Quality measures for palliative care in patients with cancer: a systematic review

Algorithm-Based Palliative Care in Patients With Cancer: A Cluster Randomized Clinical Trial

Importance

Among patients with advanced solid malignant tumors, early specialty palliative care (PC) is guideline recommended, but strategies to increase PC access and effectiveness in community oncology are lacking.

Objective

To test whether algorithm-based defaults with opting out and accountable justification embedded in the electronic health record (EHR) increase completed PC visits.

Design, Setting, and Participants

This 2-arm cluster randomized clinical trial was conducted from November 1, 2022, to December 31, 2023. Eligible patients from 15 urban or rural clinics within a large community oncology network in Tennessee had advanced lung or noncolorectal gastrointestinal cancer and were identified by an automated EHR algorithm adapted from national guidelines. Data were analyzed between November 1, 2023, and March 4, 2024.

Intervention

At sites randomized to control, clinicians received weekly reports detailing PC referral rates compared with peer clinicians (peer comparison) and referred patients to PC at their discretion. At sites randomized to intervention, clinicians also received default PC orders using the EHR. Clinicians who opted out of PC consultation were asked to provide justification (accountable justification). If clinicians did not opt out, a study coordinator contacted patients to introduce and schedule PC visits using a standardized, predefined script.

Main Outcomes and Measures

The primary outcome was a completed PC consultation within 12 weeks of enrollment. Exploratory outcomes included quality of life, feeling heard and understood, and intensive end-of-life care. Outcomes were analyzed using clustered generalized linear and logistic regression models.

Results

The trial enrolled 562 patients (mean [SD] age, 68.5 [10.1] years; 288 male [51.2%]), of whom 433 (77.0%) had lung cancer. There were 130 of 296 patients (43.9%) randomized to the intervention group and 22 of 266 (8.3%) randomized to the control group who completed PC visits (adjusted odds ratio, 8.9 [95% CI, 5.5-14.6]; P < .001). Among 179 patients who died at the 24-week follow-up, 6 of 92 (6.5%) in the intervention group compared with 14 of 87 (16.1%) in the control group received systemic therapy within 14 days of death (adjusted odds ratio, 0.3 [95% CI, 0.1-0.7]; P = .05). There were no differences in quality of life, feeling heard and understood, or late hospice referral.

Conclusions and Relevance

In this randomized clinical trial of algorithm-based EHR defaults, the intervention increased PC consultations and decreased end-of-life systemic therapy. The intervention provides a scalable implementation strategy to increase specialty PC referrals in the community oncology setting.

Trial Registration

ClinicalTrials.gov Identifier: NCT05590962.

The Impact of Hospice Care Structures on Care Processes: A Retrospective Cohort Study

Background: Palliative care is subject to substantial variations in care, which may be shaped through adapting the organisational structures through which care is provided. Whilst the goal of these structures is to improve patient care, there is a lack of evidence regarding their effect on care processes and patient outcomes. Aims: This study aims to describe the relationship between care structures and the quantity and domains of care processes in hospice care. Design: Retrospective cohort study. Settings/Participants: Data were collected from Dutch hospice patient's clinical records and hospice surveys, detailing hospice structures, patient clinical characteristics and care processes. Results: 662 patients were included from 42 hospices, mean age 76.1 years. Hospices were categorised according to their care structures - structured clinical documentation and multidisciplinary meetings. Patients receiving care in hospices with structured multidisciplinary meetings had an increased quantity of documented care processes per patient on admission through identification (median 4 vs 3, P < .001), medication (2 vs 1, P = .004) and non-medication (1 vs 0, P < .001) interventions, monitoring (2 vs 1, P < .001) and evaluation (0 vs 0, P = .014), and prior to death. Similar increases were identified for patients who received care in hospices with structured documentation upon admission, but these changes were not consistent prior to death. Conclusions: This study details that the care structures of documentation and multidisciplinary meetings are associated with increased quantity and breadth of documentation of care processes in hospice care. Employing these existing structures may result in improvements in the documentation of patient care processes, and thus better communication around patient care.

End-Of-Life Care From the Perspectives of Patients With Cancer and Their Nurses: A Qualitative Study

This study aimed to determine the needs of end-of-life cancer patients' and their nurses' perspectives and experiences regarding end of life period. A qualitative descriptive phenomenological study design was adopted comprising face-to-face, semi-structured interviews with patients and their nurses. Content analysis was conducted using the 'Induction' approach. 15 patients and 15 nurses participated in study. This study emerged three categories, nine themes for patients, and seven themes for nurses. Categories were determined according to the Donabedian model. The interviews revealed that although the nurses wanted to provide the necessary care, they could not accomplish it because of excessive workload, inadequately informed patients, and less than desired knowledge and education levels of the nurses and healthcare team. Improved care coordination and partnership working are essential for supporting both patient and their nurses at the end of life.

Increasing interprofessional collaboration in community-based palliative care: a pilot study of the CAPACITI education program for primary care providers

Interprofessional collaboration in palliative care is essential to ensuring high-quality care for seriously ill patients. Education interventions to increase competency in palliative care should incorporate team-building skills to encourage an interprofessional approach. We developed and piloted a virtual educational program named CAPACITI for interprofessional teams to promote a community palliative approach to care. Primary care teams from across Ontario, Canada, participated in CAPACITI which consisted of 10 facilitated sessions that emphasized how to operationalize a palliative care approach as a team. Pre- and post-study questionnaires were completed by each team, including the AITCS-II, a validated instrument that measures interprofessional collaboration. We analyzed individual paired differences in summary scores and in each of three subdomains of the AITCS-II questionnaire: partnership, cooperation, and coordination. Seventeen teams completed the AITCS-II post survey, representing 133 participants. Teams varied demographically and ranged from 5 to 16 members. After CAPACITI, the overall mean AITCS-II summary score among teams increased to 96.0 (SD = 10.0) for a significant paired mean difference increase of 9.4 (p = .03). There were also significant increases in the partnership (p = .01) and in the cooperation subdomains (p = .04). CAPACITI demonstrated the potential for improving collaboration among primary care teams, which can lead to improved provider and patient outcomes in palliative care.

Defining the Denominator for Measuring Quality of End-of-Life Care in Children with Cancer: Results of a Nominal Group Technique

OBJECTIVE

To determine which groups of children with cancer for whom to apply the newly developed quality measures (QMs) for end-of-life (EOL) care.

STUDY DESIGN

In a series of nominal groups, panelists answered the question: "Which children, diagnoses, conditions, or prognoses should be included when examining the quality of EOL care for children with cancer?" In each group, individual panelists proposed answers to the question. After collating individual responses, each panelist ranked their 5 top answers and points were assigned (5 pts for the best answer, 4 pts the second best, etc.). A team of pediatric oncology and palliative care clinician-scientists developed and applied a coding structure for responses and associated themes and subthemes for responses.

RESULTS

We conducted 5 nominal groups with a total of 44 participants. Most participants identified as female (88%) and non-Hispanic White (86%). Seventy-nine percent were clinicians, mainly in pediatric palliative care, pediatric oncology, or hospice; 40% were researchers and 12% were bereaved parents. Responses fell into 5 themes: (1) poor prognosis cancer; (2) specific treatment scenarios; (3) certain populations; (4) certain symptoms; and (5) specific utilization scenarios. Poor prognosis cancer and specific treatment scenarios received the most points (320 pts [49%] and 147 pts [23%], respectively).

CONCLUSIONS

Participants developed a framework to identify which children should be included in EOL QMs for children with cancer. The deliberate identification of the denominator for pediatric QMs serves as a potent tool for enhancing quality, conducting research, and developing clinical programs.

Development of a Simple Patient-reported Outcome Measurement for Terminally Ill Cancer Patients Receiving Home-based Palliative Care

Objective

To develop a patient-reported outcome measurement for terminally ill cancer patients (PROMs-TCP) receiving home-based palliative care, which is valid, reliable and easy to use by patients or caregivers to indicate urgent needs for assistance from the care team.

Materials and Methods

Three-step approach consisting of literature review, focus groups and questionnaire testing. 169 terminally ill cancer patients who received palliative care at Cancer hospital, tertiary-care hospital and university school of medicine in Thailand. The PROMs-TCP comprised five key questions with a total score of 10 and one supplemental question. PROMs-TCP was tested for content validity, internal consistency and inter-rater reliability, criterion validity, discriminant validity and sensitivity to change. The palliative care outcome scale (POS) was used as an indicator.

Results

PROMs-TCP consists of five questions. The item-level content validity index (CVI) ranged from 0.8 to 1, and the scale-level CVI was 0.97. PROMs-TCP correlated well with POS scores, with correlations ranging from -0.7 to -0.8. Internal consistency was good (Cronbach's α = 0.85), while inter-rater agreements between patients and caregivers and between patients and nurses were moderate to good (Cohen's weighted k = 0.69-0.87). The tool could reasonably discriminate terrible days from good days for the patients. It was also responsive to change scores, with effect size scores of 0.36.

Conclusion

PROMs-TCP could be used for daily health status assessment of home-based patients with terminally ill cancer, supporting the provision of palliative care in primary care settings.

Association of patient socioeconomic status with outcomes after palliative treatment for disseminated cancer

BACKGROUND

Palliative treatment has been associated with improved quality of life and survival for a wide variety of metastatic cancers. However, it is unclear whether the benefits of palliative treatment are uniformly experienced across the US cancer population. We evaluated patterns and outcomes of palliative treatment based on socioeconomic, sociodemographic and treating facility characteristics.

METHODS

Patients diagnosed between 2008 and 2019 with Stage IV primary cancer of nine organ sites were analyzed in the National Cancer Database. The association between identified variables, and outcomes concerning the administration of palliative treatment were analyzed with multivariable logistic regression and Cox proportional hazard models.

RESULTS

Overall 238,995 (23.6%) of Stage IV patients received palliative treatment, which increased over time for all cancers (from 20.7% in 2008 to 25.6% in 2019). Palliative treatment utilization differed significantly by region (West less than Northeast, OR: 0.55 [0.54-0.56], p < 0.001) and insurance payer status (uninsured greater than private insurance, OR: 1.35 [1.32-1.39], p < 0.001). Black race and Hispanic ethnicity were also associated with lower rates of palliative treatment compared to White and non-Hispanics respectively (OR for Blacks: 0.91 [0.90-0.93], p < 0.001 and OR for Hispanics: 0.79 [0.77-0.81] p < 0.001).

CONCLUSIONS

There are important differences in the utilization of palliative treatment across different populations in the United States. A better understanding of variability in palliative treatment use and outcomes may identify opportunities to improve informed decision making and optimize quality of care at the end-of-life.

Evaluating a vertical nurse-led service in the integration of palliative care in a tertiary academic hospital

Background

Groote Schuur Hospital is a large Academic Hospital in South Africa that is in the process of integrating palliative care (PC) via a vertical nurse-led doctor-supported (VNLDS) service that was initially established to deliver clinical care. PC integration should occur across multiple dimensions and may result in variable degrees of integration between levels of the healthcare system. This research evaluates the VNLDS through a theory-driven evaluation to describe how the service affected integration.

Methods

A mixed-method sequential design consisting of a narrative literature review on the theory of integration and PC, retrospective quantitative data from a PC service delivery database, qualitative data from semi-structured interviews and document analyses. It was structured in three phases which assisted in confirming and expanding the data. Statistical analyses, deductive thematic coding and documentary analyses were conducted according to the conceptual framework of PC integration.

Results

The PC integration process was facilitated in the following ways: (i) the service provided good clinical PC; (ii) it was able to integrate on a professional level into specific diseases, such as cancer but not in all diseases; (iii) developing organizational structures within the service and (iv) the observed benefit of good clinical care increased the value stakeholders assigned to PC, thereby driving the adoption of PC. However, there are still clinicians who do not refer to PC services. This gap in referral may be grounded in assumptions and misconceptions about PC, especially at the organizational level.

Discussion

Observed PC service delivery is core to integrating PC across the healthcare system because it challenges normative barriers. However, the VNLDS could not achieve integration in leadership and governance, education and hospital-wide guidelines and policies. Whole system integration, foregrounding organizational commitment to PC excellence, is core to integrating PC.

Conclusion

The VNLDS service has effectively linked PC in specific disease profiles and normalized the PC approach where healthcare workers observed the service. These integrational gaps may be grounded in assumptions and misconceptions about PC, especially at the organizational level.

The Chinese Version of the Palliative Nursing Care Quality Scale: Translation, Cross-Cultural Adaptation, and Validity

BACKGROUND

Nurses play an important role in palliative care, and high-quality assessment tools can help standardize palliative-related nursing behaviors, but there are no such tools in China.

OBJECTIVE

This study aimed to revise, cross-culturally adapt, and validate the Palliative Nursing Care Quality Scale (PNCQS) to provide an effective tool that can help nurses in mainland China assess the quality of palliative care.

METHODS

This study involved a 2-steps process. First, the PNCQS was translated, back-translated, and cross-cultural adapted using Brislin's translation model. Second, a cross-sectional study was used to evaluate the reliability and validity of the revised scale. From January to February 2023, 367 nurses engaged in palliative care-related nursing from 3 tertiary A general hospitals were surveyed with the revised scale. The evaluation methods used in this study included item analysis, test-retest reliability, internal consistency, criterion-related validity, content validity, and construct validity.

RESULTS

The PNCQS-Chinese included 20 items. In this study, the item-total correlation coefficients ranged from 0.67 to 0.83 (P < .01), and the critical ratio value of the items was 12.10 to 23.34 (P < .01). The scale-level content validity index was 0.98, and the item-level content validity ranged from 0.86 to 1.00. The total Cronbach's α and test-retest reliability of the scale were 0.96 and 0.79, respectively. Factor analysis of 20 items extracted 1 factor, and the contribution rate of cumulative variance was 60.03%.

CONCLUSIONS

PNCQS-Chinese shows acceptable validity and reliability for assessing the quality of palliative care-related nursing in mainland China.

Cancer Pain Management: A Narrative Review of Current Concepts, Strategies, and Techniques

Pain is frequently reported during cancer disease, and it still remains poorly controlled in 40% of patients. Recent developments in oncology have helped to better control pain. Targeted treatments may cure cancer disease and significantly increase survival. Therefore, a novel population of patients (cancer survivors) has emerged, also enduring chronic pain (27.6% moderate to severe pain). The present review discusses the different options currently available to manage pain in (former) cancer patients in light of progress made in the last decade. Major progress in the field includes the recent development of a chronic cancer pain taxonomy now included in the International Classification of Diseases (ICD-11) and the update of the WHO analgesic ladder. Until recently, cancer pain management has mostly relied on pharmacotherapy, with opioids being considered as the mainstay. The opioids crisis has prompted the reassessment of opioids use in cancer patients and survivors. This review focuses on the current utilization of opioids, the neuropathic pain component often neglected, and the techniques and non-pharmacological strategies available which help to personalize patient treatment. Cancer pain management is now closer to the management of chronic non-cancer pain, i.e., "an integrative and supportive pain care" aiming to improve patient's quality of life.

Description of patient reported experience measures (PREMs) for hospitalised patients with palliative care needs and their families, and how these map to noted areas of importance for quality care: A systematic review

BACKGROUND

The global need for focused improvements in palliative care within the acute hospital setting is well noted. A large volume of evidence exists detailing what hospitalised patients with palliative care needs and their families note as important for high quality care. Patient Reported Experience Measures (PREMs) are one mechanism that hospitals could use to inform improvement work. To date there has not been a review of PREMs available for hospitalised patients with palliative care needs and/or their family, nor how they align with noted priorities for high quality care.

AIM

To identify and describe PREMs designed for hospitalised patients with palliative care needs and their families; and their alignment with patient and family identified domains for high quality care.

DESIGN

A systematic review.

DATA SOURCES

A systematic search of CINAHL, Medline and PsycInfo was conducted up to September 23, 2022 and supplemented by handsearching article reference lists and internet searches. PREMs written in English and designed for patients with palliative care needs in acute hospitals were eligible for inclusion. Included PREMs were described by: summarising key characteristics; and mapping their items to domains noted to be important to hospitalised patients with palliative care needs and their families informed by outcomes from a published study completed in 2021. Evidence for psychometric properties were reviewed.

RESULTS

Forty-four PREMs with 827 items were included. Items per PREM varied from 2 to 85 (median 25, IQR 13-42). Two-thirds (n = 534, 65%) of the items were designed for families and a third (n = 283, 34%) for hospitalised patients, and very few (n = 10, 1%) for both. Sixty-six percent of items measured person-centred care, 30% expert care and 4% environmental aspects of care. Available PREMs address between 1 and 11 of the 14 domains of importance for quality palliative care. PREMs had a median of 38% (IQR 25.4-56.3) of items >Grade 8 measured by the Flesch-Kincaid readability test, with Grade 8 or lower recommended to ensure health information is as accessible as possible across the population.

CONCLUSIONS

Whilst 44 PREMs are available for hospitalised patients with palliative care needs or their families, a varied number of items are available for some domains of care provision that are important, compared to others. Few are suitable for people with lower levels of literacy or limited cognitive capacity due to illness.

Index Symptoms and Prognosis Awareness of Patients With Pancreatic Cancer: A Multi-Site Palliative Care Collaborative

BACKGROUND

Pancreatic cancer has a poor 5-year survival and carries significant morbidity. Pain is a commonly studied symptom in pancreatic cancer; however, few studies examine the frequency of multiple patient-reported symptoms. Our aim is to ascertain patient-reported symptom burden at initial consultation with a palliative care provider and compare patient prognostic awareness to provider estimation of prognosis.

METHODS

Data were extracted from the standardized Quality Data Collection Tool (QDACT). Adults with pancreatic cancer seen by a palliative care provider were included. Descriptive statistics were used to describe demographic features, symptom prevalence and burden, as well as assess patient prognosis awareness defined by congruence or incongruence with provider estimated prognosis.

RESULTS

285 patients were included in our analysis. The average age was 68 years (SD: 12.4), 87.2% were white, 50% male. The mean number of moderate/severe symptoms was 2.6 (SD: 2) out of 9 symptoms. Tiredness (66.7%), appetite (64.5%) and pain (46.2%) had the highest rates of moderate/severe symptom burden. Patients with a prognosis of 1-6 months had the lowest proportion of congruence with provider estimation (56.5%).

CONCLUSION

Our study suggests targets to improve patient-centered care of pancreatic cancer. Patients commonly have multiple symptoms that are moderate/severe at time of palliative care referral. While pain has been well-reported, tiredness and decreased appetite are more prevalent at initial visit. This emphasizes the importance of assessing multiple symptoms and working closely with palliative care for early referral. Overall, one third of patient prognosis estimates differed from the provider assessment of prognosis. Our data support the importance of early referral to palliative care to manage symptoms and better prepare patients for end-of-life care.

Integrating Patient and Expert Perspectives to Conceptualize High-Quality Palliative Cancer Care for Symptoms in the US Veterans Health Administration: A Qualitative Study

Quality measurement is typically the domain of clinical experts and health system leaders; patient/caregiver perspectives are rarely solicited. We aimed to describe and integrate clinician and patient/caregiver conceptualizations of high-quality palliative symptom care for patients receiving care for advanced cancer within the US Veterans Health Administration in the context of existing quality measures. We conducted a secondary qualitative analysis of transcripts from prioritization discussions of process quality measures relevant to cancer palliative care. These discussions occurred during 2 modified RAND-UCLA appropriateness panels: a panel of 10 palliative care clinical expert stakeholders (7 physicians, 2 nurses, 1 social worker) and a panel of 9 patients/caregivers with cancer experience. Discussions were recorded, transcribed, and independently double-coded using an a priori logical framework. Content analysis was used to identify subthemes within codes and axial coding was used to identify crosscutting themes. Patients/caregivers and clinical experts contributed important perspectives to 3 crosscutting themes. First, proactive elicitation of symptoms is critical. Patients/caregivers especially emphasized importance of comprehensive and proactive screening and assessment, especially for pain and mental health. Second, screening and assessment alone is not enough; information elicited from patients must inform care. Measuring screening/assessment and management care processes separately has important limitations. Lastly, high-quality symptom management can be broadly defined if it is patient-centered; high-quality care takes an individualized approach and might include non-medical or non-pharmacological symptom management. Integrating the perspectives of clinical experts and patients/caregivers is critical for health systems to consider as they design and implement quality measures for palliative cancer care.

Top Ten Tips Palliative Care Clinicians Should Know About Leveraging the Electronic Health Record for Data Collection and Quality Improvement

As palliative care (PC) programs rapidly grow and expand across settings, the need to measure, improve, and standardize high-quality PC has also grown. The electronic health record (EHR) is a key component of these efforts as a central hub of care delivery and a repository of patient and system data. Deliberate efforts to leverage the EHR for PC quality improvement (QI) can help PC programs and health systems improve care for patients with serious illnesses. This article, written by clinicians with experience in QI, informatics, and clinical program development, provides practical tips and guidance on EHR strategies and tools for QI and quality measurement.

Charting a path to high-quality end-of-life care for children with cancer

There are currently no quality measures for end-of-life (EOL) care for children with cancer. In this commentary, we address why it is essential that we develop quality measures for EOL care for children with cancer, review the progress made to date, and chart the course for future work in this area.

Goals of care documentation by medical oncologists and oncology patient end-of-life care outcomes

BACKGROUND

Goals of care (GOC) documentation is important but underused. We aimed to improve oncologist GOC documentation and end-of-life (EOL) care.

METHODS

In April 2020, our cancer center launched a GOC note template, including optional fields for documenting discussion with the patient about: cancer natural history, goals, and/or EOL (resuscitation preferences, hospice receptivity). Associations between GOC notes and EOL care were evaluated.

RESULTS

Among 1721 patients dying between June 1, 2020 and June 30, 2021, median days from first GOC note (± with documentation of EOL discussion) to death was 92, whereas a GOC note including EOL discussion ("GOC EOL note"), specifically, was 31. Patients with a first GOC note >60 days before death spent fewer days inpatient (6.7 vs 10.6 days, p < .001). Among patients with GOC EOL notes, those with such documentation >30 days before death had fewer inpatient (5 vs 11, p < .001) and intensive care unit days (0.5 vs 1.5, p < .001), more hospice referrals (57% vs 44%, p = .003), and less chemotherapy ≤14 days before death (6% vs 11%, p = .010). Of 925 admissions of patients dying within ≤30 days, those with GOC EOL notes were shorter (7 vs 9 days, p = .013) but not associated with more hospice discharge (30% vs 25%, p = .163). Oncologist (vs nononcologist) GOC documentation and earlier documentation of EOL discussion were associated in subset analyses with less inpatient care and more hospice referrals.

CONCLUSIONS

Documentation of GOC, including EOL discussions, is associated with favorable performance on accepted indicators of quality EOL care.

Psychosocial Aspects of Living Long Term with Advanced Cancer and Ongoing Systemic Treatment: A Scoping Review

(1) Background: Studies examining the psychosocial impact of living long term on systemic treatment in advanced cancer patients are scarce. This scoping review aimed to answer the research question "What has been reported about psychosocial factors among patients living with advanced cancer receiving life-long systemic treatment?", by synthesizing psychosocial data, and evaluating the terminology used to address these patients; (2) Methods: This scoping review was conducted following the five stages of the framework of Arksey and O'Malley (2005); (3) Results: 141 articles published between 2000 and 2021 (69% after 2015) were included. A large variety of terms referring to the patient group was observed. Synthesizing qualitative studies identified ongoing uncertainty, anxiety and fear of disease progression or death, hope in treatment results and new treatment options, loss in several aspects of life, and worries about the impact of disease on loved ones and changes in social life to be prominent psychosocial themes. Of 82 quantitative studies included in the review, 76% examined quality of life, 46% fear of disease progression or death, 26% distress or depression, and 4% hope, while few studies reported on adaptation or cognitive aspects. No quantitative studies focused on uncertainty, loss, or social impact; (4) Conclusion and clinical implications: Prominent psychosocial themes reported in qualitative studies were not included in quantitative research using specific validated questionnaires. More robust studies using quantitative research designs should be conducted to further understand these psychological constructs. Furthermore, the diversity of terminology found in the literature calls for a uniform definition to better address this specific patient group in research and in practice.

End-of-life care quality measures: beyond place of death

BACKGROUND

How quality in healthcare is measured shapes care provision, including how and what care is delivered. In end-of-life care, appropriate measurement can facilitate effective care and research, and when used in policy, highlight deficits and developments in provision and endorse the discipline necessity. The most prevalent end-of-life quality metric, place of death, is not a quality measure: it gives no indication of the quality of care or patient experience in the place of death.

AIM

To evaluate alternative measures to place of death for assessing quality of care in end-of-life provision in all settings.

METHOD

We examine current end-of-life care quality measures for use as metrics for quality in end-of-life care. We categorise approaches to measurement as either: clinical instruments, mortality follow-back surveys or organisational data. We review each category using four criteria: care setting, patient population, measure feasibility, care quality.

RESULTS

While many of the measure types were highly developed for their specific use, each had limitations for measuring quality of care for a population. Measures were deficient because they lacked potential for reporting end-of-life care for patients not in receipt of specialist palliative care, were reliant on patient-proxy accounts, or were not feasible across all care settings.

CONCLUSION

None of the current end-of-life care metric categories can currently be feasibly used to compare the quality of end-of-life care provision for all patients in all care settings. We recommend the development of a bespoke measure or judicious selection and combination of existing measures for reviewing end-of-life care quality.

Pain and Spiritual Distress at End of Life: A Correlational Study

Objective: The purpose of this study is to examine the relationship between unmanaged pain and spiritual distress in adults newly admitted to hospice. Background: Current evidence supports the presence of a positive relationship between increased physical pain and spiritual distress for those with advanced cancer and/or receiving palliative care services. Nonetheless, spiritual distress remains a relatively understudied area; anecdotally, assessment and management of physical symptoms often take precedence over interventions for spiritual distress in patients at end of life (EOL) on hospice. Further research is needed to examine the relationships between physical pain, spiritual distress, and factors such as age, gender, and religious affiliation/spiritual practice specific to EOL patients receiving home hospice care. The Total Pain Model underpins this study. Methods: In this cross-sectional correlational study, pre-existing data were extracted from a hospice agency's electronic health record (EHR) to examine age, gender, marital status, race/ethnicity, religious affiliation and/or spiritual practice, hospice diagnosis, pain severity, and spiritual distress in adult patients (age 18 and over) admitted to home hospice services (N = 3484). Descriptive, bivariate, and multivariate analyzes were conducted. Results: The age range for this sample was 25 to 107 years old (M = 82, SD = 12.08). Over half of the sample were female and white. One third of the patients were married or had a designated life partner. Over 85% identified as either Catholic or Protestant. Sixteen percent reported moderate to severe pain and 9.6% experienced spiritual distress. Marital status (χ² (3, N = 2483) = 20.21, P < .001, Cramer's V = .09), hospice diagnosis (χ² (5, N = 3481) = 22.66, P < .001, Cramer's V = .08), pain severity (χ² (1, N = 3464) = 19.75, P < .001, Cramer's V = .08), and age (t (393.17) = 2.84, P = .005, d = .17) were significantly related to spiritual distress. The binary logistic model was statistically significant, χ² (11) = 45.25, P < .001, and cases indicating the highest odds of experiencing spiritual distress had pulmonary disease (OR = 1.8, P = .02), were single (OR = 1.6, P = .02), and had moderate to severe pain (OR = 1.4, P = .04). Conclusions: Moderate to severe pain, marital status, and diagnosis should be considered for inclusion in a refined spiritual distress hospice admission screening process. Future research should examine the unique contributions of diagnosis in predicting spiritual distress, particularly pulmonary disease.

Patient and Caregiver Prioritization of Palliative and End-of-Life Cancer Care Quality Measures

BACKGROUND

Development and prioritization of quality measures typically relies on experts in clinical medicine, but patients and their caregivers may have different perspectives on quality measurement priorities.

OBJECTIVE

To inform priorities for health system implementation of palliative cancer and end-of-life care quality measures by eliciting perspectives of patients and caregivers.

DESIGN

Using modified RAND-UCLA Appropriateness Panel methods and materials tailored for knowledgeable lay participants, we convened a panel to rate cancer palliative care process quality measure concepts before and after a 1-day, in-person meeting.

PARTICIPANTS

Nine patients and caregivers with experience living with or caring for patients with cancer.

MAIN MEASURES

Panelists rated each concept on importance for providing patient- and family-centered care on a nine-point scale and each panelist nominated five highest priority measure concepts ("top 5").

KEY RESULTS

Cancer patient and caregiver panelists rated all measure concepts presented as highly important to patient- and family- centered care (median rating ≥ 7) in pre-panel (mean rating range, 6.9-8.8) and post-panel ratings (mean rating range, 7.2-8.9). Forced choice nominations of the "top 5" helped distinguish similarly rated measure concepts. Measure concepts nominated into the "top 5" by three or more panelists included two measure concepts of communication (goals of care discussions and discussion of prognosis), one measure concept on providing comprehensive assessments of patients, and three on symptoms including pain management plans, improvement in pain, and depression management plans. Patients and caregivers nominated one additional measure concept (pain screening) back into consideration, bringing the total number of measure concepts under consideration to 21.

CONCLUSIONS

Input from cancer patients and caregivers helped identify quality measurement priorities for health system implementation. Forced choice nominations were useful to discriminate concepts with the highest perceived importance. Our approach serves as a model for incorporating patient and caregiver priorities in quality measure development and implementation.

Personal positioning of oncology patients in palliative care: a mixed-methods study

Background

Advanced oncological disease requires comprehensive health care, although attention is predominantly paid to the physical dimension of care. The consideration of personal positioning encompasses other dimensions of patients’ management of their illness, such as existential management and expanding forms of care. The objective of this study was to understand the personal positioning of cancer patients in palliative care.

Methods

This was a cross-sectional study using the mixed convergent parallel method. The sample consisted of 71 cancer patients in palliative care, of whom 14 participated in the qualitative and quantitative portions and 57 participated in only the quantitative portion. Phenomenological interviews were performed, and qualitative and quantitative methods were used to collect meaning of life (PIL-Test), quality of life (EORTC QLQ C-30), anxiety and depression (HADS) and sociodemographic data. The interview results were analysed according to the principles of classical phenomenology, and the quantitative data were analysed using the generalized structural equations model.

Results

The results showed that the patients turned to living, focusing on their possibilities and distancing themselves from the impact of the illness and the factuality of death, which the patients themselves associated with not succumbing to depression, a condition whose signs were exhibited by 21% of the sample. Sustaining this positioning required a tenacious fight, which feeds on sensitivity to life. Linked to this position was the belief in the continuation of life through religious faith, together with the patients’ realization of the meaning of their lives. In this same direction, there was a direct association between awareness of the meaning of life and increased scores on the functional scales (p <  0.01) and decreased scores for symptoms (p <  0.01), anxiety (p = 0.02) and depression (p < 0.01). The last element that emerged and structured this experience was the intense will to live and a sense of the value of life.

Conclusions

Through the use of mixed methods, the present study recognized the existential positioning of cancer patients in palliative care. This understanding can aid in the realization of more comprehensive and meaningful treatment plans and can contribute to the goal of achieving humanization in this area of treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00916-5.

The Pediatric Palliative Improvement Network: A national Healthcare Learning Collaborative

CONTEXT AND OBJECTIVES

Although multiple national organizations have created consensus guidelines and metrics for pediatric palliative care (PPC), standardized implementation and measurement has been challenging. In 2016, 6 PPC physician-experts in program development and quality improvement (QI) formed a healthcare learning collaborative network entitled the Pediatric Palliative Improvement Network (PPIN).

METHODS

The primary drivers identified were 1) Feasibility of a national learning network demonstrated through the completion of one small QI project, 2) Standard education in QI methodology and 3) Salient pediatric palliative care operational, clinical and satisfaction metrics clearly defined.

RESULTS

PPIN now includes146 members representing 51 organizations. In 2019 the group completed a national collaborative QI project focused on pain assessment at the time of initial consult, demonstrating a national increase in pain assessment from 75.8% to >90% over 12 months. PPIN has hosted two national QI workshops training more than 50 PPC clinicians in QI, with a 2-hour webinar provided in 2020 due to COVID. Monthly calls since 2017 provide QI methods "refreshers", share local works in progress, and provide infrastructure for future collaborative projects.

CONCLUSIONS

PPIN has become a sustainable organization which improves the quality of PPC through focus on national QI methods training, successful collaborative projects, and the creation of a learning and peer support community with regular calls. With the advent of the Palliative Care Quality Collaborative in 2020, PPIN provides critical educational and organizational infrastructure to inform ongoing quality efforts in PPC, now and in the future.

Quality Indicators in Surgical Palliative Care: A Systematic Review

CONTEXT

Defining high quality palliative care in seriously ill surgical patients is essential to provide patient-centered surgical care. Quality indicators specifically for seriously ill surgical patients are necessary in order to integrate palliative care into existing surgical quality improvement programs.

OBJECTIVES

To identify existing quality indicators that measure palliative care delivery in seriously ill surgical patients, characterize their development, and assess their methodological quality.

METHODS

A PRISMA-guided systematic review included studies that reported on the development process and characteristics of palliative care quality indicators and guidelines in adult surgical patients. Relevant measures were categorized into the previously defined National Consensus Project domains of palliative care and the Donabedian quality framework, and assessed for methodological quality.

RESULTS

There were 263 unique measures identified from 26 studies, of which 70% were process measures. Indicators addressing Care of the Patient Near the End of Life (31.5%) and Physical Aspects of Care (20.8%) were the most common. Indicators addressing Spiritual (2.6%) and Cultural Aspects of Care (1.2%) were the least common. Methodological quality varied widely across studies. Although most studies defined a purpose for the indicators and used scientific evidence, many studies lacked input from target populations and few had discussed the practical application of indicators.

CONCLUSION

This review was a key step that informed efforts to develop quality indicators for seriously ill surgical patients. Few indicators addressed non-physical aspects of suffering and no indicators were identified addressing palliative surgery. Future attention is needed toward the development and practical application of palliative care quality indicators in surgical patients.

Structure and process of palliative care provision: a nationwide study of public hospitals in Thailand

Background

The demand for palliative care in hospitals in Thailand has rapidly increased in recent years. Subsequently, the way in which palliative care systems should be arranged to facilitate the care process and patient preparation for their end stage of life is still an ongoing debate among policy makers and researchers. Although palliative care is provided in most facilities, there is no clear protocol for palliative care due to a lack of empirical evidence. Thus, this study attempts to analyse the situation and quality of palliative care provision in Thai public hospitals.

Methods

A cross-sectional study was conducted in 2018. A questionnaire with measures concerning hospital characteristics, the structure of palliative care provision, and processes related to achieving a good death was developed. The questionnaire was sent to all 862 public hospitals across 76 provinces, and the response rate was 62.88%. A structural equation model was specified to operationalize Donabedian’s framework. To our knowledge, this is the first nationwide study to investigate facility-level palliative care provision in Thailand.

Results

The study results confirmed the relationships between the structure and process of palliative care provision in hospitals. The sufficiency and competency of doctors and nurses and the variety of relaxation equipment were either directly or indirectly associated with the process components relevant to the response to the patient’s needs, effective communication, and respect for the patient’s dignity. In addition, the performance of palliative care research in hospitals was associated with the response to the patient’s needs and effective communication, while the allocation of physical areas was associated with effective communication.

Conclusion

This model can be used to evaluate the overall situation of palliative care provision at the national level. It could also contribute to the development of standard measurements for evidence-based palliative care quality improvement in hospitals.

Expert Stakeholder Prioritization of Process Quality Measures to Achieve Patient- and Family-Centered Palliative and End-of-Life Cancer Care

Importance: Quality measures of palliative and end-of-life care relevant to patients with advanced cancer have been developed, but few are in routine use. It is unclear which of these measures are most important for providing patient- and family-centered care and have high potential for improving quality of care. Objective: To prioritize process quality measures for assessing delivery of patient- and family-centered palliative and end-of-life cancer care in US Veterans Affairs (VA) health care facilities. Design, Setting, Participants: A panel of 10 palliative and cancer care expert stakeholders (7 physicians, 2 nurses, 1 social worker) rated process quality measure concepts before and after a 1-day meeting. Measures: Panelists rated 64 measure concepts on a nine-point scale on: (1) importance to providing patient- and family-centered care, and (2) potential for quality improvement (QI). Panelists also nominated five highest priority measure concepts ("top 5") on each attribute. Results: Panelists rated most measure concepts (54 premeeting, 56 post-meeting) as highly important to patient- and family-centered care (median rating ≥7). Considerably fewer (17 premeeting, 22 post-meeting) were rated as having high potential for QI. Measure concepts having postpanel median ratings ≥7 and nominated by one or more panelists as "top 5" on either attribute comprised a shortlist of 20 measure concepts. Conclusions: A panel of expert stakeholders helped prioritize 64 measure concepts into a shortlist of 20. Half of the shortlisted measures were related to communication about patient preferences and decision making, and half were related to symptom assessment and treatment.

Changes in the place of death for older adults with cancer: Reason to celebrate or a risk for unintended disparities?

BACKGROUND

Place of death is important to patients and caregivers, and often a surrogate measure of health care disparities. While recent trends in place of death suggest an increased frequency of dying at home, data is largely unknown for older adults with cancer.

METHODS

Deidentified death certificate data were obtained via the National Center for Health Statistics. All lung, colon, prostate, breast, and pancreas cancer deaths for older adults (defined as >65 years of age) from 2003 to 2017 were included. Multinomial logistic regression was used to test for differences in place of death associated with sociodemographic variables.

RESULTS

From 2003 through 2017, a total of 3,182,707 older adults died from lung, colon, breast, prostate and pancreas cancer. During this time, hospital and nursing home deaths decreased, and the rate of home and hospice facility deaths increased (all p < 0.001). In multivariable regression, all assessed variables were found to be associated with place of death. Overall, older age was associated with increased risk of nursing facility death versus home death. Black patients were more likely to experience hospital death (OR 1.7) and Hispanic ethnicity had lower odds of death in a nursing facility (OR 0.55). Since 2003, deaths in hospice facilities rapidly increased by 15%.

CONCLUSION

Hospital and nursing facility cancer deaths among older adults with cancer decreased since 2003, while deaths at home and hospice facilities increased. Differences in place of death were noted for non-white patients and older adults of advanced age.

Quality of Palliative Care: Perspective of Healthcare Providers at a Tertiary Hospital in Riyadh, Saudi Arabia

This study aimed to measure the quality of palliative care from the perspective of healthcare professionals at a tertiary hospital in Riyadh, Saudi Arabia. A cross-sectional survey was distributed to 80 healthcare professionals working at the palliative care department. The questionnaire assessed the dimensions that measure the quality of palliative care (Structure and Aspects of Care, Cultural Aspects of Care, Care of the Imminently Dying Patient, Ethical Issues), overall quality of care, ethical Processes of Care, Physical Aspects of Care, Psychological/Psychiatric Aspects dilemmas occurring in the practice setting, and barriers to the provision of optimal end-of-life care. The total mean for the quality for care was 4.26 (SD = 0.45), indicating that all participants' perceptions regarding all dimensions tended to skew toward agree and strongly agree. However, the score on the psychological/psychiatric aspects of care was the lowest compared to other dimensions, with a mean of 3.7, which means it needs more consideration. Moreover, participants' mean rate of agreement on the quality of palliative care services was 4.62 out of 5. The majority of the participants agreed that they and their colleagues provided high-quality end-of-life care. Regarding barriers to the provision of optimal end-of-life care, with a mean score of 3.22 out of 5, participants agreed that such barriers existed in the palliative department. The present findings indicate that healthcare providers considered the overall quality of palliative care to be high, but the psychological/psychiatric aspects of care needed further consideration. Further, the occurrence of ethical dilemmas and barriers to the provision of optimal end of life needs to be managed appropriately.

Measure Scan and Synthesis of Palliative and End-of-Life Process Quality Measures for Advanced Cancer

PURPOSE

Monitoring and improving the quality of palliative and end-of-life cancer care remain pressing needs in the United States. Among existing measures that assess the quality of palliative and end-of-life care, many operationalize similar concepts. We identified existing palliative care process measures and synthesized these measures to aid stakeholder prioritization that will facilitate health system implementation in patients with advanced cancer.

METHODS

We reviewed MEDLINE/PubMed-indexed articles for process quality measures related to palliative and end-of-life care for patients with advanced cancer, supplemented by expert input. Measures were inductively grouped into "measure concepts" and higher-level groups.

RESULTS

Literature review identified 226 unique measures from 23 measure sources, which we grouped into 64 measure concepts within 12 groups. Groups were advance care planning (11 measure concepts), pain (7), dyspnea (9), palliative care-specific issues (6), other specific symptoms (17), comprehensive assessment (2), symptom assessment (1), hospice/palliative care referral (1), spiritual care (2), mental health (5), information provision (2), and culturally appropriate care (1).

CONCLUSION

Measure concepts covered the spectrum of care from acute symptom management to advance care planning and psychosocial needs, with variability in the number of measure concepts per group. This taxonomy of process quality measure concepts can be used by health systems seeking stakeholder input to prioritize targets for improving palliative and end-of-life care quality in patients with advanced cancer.

Introducing the trajectory Touchpoint technique: a systematic methodology for capturing the service experiences of palliative care patients and their families

Background

Evaluation of palliative care services is crucial in order to ensure high quality care and to plan future services in light of growing demand. There is also an acknowledgement of the need to better understand patient experiences as part of the paradigm shift from paternalistic professional and passive patient to a more collaborative partnership. However, while clinical decision-making is well-developed, the science of the delivery of care is relatively novel for most clinicians. We therefore introduce the Trajectory Touchpoint Technique (TTT), a systematic methodology designed using service delivery models and theories, for capturing the voices of palliative care service users.

Methods

We used design science research as our overarching methodology to build our Trajectory Touchpoint Technique. We also incorporated a range of kernel theories and service design models from the wider social sciences. We developed and tested our Trajectory Touchpoint Technique with palliative care patients and their families (n = 239) in collaboration with different hospices and hospital-based palliative care providers (n = 8).

Results

The Trajectory Touchpoint Technique is user-friendly, enables systematic data collection and analysis, and incorporates all tangible and intangible dimensions of palliative care important to the service user. These dimensions often go beyond clinical care to encompass wider aspects that are important to the people who use the service. Our collaborating organisations have already begun to make changes to their service delivery based on our results.

Conclusions

The Trajectory Touchpoint Technique overcomes several limitations of other palliative care evaluation methods, while being more comprehensive. The new technique incorporates physical, psychosocial, and spiritual aspects of palliative care, and is user-friendly for inpatients, outpatients, families, and the bereaved. The new technique has been tested with people who have a range of illnesses, in a variety of locations, among people with learning disabilities and low levels of literacy, and with children as well as adults. The Trajectory Touchpoint Technique has already uncovered many previously unrecognised opportunities for service improvement, demonstrating its ability to shape palliative care services to better meet the needs of patients and their families.

Resource Utilization in Hospitalized Patients With Cancer From Hospice Decision to Discharge and Provider-Type Differences

Aggressive resource utilization for patients with cancer at the end of life has been associated with poor outcomes for patients and their families. To our knowledge, no previous studies have characterized resource utilization as a proxy for quality end-of-life care in hospitalized patients awaiting discharge to hospice by physician and advanced practice providers (APPs). We conducted a retrospective cohort study to examine resource utilization and the quality metrics for end-of-life care in patients at Memorial Sloan Kettering Cancer Center from the date of hospice decision to discharge. Patients under the care of APP teams were less likely to receive laboratory testing (50% vs 59%, P = .046) and received fewer tests than those with house staff teams, though performance on end-of-life quality metrics was similar. Our findings suggest APPs may improve quality of end-of-life care by avoiding unnecessary or aggressive measures compared to house staff.

Oncology Fellow-Led Quality Improvement Project to Improve Rates of Palliative Care Utilization in Patients With Advanced Cancer

PURPOSE

ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. First-year oncology fellows at our institution identified low rates of PC utilization in their longitudinal clinic as a metric needing improvement.

METHODS

A fellow-led multidisciplinary team aimed to increase PC utilization for patients with advanced cancer followed in he first-year fellows' clinic from a baseline of 11.5% (5 of 43 patients, July to December of 2018) to 30% over a 6-month period. Utilization was defined as evaluation in the outpatient PC clinic hosted in the cancer center. The team identified the following barriers to referral: orders difficult to find in the electronic medical record (EMR), multiple consulting mechanisms (EMR, by phone, or in person), EMR request not activating formal consult, no centralized scheduler to contact or confirm appointment, and poor awareness of team structure. Plan-Do-Study-Act (PDSA) cycles were implemented based on identified opportunities. Data were obtained from the EMR.

RESULTS

The first PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and disseminating process changes. PDSA cycles were implemented from January to June of 2019. Rates of PC use increased from 11.5% before the intervention to 48.4% (48 of 99 patients) after the intervention.

CONCLUSION

A multidisciplinary approach and classic quality improvement methodology improved PC use in patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stakeholders, and institutional and leadership support. Straightforward EMR interventions and ancillary staff use are effective in addressing underreferrals.

The Impact of Measuring Patient-Reported Outcome Measures on Quality of and Access to Palliative Care

BACKGROUND

Measuring performance for palliative care is complex as care is delivered in many sites, over time and jointly to the patient and family. Measures of structural processes do not necessarily capture aspects that are important to patients and families nor reflect holistic multidisciplinary outcomes of care. This article focuses on the question as to whether measurement of patient-reported outcome measures improves the outcomes of quality and access to palliative care.

OBJECTIVES

To review the international evidence that measurement of indicators of desired outcomes improves the quality of and access to palliative care, in order to apply them to the Canadian context.

DESIGN

Rapid review.

SETTING

Canadian context.

FINDINGS

This review identified six systematic reviews and forty-seven studies that describe largely national efforts to arrive at a consensus as to what needs to be measured to assess quality of palliative care. Patient-reported outcome measures (PROMs) are becoming more prevalent, with emerging evidence to suggest that their measurement improves outcomes that are important to patients. Several Canadian initiatives are in place, including the Canadian Partnership Against Cancer's efforts, in conjunction with other partners, to develop common quality measures. Results from Australia's Palliative Care Outcomes Collaborative demonstrate that patient-centered improvements in palliative care can be measured by using patient-reported outcomes derived at the point of care and delivered nationally.

CONCLUSIONS

Measurement of quality palliative and end-of-life care is very complex. It requires that both administrative data and PROMs be assessed to reflect outcomes that are important to patients and families. Australia's national initiative is a promising exemplar for continued work in this area.

The role of geriatric palliative care in hospitalized older adults

Take-Away Points:1. Geriatric palliative care requires integrating the disciplines of hospital medicine and palliative care in pursuit of delivering comprehensive, whole-person care to aging patients with serious illnesses.2. Older adults have unique palliative care needs compared to the general population, different prevalence and intensity of symptoms, more frequent neuropsychiatric challenges, increased social needs, distinct spiritual, religious, and cultural considerations, and complex medicolegal and ethical issues.3. Hospital-based palliative care interdisciplinary teams can take many forms and provide high-quality, goal-concordant care to older adults and their families.

Standards, Guidelines, and Quality Measures for Successful Specialty Palliative Care Integration Into Oncology: Current Approaches and Future Directions

Although robust evidence demonstrates that specialty palliative care integrated into oncology care improves patient and health system outcomes, few clinicians are familiar with the standards, guidelines, and quality measures related to integration. These types of guidance outline principles of best practice and provide a framework for assessing the fidelity of their implementation. Significant advances in the understanding of effective methods and procedures to guide integration of specialty palliative care into oncology have led to a proliferation of guidance documents around the world, with several areas of commonality but also some key differences. Commonalities originate from a shared vision for integration; differences arise from diverse roles of palliative care specialists within cancer care globally. In this review we discuss three of the most cited standards/guidelines, as well as quality measures related to integrated palliative and oncology care. We also recommend changes to the quality measurement framework for palliative care and a new way to match palliative care services to patients with advanced cancer on the basis of care complexity and patient needs, irrespective of prognosis.

International palliative care research priorities: A systematic review

BACKGROUND

There has been increasing evidence and debate on palliative care research priorities and the international research agenda. To date, however, there is a lack of synthesis of this evidence, examining commonalities, differences, and gaps. To identify and synthesize literature on international palliative care research priorities originating from Western countries mapped to a quality assessment framework.

METHODS

A systematic review of several academic and grey databases were searched from January 2008-June 2019 for studies eliciting research priorities in palliative care in English. Two researchers independently reviewed, critically appraised, and conducted data extraction and synthesis.

RESULTS

The search yielded 10,235 articles (academic databases, n = 4108; grey literature, n = 6127), of which ten were included for appraisal and review. Priority areas were identified: service models; continuity of care; training and education; inequality; communication; living well and independently; and recognising family/carer needs and the importance of families. Methodological approaches and process of reporting varied. There was little representation of patient and caregiver driven agendas. The priorities were mapped to the Donabedian framework for assessing quality reflecting structure, process and outcomes and key priority areas.

CONCLUSIONS

Limited evidence exists pertaining to research priorities across palliative care. Whilst a broad range of topics were elicited, approaches and samples varied questioning the credibility of findings. The voice of the care provider dominated, calling for more inclusive means to capture the patient and family voice. The findings of this study may serve as a template to understand the commonalities of research, identify gaps, and extend the palliative care research agenda.

Population-Based Quality Indicators for End-of-Life Cancer Care: A Systematic Review

Importance

Improving the quality of cancer care is an international priority. Population-based quality indicators (QIs) are key to this process yet remain almost exclusively used for evaluating care during the early, often curative, stages of disease.

Objectives

To identify all existing QIs for the care of patients with cancer who have advanced disease and/or are at the end of life and to evaluate each indicator's measurement properties and appropriateness for use.

Evidence Review

For this systematic review, 5 electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, and the Cochrane Library) were searched from inception through February 4, 2019, for studies describing the development, review, and/or testing of QIs for the care of patients with cancer who have advanced disease and/or are at the end of life. For each QI identified, descriptive information was extracted and 6 measurement properties (acceptability, evidence base, definition, feasibility, reliability, and validity) were assessed using previously established criteria, with 4 possible ratings: positive, intermediate, negative, and unknown. Ratings were collated and each QI classified as appropriate for use, inappropriate for use, or of limited testing. Among the QIs determined as appropriate for use, a recommended shortlist was generated by excluding those that were specific to patient subgroups and/or care settings; related QIs were identified, and the indicator with the highest rating was retained.

Findings

The search yielded 7231 references, 35 of which (from 28 individual studies) met the eligibility criteria. Of 288 QIs extracted (260 unique), 103 (35.8%) evaluated physical aspects of care and 109 (37.8%) evaluated processes of care. Quality indicators relevant to psychosocial (18 [6.3%]) or spiritual and cultural (3 [1.0%]) care domains were limited. Eighty QIs (27.8%) were determined to be appropriate for use, 116 (40.3%) inappropriate for use, and 92 (31.9%) of limited testing. The measurement properties with the fewest positive assessments were acceptability (38 [13.2%]) and validity (63 [21.9%]). Benchmarking data were reported for only 16 QIs (5.6%). The final 15 recommended QIs came from 6 studies.

Conclusions and Relevance

The findings suggest that only a small proportion of QIs developed for the care of patients with cancer who have advanced disease and/or are at the end of life have received adequate testing and/or are appropriate for use. Further testing may be needed, as is research to establish benchmarking data and to expand QIs relevant to psychosocial, cultural, and spiritual care domains.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

EXPOSURES

Patients with CVD who presented for an initial PC visit.

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

National Trends in End-of-Life Care for Veterans With Advanced Cancer in the Veterans Health Administration: 2009 to 2016

PURPOSE

It is imperative to provide quality end-of-life (EOL) care for patients with cancer. Although rates of hospice use within the Veterans Health Administration have improved, antineoplastic administration and intensive care unit (ICU) admission at the EOL, indicators of aggressive care, have not clearly declined over recent years.

METHODS

We identified 32,665 veterans diagnosed with stage IV lung, colorectal, or pancreatic cancer who died between 2009 and 2016 using a novel EOL Dashboard Tool created from Veterans Administration Cancer Registry data. This EOL tool reports the incidence of antineoplastic drug use in the last 14 days of life, ICU admission in the last 30 days of life, and hospice admission or consult. Change from 2009 to 2016 was assessed using a repeated measures one-way analysis of variance with post hoc test for linear trend of time for individual cancers and two-way analysis of variance for all cancers combined.

RESULTS

Antineoplastic use in the last 14 days of life declined from 6.8% in 2009 to 4.4% in 2016 (P = .03). ICU admission in the last 30 days did not change significantly, from 13.3% in 2009 to 14.7% in 2016. The exception was patients with stage IV lung cancer, in whom ICU admissions increased from 12.9% to 16.2% (P = .01). Patients using hospice services increased from 32.4% to 52.6% (P < .01).

CONCLUSION

Although antineoplastic administration at the EOL is declining for veterans with stage IV cancer, ICU admissions are unchanged and becoming more common in stage IV lung cancer despite increasing hospice use.

Quality Measures in Foot and Ankle Care

BACKGROUND

Quality measures may be operationalized in payment models or quality reporting programs to assess foot and ankle surgeons, but if existing measures allow accurate representation of a foot and ankle surgeon's practice is unclear.

METHODS

National quality measures databases, clinical guidelines, and MEDLINE/PubMed were systematically reviewed for quality measures relevant to foot and ankle care. Measures meeting internal criteria were categorized by clinical diagnosis, National Quality Strategy priority, and Donabedian domain.

RESULTS

Of 12 quality measures and 16 candidate measures, National Quality Strategy priorities most commonly addressed "Effective Clinical Care" (n = 19) and "Communication and Coordination of Care" (n = 6). Donabedian classifications addressed were process (n = 25) and outcome (n = 3). Diabetic foot care was most commonly addressed (n = 18).

CONCLUSIONS

Available foot and ankle quality measures are limited in number and scope, which may hinder appropriate assessment of care, analysis of trends, and quality improvement. Additional measures are needed to support the transition to a value-based system.

LEVEL OF EVIDENCE

Level I.

Social consequences of advanced cancer in patients and their informal caregivers: a qualitative study

PURPOSE

Cancer threatens the social well-being of patients and their informal caregivers. Social life is even more profoundly affected in advanced diseases, but research on social consequences of advanced cancer is scarce. This study aims to explore social consequences of advanced cancer as experienced by patients and their informal caregivers.

METHODS

Seven focus groups and seven in-depth semi-structured interviews with patients (n = 18) suffering from advanced cancer and their informal caregivers (n = 15) were conducted. Audiotapes were transcribed verbatim and open coded using a thematic analysis approach.

RESULTS

Social consequences were categorized in three themes: "social engagement," "social identity," and "social network." Regarding social engagement, patients and informal caregivers said that they strive for normality by continuing their life as prior to the diagnosis, but experienced barriers in doing so. Regarding social identity, patients and informal caregivers reported feelings of social isolation. The social network became more transparent, and the value of social relations had increased since the diagnosis. Many experienced positive and negative shifts in the quantity and quality of their social relations.

CONCLUSIONS

Social consequences of advanced cancer are substantial. There appears to be a great risk of social isolation in which responses from social relations play an important role. Empowering patients and informal caregivers to discuss their experienced social consequences is beneficial. Creating awareness among healthcare professionals is essential as they provide social support and anticipate on social problems. Finally, educating social relations regarding the impact of advanced cancer and effective support methods may empower social support systems and reduce feelings of isolation.

Follow the trail: Using insights from the growth of palliative care to propose a roadmap for cancer rehabilitation

Despite research explicating the benefits of cancer rehabilitation interventions to optimize physical, social, emotional, and vocational functioning, many reports document low rates of referral to and uptake of rehabilitation in oncology. Cancer rehabilitation clinicians, researchers, and policy makers could learn from the multidisciplinary specialty of palliative care, which has benefited from a growth strategy and has garnered national recognition as an important and necessary aspect of oncology care. The purpose of this article is to explore the actions that have increased the uptake and integration of palliative care to yield insights and multimodal strategies for the development and growth of cancer rehabilitation. After examining the history of palliative care and its growth, the authors highlight 5 key strategies that may benefit the field of cancer rehabilitation: 1) stimulating the science in specific gap areas; 2) creating clinical practice guidelines; 3) building clinical capacity; 4) ascertaining and responding to public opinion; and 5) advocating for public policy change. Coordinated and simultaneous advances on these 5 strategies may catalyze the growth, utilization, and effectiveness of patient screening, timely referrals, and delivery of appropriate cancer rehabilitation care that reduces disability and improves quality of life for cancer survivors who need these services.

Pain Management Issues as Part of the Comprehensive Care of Patients with Sickle Cell Disease

BACKGROUND

Vaso-occlusive pain crisis is one of the primary complications of sickle cell disease (SCD) and is responsible for the majority of hospital visits in patients with SCD. Stints of severe pain can last for hours to days and are difficult to treat and manage, often resulting in drastically reduced quality of life.

PURPOSE

Our purpose is to provide an overview of pain management issues in SCD populations.

METHODS

We explored literature using PubMed and Embase for the etiology and management of pain in SCD. Databases were searched employing the following terms: sickle cell, pain pathways, pain perception, pharmacological therapies, psychological therapies, physical therapies and genetics.

RESULTS

Pain in SCD can vary from acute to chronic (persistent) or mixed and understanding of the underlying mechanisms is important for proper pain management. Currently, there are many means of managing pain in children with SCD, which involve pharmacological and non-pharmacological approaches. A combination of psychotherapy and pain medications can be used for treatment of pain and other psychosocial co-morbidities in complex persistent pain.

CONCLUSIONS

Providing more appropriate medication and optimal dosage based on individual's genomic variations is the future of medicine, and this will allow the physicians to hone in on optimal pain management in patients with SCD.

Advance Care Planning and End-of-Life Decision Making for Patients with Cancer

OBJECTIVE

To highlight the importance, challenges, and evolution of advance care planning for patients with cancer.

DATA SOURCES

Peer-reviewed journal articles and clinical guidelines.

CONCLUSION

Advance care planning is fundamental to support the personhood of patients with advanced cancer. Patients must be encouraged by physicians and nurses to articulate what matters and provides meaning to them as they live, cope, and receive treatment for their cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can facilitate advance care planning and primary palliative care, to support patients and families to make informed and value-concordant decisions regarding cancer and end-of-life treatments.

What Is the State of Quality Measurement in Spine Surgery?

BACKGROUND

Value-based healthcare models rely on quality measures to evaluate the efficacy of healthcare delivery and to identify areas for improvement. Quality measure research in other areas of health care has generally shown that there is a limited number of available quality measures and that those that exist disproportionately focus on processes as opposed to outcomes. The purpose of this study was to assess the current state of quality measures and candidate quality measures in spine surgery.

QUESTIONS/PURPOSES

(1) How many quality measures and candidate quality measures are currently available? (2) According to Donabedian domains and National Quality Strategy (NQS) priorities, what aspects or domains of care do the present quality measures and candidate quality measures represent?

METHODS

We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures relevant to spine surgery. A systematic search for candidate quality measures was also performed using MEDLINE/PubMed and Embase as well as publications from the American Academy of Orthopaedic Surgeons, Congress of Neurological Surgeons, and the North American Spine Society. Clinical practice guidelines were included as candidate quality measures if their development was in accordance with Institute of Medicine criteria for the development of clinical practice guidelines, they were based on consistent clinical evidence including at least one Level I study, and they carried the strongest possible recommendation by the developing body. Quality measures and candidate quality measures were then pooled for analysis and categorized by clinical focus, NQS priority, and Donabedian domain. Our initial search yielded a total of 3940 articles, clinical practice guidelines, and quality measures, 74 of which met criteria for inclusion in this study.

RESULTS

Of the 74 measures studied, 29 (39%) were quality measures and 45 (61%) were candidate quality measures. Fifty of 74 (68%) were specific to the care of the spine, and 24 of 74 (32%) were related to the general care of spine patients. The majority of the spine-specific measures were process measures (45 [90%]) and focused on the NQS priority of "Effective Clinical Care" (44 [88%]). The majority of the general care measures were also process measures (14 [58%]), the highest portion of which focused on the NQS priority of "Patient Safety" (10 [42%]).

CONCLUSIONS

Given the large number of pathologies treated by spine surgeons, the limited number of available quality measures and candidate quality measures in spine surgery is inadequate to support the transition to a value-based care model. Additionally, current measures disproportionately focus on certain aspects or domains of care, which may hinder the ability to appropriately judge an episode of care, extract usable data, and improve quality. Physicians can steward the creation of meaningful quality measures by participating in clinical practice guideline development, assisting with the creation and submission of formal quality measures, and conducting the high-quality research on which effective guidelines and quality measures depend.

National quality indicators and policies from 15 countries leading in adult end-of-life care: a systematic environmental scan

Background

The importance of measuring the quality of end-of-life care provision is undisputed, but determining how best to achieve this is yet to be confirmed. This study sought to identify and describe national end-of-life care quality indicators and supporting policies used by countries leading in their end-of-life care provision.

Methods

A systematic environmental scan that included a web search to identify relevant national policies and indicators; hand searching for additional materials; information from experts listed for the top 10 (n=15) countries ranked in the ‘quality of care’ category of the 2015 Quality of Death Index study; and snowballing from Index experts.

Findings

Ten countries (66%) have national policy support for end-of-life care measurement, five have national indicator sets, with two indicator sets suitable for all service providers. No countries mandate indicator use, and there is limited evidence of consumer engagement in development of indicators. Two thirds of the 128 identified indicators are outcomes measures (62%), and 38% are process measures. Most indicators pertain to symptom management (38%), social care (32%) or care delivery (27%).

Interpretations

Measurement of end-of-life care quality varies globally and rarely covers all care domains or service providers. There is a need to reduce duplication of indicator development, involve consumers, consider all care providers and ensure measurable and relevant indicators to improve end-of-life care experiences for patients and families.

The Role of Palliative Care in Oncology

Palliative care is a powerful adjunct to oncology that adds distinct value to the physical, mental, and psychosocial well-being of patients living with cancer. Its expanding role and integration with standard oncologic care has proven clinical benefit, as the practice of palliative care can help alleviate symptom burden, enhance illness and prognostic understanding, and improve both the quality of life and overall survival for patients. The primary aim of this review article is to highlight the significant interplay between palliative care and oncology and, in doing so, shed light on the areas for improvement and modern challenges that exist to meet the complex palliative care needs of patients with cancer.