The impact of outpatient supportive oncology on cancer care cost and utilization

BACKGROUND

Supportive oncology (SO) care reduces symptom severity, admissions, and costs in patients with advanced cancer. This study examines the impact of SO care on utilization and costs.

METHODS

Retrospective analysis of utilization and costs comparing patients enrolled in SO versus three comparison cohorts who did not receive SO. Using claims, the authors estimated differences in health care utilization and cost between the treatment group and comparison cohorts. The treatment group consisting of patients treated for cancer at an National Cancer Institute-designated cancer center who received SO between January 2018 and December 2019 were compared to an asynchronous cohort that received cancer care before January 2018 (n = 60), a contemporaneous cohort with palliative care receiving SO care from other providers in the Southeastern Pennsylvania region during the program period (n = 86), and a contemporaneous cohort without palliative care consisting of patients at other cancer centers who were eligible for but did not receive SO care (n = 393).

RESULTS

At 30, 60, and 90 days post-enrollment into SO, the treatment group had between 27% and 70% fewer inpatient admissions and between 16% and 54% fewer emergency department visits (p < .05) compared to non-SO cohorts. At 90 days following enrollment in SO care, total medical costs were between 4.4% and 24.5% lower for the treatment group across all comparisons (p < .05).

CONCLUSIONS

SO is associated with reduced admissions, emergency department visits, and total costs in advanced cancer patients. Developing innovative reimbursement models could be a cost-effective approach to improve care of patients with advanced cancer.

Perspectives from patients with chronic lung disease on a telehealth-facilitated integrated palliative care model: a qualitative content analysis study

BACKGROUND

Chronic lung disease affects nearly 37 million Americans and often results in significant quality of life impairment and healthcare burden. Despite guidelines calling for palliative care (PC) integration into pulmonary care as a vital part of chronic lung disease management, existing PC models have limited access and lack scalability. Use of telehealth to provide PC offers a potential solution to these barriers. This study explored perceptions of patients with chronic lung disease regarding a telehealth integrated palliative care (TIPC) model, with plans to use findings to inform development of an intervention protocol for future testing.

METHODS

For this qualitative study, we conducted semi-structured interviews between June 2021- December 2021 with patients with advanced chronic lung disease. Interviews explored experiences with chronic lung disease, understanding of PC, and perceived acceptability of the proposed model along with anticipated facilitators and barriers of the TIPC model. We analyzed findings with a content analysis approach.

RESULTS

We completed 20 interviews, with two that included both a patient and caregiver together due to patient preference. Perceptions were primarily related to three categories: burden of chronic lung disease, pre-conceived understanding of PC, and perspective on the proposed TIPC model. Analysis revealed a high level of disease burden related to chronic lung disease and its impact on day-to-day functioning. Although PC was not well understood, the TIPC model using a shared care planning approach via telehealth was seen by most as an acceptable addition to their chronic lung disease care.

CONCLUSIONS

These findings emphasize the need for a patient-centered, shared care planning approach in chronic lung disease. The TIPC model may be one option that may be acceptable to individuals with chronic lung disease. Future work includes using findings to refine our TIPC model and conducting pilot testing to assess acceptability and utility of the model.

Toward reducing racialized pain care disparities: Approaching cannabis research and access through the lens of equity and inclusion

There is growing interest in cannabis use for cancer pain. This commentary aims to discuss the evidence surrounding cannabis use for cancer pain in the context of the long-racialized landscape of cannabis policies and the disparity in pain control among cancer patients holding minoritized racial identities. Much evidence surrounding both the benefits and harms of cannabis use in cancer patients, and all patients in general, is lacking. Although drawing on the research in cancer that is available, it is also important to illustrate the broader context about how cannabis' deep roots in medical, political, and social history impact patient use and health care policies. There are lessons we can learn from the racialized disparities in opioid risk mitigation strategies, so they are not replicated in the settings of cannabis for cancer symptom management. Additionally, the authors intentionally use the term "cannabis" here rather than "marijuana.: In the early 1900s, the lay press and government popularized the use of the word "marijuana" instead of the more common "cannabis" to tie the drug to anti-Mexican prejudice.

A Prioritized Patient-Centered Research Agenda to Reduce Disparities in Telehealth Uptake: Results from a National Consensus Conference

Introduction

We hosted a national consensus conference with a diverse group of stakeholders to develop a patient-centered research agenda focused on reducing disparities in telehealth use.

Methods

Attendees were purposively invited to participate in a 2-day virtual conference. The group developed a prioritized research agenda focused on reducing disparities in telehealth uptake, with discussion informed by findings from a scoping review. All work was conducted in partnership with a Steering Committee of national experts in telehealth and patient-centered care (n = 5) and a community-based Telehealth Advisory Board with experience with telehealth use and barriers (n = 8).

Results

Sixty individuals participated in the conference and discussion resulted in a final list of 20 questions. Fifty-two attendees voted on the final prioritization of these questions. Results were aggregated for all voters (n = 52) and patient-only voters (n = 8). The top question identified by both groups focused on patient and family perspectives on important barriers to telehealth use. The entire group voting identified telehealth's impact on patient outcomes as the next most important questions, while the patient-only group identified trust-related considerations and cultural factors impacting telehealth use as next priorities.

Conclusions

This project involved extensive patient and stakeholder engagement. While voting varied between patients only and the entire group of conference attendees, top identified priorities included patient and family perspectives on important barriers to telehealth, trust and cultural barriers and facilitators to telehealth, and assessment of telehealth's impact on patient outcomes. This research agenda can inform design of future research focused on addressing disparities in telehealth use.

Impact of Head and Neck Cancer Diagnosis and Treatment on Patient-Partner Intimacy

OBJECTIVE

To determine the effects of head and neck squamous cell carcinoma diagnosis and treatment on patient- and partner-perceived intimacy and to understand if a diagnosis of HPV-related head and neck squamous cell carcinoma influences patient-partner intimacy.

STUDY DESIGN

Prospective observational.

SETTING

Single tertiary care center.

METHODS

An investigator-developed questionnaire was used to prospectively survey patients and partners in 2 groups based on human papillomavirus (HPV) status: HPV+ and HPV- at diagnosis (visit 1) and after treatment (visit 2). Surveys were scored on a 60-point scale, and results were categorized as follows: loss of intimacy (0-30), stable relationship (31-41), or improvement in intimacy (42-60). Responses of couples who participated together were assessed for concordance. Responses were considered discordant if patient and partner scores equated to different levels of perceived intimacy. Median patient and partner scores were compared via Mann-Whitney U test, and concordance was assessed with a chi-square test.

RESULTS

Thirty-four patients and 28 partners completed surveys at visit 1 and 28 patients and 15 partners at visit 2. Median scores among patients and partners were similar at the first time point (HPV+, 45 vs 45, P = .64; HPV-, 42.6 vs 40.8, P = .29) and the second (HPV+, 44.5 vs 44, P = .87; HPV-, 40.2 vs 39.6, P = .90). Concordance rates between HPV+ and HPV- couples were 63% vs 44% (P = .43) for the first time point and 89% vs 50% (P = .24) for the second.

CONCLUSION

Patients and partners reported stable or improved intimacy at both time points, and most couples tended to agree on their levels of perceived intimacy. A diagnosis of HPV did not appear to significantly affect intimacy scores.

Perioperative opioids and survival outcomes in resectable head and neck cancer: A systematic review

BACKGROUND

Opioids are a mainstay in pain control for oncologic surgery. The objective of this systematic review is to evaluate the associations of perioperative opioid use with overall survival (OS) and disease-free survival (DFS) in patients with resectable head and neck cancer (HNC).

METHODS

A systematic review of PubMed, SCOPUS, and CINAHL between 2000 and 2022 was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies investigating perioperative opioid use for patients with HNC undergoing surgical resection and its association with OS and DFS were included.

RESULTS

Three thousand three hundred seventy-eight studies met initial inclusion criteria, and three studies representing 562 patients (intraoperative opioids, n = 463; postoperative opioids, n = 99) met final exclusion criteria. One study identified that high intraoperative opioid requirement in oral cancer surgery was associated with decreased OS (HR = 1.77, 95% CI 0.995-3.149) but was not an independent predictor of decreased DFS. Another study found that increased intraoperative opioid requirements in treating laryngeal cancer was demonstrated to have a weak but statistically significant inverse relationship with DFS (HR = 1.001, p = 0.02) and OS (HR = 1.001, p = 0.02). The last study identified that patients with chronic opioid after resection of oral cavity cancer had decreased DFS (HR = 2.7, 95% CI 1.1-6.6) compared to those who were not chronically using opioids postoperatively.

CONCLUSION

An association may exist between perioperative opioid use and OS and DFS in patients with resectable HNC. Additional investigation is required to further delineate this relationship and promote appropriate stewardship of opioid use with adjunctive nonopioid analgesic regimens.

Physicians' Perspectives on Their Training for and Role Within Pennsylvania's Medical Cannabis Program

BACKGROUND

Physicians' ability to guide their patients on the use of medical cannabis can vary widely and is often shaped by their training, experiences, and the regulations and policies of their state. The goal of this qualitative study is to understand how prepared physicians are to certify and advise their patients to use medical cannabis. A secondary goal is to explore how physicians integrate certification into their clinical practices, and what factors shape their decisions and behaviors around certification.

METHOD

Using semi-structured interviews with 24 physicians authorized to certify patients to use medical cannabis in Pennsylvania, a state with a medical access only program, we explored how physicians are trained and set up their practices. Interviews were analyzed using a blend of directed and conventional, and summative content analysis.

RESULTS

Three main themes emerged from the data around training, system-level factors, and practice-level factors that shaped how physicians are trained and practice medical cannabis certification. Although participants were largely satisfied with their CME training, they noted areas for improvement and a need for more high-quality research. Participants also noted system-level factors that prohibited treating cannabis as a traditional medical therapy, including communication barriers between physicians and dispensaries and confusion about insurance coverage for certification exams.

CONCLUSION

Physicians require additional training to improve the operation of the medical cannabis program in Pennsylvania. Participants suggested that the program could be improved by reducing communication barriers between them, their patients, and the dispensaries around the product purchase, selection, use, and effectiveness of medical cannabis.

Social Determinants of Health Associated with How Cannabis is Obtained and Used in Patients with Cancer Receiving Care at a Cancer Treatment Center in Pennsylvania

Despite increased rates of cannabis use among patients with cancer, there are gaps in our understanding of barriers to accessing cannabis. Social determinants of health (SDoH) are associated with access to healthcare, but few studies have evaluated how SDoH relate to cannabis access and use among cancer patients. We examined whether access to and modes of cannabis use differed across indicators of SDoH among patients receiving treatment from a large National Cancer Institute (NCI) designated cancer center. This anonymous cross-sectional survey was developed in collaboration with the NCI Cannabis Supplement consortium, which funded 12 supplements to NCI Center Core Grants across the United States. We evaluated the association of race, gender, income, and age with mode of cannabis use, source of obtaining cannabis, what influences their purchase, and medical cannabis certification status. Overall, 1,053 patients receiving treatment for cancer in Pennsylvania completed the survey and 352 (33.4%) reported using cannabis since their cancer diagnosis. Patients who identified as Black/African-American were less likely to have medical cannabis certifications (p=0.04). Males and Black/African-Americans were more likely to report smoking cannabis (vs other forms, ps<0.01) and to purchase cannabis from an unlicensed dealer/seller (p<0.01). Lower-income patients were more likely to be influenced by price and ease of access (ps<0.05). Although cannabis users were younger than non-users, age was not associated with any outcomes. The current data shed light on how critical drivers of health disparities (such as race, gender, and income) are associated with where patients with cancer obtain cannabis, what forms they use, and what may influence their purchase decisions.

SIO-ASCO guideline on integrative medicine for cancer pain management: implications for racial and ethnic pain disparities

Racial and ethnic disparities in pain management pose major challenges to equitable cancer care delivery. These disparities are driven by complex interactions between patient-, provider-, and system-related factors that resist reductionistic solutions and require innovative, holistic approaches. On September 19, 2022, the Society for Integrative Oncology and the American Society of Clinical Oncology published a joint guideline to provide evidence-based recommendations on integrative medicine for cancer pain management. Integrative medicine, which combines conventional treatments with complementary modalities from cultures and traditions around the world, are uniquely equipped to resonate with diverse cancer populations and fill existing gaps in pain management. Although some complementary modalities, such as music therapy and yoga, lack sufficient evidence to make a specific recommendation, other modalities, such as acupuncture, massage, and hypnosis, demonstrated an intermediate level of evidence, resulting in moderate strength recommendations for their use in cancer pain management. However, several factors may hinder real-world implementation of the Society for Integrative Oncology and the American Society of Clinical Oncology guideline and must be addressed to ensure equitable pain management for all communities. These barriers include, but are not limited to, the lack of insurance coverage for many complementary therapies, the limited diversity and availability of complementary therapy providers, the negative social norms surrounding complementary therapies, the underrepresentation of racial and ethnic subgroups in the clinical research of complementary therapies, and the paucity of culturally attuned interventions tailored to diverse individuals. This commentary examines both the challenges and the opportunities for addressing racial and ethnic disparities in cancer pain management through integrative medicine.

Patient-Important Needs and Goals Related to Nutrition Interventions during Cancer Treatment

Patients with cancer often experience nutrition-related challenges for which they are subsequently connected with nutritional support. Yet to date there are no validated tools to assess whether nutrition interventions sufficiently address patients' needs. A vital step toward developing a tool is to identify primary patient-important goals related to receiving nutrition support during cancer care. To that end, we interviewed patients and clinicians to identify nutrition-related needs and goals of patients undergoing cancer treatment. We interviewed 31 patients undergoing cancer treatment and 17 clinicians at the Sidney Kimmel Cancer Center at Thomas Jefferson University in Philadelphia, PA. Two coders analyzed transcripts using a conventional qualitative content analysis approach. Patients and clinicians both identified weight maintenance, improved food satisfaction and intake, and improved quality of life metrics - such as reduced emotional and financial stress - as top nutrition-related goals. Participants also highlighted the importance of patients receiving food they like and having control over what they eat when designing optimal nutrition interventions. These findings will be used in future work to create a patient-centered assessment tool designed to capture a range of patient goals related to nutrition interventions.

Feasibility and Cost of Telehealth Head and Neck Cancer Survivorship Care: A Systematic Review

OBJECTIVE

Evaluate the feasibility and cost-effectiveness of telehealth head and neck cancer (HNC) survivorship care.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, CINAHL.

REVIEW METHODS

A systematic search for peer-reviewed feasibility studies on telehealth models for HNC survivorship care published between 2005 and 2021 was conducted using the terms "head and neck cancer" and "telehealth" and their synonyms. Inclusion criteria were studies on telehealth survivorship program interventions for HNC patients with quantitative feasibility outcome measures (eg, enrollment, retention, attrition/dropout rate, adherence/task completion rate, patient satisfaction, cost).

RESULTS

Thirty-eight studies out of 1557 identified met inclusion criteria and were included for analysis. Feasibility outcomes evaluated were enrollment and attrition rates, adherence/task completion rates, patient satisfaction, and user feedback surveys in different survivorship domains. Patient enrollment ranged from 20.8% to 85.7%, while attrition ranged from 7% to 47.7%. Overall, adherence was 30.2% higher in the intervention group than in the control group (46.8% vs 16.6%). Studies with cost analysis found telehealth models of care to be statistically significantly less expensive and more cost-efficient than the standard model of care, with a $642.30 saving per patient (n = 3). Telehealth models also substantially reduced work time saving per visit (on average, 7 days per visit).

CONCLUSION

While telehealth survivorship programs are feasible and cost-effective and are associated with improved patient outcomes, they might not be ideal for every patient. Further investigations are needed to understand the role of telehealth in survivorship care, given the variability in study design, reporting, measures, and methodological quality.

Cannabis Use in Patients With Cancer: A Clinical Review

Cannabis use and interest continues to increase among patients with cancer and caregivers. High-quality research remains scant in many areas, causing hesitancy or discomfort among most clinical providers. Although we have limitations on hard outcomes, we can provide some guidance and more proactively engage in conversations with patients and family about cannabis. Several studies support the efficacy of cannabis for various cancer and treatment-related symptoms, such as chemotherapy-induced nausea and cancer pain. Although formulations and dosing guidelines for clinicians do not formally exist at present, attention to tetrahydrocannabinol concentration and understanding of risks with inhalation can reduce risk. Conflicting information exists on the interaction between cannabis and immunotherapy as well as estrogen receptor interactions. Motivational interviewing can help engage in more productive, less stigmatized conversations.

Increasing equitable access to telehealth oncology care in the COVID-19 National Emergency: Creation of a telehealth task force

INTRODUCTION

Telehealth (TH) utilization in cancer care prior to COVID-19 was variable. Research highlights disparities in access determined by socioeconomic factors including education, income, race, and age. In response to COVID-19 and these disparities, we assessed the impact of a personalized digital support structure, the Telehealth Task Force (TTF), to reduce disparities in TH.

METHODS

We performed a retrospective review of cohorts between January 1, 2020 and August 30, 2020: Pre (TH use with basic telephone support), Intervention (TH access with TTF), and Post (TH access after TTF initiation and educational material dissemination). Data collected included successful TH access, health literacy (HL), and Area Deprivation Index, a ranking of neighborhoods by socioeconomic disadvantage (ADI). The data were analyzed in univariate ordinary least squares model and adjacent categories ratio model using statistical software R to understand the relationship between TTF, HL, ADI, and TH access.

RESULTS

We included 555 patients from January 1, 2020 to August 30, 2020 (90 preintervention, 194 intervention, and 271 postintervention), excluding patients without ADI/HL. TTF support successfully engaged older, racially, and socioeconomically diverse patients in TH; ADI is significantly higher in the postintervention group vs. preintervention (mean difference = 7.66, 95% CI 1.00-4.32, p = 0.024) and more patients had low HL during intervention compared with preintervention (adjacent categories ratio = 0.62, 95% CI 0.41-0.93, p = 0.021).

DISCUSSION

COVID-19 created an immediate need for TH. Implementation of the TTF helped close the digital divide, increasing TH access for vulnerable patients. Attention to digital readiness can mitigate disparities in access to care. Future research should explore the implementation of widespread routine digital support initiatives.

"1,000 conversations I'd rather have than that one:" A qualitative study of prescriber experiences with opioids and the impact of a prescription drug monitoring program

BACKGROUND

Prescription Drug Monitoring Programs (PDMPs) have shown impacts on a number of opioid-related outcomes but their role in clinician emotional experience of opioid prescribing has not been studied.

OBJECTIVES

This study explores the impact of PDMPs on clinician attitudes toward and comfort with opioid prescribing, their satisfaction with patient interactions involving discussion of opioid prescriptions, and their recognition of opioid use disorder (OUD) and ability to refer patients to treatment.

METHODS

Researchers conducted semi-structured interviews with five physicians and two nurse practitioners from a variety of specialties and practice environments.

RESULTS

Many participants reported negative emotions surrounding opioid-related patient encounters, with decreased anxiety related to PDMP availability. These effects were less pronounced with clinicians who had greater opioid prescribing experience (either longer careers or higher-volume pain practices). Many participants felt uncomfortable around opioid prescribing. Data from the PDMP often changed prescribing practices, sometimes leading to greater comfort writing a prescription that might have felt riskier without PDMP data. Clinicians easily recognized patient behaviors, symptoms, and prescription requests suggesting that opioid-related adverse events were accumulating, but did not usually apply a label of OUD to these situations. PDMP findings occasionally contributed to a diagnosis and treatment referral for OUD.

CONCLUSIONS

PDMP data is part of a nuanced approach to prescribing opioids. The objectivity of the data may be helpful in mitigating clinician negative emotions that are common around opioid therapy.

Analysis of the likelihood of depression versus distress screening to identify need for intervention

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Background: Psychosocial assessments are increasingly used to evaluate a patient-centered approach to quality cancer care delivery. Value-based oncology programs endorse screening metrics at every encounter. To comply with expectations of these programs, our cancer center utilizes two standardized tools: Patient Health Questionnaire (PHQ) to screen for depression at every encounter; National Comprehensive Cancer Network Distress Thermometer (NCCNDT) to screen for acute distress at clinically meaningful intervals. In 2021, oncology patients completed, on average, 5 annual appointments at Sidney Kimmel Cancer Center (SKCC), with a median appointment frequency of once every 19 days. Given the high encounter-per-patient ratio, we aimed to assess utility of frequent screening leading to supportive intervention. Methods: A retrospective analysis was conducted of medical oncology patients seeking care at SKCC with a completed depression and/or distress screening, as recorded in the patient’s electronic health record, between 1/1/2021 and 12/31/2021. This analysis intended to evaluate the percentage of patients whose scores indicate need for intervention. Patients who received more than one screening were attributed the highest score recorded during the measurement period. Results: A total 13,342 patients were screened at least once for either depression (n = 7,433), distress (n = 1,325), or both (n = 4,584). 3% of all patients screened ever met the intervention threshold (IT) for depression; 33% met the IT for distress. Of the patients who received both types of screenings, 31% met the IT for distress without meeting the threshold for depression. Those 1,418 patients would not have been referred for intervention through depression screening alone. Conclusions: This analysis highlights routine depression screening among a cancer population with a high encounter-per-patient ratio may not be sensitive in identifying need for supportive intervention. It also suggests that distress screening is more likely to lead to a supportive intervention than depression screening alone. This analysis combined with the anecdotal assessment by social workers supports the value of distress at clinically meaningful intervals over depression screening at each encounter. [Table: see text]

Impact of personalized care discussions on advance care planning

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Background: Advanced Care Planning (ACP) involves learning about decisions that may need to be made during care so they are known to family and providers. ACP has been associated with less aggressive medical care near death and improved quality of life.However, despite evidence for their benefit, ACP is inconsistent among patients with advanced cancer. At our institution, only 52% of patients with cancer undergoing palliative intent treatment had an ACP at the time of death. We sought to increase ACP through a quality improvement project intended to proactively identify and introduce patients to Personalized Care Discussions (PCDs). PCDs engage oncology patients and palliative care providers in ACP to articulate goals of care. Methods: A team of palliative care providers, medical oncologists, and administrative staff designed each phase of the intervention. Inclusion criteria to proactively identify patients eligible for a PCD were created along with a workflow to introduce PCDs and schedule a PCD appointment. A plan-do-study-act (PDSA) model was used to test impact of change to the PCD referral workflow and patient inclusion criteria. Each PDSA cycle lasted between 4 and 9 weeks between 6/1/2021 and 1/31/2022. PDSA 1: Oncologist referral to PCD for new patients. PDSA 2: Oncologist referral to PCD for Stage IV patients. PDSA 3: Automatic referral to PCD of Stage IV patients. PDSA 4: Pancreatic patients, any stage, added to PDSA 3 criteria. Results: During the measurement period, 68 patients completed a PCD. While changes to the inclusion criteria throughout PDSA cycles resulted in more total unique patients completing PCDs, the completion rate of eligible patients did not vary significantly across cycles. However, the proportion of patients completing PCDs for oncologists engaged in the project increased during the eight-month QI period (92%) from the previous eight-month period (86%). Conclusions: This project sought to identify and introduce patients to PCDs to improve ACP. We found that access to PCDs was not sufficient to increase completion of PCDs, since fewer than half completed the appointment. However, 68 patients who otherwise may not have completed a PCD did so because of this intervention. Misperceptions of palliative care may contribute to high cancellation rates of PCD appointments. This pattern is seen in the overall low completion rate of palliative care appointments (56% in same timeframe). Informal patient feedback often indicated a preference for care discussions to be with the primary oncologist, whereas our intervention introduced a new provider. These results demonstrate that a trigger to identify patients for PCDs without primary oncologist engagement falls short. Continued focus is needed to determine a proactive approach to identify patients who will benefit most from PCDs to complete ACP proactively.[Table: see text]

Prevalence and perceptions of cannabis use among racially diverse patients with cancer pain: Results from a multi-site survey

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Background: While access to cannabis is prevalent among cancer patients1, unknowns persist about real-time use, perceived effectiveness in cancer pain management and impact on other medication use, including opioids. Moreover, racial disparities in cancer pain management persist2-3 with Black patients more likely to have undiagnosed pain.4 Studies on the intersection of cannabis, opioids, race and cancer pain are needed. As part of an NCI-funded initiative, we assessed the perceived effectiveness of cannabis vs. opioids for pain control by race. Methods: A survey was created by three Mid-Atlantic, cancer centers to examine self-reported cannabis use and knowledge, barriers and perceptions about cannabis among cancer patients. All sites assessed common core questions and included additional questions assessing cannabis and opioid use. Patients were eligible to participate if they were treated for cancer within the prior year. Surveys were distributed both by mail and electronically via REDCap. Results are compared separately by site. Results: In all, 2,734 patients are included in this analysis. Rates of cannabis use since diagnosis ranged from 32-41% of respondents, with similar rates of use between gender and race. Patients under age 65 more frequently reported cannabis use. Across sites, only 7-8% of patients reported currently using opioids. A sizable number patients who use cannabis reported using cannabis instead of opioids to treat pain. Of those using cannabis, most felt that cannabis was better in managing their pain than opioids, with Black patients reporting this much more frequently than White patients across two sites (Site A 62.2% vs 43.2%, Site B 77.78 vs 48.96%, Site C 50.0% vs. 65.5%). The most common reasons patients reported using cannabis instead of opioids included the perception that: “cannabis is safer” (80-82%), “cannabis is less addictive” (70-73%), and “cannabis has fewer side effects” (68-74%). Conclusions: Cannabis is frequently used by cancer patients, with many reporting use instead of opioids for pain management. Of those using cannabis for pain management, a significant majority felt that it is more effective than opioids. Black patients report cannabis as more effective than opioids for pain control more frequently than other races. Given the ongoing under-treatment of cancer pain in Black patients, more data is needed to understand whether cannabis is an effective tool to reduce disparities in cancer pain management. [Table: see text]

COVID-19 Pandemic Influence on Medical Oncology Provider Perceptions of Telehealth Video Visits

PURPOSE

The COVID-19 pandemic necessitated a rapid expansion of telehealth use in oncology, a specialty in which prior utilization was low in part because of barriers perceived by providers. Understanding the changing perceptions of medical oncology providers during the pandemic is critical for continued expansion and improvement of telehealth in cancer care. This study was designed to identify medical oncology providers' perceptions of telehealth video visits as influenced by the COVID-19 pandemic.

METHODS

We conducted semi-structured interviews with medical oncology providers from November 20, 2020, to January 27, 2021, at the Sidney Kimmel Cancer Center at Thomas Jefferson University, a National Cancer Institute-designated cancer center in an urban, academic health system in Philadelphia, PA. We assessed provider perceptions of the impact of the COVID-19 pandemic on (1) provider-level comfort and willingness for telehealth, (2) provider-perceived patient comfort and willingness to engage in telehealth, and (3) continued barriers to successful telehealth use.

RESULTS

Volunteer and convenience sampling resulted in the participation of 25 medical oncology providers, including 18 physicians and seven advanced practice providers, in semi-structured interviews. Of the 25 participants, 13 (52%) were female and 19 (76%) were White, with an average age of 48.5 years (standard deviation = 12.6). Respondents largely stated an increased comfort level and willingness for use of video visits. In addition, respondents perceived a positive change in patient comfort and willingness, mostly driven by convenience, accessibility, and reduced risk of COVID-19 exposure. However, several reported technologic issues and limited physical examination capability as remaining barriers to telehealth adoption.

CONCLUSION

The rapid adoption of telehealth necessitated by the COVID-19 pandemic has increased provider-level and provider-perceived patient comfort and willingness to engage in video visits for cancer care. As both providers and patients increasingly accept telehealth across many use cases, future work should focus on further addressing technology and physical examination barriers and ensuring continued reimbursement for telehealth as a routine part of covered care.

A Failure to Guide: Patient Experiences within a State-Run Cannabis Program in Pennsylvania, United States

INTRODUCTION

Medical cannabis has been available for purchase in dispensaries in Pennsylvania, United States since April 2018. Patients wanting to access medical cannabis must receive certification from physicians for a limited number of physical and psychological conditions. Despite increasing numbers of patients using cannabis in the United States, little is known about the patient experience during certification and entry into state-regulated cannabis programs and how and if they are guided by health care professionals and dispensary staff. Through focus group discussions, we sought to capture patient perspectives of certification, cannabis acquisition and cannabis use.

METHODS

Twenty-seven Pennsylvania participants took part in 7 virtual focus groups from June to July 2020. Participants were recruited statewide from the community, medical settings, and dispensaries.

RESULTS

Focus group results indicate that while the medical cannabis program is functional, policymakers and the medical community have failed to meaningfully integrate cannabis into the health care system. Participants expressed frustration around two central themes: there was no overarching education about medical use of cannabis and there was little consistency and availability for people once they found a suitable product, resulting in inadequate symptom relief and exorbitant out of pocket costs to pursue cannabis use as an adjuvant therapeutic. Participants noted a siloed experience between the certification process, accessing dispensaries, and receiving ongoing medical care. The lack of integrated care required high levels of self-reliance and experimentation with medical cannabis for participants.

CONCLUSION

We recommend that cannabis be better integrated into medical care for patients with qualifying conditions.

Shared Decision-Making in Managing Breakthrough Cancer Pain in Patients With Advanced Cancer

Background: Pain is a significant problem in patients with cancer. Breakthrough cancer pain contributes to the pain experience, but it is often underassessed and underrecognized. Shared decision-making (SDM), where patient preferences, goals, and concerns are discussed and integrated into a shared decision, can potentially foster earlier identification of pain, including breakthrough cancer pain, and improve pain management. Objectives: To explore the use of SDM to evaluate its impact on cancer pain management. Methods: This prospective, multisite study engaged patients with advanced cancer to explore the use of SDM in managing cancer pain using a digital platform with an expanded pain assessment. Decision preferences were noted and incorporated into care. Outcomes included pain and patient-perceived pain care quality. Results: 51 patients with advanced cancer enrolled in the study. The mean pain score was 5 out of 10 throughout the three study time points. 88% of patients experienced breakthrough cancer pain of severe intensity at baseline and approximately 70% at visits two and three. The majority of breakthrough cancer pain episodes lasted longer than 30 minutes. The majority (86%) of participating patients desired shared decision-making or patient-driven decision-making. Most patients expressed satisfaction with the level of shared decision-making in managing their cancer pain. Breakthrough cancer pain remained significant for most patients. Conclusions: SDM incorporated into pain discussions has the potential to improve pain outcomes, but significant challenges remain in managing breakthrough cancer pain.

Clinician Attitudes, Training, and Beliefs About Cannabis: An Interprofessional Assessment

Background: Medical use of cannabis is growing in popularity across the United States, but medical education and clinician comfort discussing cannabis use for medical purposes have not kept pace. Materials and Methods: A total of 344 clinicians in the state of Pennsylvania (response rate 14%) completed a brief online survey about their attitudes, training, and experiences regarding medical cannabis and certifying patients to use medical cannabis. Results: Only 51% of clinicians reported completing any formal training on medical cannabis. Compared with noncertifying clinicians (pharmacists, nurse practitioners, and physician assistants), physicians were significantly more comfortable with patient use of medical cannabis, saw fewer risks, more benefits, and felt better prepared to discuss its use with vulnerable populations. All clinicians noted significant limitations to their understanding of how medical cannabis can affect patients, and many indicated a desire for more research and training to fill in gaps in their knowledge. Conclusions: Insufficient medical curricula on the medical uses of cannabis are available to interprofessional clinicians across their disciplines, and clinicians report significant deficits in their knowledge base about its effects. Additionally, these data suggest an urgent need to expand training opportunities to the full spectrum of clinicians as all are involved in caring for patients who use medical cannabis.

Impact of Cannabis Use on Least Pain Scores Among African American and White Patients with Cancer Pain: A Moderation Analysis

INTRODUCTION

Based on many published reports, African American patients with cancer experience higher pain severity scores and lower pain relief than White patients. This disparity results from undertreatment of pain and is compounded by low adherence to prescribed non-opioid and opioid analgesics among African American patients with cancer. While nearly one in four patients use cannabis to manage cancer-related symptoms, less is known about how cannabis use influences pain relief in this patient population.

METHODS

This study is based on preliminary data from an ongoing study of longitudinal outcomes of opioid therapy among African American and White patients with cancer. Linear mixed-effects models were utilized to assess the interaction of race and cannabis use on pain relief using "least pain" item scores from the Brief Pain Inventory (BPI) averaged across three time points. Models were adjusted for sociodemographic and clinical variables.

RESULTS

This analysis included 136 patients (49 African American, 87 White). Overall, 30.1% of the sample reported cannabis use for cancer pain. The mean "least pain" score on BPI was 3.3 (SD=2.42) on a scale of 0-10. African American patients had a mean "least pain" score 1.32±0.48 units higher (indicating lower pain relief) than White patients (p=0.006). Cannabis use did not have a significant main effect (p=0.28). However, cannabis use was a significant moderator of the relationship between race and "least pain" (p=0.03). In the absence of cannabis use, African Americans reported higher "least pain" scores compared to Whites (mean difference=1.631±0.5, p=0.001). However, this disparity was no longer observed in African American patients reporting cannabis use (mean "least pain" difference=0.587±0.59, p=0.32).

CONCLUSION

These findings point to the possible role of cannabis in cancer pain management and its potential to reduce racial disparities. These findings are preliminary and further research into the role of cannabis in cancer pain outcomes is needed.

Piloting the REDUCE score to decrease acute care utilization

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Background: Emergency department visits and hospitalizations are common in patients with cancer, with nearly three quarters of patients with advanced disease hospitalized at least once in the year after their diagnosis. Efforts to prospectively identify patients at highest risk for this acute care utilization (ACU) are needed. While many risk scoring systems have been developed for this purpose, few have been effectively integrated into clinical practice. We piloted a prospective risk assessment tool using a quality improvement framework. Methods: We utilized our previously published REDUCE score (Reducing ED Utilization in the Cancer Experience) to pilot clinical interventions to reduce ACU using PDSA cycles. Cycle 1 included a chart review and targeted outreach by a nurse navigator to high risk patients identified by REDUCE. Outreach resulted in communication of patient needs to the care team, which may or may not have resulted in additional interventions. Cycle 2 involved initial identification by REDUCE followed by further assessment with a distress screening. Those who were high risk and had high distress (score ≥4) were discussed by an interdisciplinary team (including supportive medicine physicians, social work, nurses, nurse practitioners) to determine an appropriate intervention. Results: Of the patients in Cycle 1 (N = 138), 26.1% had ACU after outreach by a nurse navigator, while in Cycle 2 (N = 169) 7.1% had ACU after the intervention determined by the interdisciplinary team. The average distress score among all patients in Cycle 2 was 6.0 and the REDUCE score was 2.87, while the subset of patients who experienced ACU had an average distress score of 6.4 and a REDUCE score of 3.22. Conclusions: The REDUCE score may be a valuable tool to assist in identifying patients at risk for ACU. We found that combining the risk score with a biopsychosocial screening tool and multidisciplinary team discussion may prove more valuable than the risk score alone, with Cycle 2 findings suggesting that there is a directional correlation between REDUCE score and distress screening results. More work is needed to understand the relative impact of the REDUCE score and the biopsychosocial screening and team discussion on decreasing ACU.

Living Through the Pandemic: The Voices of Persons With Dementia and Their Caregivers

Social-distancing guidelines from the COVID-19 pandemic have potential to compound morbidity in persons with dementia (PwD) and increase caregiver burden. This qualitative study utilized semi-structured interviews between August-November 2020 to explore the impact of COVID-19 on PwD and caregivers. Conventional qualitative content analysis was used. Inter-coder reliability was confirmed using the kappa coefficient. Twenty-five interviews were completed with four themes emerging: disruption of socialization, fear and risk mitigation, coping strategies, and caregiver burden. Participants described how lack of socialization and confinement led to feelings of loneliness, depression, and worsening memory problems. Caregivers reported increased burden and heightened feelings of responsibility for their loved one. Increased isolation imposed by the pandemic has a detrimental impact on PwD. Further work is needed to develop interventions to support PwD and other cognitive impairments and caregivers during the pandemic and when in-person socialization is not possible.

Digital Literacy at an Urban Cancer Center: Implications for Technology Use and Vulnerable Patients

PURPOSE

eHealth literacy, or the ability to seek, find, understand, and appraise health information from electronic sources, has become increasingly relevant in the era of COVID-19, when so many aspects of patient care became dependent on technology. We aimed to understand eHealth literacy among a diverse sample of patients with cancer and discuss ways for health systems and cancer centers to ensure that all patients have access to high-quality care.

METHODS

A cross-sectional survey of patients with cancer and caregivers was conducted at an NCI-designated cancer center to assess access to the Internet, smartphone ownership, use of mobile apps, willingness to engage remotely with the health care team, and use of the patient portal. Descriptive statistics and bivariate analyses were used to assess frequencies and significant differences between variables.

RESULTS

Of 363 participants, 55% (n = 201) were female, 71% (n = 241) identified as non-Hispanic White, and 29% (n = 85) reported that their highest level of education was a high school diploma. Most (90%, n = 323) reported having access to the Internet and most (82%, n = 283) reported owning a smartphone. Younger patients or those with a college degree were significantly more likely to own a smartphone, access health information online, know how to download an app on their own, have an interest in communicating with their health care team remotely, or have an account on the electronic patient portal.

CONCLUSION

As cancer centers increasingly engage patients through electronic and mobile applications, patients with low or limited digital literacy may be excluded, exacerbating current cancer health disparities. Patient-, provider- and system-level technology barriers must be understood and mitigated.

Can acute care utilization be reduced by a risk score-based intervention alone?

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Background: Acute care utilization (ACU), encompassing both emergency department visits and hospitalizations, is common in patients with cancer, with nearly three quarters of patients with advanced disease hospitalized at least once in the year after their diagnosis. From a population health perspective, focusing on the highest risk patients is likely to identify the top 5% while the next 30% can be considered rising risk and are likely to need care management support. Many risk scoring systems have been developed, but few have demonstrated effective integration in clinical practice. We sought to evaluate if a risk assessment tool alone was adequate to determine an appropriate patient outreach strategy that results in reduced ACU. Methods: We utilized the REDUCE score (Reducing ED Utilization in the Cancer Experience - see 2020 ASCO Quality Abstract 208) to develop an intervention conducted in two phases. Phase I included a chart review and targeted outreach to high risk patients identified by REDUCE by a nurse navigator. Outreach resulted in communication of patient needs to the care team. Phase II involved initial identification by REDUCE followed by further screening assessment with a distress screen. Those who were high risk and had high distress (score ≥4) were discussed by an interdisciplinary team (supportive medicine physicians, social work, nurses, nurse practitioners) to determine an intervention. Results: Of the patients in phase I (N = 138), 26.1% had ACU afterward, while in phase II (N = 169) 7.1% had ACU. The average distress score among all patients in the phase II group was 6.0 and the REDUCE score was 2.87, while the subset of patients who experienced ACU had an average distress score of 6.4 and a REDUCE score of 3.22. These findings indicate that there is a directional correlation between REDUCE score and distress screening results. Conclusions: The REDUCE score may be a valuable tool to assist in identifying patients at risk for ACU, but the significantly less ACU in phase II compared to phase I suggests that the risk score combined with a biopsychosocial screening, such as distress as required by the Commission on Cancer, may prove more valuable than the risk score alone. To identify the most impactful intervention, and to fully understand the implications of a patient’s specific REDUCE score within the high risk category, additional assessment would be beneficial. These preliminary results highlight that directionally correlated measures obtained from a biopsychosocial screening in combination with a risk score gives a more complete picture of patient’s overall risk of ACU.

Distress screening for patients with a history of cancer during the COVID-19 pandemic

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Background: Although a diagnosis of cancer is widely accepted as resulting in significant levels of distress, distress itself cannot be considered benign and screening for distress is considered a best practice metric for patients receiving oncological care. Endorsed by NCCN, the Distress Thermometer (DT) considers a cutoff score of 4 or greater to identify patient with clinically relevant levels of distress. We hypothesized that the COVID-19 pandemic would manifest with higher levels of stress and anxiety in most persons by compounding the distress experienced by patients with a diagnosis of cancer. Methods: Patients with a new diagnosis of cancer underwent distress screening with the DT prior to a clinical appointment at a NCI-designated academic cancer center. Patients who scored 4 or higher were discussed at an Interprofessional Supportive Medicine patient conference or referred to oncology social work for appropriate evaluation and therapeutic care. By mid-March 2020, the SKCC catchment area was under a public health emergency with limited access to non-essential healthcare; therefore, we present data from 1/1-3/15/20 (pre-pandemic), 3/16-6/7/20 (pandemic peak with 2000+ daily cases in late April and peak daily deaths 300+ in May), and 6/8-8/30/20 (daily cases generally less than 700 except for occasional levels of 1000-in July and daily deaths less than 40 daily). Results: In the pre-pandemic time period, 60% of patients assessed reported a score of 4 or higher. During the subsequent periods—the first pandemic peak and the first post-pandemic period—the incidence of an elevated distress screen (4 or higher) was relatively stable at about 30%. Conclusions: Contrary to expectations, the DT screen identified less patient distress during the pandemic compared to pre-pandemic. Our results may be due to multiple factors—changes in processes and procedures to prioritize DT screening as pandemic risk became more apparent; an increased use of telemedicine; and the compounding of new, non-cancer related stressors resulting in the greater resiliency noted in disaster psychology. For example, during the first pandemic peak when the majority of patients were seen via telemedicine, the opportunity afforded by telemedicine for safety and decreased risk for COVID-19 infection may have reduced the overall distress experience. In addition, the compounding of stressors—the diagnosis of cancer, the risk of the pandemic, and its economic and financial stressors—may have influenced distress perception. Future work incorporating multiple distress assessment points may help better understand the impact of the layers of stress experienced by persons with cancer.[Table: see text]

Creation of a telehealth task force to improve successful use of telehealth to maintain patient access during the COVID-19 pandemic

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Background: In response to the COVID-19 National Emergency, the Sidney Kimmel Cancer Center (SKCC) medical oncology practice desired to greatly expand telehealth (TH) utilization to decrease patient risk while maintaining access to care. TH utilization requires resources (smart phones, internet) and there are disparities in digital media access in our patient population. A digital literacy survey performed at the SKCC in 2018 noted that 30% of patients used Android phones and > 60% of patients accessed the internet from a PC. Methods: In response to increased TH demand and need for support, the SKCC launched an oncology-dedicated Telehealth Task Force (TTF) to address barriers to TH access. The TTF team consisted of nine full-time individuals with digital and healthcare literacy to assist in telehealth and patient portal troubleshooting. Critical functions of TTF’s targeted patient solutions include; set-up and delivery of smartphones, creating email accounts, performing test visits, creating EHR patient portal accounts, real- time assistance during TH visits with implementation of this intervention beginning on April 3, 2020 with monitoring of patient interactions/touchpoints. Results: The SKCC medical oncology TTF noted increased interactions with patients immediately with a marked increase in the composite of medical oncology appointments completed by TH (51.0% in April 2020 compared to a prior level of 15.7% in March 2020). Additionally, there was a statistically significant increase in the proportion of patients have an active patient portal EHR account during this same period (14.6%; 95% CI, 12.3% to 16.9%; p < 0.0001). Oncology infusion treatment appointments remained relatively consistent over time. Conclusions: The SKCC medical oncology practice experienced an exponential rise in TH utilization during an uncertain public health crisis. Disparity in digital literacy and resources essential for successful TH use were quickly appreciated as potential barriers to access. The creation of a dedicated Telehealth Task Force was critical in maintain access to care for oncology patients given their vulnerability to infection. Further investigation of TH supports to improve TH use are warranted. [Table: see text]

Abstract S11-01: Assessing the impact of the COVID-19 pandemic on cancer patients, survivors, and caregivers

Background: The COVID-19 global pandemic created significant and unprecedented disruptions in in medical care and social services. Cancer patients are at increased risk of COVID-19 infection due to their immunosuppressive state and may fare worse than others who are COVID-19 positive because of their aggressive underlying disease. While presumed to be substantial, the extent of the impact of the pandemic on cancer patients, survivors, and caregivers was unknown.

Methods: Between April 23, 2020 and May 19, 2020, our urban, NCI-designated cancer center launched a “COVID and Cancer” survey for cancer patients, survivors, and caregivers. The purpose of the survey was to assess disruptions to cancer care, use and perceptions of telemedicine, access to social services and cancer support programs, and psychosocial well-being. The online survey was distributed through our cancer center’s email list for patient and survivor programming, via the electronic patient portal to patients in active treatment, and across our cancer center’s social media platforms. Descriptive statistics reported mean scores and frequencies while bivariate statistics reported differences in outcomes by respondent characteristics. The protocol and survey were approved by our Institutional Review Board.

Results: In less than one month and in the height of the pandemic, 1,107 people completed the survey. After removing duplicate and incomplete responses, the final sample of 985 respondents included 377 (38%) patients in active treatment, 576 (56%) survivors, and 18 (2%) caregivers. Fifty-six percent (n=555) were female; the mean age of respondents was 63 years old (SD= 11.9). Seventy-two percent (n=705) of respondents had solid tumor cancers while some had either a heme malignancy (22%) or both (4%). Among the 688 respondents who needed cancer care during the pandemic, 294 (43%) reported disruptions in appointments, labs, or scans. Fewer (&lt;5%) reported disruptions in surgery, chemotherapy, or radiation. Almost half (n=335, 49%) reported a telehealth visit during this time. Most respondents (n=612, 62%) were worried about contracting COVID-19. Cancer patients who were in active treatment were significantly more likely to be worried about contracting COVID-19, as well as accessing medication, transportation, or caregiver support, than those who were not in active treatment.

Conclusions: Disruptions in cancer care were observed during the pandemic. Cancer patients in active treatment were more worried that resources needed for their care such as medication, transportation, and caregiver support would be impacted by the pandemic. At our cancer center, we tried to mitigate some of the survey observations by developing COVID-specific patient and caregiver support programs, partnering with local agencies to provide groceries and transportation to patients, and enhancing infrastructure to assist with telehealth appointments. Cancer center support services can overcome these barriers and ensure patient care, even in a pandemic.

Citation Format: Amy Leader, Preethi Selvan, Lisa Capparella, Rebecca Cammy, Janene Palidora, Ayako Shimada, Benjamin Leiby, Gregory Garber, Brooke Worster. Assessing the impact of the COVID-19 pandemic on cancer patients, survivors, and caregivers [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr S11-01.

Abstract PO-037: SKCC medical oncology telehealth experience during Covid-19 pandemic: Lessons learned and operational changes to leverage telehealth to maintain patient access

The purpose of this report is to share lessons learned at the Sidney Kimmel Cancer Center (SKCC) in response to the COVID-19 National Emergency, marked by expanding telehealth (TH) to decrease patient risk while maintaining access to care. TH utilization requires resources (smart phones/tablets, email, internet), and there are disparities in digital media access in our patient population. We learned from a digital literacy survey performed at the SKCC in 2018 that 30% of our patients used Android phones and &gt; 60% of patients accessed the internet from a PC. Our EHR was built to support a “nonpandemic” level of TH visits, which increased in a short span from 29 visits in January 2020 to 1,700 visits in April 2020. Pre-COVID, the Jefferson TH office had 5 support employees to assist patients with TH. Though some patients needed support, the TH team had a manageable caseload. During the first weeks of the pandemic, the EHR TH software was updated to accommodate increased demand, requiring PC/mobile device upgrades/setting changes, which posed a potential barrier to care. In response to increased TH demand and need for support, the SKCC launched an oncology-dedicated Telehealth Task Force (TTF) to address barriers to TH access. Examples of TTF’s targeted patient solutions include set-up and delivery of smartphones, creating email accounts, disseminating instructions for TH use, and real- time assistance during TH visits. Daily protocol for support staff across the SKCC adapted to accommodate the increase in TH visits. Phone room staff experienced increased volume of scheduling requests to change in-person visits to TH, from 165 rescheduled in March 2020 to 431 in April 2020, and established new scripting and triage protocol. Administrative staff now follows up telephonically for TH visits. Providers noted challenges in completing TH visits within predetermined appointment length due to technical delays and increased time needed for novice users. The nurse’s role in the care team was vital in reinforcing to patients the availability of TTF supports prior to their TH visits and communicating appointment delays to improve patient experience. Providers noted the need to document at the point of care as support staff rely on this to schedule testing/follow-up visits. Supportive resources for TH were quickly appreciated, such as access to forms for timely documentation of treatment consent. The SKCC experienced an exponential rise in TH use and made critical workflow adjustments as well as creating a dedicated TTF to maintain access to care for oncology patients during an uncertain public health crisis.

Citation Format: Avnish Bhatia, Lauren Waldman, Gregory Garber, Megan Sabonjian, Melissa Hunt, Janene Palidora, Amy Leader, Brooke Worster. SKCC medical oncology telehealth experience during Covid-19 pandemic: Lessons learned and operational changes to leverage telehealth to maintain patient access [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-037.

Screening for health literacy at an urban academic cancer center

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Background: Low health literacy is more prevalent among older adults and minority populations, and it has been linked to excess health care utilization and poor health outcomes in cancer patients. Screening for health literacy may improve communication and care, such that discussions and information can be tailored to patient need. The purpose of this study was to describe health literacy levels and correlates among patients at an urban, NCI-designated cancer center. Methods: In September 2019, we began health literacy screening for each newly diagnosed, English-speaking cancer patient. Patients were categorized as having low, medium, or high health literacy using the BRIEF health literacy screener; results are visible in the EMR. For this analysis, we included patient age, gender, insurance type, race/ethnicity, and socio-economic status (SES), which was calculated using an Area Deprivation Index (ADI) ranging from 0 (no deprivation) to 100 (extreme deprivation). Data was summarized using descriptive statistics; ANOVA and Chi-squared tests investigated associations between patient’s health literacy levels and potential correlates. Results: Among 284 patients, 68%, (n = 195) were Caucasian, 25% (n = 70) were African American and 7%, (n = 19) identified as Hispanic, Asian American or some other race. Seventy-five percent (n = 211) were male; the mean age was 63 years (SD: 12). The mean ADI was 42 (SD: 28), indicating a low to moderate SES. Seventy percent (n = 200) had a high health literacy score, 20% (n = 57) had a medium score, and 10% (n = 27) had a low health literacy score. Only a patient’s race/ethnicity and the ADI were significantly associated with their health literacy score. Seventy-seven percent of Caucasian patients had high health literacy scores compared to 59% of African American patients and 48% patients of Hispanic, Asian or some other origin (P < .001). Patients with low health literacy had an ADI score (65.1) that was almost double the score of patients with high health literacy scores (38.5) (p < .001). Conclusions: Roughly one-third of patients seen at this urban cancer center did not have a high health literacy score. Socio-economic status was a stronger correlate to health literacy than patient age, marital status, or insurance type. EMRs should capture a patient’s SES in some manner, as this is strongly associated with health literacy.

Recruiting patients with advanced cancer to participate in a non-opioid intervention for chronic pain management

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Background: Chronic pain related to advanced cancer is difficult to treat. In addition to traditional analgesics, non-pharmacological interventions, such as music therapy, may help alleviate pain in this population. Research studies to test the efficacy of these non-pharmacological interventions are necessary and important. However, recruiting patients with advanced cancer to participate in such interventions can be challenging. Identifying effective sources of referrals and barriers to participation may help increase recruitment rates in the future. Methods: We recruited patients with advanced cancer (stage III or IV) with chronic pain from two major hospital systems to participate in a pain management interventional study. The experimental group received individualized music therapy, while the control group received talk therapy. Participants attended six weekly sessions at the hospital and were compensated for time and travel. Recruitment methods included referrals from care teams, advertisement through flyers and posters, EMR chart reviews, and in-person recruitment at multiple infusion centers. Missing data was excluded from analyses. Chi-square tests assessed significant differences between groups. Results: Of 594 patients that were referred to the study, 7% enrolled (n = 40), 35% declined (n = 208), and 58% were ineligible (n = 346). Forty-seven percent (n = 19) of enrolled participants were female; race/ethnic distributions were the following: African American/Black (55%; n = 22), Caucasian/White (28%; n = 11), or other (17%; n = 7). The most effective recruitment method was through self-referral; of the 40 patients enrolled in the study, 9 (23%) were enrolled through this method. There were no statistically significant differences between referral source and enrollment. The top three reasons patients declined to participate included lack of interest (32%; n = 67), lack of time and/or energy (28%; n = 59), and lack of transportation (16%, n = 34). Conclusions: Although there were no differences in referral sources, more patients were enrolled through self-referral or in-person recruitment, showing the power of personal motivation and personal touch. While lack of participation due to interest, time, or energy are hard to overcome, future research should consider campaigns to reach patients who are motivated to participate. In addition to referrals, resources for in-person recruitment and transportation to help alleviate barriers to research participation should be considered.

Effect of a supportive medicine program for cancer patients on patient connectivity to care and health care utilization

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Background: The benefits of supportive medicine (SM) for cancer patients include improved quality of life, increased patient satisfaction, improved symptom management, increased cost savings and improved survival rates. At one NCI-designated cancer center, all patients were screened for distress; those who screened positive or were directly referred by a provider were enrolled into our multi-disciplinary SM program. Here, we document the impact of the supportive medicine program on outcomes of emergency department (ED) visits, hospital readmission, and non-billable touchpoints associated with patient navigation and resource referrals. Methods: The program systematically screened for biopsychosocial distress utilizing the National Comprehensive Cancer Center Distress Thermometer (DT) and the Problem Checklist (PC) to identify practical, emotional, spiritual and physical issues. Patients were categorized into three types: screened and enrolled in the SM program, and screened and not enrolled in the SM program, or provider referral into the SM program. Data included patient’s age, number of hospital admissions, emergency department visits, and non-billable touchpoints at 90 and 180 days after the distress screening or referral. Descriptive data were analyzed with counts and percentages for categorical variables and summarized with mean and standard deviation for numerical variables. For investigation of the effects of time and patient type on the change in utilization rate, generalized estimation equations for Poisson regression were conducted for each outcome. Results: In all, 2,738 patients were included in the analysis. Patients who were referred from a provider tended to be younger (p < .01) and more likely to die within 90 days (p < .001). At 180 days, ED visits decreased 18% for patients referred to the SM program and 42% for patients screened into the SM program, compared to a 3% decrease in ED visits among those not enrolled in the SM program (p < .01). Similarly, hospital admissions decreased 34% for patients referred to and 39% screened into the SM program, compared to a 4% increase for patients not enrolled in the SM program (p < .01). Non-billable touchpoints increased among all types of patients. Conclusions: An SM program reduces hospital admissions and ED visits, therefore improving outcomes and potentially reducing the cost of care for cancer patients. Future research should link this data to claims data to definitely evaluate the impact of SM programs on cost.

Validity of the screener and opioid assessment for patients with pain-revised (SOAPP-R) in patients with cancer

OBJECTIVE

To determine the utility of the screener and opioid assessment for patients with pain-revised (SOAPP-R) for patients with cancer-related pain.

DESIGN

The authors performed a retrospective analysis of cancer patients screened with the SOAPP-R. Opiate abuse was determined using a combination of urine drug screens and analysis of patients' electronic medical records.

SETTING/PATIENTS

Patients who were seen at a palliative care clinic presenting with pain or needing an opioid prescription at an academic medical center with any type of cancer were screened using the SOAPP-R (N = 69).

OUTCOME MEASURES

Aberrant opioid-related behavior was determined using a combination of provider notes and urine drug screens.

RESULTS

A positive SOAPP-R score (⩾18) was observed in 27 participants (39.1 percent). The sensitivity and specificity of the SOAPP-R in the study population was 0.75 and 0.80, respectively.

CONCLUSIONS

The SOAPP-R, in its current form, may have value in screening patients with cancer for substance abuse. Incorporation of the screening tool in palliative and oncology settings may help reduce opioid abuse in cancer patients.

Development of a multidisciplinary approach to supportive care for patients with genitourinary cancers

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Background: Patients with cancer who engage early with palliative care may experience improved quality of life (QOL), increased overall survival (OS), and decreased acute care utilization. The Neu Center for Supportive Medicine and Cancer Survivorship (NCSMC) at Thomas Jefferson University is a program designed to identify patients who would benefit from early intervention palliative and supportive care and deliver appropriate services. After initial experience with the model in patients with gastrointestinal and head and neck malignancies, the NCSMC is expanding to patients with genitourinary cancers. Methods: A multidisciplinary team consisting of palliative care physicians, social work, psychology, and navigation conducts biopsychosocial screening (using the NCCN Distress Thermometer) and initiates a personalized care plan for each patient to clarify treatment goals and offer assistance. Prior to deploying the program, multiple stakeholders were engaged to discuss optimal screening points in the patient journey. Patients with a new cancer diagnosis are approached at a post-operative visit in the urology clinic; patients with high distress or significant barriers are discussed at a weekly interdisciplinary meeting with a team of physicians, nurses, social workers, and psychiatry. Patients are subsequently referred to services identified as potentially beneficial. Results: In the first 10 weeks of the program, 67 patients with new diagnoses of bladder (28, 41.8%), prostate (21, 31.3%), kidney (12, 17.9%), urothelial (5, 7.5%), and testicular (1, 1.5%) cancers were screened. 38 (59.4%) patients were identified as low distress; 24 patients (36%) were identified as high distress and offered NCSMC services. Two patients utilized services. Conclusions: Distress and barriers to care amongst patients with newly diagnosed genitourinary cancers are highly variable. While evaluating all patients in the immediate post-operative period is effective at identifying affected patients, the process is resource intensive. An iterative approach testing the intervention at different points in the patient journey is ongoing. As the program matures, impact on QOL, OS, and utilization will be measured.

Medical Cannabis: A guide to the clinical and legal landscapes

If your patient expresses interest in medical marijuana, you'll find evidence on maximizing benefit while minimizing risk. But be cautious: Data are often contradictory.

Proactive, multidisciplinary approach to supportive medicine: Improving health outcomes and care utilization

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Background: Evidence suggests that cancer patients who receive palliative care early in their disease have improved quality of life, decreased emergency department (ED) visits, and less aggressive end-of-life care. In 2017, the Sidney Kimmel Cancer Center at Jefferson established the Neu Center for Supportive Medicine and Cancer Survivorship (NCSMCS) as a model for integrated care in the outpatient setting for all cancer patients. A multidisciplinary team consisting of palliative care physicians, social work, psychology, and navigation conducts biopsychosocial screening and initiates a personalized care plan for each patient to clarify treatment goals and offer assistance. Objectives: To use biopsychosocial screening at specified time points to identify needs and evaluate the impact of supportive care as part of standardized oncology care regardless of stage. Methods: This assessment utilized Oncology Care Model (OCM) data for Jefferson Medicare patients between 7/1/16 to 7/31/18. Incidence of ED admits ED/Observation and admissions were evaluated as well as ICU utilization and advanced care planning. Poisson regression was used to generate incidence rate ratios (IRR) and 95% confidence intervals (CI) to facilitate the comparison of post- vs. pre- incidence rates of hospitalization. Results: The post-intervention hospital admissions decreased by 31% in NCSMCS (IRR 0.69; 95% CI 0.48-0.98) and by 10% in Non-NCSMCS (IRR 0.90; 0.84-0.96) and advanced care plans were more likely to be on file for NCSMCS (9.0% vs. 4.9%). The intensive care unit (ICU) admissions were decreased by 17% among Non-NCSMCS (IRR 0.83; 95% CI 0.74-0.93). The utilization rates for ED admissions were not statistically different among both the groups. Conclusions: The preliminary data is promising and impact will be monitored as the intervention is expanded. Reducing admissions has benefits from both a cost savings as well as quality of life perspective. Future analyses will consider the impact of the intervention on a patient’s quality of life.

Advance Care Planning in a Geriatric Primary Care Clinic: A Retrospective Chart Review

PURPOSE:

Advance care planning (ACP) is theorized to benefit both the patient and their family when end of life is near as well as earlier in the course of serious illness. However, ACP remains underutilized, and little is known about the nature of ACP documentation in geriatrics practices. The study investigated the prevalence and nature of ACP documentation within a geriatric primary care clinic.

METHODS:

A retrospective chart review was conducted on a randomly selected sample of electronic medical record (EMR) charts. The sample consisted of patients aged 65 and older who were seen in the clinic from January 1, 2015, to December 31, 2016. Charts were reviewed for ACP documentation and data regarding age, gender, race, religion, comorbidities (end-stage renal disease, congestive heart failure, cancer, and dementia), recent hospitalizations, and visit type.

RESULTS:

Ninety-eight charts were reviewed (n = 98). Nine patients (9.18%) had an advance directive (AD) or power of attorney (POA) available within their EMR. Twenty-five patients (25.5%) had provider notes documenting that they have an AD, POA, or preferred health-care decision maker; however, no documents were available. The remaining 64 (65.3%) patients had no evidence of ACP documentation within their EMR. Age was the only demographic variable associated with completion of an AD ( P = .038).

DISCUSSION:

The rate of ACP documentation (34.6%) was lower than the average among US adults aged 65 and over (45.6%); further, most patients with ACP documentation did not have an AD or POA on file. The authors plan to reevaluate ACP statistics in the same office following a future intervention.

Telemedicine and Palliative Care: an Increasing Role in Supportive Oncology

With the emergence of telemedicine as a routine form of care in various venues, the opportunities to use technology to care for the most vulnerable, most ill cancer patients are extremely appealing. Increasingly, evidence supports early integration of palliative care with standard oncologic care, supported by recent NCCN guidelines to increase and improve access to palliative care. This review looks at the use of telemedicine to expand access to palliative care as well as provide better care for patients and families where travel is difficult, if not impossible. When telemedicine has been used, often in Europe, for palliative care, the results show improvements in symptom management, comfort with care as well as patient and family satisfaction. One barrier to use of telemedicine is the concerns with technology and technology-related complications in population that is often elderly, frail and not always comfortable with non-face-to-face physician care. There remain significant opportunities to explore this intersection of supportive care and telemedicine.

Race as a Predictor of Palliative Care Referral Time, Hospice Utilization, and Hospital Length of Stay: A Retrospective Noncomparative Analysis

BACKGROUND

Palliative care is associated with significant benefits, including reduced pain and suffering, an increased likelihood of patients dying in their preferred location, and decreased health-care expenditures. Racial and ethnic disparities are well-documented in hospice use and referral patterns; however, it is unclear whether these disparities apply to inpatient palliative care services.

OBJECTIVE

To determine if race is a significant predictor of time to inpatient palliative care consult, patient enrollment in hospice, and patients' overall hospital length of stay among patients of an inpatient palliative care service.

DESIGN

Retrospective noncomparative analysis.

SETTING

Urban academic medical center in the United States.

PATIENTS

3207 patients referred to an inpatient palliative care service between March 2006 and April 2015.

MEASUREMENTS

Time to palliative care consult, disposition of hospice/not hospice (excluding patients who died), and hospital length of stay among patients by racial (Asian, black, Native American/Eskimo, Hispanic, white, Unknown) and ethnic (Hispanic/Latino, non-Hispanic, Unknown) background.

RESULTS

Race was not a significant predictor of time to inpatient palliative care consult, discharge to hospice, or hospital length of stay. Similarly, black/white, Hispanic/white, and Asian/white variables were not significant predictors of hospice enrollment ( Ps > .05).

LIMITATIONS

Study was conducted at 1 urban academic medical center, limiting generalizability; hospital race and ethnicity categorizations may also limit interpretation of results.

CONCLUSIONS

In this urban hospital, race was not a predictor of time to inpatient palliative care service consult, discharge to hospice, or hospital length of stay. Confirmatory studies of inpatient palliative care services in other institutions are needed.

Common questions about wound care

Lacerations, abrasions, burns, and puncture wounds are common in the outpatient setting. Because wounds can quickly become infected, the most important aspect of treating a minor wound is irrigation and cleaning. There is no evidence that antiseptic irrigation is superior to sterile saline or tap water. Occlusion of the wound is key to preventing contamination. Suturing, if required, can be completed up to 24 hours after the trauma occurs, depending on the wound site. Tissue adhesives are equally effective for low-tension wounds with linear edges that can be evenly approximated. Although patients are often instructed to keep their wounds covered and dry after suturing, they can get wet within the first 24 to 48 hours without increasing the risk of infection. There is no evidence that prophylactic antibiotics improve outcomes for most simple wounds. Tetanus toxoid should be administered as soon as possible to patients who have not received a booster in the past 10 years. Superficial mild wound infections can be treated with topical agents, whereas deeper mild and moderate infections should be treated with oral antibiotics. Most severe infections, and moderate infections in high-risk patients, require initial parenteral antibiotics. Severe burns and wounds that cover large areas of the body or involve the face, joints, bone, tendons, or nerves should generally be referred to wound care specialists.