer. The goal of this study was to investigate how functional impairment is associated with symptom burden and healthcare utilization and clinical outcomes. PATIENTS AND METHODS We conducted a prospective observational study of patients with advanced cancer with unplanned hospitalizations at Massachusetts General Hospital from September 2014 through March 2016. Upon admission, nurses assessed patients' activities of daily living (ADLs; mobility, feeding, bathing, dressing, and grooming). Patients with any ADL impairment on admission were classified as having functional impairment. We used the revised Edmonton Symptom Assessment System (ESAS-r) and Patient Health Questionnaire-4 to assess physical and psychological symptoms, respectively. Multivariable regression models were used to assess the relationships between functional impairment, hospital length of stay, and survival. RESULTS Among 971 patients, 390 (40.2%) had functional impairment. Those with functional impairment were older (mean age, 67.18 vs 60.81 years; P<.001) and had a higher physical symptom burden (mean ESAS physical score, 35.29 vs 30.85; P<.001) compared with those with no functional impairment. They were also more likely to report moderate-to-severe pain (74.9% vs 63.1%; P<.001) and symptoms of depression (38.3% vs 23.6%; P<.001) and anxiety (35.9% vs 22.4%; P<.001). Functional impairment was associated with longer hospital length of stay (β = 1.29; P<.001) and worse survival (hazard ratio, 1.73; P<.001). CONCLUSIONS Hospitalized patients with advanced cancer who had functional impairment experienced a significantly higher symptom burden and worse clinical outcomes compared with those without functional impairment. These findings provide evidence supporting the routine assessment of functional status on hospital admission and using this to inform discharge planning, discussions about prognosis, and the development of interventions addressing patients' symptoms and physical function.
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Affiliation(s)
- Daniel E Lage
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Richard A Newcomb
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - David P Ryan
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- 4Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ryan D Nipp
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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18
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Le QV, Trinh HL, Mai KNT, Pham MD, Glare PA. Screening Patients With Cancer Admitted to Hanoi Medical University Hospital for Palliative Care Needs. JCO Glob Oncol 2021; 6:1321-1327. [PMID: 32841066 PMCID: PMC7456321 DOI: 10.1200/go.20.00102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To evaluate a screening tool for identifying which patients admitted to the oncology ward of a Vietnamese hospital should be referred to specialist palliative care (PC). METHODS We performed a cross-sectional survey of consecutive patients hospitalized in the Department of Oncology and Palliative Care at Hanoi Medical University Hospital between June 2019 and September 2019. We translated a validated 11-item screening tool into Vietnamese and used a total score of ≥ 5 as a positive screen. RESULTS One hundred participants were recruited. Forty-four patients (44%) screened positive. Of these, 37 (84%) had locally advanced or metastatic disease, 31 (70%) had uncontrolled symptoms, and 43 (98%) requested a PC consultation. A score ≥ 5 was significantly more common in patients with stage IV disease versus earlier stage, performance status of Eastern Cooperative Oncology Group (ECOG) 2 versus ECOG 0, and when life-limiting complications of cancer were present. Screening identified four patients overlooked by oncologists as needing referral, and 34% of patients requesting a referral had scores < 5. CONCLUSION This screening tool provided oncologists with easy-to-use criteria for referring patients for PC. At the same time, it relieved the work load for under-resourced PC physicians by screening out requests with low-level need. This tool should be part of routine assessment on admission in all oncology units in Vietnam.
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Affiliation(s)
- Quang V Le
- Department of Oncology and Palliative Care, Hanoi Medical University Hospital, Hanoi, Socialist Republic of Vietnam
| | - Huy L Trinh
- Department of Oncology and Palliative Care, Hanoi Medical University Hospital, Hanoi, Socialist Republic of Vietnam
| | - Kim Ngan T Mai
- Department of Oncology and Palliative Care, Hanoi Medical University Hospital, Hanoi, Socialist Republic of Vietnam
| | - Manh D Pham
- Hanoi Medical University, Hanoi, Socialist Republic of Vietnam
| | - Paul A Glare
- Sydney Medical School, University of Sydney, New South Wales, Australia
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19
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Chan AS, Rout A, D 'Adamo CR, Lev I, Yu A, Miller K. Palliative Referrals in Advanced Cancer Patients: Utilizing the Supportive and Palliative Care Indicators Tool and Rothman Index. Am J Hosp Palliat Care 2021; 39:164-168. [PMID: 34002623 DOI: 10.1177/10499091211017873] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Timely identification of palliative care needs can reduce hospitalizations and improve quality of life. The Supportive & Palliative Care Indicators Tool (SPICT) identifies patients with advanced medical conditions who may need special care planning. The Rothman Index (RI) detects patients at high risk of acutely decompensating in the inpatient setting. SPICT and RI among cancer patients were utilized in this study to evaluate their potential roles in palliative care referrals. METHODS Advanced cancer patients admitted to an institution in Baltimore, Maryland in 2019 were retrospectively reviewed. Patient demographics, length of hospital stay (LOS), palliative care referrals, RI scores, and SPICT scores were obtained. Patients were divided into SPICT positive or negative and RI > 60 or RI < 60.Unpaired t-tests and chi-square tests were utilized to determine the associations between SPICT and RI and early palliative care needs and mortality. RESULTS 227 patients were included, with a mean age of 68 years, 63% Black, 59% female, with the majority having lung and GI malignancies. Sixty percent were SPICT +, 21% had RI < 60. SPICT + patients were more likely to have RI < 60 (p = 0.001). SPICT + and RI < 60 patients were more likely to have longer LOS, change in code status, more palliative/hospice referrals, and increased mortality (p <0.05). CONCLUSIONS SPICT and RI are valuable tools in predicting mortality and palliative/hospice care referrals. These can also be utilized to initiate early palliative and goals of care discussions in patients with advanced cancer.
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Affiliation(s)
- Abigail Sy Chan
- Department of Medicine, Sinai Hospital of Baltimore, MD, USA.,Department of Hematology/Oncology, University of Louisville, KY, USA
| | - Amit Rout
- Department of Medicine, Sinai Hospital of Baltimore, MD, USA
| | - Christopher R D 'Adamo
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Irina Lev
- Department of Medicine, Sinai Hospital of Baltimore, MD, USA
| | - Amy Yu
- Department of Medicine, Sinai Hospital of Baltimore, MD, USA
| | - Kenneth Miller
- Department of Hematology/Oncology, Sinai Hospital of Baltimore, Baltimore, MD, USA
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20
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Hanson LC, Ernecoff NC, Wessell KL, Lin FC, Milowsky MI, Collichio FA, Wood WA, Rosenstein DL. Mortality Risk for Patients With Stage IV Cancer and Acute Illness Hospitalization. J Pain Symptom Manage 2021; 61:797-804. [PMID: 33096216 PMCID: PMC8075274 DOI: 10.1016/j.jpainsymman.2020.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/03/2020] [Accepted: 10/11/2020] [Indexed: 12/25/2022]
Abstract
CONTEXT Cancer prognosis data often come from clinical trials which exclude patients with acute illness. OBJECTIVES For patients with Stage IV cancer and acute illness hospitalization to 1) describe predictors of 60-day mortality and 2) compare documented decision-making for survivors and decedents. METHODS Investigators studied a consecutive prospective cohort of patients with Stage IV cancer and acute illness hospitalization. Structured health record and obituary reviews provided data on 60-day mortality (outcome), demographics, health status, and treatment; logistic regression models identified mortality predictors. RESULTS Four hundred ninety-two patients with Stage IV cancer and acute illness hospitalization had median age of 60.2 (51% female, 38% minority race/ethnicity); 156 (32%) died within 60 days, and median survival for decedents was 28 days. Nutritional insufficiency (odds rato [OR] 1.83), serum albumin (OR 2.15 per 1.0 g/dL), and hospital days (OR 1.04) were associated with mortality; age, gender, race, cancer, and acute illness type were not predictive. On admission, 79% of patients had orders indicating Full Code. During 60-day follow-up, 42% of patients discussed goals of care. Documented goals of care discussions were more common for decedents than survivors (70% vs. 28%, P < 0.001), as were orders for do not resuscitate/do not intubate (68% vs. 24%, P < 0.001), stopping cancer-directed therapy (29% vs. 10%, P < 0.001), specialty Palliative Care (79% vs. 44%, P < 0.001), and Hospice (68% vs. 14%, P < 0.001). CONCLUSION Acute illness hospitalization is a sentinel event in Stage IV cancer. Short-term mortality is high; nutritional decline increases risk. For patients with Stage IV cancer, acute illness hospitalization should trigger goals of care discussions.
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Affiliation(s)
- Laura C Hanson
- Division of Geriatric Medicine & Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - Natalie C Ernecoff
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kathryn L Wessell
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Feng-Chang Lin
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Matthew I Milowsky
- Division of Hematology and Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Frances A Collichio
- Division of Hematology and Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - William A Wood
- Division of Hematology and Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Cotogni P, Stragliotto S, Ossola M, Collo A, Riso S. The Role of Nutritional Support for Cancer Patients in Palliative Care. Nutrients 2021; 13:306. [PMID: 33498997 PMCID: PMC7911232 DOI: 10.3390/nu13020306] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/11/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
The role of nutritional support for cancer patients in palliative care is still a controversial topic, in part because there is no consensus on the definition of a palliative care patient because of ambiguity in the common medical use of the adjective palliative. Nonetheless, guidelines recommend assessing nutritional deficiencies in all such patients because, regardless of whether they are still on anticancer treatments or not, malnutrition leads to low performance status, impaired quality of life (QoL), unplanned hospitalizations, and reduced survival. Because nutritional interventions tailored to individual needs may be beneficial, guidelines recommend that if oral food intake remains inadequate despite counseling and oral nutritional supplements, home enteral nutrition or, if this is not sufficient or feasible, home parenteral nutrition (supplemental or total) should be considered in suitable patients. The purpose of this narrative review is to identify in these cancer patients the area of overlapping between the two therapeutic approaches consisting of nutritional support and palliative care in light of the variables that determine its identification (guidelines, evidence, ethics, and law). However, nutritional support for cancer patients in palliative care may be more likely to contribute to improving their QoL when part of a comprehensive early palliative care approach.
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Affiliation(s)
- Paolo Cotogni
- Department of Anesthesia, Pain Management and Palliative Care, Intensive Care and Emergency, Molinette Hospital, University of Turin, 10126 Turin, Italy
| | - Silvia Stragliotto
- Medical Oncology 1, Veneto Institute of Oncology-IRCCS, 35128 Padova, Italy;
| | - Marta Ossola
- Clinical Nutrition and Dietetics Unit, Department of Internal Medicine, Molinette Hospital, 10126 Turin, Italy;
| | - Alessandro Collo
- Clinical Nutrition and Dietetics Unit, Maggiore della Carità Hospital, University of Eastern Piedmont, 28100 Novara, Italy; (S.R.); (A.C.)
| | - Sergio Riso
- Clinical Nutrition and Dietetics Unit, Maggiore della Carità Hospital, University of Eastern Piedmont, 28100 Novara, Italy; (S.R.); (A.C.)
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22
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Ferrell B, Chung V, Hughes MT, Koczywas M, Azad NS, Ruel NH, Knight L, Cooper RS, Smith TJ. A Palliative Care Intervention for Patients on Phase 1 Studies. J Palliat Med 2020; 24:846-856. [PMID: 33103938 DOI: 10.1089/jpm.2020.0597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Phase 1 clinical trials remain vital for oncology care. Patients on these trials require supportive care for quality-of-life (QOL) concerns. Objective: To test a Palliative Care Intervention (PCI) for patients with solid tumors enrolled in Phase I therapeutic trials with a priori hypothesis that psychological distress, QOL, satisfaction, symptoms, and resource utilization would be improved in the PCI group. Design: This unblinded randomized trial compared the PCI with usual care in patients accrued to Phase I Clinical Trials. Subjects (n = 479) were followed for 24 weeks, with 12 weeks as the primary outcome. Setting: Two Comprehensive Cancer Centers in the United States. Subjects: A consecutive sample, 21 years or older, English fluency, with solid tumors initiating a Phase 1 trial. Measurements: Psychological Distress (Distress Thermometer), QOL total and subscales (FACT-G), satisfaction (FAM-CARE), survival, and resource utilization (chart audit). Results: PCI subjects showed improved Psychological Distress (-0.47, p = 0.015) and Emotional Well-Being (0.81, p = 0.045), with differences on variables of QOL and distress between sites. High rates of symptom-management admissions (41.3%) and low rates of Advance Directive completion (39.0%), and hospice enrollment (30.7%), despite a median survival in both groups of 10.1 months from initiating a Phase 1 study. Conclusions: A nurse-delivered PCI can improve some QOL outcomes and distress for patients participating in Phase 1 trials. Greater integration of PC is needed to provide quality care to these patients and to support transitions from treatment to supportive care, especially at the end of life. ClinicalTrials.gov Identifier: NCT01612598.
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Affiliation(s)
- Betty Ferrell
- Division of Nursing Research and Education, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, USA
| | - Vincent Chung
- Department of Medical Oncology and Therapeutics Research, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, USA
| | - Mark T Hughes
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marianna Koczywas
- Department of Medical Oncology and Therapeutics Research, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, USA
| | - Nilofer Saba Azad
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Nora H Ruel
- Department of Computational and Quantitative Medicine, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, USA
| | - Louise Knight
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Rhonda S Cooper
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Thomas J Smith
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
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23
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Numico G, Zanelli C, Ippoliti R, Rossi M, Traverso E, Antonuzzo A, Bellini R. The hospital care of patients with cancer: a retrospective analysis of the characteristics of their hospital stay in comparison with other medical conditions. Eur J Cancer 2020; 139:99-106. [PMID: 32979648 DOI: 10.1016/j.ejca.2020.08.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/12/2020] [Accepted: 08/18/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE Hospital admission is a frequent occurrence among patients with cancer, and a significant proportion of patients admitted to medical units have cancer. Their hospital stay has features that may be different compared with patients without cancer. We performed a retrospective analysis of the characteristics of patients with cancer admitted for medical conditions. PATIENTS AND METHODS We studied the administrative data of patients with solid cancer admitted to the medical department of a large referral hospital over a 12-month period and compared them with those of patients without cancer. RESULTS Seven thousand eight hundred two consecutive admissions were analysed, of which 1099 (14.1%) had a principal or associated diagnosis of cancer. Admissions were distributed across 12 units, with 44% concentrated in the medical oncology unit and 56% in other units. Patients with cancer were more frequently men and were younger than patients without cancer. Admission less frequently involved the emergency department (ED), while discharge was more frequently assisted. The in-hospital death rate was higher, as was the readmission rate. Length of stay was longer (11.3 days vs. 9.8 days; p < 0.0001). Patients with cancer admitted to the medical oncology unit used the ED even less, and their length of stay was shorter than that of patients with cancer admitted in other units. CONCLUSIONS The in-hospital pathway of patients with cancer displays specific issues and adds complexity to hospital stay of patients with medical conditions. The medical oncology unit plays a role in reducing ED use and in providing efficient care. The evidence gathered should help in shaping new models of care and in improving adequate clinical competencies.
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Affiliation(s)
- Gianmauro Numico
- Medical Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.
| | - Cristian Zanelli
- Quality and Management Control Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Roberto Ippoliti
- University of Bielefeld, Department of Business Administration and Economics, Bielefeld, Germany
| | - Maura Rossi
- Medical Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Elena Traverso
- Medical Oncology Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Andrea Antonuzzo
- Medical Oncology Unit 1, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Roberta Bellini
- Quality and Management Control Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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24
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Chi NC, Barani E, Fu YK, Nakad L, Gilbertson-White S, Herr K, Saeidzadeh S. Interventions to Support Family Caregivers in Pain Management: A Systematic Review. J Pain Symptom Manage 2020; 60:630-656.e31. [PMID: 32339651 PMCID: PMC7483228 DOI: 10.1016/j.jpainsymman.2020.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 12/29/2022]
Abstract
CONTEXT Family caregivers encounter many challenges when managing pain for their loved ones. There is a lack of clear recommendations on how to prepare caregivers in pain management. OBJECTIVES To evaluate existing interventions that support family caregivers in providing pain management to patients with all disease types. METHODS Four electronic databases were systematically searched (PubMed, Cumulative Index for Nursing Allied Health Literature, PsycINFO, and Scopus) using index and keyword methods for articles published before December 2019. The Mixed Methods Appraisal Tool was used to assess the quality. RESULTS The search identified 6851 studies, and 25 studies met the inclusion criteria. Only two studies exclusively focused on noncancer populations (8%). Three types of interventions were identified in this review: educational interventions, cognitive-behavioral interventions, and technology-based interventions. Both educational and cognitive-behavioral interventions improved family caregiver and patient outcomes, but the content and intensity of these interventions in these studies varied widely, and there was a limited number of randomized clinical trials (68%). Hence, it is unclear what strategies are most effective to prepare family caregivers in pain management. Technology-based interventions were feasible to support family caregivers in providing pain management. CONCLUSION Providing adequate pain management training can improve patient and family caregiver outcomes. However, the most effective interventions for family caregivers are still unclear. More rigorous and replicable clinical trials are needed to examine the effects of educational interventions, cognitive-behavioral interventions, and technology-based interventions. Also, more studies are needed in patients with a noncancer diagnosis or multimorbidity.
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Affiliation(s)
- Nai-Ching Chi
- College of Nursing, University of Iowa, Iowa City, Iowa, USA.
| | - Emelia Barani
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Ying-Kai Fu
- College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Lynn Nakad
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
| | | | - Keela Herr
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
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25
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Freed JA, Hale AJ, Rangachari D, Ricotta DN. Twelve tips for teaching oncology to non-oncologists. MEDICAL TEACHER 2020; 42:987-992. [PMID: 31663798 DOI: 10.1080/0142159x.2019.1682534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background: Teaching subspecialty care to trainees who are not pursuing that subspecialty poses many challenges. These challenges are amplified in the teaching of oncology to non-oncologists because there are more new therapies emerging in oncology than in any other discipline, and there are few oncologic issues managed by generalists without consultation. Concurrently, there is an increasing need for generalists to manage many aspects of care for patients with cancer.Aim: To provide 12 tips for oncologists to use to educate trainees on their oncology rotations.Method: The tips provided are based upon the available literature and the authors' own experience.Results: The 12 tips presented offer specific strategies for oncologists to enhance their teaching by selection of appropriate content and enhancing delivery. Focus is placed on aspects of oncology that trainees are likely to encounter as a generalist or non-cancer subspecialist. While oncology is used as the case study, these strategies are adaptable to any subspecialty area.Conclusion: Oncologists and other subspecialists can be core medical educators.
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Affiliation(s)
- Jason A Freed
- Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andrew J Hale
- Division of Infectious Disease, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Deepa Rangachari
- Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel N Ricotta
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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26
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Bernardes CM, Beesley V, Shahid S, Medlin L, Garvey G, Valery PC. End-of-life care for Aboriginal and Torres Strait Islander people with cancer: an exploratory study of service utilisation and unmet supportive care needs. Support Care Cancer 2020; 29:2073-2082. [PMID: 32862355 DOI: 10.1007/s00520-020-05714-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/21/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Indigenous Australians diagnosed with cancer have substantially higher cancer mortality rates compared with non-Indigenous Australians, yet there is a paucity of information about their end-of-life service utilisation and supportive care needs. PURPOSE To describe the service utilisation and supportive care needs of Aboriginal and Torres Strait Islander people with cancer at end-of-life. METHOD Hospital admission data were linked to self-reported data from a study of Indigenous cancer patients from Queensland, Australia during the last year of their life. Needs were assessed by the Supportive Care Needs Assessment Tool for Indigenous Cancer Patients which measures 26 need items across 4 domains (physical/psychological; hospital care; information/communication; practical/cultural). A descriptive analysis of health service utilisation and unmet needs was conducted. RESULTS In total, 58 Indigenous cancer patients were included in this analysis. All patients had at least one hospital admission within the last year of their life. Most hospital admissions occurred through emergency (38%) and outpatient (31%) departments and were for acute care (85%). Palliative care represented 14% of admissions and 78% died in hospital. Approximately half (48%) did not report any unmet needs. The most frequently reported moderate-to-high unmet need items were worry about the treatment results (17%), money worries (16%) and anxiety (16%). CONCLUSIONS Utilisation of palliative care services that manage a full range of physical and psychosocial needs was low. Addressing worries about treatment results, finances and generalised anxiety are priorities in this population.
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Affiliation(s)
- Christina M Bernardes
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD 4006, Australia.
| | - Vanessa Beesley
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD 4006, Australia
| | - Shaouli Shahid
- Centre for Aboriginal Studies, Curtin University, Bentley, WA, Australia
| | - Linda Medlin
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD 4006, Australia
| | - Gail Garvey
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Patricia C Valery
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD 4006, Australia
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27
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Brooks GA, Uno H, Aiello Bowles EJ, Menter AR, O'Keeffe-Rosetti M, Tosteson ANA, Ritzwoller DP, Schrag D. Hospitalization Risk During Chemotherapy for Advanced Cancer: Development and Validation of Risk Stratification Models Using Real-World Data. JCO Clin Cancer Inform 2020; 3:1-10. [PMID: 30995122 DOI: 10.1200/cci.18.00147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Hospitalizations are a common occurrence during chemotherapy for advanced cancer. Validated risk stratification tools could facilitate proactive approaches for reducing hospitalizations by identifying at-risk patients. PATIENTS AND METHODS We assembled two retrospective cohorts of patients receiving chemotherapy for advanced nonhematologic cancer; cohorts were drawn from three integrated health plans of the Cancer Research Network. We used these cohorts to develop and validate logistic regression models estimating 30-day hospitalization risk after chemotherapy initiation. The development cohort included patients in two health plans from 2005 to 2013. The validation cohort included patients in a third health plan from 2007 to 2016. Candidate predictor variables were derived from clinical data in institutional data warehouses. Models were validated based on the C-statistic, positive predictive value, and negative predictive value. Positive predictive value and negative predictive value were calculated in reference to a prespecified risk threshold (hospitalization risk ≥ 18.0%). RESULTS There were 3,606 patients in the development cohort (median age, 63 years) and 634 evaluable patients in the validation cohort (median age, 64 years). Lung cancer was the most common diagnosis in both cohorts (26% and 31%, respectively). The selected risk stratification model included two variables: albumin and sodium. The model C-statistic in the validation cohort was 0.69 (95% CI, 0.62 to 0.75); 39% of patients were classified as high risk according to the prespecified threshold; 30-day hospitalization risk was 24.2% (95% CI, 19.9% to 32.0%) in the high-risk group and 8.7% (95% CI, 6.1% to 12.0%) in the low-risk group. CONCLUSION A model based on data elements routinely collected during cancer treatment can reliably identify patients at high risk for hospitalization after chemotherapy initiation. Additional research is necessary to determine whether this model can be deployed to prevent chemotherapy-related hospitalizations.
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Affiliation(s)
| | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, MA
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28
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de Man Y, Groenewoud S, Oosterveld-Vlug MG, Brom L, Onwuteaka-Philipsen BD, Westert GP, Atsma F. Regional variation in hospital care at the end-of-life of Dutch patients with lung cancer exists and is not correlated with primary and long-term care. Int J Qual Health Care 2020; 32:190-195. [PMID: 32186705 PMCID: PMC7238674 DOI: 10.1093/intqhc/mzaa004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 12/11/2019] [Accepted: 01/28/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To examine the regional variation in hospital care utilization in the last 6 months of life of Dutch patients with lung cancer and to test whether higher degrees of hospital utilization coincide with less general practitioner (GP) and long-term care use. DESIGN Cross-sectional claims data study. SETTING The Netherlands. PARTICIPANTS Patients deceased in 2013-2015 with lung cancer (N = 25 553). MAIN OUTCOME MEASURES We calculated regional medical practice variation scores, adjusted for age, gender and socioeconomic status, for radiotherapy, chemotherapy, CT-scans, emergency room contacts and hospital admission days during the last 6 months of life; Spearman Rank correlation coefficients measured the association between the adjusted regional medical practice variation scores for hospital admissions and ER contacts and GP and long-term care utilization. RESULTS The utilization of hospital services in high-using regions is 2.3-3.6 times higher than in low-using regions. The variation was highest in 2015 and lowest in 2013. For all 3 years, hospital care was not significantly correlated with out-of-hospital care at a regional level. CONCLUSIONS Hospital care utilization during the last 6 months of life of patients with lung cancer shows regional medical practice variation over the course of multiple years and seems to increase. Higher healthcare utilization in hospitals does not seem to be associated with less intensive GP and long-term care. In-depth research is needed to explore the causes of the variation and its relation to quality of care provided at the level of daily practice.
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Affiliation(s)
- Yvonne de Man
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Stef Groenewoud
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Mariska G Oosterveld-Vlug
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands, and
| | - Linda Brom
- IKNL, Netherlands Comprehensive Cancer Organization, Godebaldkwartier 419, 3511 DT Utrecht, the Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands, and
| | - Gert P Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Femke Atsma
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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Venous Thromboembolism in Cancer Patients on Simultaneous and Palliative Care. Cancers (Basel) 2020; 12:cancers12051167. [PMID: 32384641 PMCID: PMC7281278 DOI: 10.3390/cancers12051167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/29/2020] [Accepted: 05/02/2020] [Indexed: 12/25/2022] Open
Abstract
Simultaneous care represents the ideal integration between early supportive and palliative care in cancer patients under active antineoplastic treatment. Cancer patients require a composite clinical, social and psychological management that can be effective only if care continuity from hospital to home is guaranteed and if such a care takes place early in the course of the disease, combining standard oncology care and palliative care. In these settings, venous thromboembolism (VTE) represents a difficult medical challenge, for the requirement of acute treatments and for the strong impact on anticancer therapies that might be delayed or, even, totally discontinued. Moreover, cancer patients not only display high rates of VTE occurrence/recurrence but are also more prone to bleeding and this forces clinicians to optimize treatment strategies, balancing between hemorrhages and thrombus formation. VTE prevention is, therefore, regarded as a double-edged sword. Indeed, while on one hand the appropriate use of antithrombotic agents can reduce VTE occurrence, on the other it significantly increases the bleeding risk, especially in the frail patients who present with multiple co-morbidities and poly-therapy that can interact with anticoagulant drugs. For these reasons, thromboprophylaxis should start while active cancer treatment is ongoing, according to a simultaneous care model in a patient-centered perspective.
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30
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Predictors of hospital readmission among older adults with cancer. J Geriatr Oncol 2020; 11:1108-1114. [PMID: 32222347 DOI: 10.1016/j.jgo.2020.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/01/2020] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Older adults with cancer are at higher risk for costly and potentially dangerous hospital readmissions. Identifying risk factors for readmission in this population is important for future prevention of readmission. MATERIALS AND METHODS Hospital discharges among patients ≥ 65 years with solid tumors on non-surgical services from 2006-2011 were reviewed in this matched case-control study. We abstracted patient/cancer characteristics; functional status; fall risk; chemotherapy line; comorbidities; laboratory values; discharge parameters; and miscellaneous information (Do Not Resuscitate Order, pain scores) from medical records. Conditional logistic regression was used for univariate and multivariable analysis. RESULTS This analysis included 184 case-patients readmitted within 30 days after discharge from the index admission and 184 sex- and age-matched control-patients discharged from index admission within three months of the cases with no readmission. Cases and controls had no differences in terms of primary cancer type, treatment, and index admission reason. Cases were more likely to have abnormal hemoglobin, albumin, sodium, and SGOT on discharge. Compared to those with ≤1 abnormal laboratory test, patients with 2 or more abnormal test results were 3 times more likely to be readmitted within 30 days. CONCLUSION This study demonstrated that older adults with cancer who had at least 2 abnormal laboratory results (hemoglobin, albumin, sodium, and SGOT) at discharge were 3 times more likely to be readmitted within 30 days compared to those with ≤1 abnormal results. These laboratory values may be predictive of the risk of readmission, and should be monitored before discharge to potentially prevent readmission.
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31
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Choi Y, Kim JW, Suh KJ, Lim YJ, Lee JY, Kang BD, Kim JW, Kim SH, Lee JO, Kim YJ, Lee KW, Kim JH, Bang SM, Lee JS. Identification of a potentially avoidable cardiopulmonary resuscitation in hematology and oncology wards. BMC Palliat Care 2019; 18:93. [PMID: 31684934 PMCID: PMC6829942 DOI: 10.1186/s12904-019-0477-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/15/2019] [Indexed: 11/23/2022] Open
Abstract
Background In-hospital cardiopulmonary resuscitation (CPR) is one of undesirable situations. We tried to identify and characterize a potentially avoidable CPR in cancer patients who were hospitalized in hematology and oncology wards. Methods A potentially avoidable CPR was determined based on chemotherapy setting, disease status and clinical situation at the time when a cardiopulmonary arrest occurred, by using a consensus-driven medical records review of two physicians. Results One hundred thirty-seven patients among 12,437 patients hospitalized at hematology and oncology wards between March 2003 and June 2015 (1.1%) underwent a CPR. Eighty-eight patients (64.2%) were men. The majority of patients with a CPR had lung cancer (41, 29.9%), hematologic malignancy (24, 17.5%), stomach cancer (23, 16.8%) or lymphoma (20, 14.6%). A potentially avoidable CPR was identified in 51 patients (37.2%). In a multivariate analysis, advanced diseases and certain tumor types (e.g., lung cancer, lymphoma) were significant risk factors for a potentially avoidable CPR. Of patients who received a potentially avoidable CPR, 29 patients (56.9%) did not have a do-not-resuscitate documentation. A first return of spontaneous circulation rate (ROSC) and in-hospital survival rate (IHSR) were much lower in patients with a potentially avoidable CPR than those with a CPR that was not avoidable (ROSC: 39.2% vs 53.5%, P = 0.106; IHSR: 2.0% vs 12.8%, P = 0.032, respectively). Conclusions A potentially avoidable CPR was common at hematology and oncology wards. A potentially avoidable CPR frequently occurred in advanced diseases and certain tumor types. Furthermore, cancer patients who received a potentially avoidable CPR showed the worse prognosis.
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Affiliation(s)
- Yeonjoo Choi
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea.,Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.,Present Address: Department of Investigational Cancer Therapeutics, The MD Anderson Cancer Center, Houston, TX, USA
| | - Jin Won Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea.
| | - Koung Jin Suh
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Yoo-Joo Lim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea.,Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Yun Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Beo-Deul Kang
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea.,Present Address: CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Ji-Won Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Se-Hyun Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Jeong-Ok Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Keun-Wook Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Jee Hyun Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Soo-Mee Bang
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Jong Seok Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
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Emiloju OE, Djibo DAM, Ford JG. Association Between the Timing of Goals-of-Care Discussion and Hospitalization Outcomes in Patients With Metastatic Cancer. Am J Hosp Palliat Care 2019; 37:433-438. [PMID: 31635471 DOI: 10.1177/1049909119882891] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Patients with cancer often require acute hospitalizations, many of which are unplanned. These hospitalizations have been shown to increase in frequency near the end of life. The American College of Physicians recommends that goals-of-care (GOC) discussions be initiated early for metastatic cancers. We hypothesized that discussing GOC during hospitalization could help reduce readmissions. Our aim was to examine the association between the timing of GOC discussion, length of hospital stay, and the time to readmission. METHODS We conducted a retrospective review of medical records of patients with stage IV cancers hospitalized between August 2017 and July 2018. We recorded timing of GOC discussion, use of palliative care services, and hospital readmissions within 90 days. χ2 tests were used to identify independent associations with GOC discussion, and logistic regression was used to examine association with readmission within 90 days. RESULTS Of all study patients (N = 241), 40.6% were female, 46% (n = 112) had a GOC discussion, and 34% (n = 82) had a palliative care consultation. Having a palliative care consult and being admitted to critical care were independently associated with having a GOC discussion. Early timing of GOC discussion was inversely associated with admission to critical care units (P < .05). Thirty-eight percent (n = 92) had unplanned hospital readmission within 90 days. Having a GOC discussion was independently associated with a reduction in the odds of an unplanned hospital readmission within 90 days by 79% (odds ratio = 0.21, 95% confidence interval: 0.12-0.37). CONCLUSION Among hospitalized patients with stage IV cancer, performing an early GOC discussion has an important association with lower hospital readmission rates and increased rates of goal-congruent patient care.
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Affiliation(s)
| | - Djeneba Audrey M Djibo
- Division of Research, Department of Medicine, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Jean G Ford
- Department of Medicine, Einstein Healthcare Network, Philadelphia, PA, USA
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Fiorin de Vasconcellos V, Rcc Bonadio R, Avanço G, Negrão MV, Pimenta Riechelmann R. Inpatient palliative chemotherapy is associated with high mortality and aggressive end-of-life care in patients with advanced solid tumors and poor performance status. BMC Palliat Care 2019; 18:42. [PMID: 31109330 PMCID: PMC6528308 DOI: 10.1186/s12904-019-0427-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 05/09/2019] [Indexed: 11/19/2022] Open
Abstract
Background The benefit of palliative chemotherapy (PC) in patients with advanced solid tumors and poor performance status (ECOG-PS) has not been prospectively validated, which makes treatment decision challenging. We aimed to evaluate the overall survival, factors associated with early mortality, and adoption of additional procedures in hospitalized patients with advanced cancer and poor ECOG-PS treated with PC. Methods We analyzed a retrospective cohort of patients with advanced cancer treated with PC during hospitalization at an academic cancer center in Brazil from 2014 to 2016. Eligibility criteria included: ECOG-PS 3–4 and start of first-line PC; or ECOG-PS ≥ 2 and start of second or subsequent lines. Primary endpoint was 30-day survival from start of PC. Kaplan-Meier method was used for survival estimates and Cox regression for factors associated with 30-day mortality. Results Two hundred twenty-eight patients were eligible. 21.9, 66.7 and 11.4% of patients had ECOG-PS 2, 3 and 4, respectively. 49.6% had gastrointestinal tumors. Median follow-up was 49 days (range 1–507). 98.2% of patients had died, 32% during the index hospitalization. The 30-day and 60-day survival rates were 55.7 and 38.5%, respectively. 30% of patients were admitted to the intensive care unit. In a multivariable analysis, ECOG-PS 3/4 (HR 2.01; P = 0.016), hypercalcemia (HR 2.19; P = 0.005), and elevated bilirubin (HR 3.17; P < 0.001) were significantly associated with 30-day mortality. Conclusions Patients with advanced cancer and poor ECOG-PS had short survival after treatment with inpatient PC. Inpatient PC was associated with aggressive end-of-life care. Prognostic markers such as ECOG-PS, hypercalcemia and elevated bilirubin can contribute to the decision-making process for these patients.
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Affiliation(s)
- Vitor Fiorin de Vasconcellos
- Medical Oncology Department, Instituto do Cancer do Estado de São Paulo (ICESP), Avenida Dr. Arnaldo, 251, Cerqueira César, São Paulo, 01246-000, Brazil.
| | - Renata Rcc Bonadio
- Medical Oncology Department, Instituto do Cancer do Estado de São Paulo (ICESP), Avenida Dr. Arnaldo, 251, Cerqueira César, São Paulo, 01246-000, Brazil
| | - Guilherme Avanço
- Medical Oncology Department, Instituto do Cancer do Estado de São Paulo (ICESP), Avenida Dr. Arnaldo, 251, Cerqueira César, São Paulo, 01246-000, Brazil
| | - Marcelo Vailati Negrão
- Medical Oncology Department, Instituto do Cancer do Estado de São Paulo (ICESP), Avenida Dr. Arnaldo, 251, Cerqueira César, São Paulo, 01246-000, Brazil.,Department of Thoracic/Head and Neck Medical Oncology, The University of Texas, MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 432, Houston, TX, 77030, USA
| | - Rachel Pimenta Riechelmann
- Department of Clinical Oncology, AC Camargo Cancer Center, R. Prof. Antônio Prudente, 211 - Liberdade, São Paulo, SP, 01509-010, Brazil
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Solomon R, Egorova N, Adelson K, Smith CB, Franco R, Bickell NA. Thirty-Day Readmissions in Patients With Metastatic Cancer: Room for Improvement? J Oncol Pract 2019; 15:e410-e419. [DOI: 10.1200/jop.18.00500] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Purpose: Cancer, with readmission rates as high as 27%, has thus far been excluded from most readmission reduction efforts. However, some readmissions for patients with advanced disease may be avoidable. We assessed the prevalence of potentially preventable readmissions and associated factors in patients with metastatic cancer. Patients and Methods: Using a merged longitudinal data set of New York State hospital discharges and vital records, we measured 30-day readmissions for anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, and sepsis among patients with metastatic cancer between 2012 and 2014. We used competing-risk models to assess the effects of demographics, comorbidities, hospital type, payer, and discharge disposition. Results: A total of 11,275 patients had 19,307 hospitalizations. The 30-day readmission rate was 24.5%; 11.9% (n = 565) of readmissions were potentially preventable. Higher readmission rates occurred in black (hazard rate [HR], 1.26; 95% CI, 1.17 to 1.35), Hispanic (HR, 1.19; 95% CI, 1.09 to 1.31), and younger patients (HR per 10 years, 0.94; 95% CI, 0.90 to 0.97). Lower rates were associated with female sex (HR, 0.95; 95% CI, 0.91 to 0.99), private insurance (HR, 0.87; 95% CI, 0.87 to 0.81), teaching hospitals, and hospice discharge (HR, 0.62; 95% CI, 0.42 to 0.91). Discharge home with services (HR, 1.21; 95% CI, 1.14 to 1.27) or to a skilled nursing facility (HR, 1.11; 95% CI, 1.01 to 1.23) increased readmission likelihood. Potentially preventable readmissions were associated with younger age (HR per 10 years, 0.98; 95% CI, 0.98 to 0.99) and discharge home with services (HR, 1.25; 95% CI, 1.04 to 1.50). Likelihood decreased if care was received at a teaching hospital (HR, 0.76; 95% CI, 0.59 to 0.99). Payer, sex, race, and comorbidities did not contribute. Conclusion: Although the overall rate of potentially preventable readmissions among patients with metastatic cancer is low, higher readmission rates among those discharged home with help suggest that services supplied may not be sufficient to address health needs.
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Affiliation(s)
| | | | - Kerin Adelson
- Smilow Cancer Hospital at Yale New Haven, Yale University School of Medicine, New Haven, CT
| | | | - Rebeca Franco
- Icahn School of Medicine at Mount Sinai, New York, NY
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White C, Noble SIR, Watson M, Swan F, Allgar VL, Napier E, Nelson A, McAuley J, Doherty J, Lee B, Johnson MJ. Prevalence, symptom burden, and natural history of deep vein thrombosis in people with advanced cancer in specialist palliative care units (HIDDen): a prospective longitudinal observational study. Lancet Haematol 2019; 6:e79-e88. [PMID: 30709436 PMCID: PMC6352715 DOI: 10.1016/s2352-3026(18)30215-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The prevalence of deep venous thrombosis in patients with advanced cancer is unconfirmed and it is unknown whether current international thromboprophylaxis guidance is applicable to this population. We aimed to determine prevalence and predictors of femoral deep vein thrombosis in patients admitted to specialist palliative care units (SPCUs). METHODS We did this prospective longitudinal observational study in five SPCUs in England, Wales, and Northern Ireland (four hospices and one palliative care unit). Consecutive adults with cancer underwent bilateral femoral vein ultrasonography on admission and weekly until death or discharge for a maximum of 3 weeks. Data were collected on performance status, attributable symptoms, and variables known to be associated with venous thromboembolism. Patients with a short estimated prognosis (<5 days) were ineligible. The primary endpoint of the study was the prevalence of femoral deep vein thrombosis within 48 h of SPCU admission, analysed by intention to treat. This study is registered with the ISRCTN registry, number ISRCTN97567719. FINDINGS Between June 20, 2016, and Oct 16, 2017, 343 participants were enrolled (mean age 68·2 years [SD 12·8; range 25-102]; 179 [52%] male; mean Australian-modified Karnofsky performance status 49 [SD 16·6; range 20-90]). Of 273 patients with evaluable scans, 92 (34%, 95% CI 28-40) had femoral deep vein thrombosis. Four participants with a scan showing no deep vein thrombosis on admission developed a deep vein thrombosis on repeat scanning over 21 days. Previous venous thromboembolism (p=0·014), being bedbound in the past 12 weeks for any reason (p=0·003), and lower limb oedema (p=0·009) independently predicted deep vein thrombosis. Serum albumin concentration (p=0·43), thromboprophylaxis (p=0·17), and survival (p=0·45) were unrelated to deep vein thrombosis. INTERPRETATION About a third of patients with advanced cancer admitted to SPCUs had a femoral deep vein thrombosis. Deep vein thrombosis was not associated with thromboprophylaxis, survival, or symptoms other than leg oedema. These findings are consistent with venous thromboembolism being a manifestation of advanced disease rather than a cause of premature death. Thromboprophylaxis for SPCU inpatients with poor performance status seems to be of little benefit. FUNDING National Institute for Health Research (Research for Patient Benefit programme).
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Affiliation(s)
- Clare White
- Northern Ireland Hospice, Belfast, UK,Belfast Health and Social Care Trust, Belfast, UK
| | - Simon I R Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Max Watson
- University of Ulster, Jordanstown, Belfast, UK
| | - Flavia Swan
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Victoria L Allgar
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | - Eoin Napier
- Belfast Health and Social Care Trust, Belfast, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | | | | | | | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK.
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Ratcliff CG, Vinson CA, Milbury K, Badr H. Moving family interventions into the real world: What matters to oncology stakeholders? J Psychosoc Oncol 2018; 37:264-284. [PMID: 30421667 DOI: 10.1080/07347332.2018.1498426] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Family interventions targeting patients and/or informal caregivers are beneficial, but few have been integrated in oncology clinical care. Understanding diverse stakeholder perspectives may inform implementation and dissemination efforts. METHODS We are currently conducting a randomized controlled trial of CareSTEPS, a telephone-based intervention for caregivers of advanced lung cancer patients. CareSTEPS seeks to improve caregiver and patient self-care behaviors, quality of life, and satisfaction with care. With an eye toward integrating CareSTEPS into clinical care, semi-structured interviews were conducted with 7 experts in integrated care [practice thought leaders] and 26 individuals representing different oncology stakeholder groups (i.e., potential end users of CareSTEPS including counselors, social workers, nurse specialists, and psychologists) [N = 13], decision-makers, including physicians and administrators [N = 6], and key dissemination partners, including representatives from cancer and caregiving advocacy groups [N = 7]). Questions focused on existing caregiver support services, barriers to integrating care for caregivers in routine patient care, and possible models for clinical uptake and dissemination. Interviews were transcribed and analyzed using directed content analysis. RESULTS Stakeholders noted a mismatch between caregiver needs and services offered, and expressed interest in broader service offerings. Barriers for integrating caregiver support into clinical care included inadequate funding, lack of interdisciplinary training among providers, and concern that research-based interventions are often not flexible enough to roll out into clinical practice. To secure buy-in, stakeholders noted the importance of evaluating intervention cost, cost savings, and revenue generation. Possible avenues for dissemination, through bottom-up and top-down (e.g., policy change) approaches, were also discussed. CONCLUSIONS Findings highlight the importance of evaluating outcomes important to diverse oncology stakeholder groups to speed translation of research into practice. They also suggest that pragmatic trials are needed that allow for flexibility in the delivery of family interventions and that consider the resource limitations of clinical care.
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Affiliation(s)
- Chelsea G Ratcliff
- a Department of Psychology , Sam Houston State University , Huntsville , Texas, USA.,b Department of Psychiatry and Behavioral Sciences , Baylor College of Medicine , Houston , Texas, USA
| | - Cynthia A Vinson
- c Division of Cancer Control and Population Sciences , National Cancer Institute , Rockville , Maryland, USA
| | - Kathrin Milbury
- d Department of Palliative Care, Rehabilitation and Integrative Medicine , The University of Texas MD Anderson Cancer Center , Houston , Texas, USA
| | - Hoda Badr
- e Department of Medicine , Baylor College of Medicine , Houston , Texas, USA
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Wong RL, El-Jawahri A, D'Arpino SM, Fuh CX, Johnson PC, Lage DE, Irwin KE, Pirl WF, Traeger L, Cashavelly BJ, Jackson VA, Greer JA, Ryan DP, Hochberg EP, Temel JS, Nipp RD. Use of Antidepressant Medications Moderates the Relationship Between Depressive Symptoms and Hospital Length of Stay in Patients with Advanced Cancer. Oncologist 2018; 24:117-124. [PMID: 30082486 PMCID: PMC6324633 DOI: 10.1634/theoncologist.2018-0096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 05/31/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Among patients with cancer, depressive symptoms are associated with worse clinical outcomes, including greater health care utilization. As use of antidepressant medications can improve depressive symptoms, we sought to examine relationships among depressive symptoms, antidepressant medications, and hospital length of stay (LOS) in patients with advanced cancer. MATERIALS AND METHODS From September 2014 to May 2016, we prospectively enrolled patients with advanced cancer who had an unplanned hospitalization. We performed chart review to obtain information regarding documented depressive symptoms in the 3 months prior to admission and use of antidepressant medications at the time of admission. We compared differences in hospital LOS by presence or absence of depressive symptoms and used adjusted linear regression to examine if antidepressant medications moderated these outcomes. RESULTS Of 1,036 patients, 126 (12.2%) had depressive symptoms documented prior to admission, and 288 (27.8%) were taking antidepressant medications at the time of admission. Patients with depressive symptoms experienced longer hospital LOS (7.25 vs. 6.13 days; p = .036). Use of antidepressant medications moderated this relationship; among patients not on antidepressant medications, depressive symptoms were associated with longer hospital LOS (7.88 vs. 6.11 days; p = .025), but among those on antidepressant medications, depressive symptoms were not associated with hospital LOS (6.57 vs. 6.17 days; p = .578). CONCLUSION Documented depressive symptoms prior to hospital admission were associated with longer hospital LOS. This effect was restricted to patients not on antidepressant medications. Future studies are needed to investigate if use of antidepressant medications decreases LOS for patients hospitalized with advanced cancer and the mechanisms by which this may occur. IMPLICATIONS FOR PRACTICE This study investigated the prevalence of documented depressive symptoms in patients with advanced cancer in the 3 months prior to an unplanned hospitalization and the prevalence of use of antidepressant medications at time of hospital admission. The relationship of these variables with hospital length of stay was also examined, and it was found that documented depressive symptoms were associated with prolonged hospital length of stay. Interestingly, antidepressant medications moderated the relationship between depressive symptoms and hospital length of stay. These findings support the need to recognize and address depressive symptoms among patients with advanced cancer, with potential implications for optimizing health care utilization.
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Affiliation(s)
- Risa L Wong
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sara M D'Arpino
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Charn-Xin Fuh
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - P Connor Johnson
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel E Lage
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kelly E Irwin
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - William F Pirl
- Department of Psychiatry, Sylvester Comprehensive Cancer Center and University of Miami, Miami, Florida, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Barbara J Cashavelly
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki A Jackson
- Division of Palliative Care, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David P Ryan
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ephraim P Hochberg
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan D Nipp
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Psychometric evaluation and cultural adaptation of the Spanish version of the "Scale for End-of Life Caregiving Appraisal". Palliat Support Care 2018; 17:314-321. [PMID: 30073939 DOI: 10.1017/s1478951518000470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To translate, culturally adapt, and psychometrically evaluate the Spanish version of the "Scale for End-of Life Caregiving Appraisal" (SEOLCAS). METHOD Observational cross-sectional study. Convenience sample of 201 informal end-of-life caregivers recruited in a southern Spanish hospital. The reliability of the questionnaire was assessed through its internal consistency (Cronbach's α) and temporal stability (Pearson's correlation coefficient [r] between test-retest). The content validity index of the items and the scale was calculated. Criterion validity was explored through performing a linear regression analysis to evaluate the SEOLCAS' predictive validity. Exploratory factor analysis was used to examine its construct validity. RESULTS The SEOLCAS' reliability was very high (Cronbach's α = 0.92). Its content validity was excellent (all items' content validity index = 0.8-1; scale's validity index = 0.88). Evidence of the SEOLCAS' criterion validity showed that the participants' scores on the SEOLCAS explained approximately 79.3% of the between-subject variation of their results on the Zarit Burden Interview. Exploratory factor analysis provided evidence of the SEOLCAS' construct validity. This analysis revealed that two factors ("internal contingencies" and "external contingencies") explained 53.77% of the total variance found and reflected the stoic Hispanic attitude toward adversity.Significance of resultsThe Spanish version of the SEOLCAS has shown to be an easily applicable, valid, reliable, and culturally appropriate tool to measure the impact of end-of-life care provision on Hispanic informal caregivers. This tool offers healthcare professionals the opportunity to easily explore Hispanic informal end-of-life caregivers' experiences and discover the type of support they may need (instrumental or emotional) even when there are communicational and organizational constraints.
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Emergency admissions and subsequent inpatient care through an emergency oncology service at a tertiary cancer centre: service users’ experiences and views. Support Care Cancer 2018; 27:451-460. [DOI: 10.1007/s00520-018-4328-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/20/2018] [Indexed: 02/06/2023]
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Batten M, Nguyen B, Burke B, Harryanto H, Mitchell I, Davis A. End-of-life care of oncology inpatients: Are we getting it right? Asia Pac J Clin Oncol 2018; 14:e528-e534. [DOI: 10.1111/ajco.13001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 05/10/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Monique Batten
- Australian National University Medical School; The Canberra Hospital; Canberra Australian Capital Territory Australia
| | - Bella Nguyen
- Department of Medical Oncology; The Canberra Hospital; Canberra Australian Capital Territory Australia
| | - Brandon Burke
- Intensive Care Unit; The Canberra Hospital; Canberra Australian Capital Territory Australia
| | - Hilman Harryanto
- The Canberra Hospital; Canberra Australian Capital Territory Australia
| | - Imogen Mitchell
- Australian National University Medical School; The Canberra Hospital; Canberra Australian Capital Territory Australia
- Intensive Care Unit; The Canberra Hospital; Canberra Australian Capital Territory Australia
| | - Alison Davis
- Australian National University Medical School; The Canberra Hospital; Canberra Australian Capital Territory Australia
- Department of Medical Oncology; The Canberra Hospital; Canberra Australian Capital Territory Australia
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Lorenzati B, Motta F, Allione A, La Ciura P, Lauria G. Trying to prolong life no matter what, or to dignify it till the end: the dilemma of modern medicine-comment. Intern Emerg Med 2018; 13:625-626. [PMID: 29498011 DOI: 10.1007/s11739-018-1801-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/21/2017] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Attilio Allione
- S.C. Medicina d'Urgenza ed Accettazione A.O. S. Croce e Carle, Cuneo, Italy
| | | | - Giuseppe Lauria
- S.C. Medicina d'Urgenza ed Accettazione A.O. S. Croce e Carle, Cuneo, Italy
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Singh S, Rodriguez A, Lee D, Min SJ, Fischer S. Usefulness of the Surprise Question on an Inpatient Oncology Service. Am J Hosp Palliat Care 2018; 35:1421-1425. [PMID: 29783852 DOI: 10.1177/1049909118777990] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Prognostication of survival in patients with advanced cancer has been challenging and contributes to poor illness understanding. Prognostic disagreement occurs even among providers and is a less studied phenomenon. OBJECTIVE We introduced the surprise question (SQ), "Would I be surprised if this patient died in the next 1 year, 6 months, and 1 month?," at multidisciplinary rounds to increase palliative care referrals through the introduction of this prognostic prompt. DESIGN, SETTING, PATIENTS This quality improvement project took place from March 2016 to May 2016 on the medical oncology service at a tertiary academic medical center. The question was asked 3 times a week at multidisciplinary rounds which are attended by the hospital medicine provider, palliative care provider, and consulting oncologist. Primary oncologists and bedside nurses were also asked the SQ. MEASUREMENTS Referral rates to outpatient palliative care clinic, community-based palliative care clinic, inpatient palliative care consults, and hospice 3 months prior to, during, and 5 months postintervention. RESULTS Regular discussion of prognosis of patients with cancer in an inpatient medical setting did not increase referrals to inpatient or outpatient palliative care or hospice. Increased clinical experience impacted hospital medicine providers and bedside nurses' estimation of prognosis differently than oncology providers. Medical oncologists were significantly more optimistic than hospital medicine providers.
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Affiliation(s)
- Sarguni Singh
- 1 Division of Hospital Medicine, University of Colorado Denver, Aurora, CO, USA
| | - Adrian Rodriguez
- 2 College of Nursing, University of Colorado Denver, Aurora, CO, USA
| | - Darrell Lee
- 2 College of Nursing, University of Colorado Denver, Aurora, CO, USA
| | - Sung-Joon Min
- 3 Division of Health Care Policy and Research, University of Colorado Denver, Aurora, CO, USA
| | - Stacy Fischer
- 4 Division of General Internal Medicine, University of Colorado Denver, Aurora, CO, USA
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Khateeb R, Puelle MR, Firn J, Saul D, Chang R, Min L. Interprofessional Rounds Improve Timing of Appropriate Palliative Care Consultation on a Hospitalist Service. Am J Med Qual 2018; 33:569-575. [PMID: 29644871 PMCID: PMC9097960 DOI: 10.1177/1062860618768069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
Despite known benefits, palliative care (PC) consultation for hospitalized patients remains underutilized. The objective was to improve frequency and timeliness of appropriate inpatient PC consultation. On 2 of 11 hospitalist teams, a PC representative attended discharge rounds twice a week. Control teams' discharge rounds were unenhanced. Subjects were all patients admitted to a hospitalist service in a quaternary academic medical center. The primary outcome was change in provision of PC consultation over time; the secondary outcome was change in time-to-consult (days). Hospitalists were surveyed regarding the intervention. The unadjusted proportion of patients receiving PC consultation increased from 2.7% to 5.2% on the intervention teams. Compared to control teams over time and adjusting for multiple covariates, the intervention increased PC consultation (difference-in-difference [DID] = 1.0 percentage-point increase [95% CI = 0.3%-1.8%]) and decreased time to consult (DID = -5 days [95% CI = -11 to -1]) in patients admitted for noncancer diagnoses. Hospitalists thought the intervention facilitated effective patient care without increased burden.
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Affiliation(s)
| | | | | | | | | | - Lillian Min
- 1 University of Michigan, Ann Arbor, MI
- 4 VA Ann Arbor Healthcare System, Ann Arbor, MI
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Habibi A, Wu SP, Gorovets D, Sansosti A, Kryger M, Beaudreault C, Chung WY, Shelton G, Silverman J, Lowy J, Kondziolka D. Early Palliative Care for Patients With Brain Metastases Decreases Inpatient Admissions and Need for Imaging Studies. Am J Hosp Palliat Care 2018; 35:1069-1075. [DOI: 10.1177/1049909118765405] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Early encounters with palliative care (PC) can influence health-care utilization, clinical outcome, and cost. Aim: To study the effect of timing of PC encounters on brain metastasis patients at an academic medical center. Setting/Participants: All patients diagnosed with brain metastases from January 2013 to August 2015 at a single institution with inpatient and/or outpatient PC records available for review (N = 145). Design: Early PC was defined as having a PC encounter within 8 weeks of diagnosis with brain metastases; late PC was defined as having PC after 8 weeks of diagnosis. Propensity score matched cohorts of early (n = 46) and late (n = 46) PC patients were compared to control for differences in age, gender, and Karnofsky Performance Status (KPS) at diagnosis. Details of the palliative encounter, patient outcomes, and health-care utilization were collected. Results: Early PC versus late PC patients had no differences in baseline KPS, age, or gender. Early PC patients had significantly fewer number of inpatient visits per patient (1.5 vs 2.9; P = .004), emergency department visits (1.2 vs 2.1; P = .006), positron emission tomography/computed tomography studies (1.2 vs 2.7, P = .005), magnetic resonance imaging scans (5.8 vs 8.1; P = .03), and radiosurgery procedures (0.6 vs 1.3; P < .001). There were no differences in overall survival (median 8.2 vs 11.2 months; P = .2). Following inpatient admissions, early PC patients were more likely to be discharged home (59% vs 35%; P = .04). Conclusions: Timely PC consultations are advisable in this patient population and can reduce health-care utilization.
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Affiliation(s)
- Akram Habibi
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, USA
- Department of Neurosurgery, NYU Medical School, New York, USA
| | - S. Peter Wu
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, USA
| | - Daniel Gorovets
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, USA
| | - Alexandra Sansosti
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, USA
- Department of Neurosurgery, NYU Medical School, New York, USA
| | - Marc Kryger
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, USA
| | - Cameron Beaudreault
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, USA
| | - Wei-Yi Chung
- Department of Population Health, NYU Medical School, New York, USA
| | - Gary Shelton
- Department of Medicine, NYU Medical School, New York, USA
| | - Joshua Silverman
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, USA
- Department of Neurosurgery, NYU Medical School, New York, USA
| | - Joseph Lowy
- Department of Medicine, NYU Medical School, New York, USA
| | - Douglas Kondziolka
- Department of Radiation Oncology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, USA
- Department of Neurosurgery, NYU Medical School, New York, USA
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45
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Nixon N, Spackman E, Clement F, Verma S, Manns B. Cost-effectiveness of symptom monitoring with patient-reported outcomes during routine cancer treatment. J Cancer Policy 2018. [DOI: 10.1016/j.jcpo.2017.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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46
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Cotogni P, Saini A, De Luca A. In-Hospital Palliative Care: Should We Need to Reconsider What Role Hospitals Should Have in Patients with End-Stage Disease or Advanced Cancer? J Clin Med 2018; 7:jcm7020018. [PMID: 29385757 PMCID: PMC5852434 DOI: 10.3390/jcm7020018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 01/08/2018] [Accepted: 01/13/2018] [Indexed: 12/25/2022] Open
Abstract
Traditionally, palliative care (PC) systems focused on the needs of advanced cancer patients, but most patients needing PC have end-stage organ diseases. Similarly, PC models focus on the needs of patients in hospices or at home; however, in most cases PC is provided in acute hospitals. Indeed, the symptom burden that these patients experience in the last year of life frequently forces them to seek care in emergency departments. The majority of them are admitted to the hospital and many die. This issue poses important concerns. Despite the efforts of attending healthcare professionals, in-hospital patients do not receive optimal care near the end-of-life. Also, evidence is emerging that delay in identifying patients needing PC have a detrimental impact on their quality of life (QoL). Therefore, there is an urgent need to identify, early and properly, these patients among those hospitalized. Several trials reported the efficacy of PC in improving the QoL in these patients. Each hospital should ensure that a multidisciplinary PC team is available to support attending physicians to achieve the best QoL for both PC patients and their families. This review discusses the role and the impact of in-hospital PC in patients with end-stage disease or advanced cancer.
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Affiliation(s)
- Paolo Cotogni
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
| | - Andrea Saini
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
| | - Anna De Luca
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
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47
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Characteristics and care pathways of advanced cancer patients in a palliative-supportive care unit and an oncological ward. Support Care Cancer 2018; 26:1961-1966. [DOI: 10.1007/s00520-017-4037-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022]
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48
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Rosenfeld EB, Chan JK, Gardner AB, Curry N, Delic L, Kapp DS. Disparities Associated With Inpatient Palliative Care Utilization by Patients With Metastatic Gynecologic Cancers: A Study of 3337 Women. Am J Hosp Palliat Care 2017; 35:697-703. [DOI: 10.1177/1049909117736750] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Emily B. Rosenfeld
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
- Division of Gynecologic Oncology, New York Medical College, Valhalla, NY, USA
| | - John K. Chan
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
| | - Austin B. Gardner
- Division of Gynecologic Oncology, Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
- Division of Gynecologic Oncology, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Natasha Curry
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
| | - Lejla Delic
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
| | - Daniel S. Kapp
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
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49
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Lipitz-Snyderman A, Klotz A, Gennarelli RL, Groeger J. A Population-Based Assessment of Emergency Department Observation Status for Older Adults With Cancer. J Natl Compr Canc Netw 2017; 15:1234-1239. [PMID: 28982749 DOI: 10.6004/jnccn.2017.0160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/19/2017] [Indexed: 12/21/2022]
Abstract
Background: Hospitals' use of observation status for patients with cancer presenting to the emergency department (ED) is not well understood. This model of care delivery may be a viable alternative to inpatient admission for patients with cancer presenting with certain conditions. Our objective was to assess the use of observation status among Medicare beneficiaries with and without cancer. Methods: Population-based SEER-Medicare data were used to assess differences in the use of observation status between Medicare beneficiaries aged ≥66 years with and without cancer using a matched analysis (n=151,183 per cohort). We assessed the ratio of observation unit use to inpatient admission, between cancer and noncancer cohorts, and for patients diagnosed with breast, colon, lung, and prostate cancers. Poisson regression models were used to calculate observation rate estimates and 95% CIs while adjusting for selected patient characteristics. Results: When considering the volume of hospitalizations, observation status is used less frequently among beneficiaries with cancer than those without (43 vs 69 observation status visits per 1,000 inpatient admissions, respectively). The estimated observation rate per 1,000 inpatient admissions was higher for beneficiaries aged <75 years versus those aged ≥75 years, those with a Charlson comorbidity index of 0 vs 1 or ≥2, and those without a prior hospitalization versus those with ≥1 prior hospitalizations. Patients with breast and prostate cancers had higher adjusted and unadjusted observation rates per 1,000 inpatient admissions compared with those with colon and lung cancers. Conclusions: Observation status is used proportionately less for beneficiaries with cancer than those without. There may be opportunities to develop standards for ED staff to manage certain conditions for patients with cancer in observation status, and to reserve hospital resources for those who need it most.
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Daly B, Hantel A, Wroblewski K, Balachandran JS, Chow S, DeBoer R, Fleming GF, Hahn OM, Kline J, Liu H, Patel BK, Verma A, Witt LJ, Fukui M, Kumar A, Howell MD, Polite BN. No Exit: Identifying Avoidable Terminal Oncology Intensive Care Unit Hospitalizations. J Oncol Pract 2017; 12:e901-e911. [PMID: 27601514 DOI: 10.1200/jop.2016.012823] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Terminal oncology intensive care unit (ICU) hospitalizations are associated with high costs and inferior quality of care. This study identifies and characterizes potentially avoidable terminal admissions of oncology patients to ICUs. METHODS This was a retrospective case series of patients cared for in an academic medical center's ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. An oncologist, intensivist, and hospitalist reviewed each patient's electronic health record from 3 months preceding terminal hospitalization until death. The primary outcome was the proportion of terminal ICU hospitalizations identified as potentially avoidable by two or more reviewers. Univariate and multivariate analysis were performed to identify characteristics associated with avoidable terminal ICU hospitalizations. RESULTS Seventy-two patients met inclusion criteria. The majority had solid tumor malignancies (71%), poor performance status (51%), and multiple encounters with the health care system. Despite high-intensity health care utilization, only 25% had documented advance directives. During a 4-day median ICU length of stay, 81% were intubated and 39% had cardiopulmonary resuscitation. Forty-seven percent of these hospitalizations were identified as potentially avoidable. Avoidable hospitalizations were associated with factors including: worse performance status before admission (median 2 v 1; P = .01), worse Charlson comorbidity score (median 8.5 v 7.0, P = .04), reason for hospitalization (P = .006), and number of prior hospitalizations (median 2 v 1; P = .05). CONCLUSION Given the high frequency of avoidable terminal ICU hospitalizations, health care leaders should develop strategies to prospectively identify patients at high risk and formulate interventions to improve end-of-life care.
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Affiliation(s)
- Bobby Daly
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Andrew Hantel
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | | | | | - Selina Chow
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Rebecca DeBoer
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Gini F Fleming
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Olwen M Hahn
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Justin Kline
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Hongtao Liu
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Bhakti K Patel
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Anshu Verma
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Leah J Witt
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Mayumi Fukui
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Aditi Kumar
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Michael D Howell
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Blase N Polite
- University of Chicago Medicine; and University of Chicago, Chicago, IL
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