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Bock M, Katz M, Sillau S, Adjepong K, Yaffe K, Ayele R, Macchi ZA, Pantilat S, Miyasaki JM, Kluger B. What's in the Sauce? The Specific Benefits of Palliative Care for Parkinson's Disease. J Pain Symptom Manage 2022; 63:1031-1040. [PMID: 35114353 PMCID: PMC9395211 DOI: 10.1016/j.jpainsymman.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/19/2022] [Accepted: 01/22/2022] [Indexed: 10/19/2022]
Abstract
CONTEXT Increasing evidence demonstrates the benefits of palliative care among individuals with Parkinson's disease and related disorders (PDRD), but the critical components that contribute to therapeutic effects are not well understood. OBJECTIVES To determine the specific items most responsive to a palliative care intervention in PDRD and identify key correlates of improvement in patient and care partner outcomes. METHODS The main trial was a pragmatic comparative effectiveness trial of outpatient integrated palliative care compared to standard care among participants with PDRD (NCT02533921), showing significantly higher patient QOL at six months and lower care partner burden at 12 months. We used longitudinal regression models to analyze changes in subdomains of patient QOL and care partner burden and Spearman correlations to evaluate key correlates of change scores in patient and care partner outcomes. We performed a secondary analysis of data from 210 patients and 175 care partners. RESULTS Compared to controls, patients in the intervention reported greater improvement in perceptions of the "self as a whole" at six months (coeff = 0.22, P < 0.05) and care partners reported greater reduction in stress, anger, and loss of control at 12 months (coeff = -.40, -0.25, -0.31, P < 0.05). Positive change in numerous patient non-motor symptoms and grief correlated with improved patient QOL, reduced patient anxiety, and increased care partner spirituality. Alleviation of care partner anxiety and depression correlated with reduced care partner burden. CONCLUSION Specific benefits of an integrated palliative approach in PDRD include improvement in patient holistic self-impressions, care partner self-efficacy, and non-motor symptoms.
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Affiliation(s)
- Meredith Bock
- Department of Neurology, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.
| | - Maya Katz
- Department of Neurology, Stanford University, California, USA
| | - Stefan Sillau
- Department of Neurology, University of Colorado Anschutz Medical Campus, Colorado, USA
| | - Kwame Adjepong
- Department of Neurology, University of California, San Francisco, California, USA
| | - Kristine Yaffe
- Department of Neurology, University of Colorado Anschutz Medical Campus, Colorado, USA; Department of Psychiatry, University of California, San Francisco, California, USA; Department of Epidemiology, University of California, San Francisco, California, USA
| | - Roman Ayele
- Department of Health Systems, Management and Policy, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Zachary A Macchi
- Department of Neurology, University of Colorado Anschutz Medical Campus, Colorado, USA
| | - Steven Pantilat
- Department of Medicine, Division of Palliative Medicine at University of California, San Francisco California, USA
| | - Janis M Miyasaki
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada
| | - Benzi Kluger
- Departments of Neurology and Medicine, Division of Palliative Care, University of Rochester, Rochester, New Year, USA
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Kluger BM, Kramer NM, Katz M, Galifianakis NB, Pantilat S, Long J, Vaughan CL, Foster LA, Creutzfeldt CJ, Holloway RG, Sillau S, Hauser J. Development and Dissemination of a Neurology Palliative Care Curriculum: Education in Palliative and End-of-Life Care Neurology. Neurol Clin Pract 2022; 12:176-182. [PMID: 35747891 PMCID: PMC9208408 DOI: 10.1212/cpj.0000000000001146] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/09/2021] [Indexed: 11/15/2022]
Abstract
ABSTRACTDespite increasing awareness of the importance of a palliative care approach to meet the needs of persons living with neurologic illness, residency and fellowship programs report meeting this educational need due to a limited pool of neuropalliative care educators and a lack of adequate educational resources. To meet this need, a group of experts in neuropalliative care and palliative medicine leveraged resources from the Education in Palliative and End-of-life Care (EPEC) program and the National Institutes of Nursing Research (NINR) to create a library of modules addressing topics relevant for neurology trainees, palliative medicine fellows and clinicians in practice. In this manuscript, we describe the development and dissemination plan of the Education in Palliative and End-of-life Care Neurology (EPEC-N) program, initial evidence of efficacy, and opportunities for neurology educators and health services researchers to utilize these resources.
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Affiliation(s)
- Benzi M Kluger
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Neha M Kramer
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Maya Katz
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Nicholas B Galifianakis
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Steven Pantilat
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Judith Long
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Christina L Vaughan
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Laura A Foster
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Claire J Creutzfeldt
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Robert G Holloway
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Stefan Sillau
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
| | - Joshua Hauser
- Departments of Neurology and Medicine (BMK, RGH), University of Rochester Medical Center, NY; Department of Internal Medicine (NMK), Rush University Medical College, Chicago, IL; Division of Palliative Medicine and Department of Medicine (MK, NBG, SP, JL), University of California, San Francisco; Department of Neurology (CLV, LAF, SS), University of Colorado Anschutz Medical Campus, Aurora; Department of Neurology (CJC), University of Washington, Seattle; and Departments of Palliative and Internal Medicine (JH), Northwestern University, Chicago, IL
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Kluger BM, Miyasaki J, Katz M, Galifianakis N, Hall K, Pantilat S, Khan R, Friedman C, Cernik W, Goto Y, Long J, Fairclough D, Sillau S, Kutner JS. Comparison of Integrated Outpatient Palliative Care With Standard Care in Patients With Parkinson Disease and Related Disorders: A Randomized Clinical Trial. JAMA Neurol 2021; 77:551-560. [PMID: 32040141 PMCID: PMC7042842 DOI: 10.1001/jamaneurol.2019.4992] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Importance Parkinson disease and related disorders (PDRD) have consequences for quality of life (QoL) and are the 14th leading cause of death in the United States. Despite growing interest in palliative care (PC) for persons with PDRD, few studies are available supporting its effectiveness. Objective To determine if outpatient PC is associated with improvements in patient-centered outcomes compared with standard care among patients with PDRD and their caregivers. Design, Setting, and Participants This randomized clinical trial enrolled participants at 3 academic tertiary care centers between November 1, 2015, and September 30, 2017, and followed them up for 1 year. A total of 584 persons with PDRD were referred to the study. Of those, 351 persons were excluded by phone and 23 were excluded during in-person screenings. Patients were eligible to participate if they had PDRD and moderate to high PC needs. Patients were excluded if they had urgent PC needs, another diagnosis meriting PC, were already receiving PC, or were unable or unwilling to follow the study protocol. Enrolled participants were assigned to receive standard care plus outpatient integrated PC or standard care alone. Data were analyzed between November 1, 2018, and December 9, 2019. Interventions Outpatient integrated PC administered by a neurologist, social worker, chaplain, and nurse using PC checklists, with guidance and selective involvement from a palliative medicine specialist. Standard care was provided by a neurologist and a primary care practitioner. Main Outcomes and Measures The primary outcomes were the differences in patient quality of life (QoL; measured by the Quality of Life in Alzheimer Disease scale) and caregiver burden (measured by the Zarit Burden Interview) between the PC intervention and standard care groups at 6 months. Results A total of 210 patients with PDRD (135 men [64.3%]; mean [SD] age, 70.1 [8.2] years) and 175 caregivers (128 women [73.1%]; mean [SD] age, 66.1 [11.1] years) were enrolled in the study; 193 participants (91.9%) were white and non-Hispanic. Compared with participants receiving standard care alone at 6 months, participants receiving the PC intervention had better QoL (mean [SD], 0.66 [5.5] improvement vs 0.84 [4.2] worsening; treatment effect estimate, 1.87; 95% CI, 0.47-3.27; P = .009). No significant difference was observed in caregiver burden (mean [SD], 2.3 [5.0] improvement vs 1.2 [5.6] improvement in the standard care group; treatment effect estimate, -1.62; 95% CI, -3.32 to 0.09; P = .06). Other significant differences favoring the PC intervention included nonmotor symptom burden, motor symptom severity, completion of advance directives, caregiver anxiety, and caregiver burden at 12 months. No outcomes favored standard care alone. Secondary analyses suggested that benefits were greater for persons with higher PC needs. Conclusions and Relevance Outpatient PC is associated with benefits among patients with PDRD compared with standard care alone. This study supports efforts to integrate PC into PDRD care. The lack of diversity and implementation of PC at experienced centers suggests a need for implementation research in other populations and care settings. Trial Registration ClinicalTrials.gov Identifier: NCT02533921.
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Affiliation(s)
- Benzi M Kluger
- Department of Neurology, Anschutz Medical Campus, University of Colorado, Denver, Aurora.,Now with Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Janis Miyasaki
- Department of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Maya Katz
- Department of Neurology, University of California, San Francisco, San Francisco
| | | | - Kirk Hall
- Department of Neurology, Anschutz Medical Campus, University of Colorado, Denver, Aurora
| | - Steven Pantilat
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco
| | - Ryan Khan
- Department of Neurology, Anschutz Medical Campus, University of Colorado, Denver, Aurora
| | - Cari Friedman
- Department of Neurology, Anschutz Medical Campus, University of Colorado, Denver, Aurora
| | - Wendy Cernik
- Department of Neurology, Anschutz Medical Campus, University of Colorado, Denver, Aurora
| | - Yuika Goto
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco
| | - Judith Long
- Department of Neurology, University of California, San Francisco, San Francisco
| | - Diane Fairclough
- Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora
| | - Stefan Sillau
- Department of Neurology, Anschutz Medical Campus, University of Colorado, Denver, Aurora
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Colorado, Aurora
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4
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Affiliation(s)
- Benzi M Kluger
- University of Rochester Medical Center, Rochester, New York
| | - Steven Pantilat
- University of California School of Medicine, San Francisco, San Francisco
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5
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Anderson WG, Puntillo K, Boyle D, Barbour S, Turner K, Cimino J, Moore E, Noort J, MacMillan J, Pearson D, Grywalski M, Liao S, Ferrell B, Meyer J, O'Neil-Page E, Cain J, Herman H, Mitchell W, Pantilat S. ICU Bedside Nurses' Involvement in Palliative Care Communication: A Multicenter Survey. J Pain Symptom Manage 2016; 51:589-596.e2. [PMID: 26596882 DOI: 10.1016/j.jpainsymman.2015.11.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 10/30/2015] [Accepted: 11/09/2015] [Indexed: 11/19/2022]
Abstract
CONTEXT Successful and sustained integration of palliative care into the intensive care unit (ICU) requires the active engagement of bedside nurses. OBJECTIVES To describe the perspectives of ICU bedside nurses on their involvement in palliative care communication. METHODS A survey was designed, based on prior work, to assess nurses' perspectives on palliative care communication, including the importance and frequency of their involvement, confidence, and barriers. The 46-item survey was distributed via e-mail in 2013 to bedside nurses working in ICUs across the five academic medical centers of the University of California, U.S. RESULTS The survey was sent to 1791 nurses; 598 (33%) responded. Most participants (88%) reported that their engagement in discussions of prognosis, goals of care, and palliative care was very important to the quality of patient care. A minority reported often discussing palliative care consultations with physicians (31%) or families (33%); 45% reported rarely or never participating in family meeting discussions. Participating nurses most frequently cited the following barriers to their involvement in palliative care communication: need for more training (66%), physicians not asking their perspective (60%), and the emotional toll of discussions (43%). CONCLUSION ICU bedside nurses see their involvement in discussions of prognosis, goals of care, and palliative care as a key element of overall quality of patient care. Based on the barriers participants identified regarding their engagement, interventions are needed to ensure that nurses have the education, opportunities, and support to actively participate in these discussions.
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Affiliation(s)
- Wendy G Anderson
- Division of Hospital Medicine and Palliative Care Program, University of California, San Francisco, California, USA.
| | - Kathleen Puntillo
- Department of Physiological Nursing, University of California San Francisco School of Nursing, San Francisco, California, USA
| | - Deborah Boyle
- University of California, Irvine Health, Orange, California, USA
| | - Susan Barbour
- University of California, San Francisco Medical Center, San Francisco, California, USA
| | - Kathleen Turner
- University of California, San Francisco Medical Center, San Francisco, California, USA
| | - Jenica Cimino
- Division of Hospital Medicine and Palliative Care Program, University of California, San Francisco, California, USA
| | - Eric Moore
- University of California, Davis Medical Center, Sacramento, California, USA
| | - Janice Noort
- University of California, Davis Medical Center, Sacramento, California, USA
| | - John MacMillan
- University of California, Davis Medical Center, Sacramento, California, USA
| | - Diana Pearson
- University of California, Davis Medical Center, Sacramento, California, USA
| | | | - Solomon Liao
- University of California, Irvine Health, Orange, California, USA
| | - Bruce Ferrell
- University of California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Jeannette Meyer
- University of California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Edith O'Neil-Page
- University of California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Julia Cain
- University of California, San Diego Medical Center, San Diego, California, USA
| | - Heather Herman
- University of California, San Diego Medical Center, San Diego, California, USA
| | - William Mitchell
- University of California, San Diego Medical Center, San Diego, California, USA
| | - Steven Pantilat
- Division of Hospital Medicine and Palliative Care Program, University of California, San Francisco, California, USA
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Howie-Esquivel J, Carroll M, Brinker E, Kao H, Pantilat S, Rago K, De Marco T. A Strategy to Reduce Heart Failure Readmissions and Inpatient Costs. Cardiol Res 2015; 6:201-208. [PMID: 28197226 PMCID: PMC5295554 DOI: 10.14740/cr384w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2015] [Indexed: 01/19/2023] Open
Abstract
Background The objective of this study was to evaluate the effect of a disease management intervention on rehospitalization rates in hospitalized heart failure (HF) patients. Methods Patients treated with the TEACH-HF intervention that included Teaching and Education, prompt follow-up Appointments, Consultation for support services, and Home follow-up phone calls (TEACH-HF) from January 2010 to January 2012 constituted the intervention group (n = 548). Patients treated from January 2007 to January 2008 constituted the usual care group (n = 485). Results Group baseline characteristics were similar with 30-day readmission rates significantly different (19% usual care vs. 12% for the intervention respectively (P = 0.003)). Patients in the usual care group were 1.5 times more likely to be hospitalized (95% CI: 1.2 - 1.9; P = 0.001) compared to the intervention group. A savings of 641 bed days with potential revenue of $640,000 occurred after TEACH-HF. Conclusions The TEACH-HF intervention was associated with significantly fewer hospital readmissions and savings in bed days.
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Affiliation(s)
- Jill Howie-Esquivel
- Department of Physiological Nursing, University of California, San Francisco, CA, USA
| | - Maureen Carroll
- University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Eileen Brinker
- University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Helen Kao
- University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Steven Pantilat
- University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Karen Rago
- University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Teresa De Marco
- University of California San Francisco Medical Center, San Francisco, CA, USA
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Brousseau RT, Jameson W, Kalanj B, Kerr K, O'Malley K, Pantilat S. A Multifaceted Approach to Spreading Palliative Care Consultation Services in California Public Hospital Systems. J Healthc Qual 2012; 34:77-85. [DOI: 10.1111/j.1945-1474.2011.00197.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
It has frequently been claimed that palliative care (PC) consultation services reduce hospital length of stay (LOS). We review 12 published studies comparing patients receiving PC or similar intervention and patients receiving usual care with regard to average total hospital LOS. None of the six observational studies showed LOS impact. Three of the four quasi-experiments and one of the two randomized controlled trials reported LOS reduction for at least one subsample. Reduced LOS was demonstrated only for decedents in intensive care unit-based interventions using experimental or quasi-experimental research designs. PC program leaders are cautioned against promising that their inpatient consultations will reduce the length of those admissions because this may be nearly impossible for a typical hospital-based PC program to demonstrate using observational data. Research to date has been handicapped by designs and methods not suitable for detecting an impact on LOS. Only three studies included survivors and decedents and disaggregated them in analysis and interpretation, despite profound differences in the meaning and implications of reduced LOS for survivors and decedents. Recommendations for future studies include conceptualizing, analyzing, and reporting outcomes separately for survivors and decedents; strengthening study design to reduce the likelihood of failing to detect actual LOS impact; using methods that allow for creation of a reasonable comparison group; and addressing the fundamental problem that LOS is both a predictor and criterion variable in observational studies of palliative care consultation services.
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Affiliation(s)
- J Brian Cassel
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia 23298-0037, USA.
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Bardach N, Zhao S, Pantilat S, Johnston SC. Adjustment for do-not-resuscitate orders reverses the apparent in-hospital mortality advantage for minorities. Am J Med 2005; 118:400-8. [PMID: 15808138 DOI: 10.1016/j.amjmed.2005.01.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2003] [Accepted: 09/21/2004] [Indexed: 12/21/2022]
Abstract
PURPOSE The use of do-not-resuscitate (DNR) orders may differ by sex or ethnicity, and DNR status may be associated with outcomes for hospitalized patients. Thus, we sought to determine whether differences in rates of DNR by sex and ethnicity influenced differences in mortality. SUBJECTS AND METHODS We included all patients admitted to nonfederal California hospitals in 1999 with stroke, congestive heart failure, pneumonia, chronic obstructive pulmonary disease, chronic renal failure, angina, or diabetes mellitus. Rates of physician orders for DNR written within 24 hours of hospital admission and in-hospital mortality were compared between sexes and ethnicities after adjustment for age, admission source and diagnosis, payment type, and comorbidity scores in multivariable logistic regression models. RESULTS Of 327890 patients included, 25196 (7.7%) had DNR orders. In adjusted models, women were more likely to have DNR orders than men (odds ratio [OR] 1.19; 95% confidence interval 1.16-1.23; P <0.001) and non-Hispanic whites were more likely to have DNR orders than other ethnicities (OR 1.75; 1.69-1.82; P <0.001). Overall, 13549 (4.1%) patients died in the hospital. Risk of death was greater in those with a DNR order (OR 7.0; 6.7-7.3; P <0.001). Non-Hispanic whites appeared to have a greater risk of in-hospital death in adjusted models (OR 1.09; 1.04-1.12; P <0.001) when DNR status was ignored; however, the risk of death appeared to be lower in non-Hispanic whites in the complete model with DNR included (OR 0.94; 0.90-0.99; P = 0.01). A survival advantage for women was also more apparent after including DNR status in the adjusted model. CONCLUSIONS Women and non-Hispanic whites are more likely to have DNR orders. DNR status affected the measurement of sex-ethnic differences in mortality risk.
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Affiliation(s)
- Naomi Bardach
- Department of Neurology, University of California-San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
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Abstract
In order to estimate the prevalence of palliative care programs in academic hospitals in the United States, we surveyed a random sample of 100 hospitals in the Council of Teaching Hospitals and Health Systems directory. Sixty percent of hospitals provided information. At least 26% of hospitals had either a palliative care consultation service or inpatient unit and 7% had both. Eighteen percent of hospitals had a palliative care consultation service alone, 19% had an inpatient palliative care unit, 22% reported a hospice affiliation, and 17% had a hospice inpatient contract. Additionally, at least 20% of the remaining hospitals were planning a palliative care program. The consultation services had an average daily census of 6; the inpatient units had an average of 12 beds. Palliative care consultation programs were largely affiliated with departments of medicine or hematology/oncology, and were typically staffed by a physician and a nurse. Only half had a dedicated social worker, one third had a chaplain, one third had a pharmacist, and a few included a bereavement coordinator or volunteer director, suggesting that the hospice model of interdisciplinary care is not being adopted regularly in palliative care programs. In comparison, almost half of hospitals noted established pain services. In conclusion, palliative care programs, although found in a minority of surveyed hospitals, are becoming an established feature of academic medical centers in the United States. More detailed information is needed about the type and quality of care they provide.
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Affiliation(s)
- J A Billings
- Palliative Care Service, Massachusetts General Hospital, Harvard Medical School Center for Palliative Care, Boston, Massachusetts, USA.
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11
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Pantilat S. Steven Pantilat: a palliative care specialist. (Interview by Barbara Boughton). Lancet Oncol 2001; 2:765-9. [PMID: 11902520 DOI: 10.1016/s1470-2045(01)00593-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVES National health care organizations recommend routinely screening patients for behavioral health risks, the effectiveness of which depends on patients' willingness to disclose risky behaviors. This study aimed to determine if primary care patients' disclosures of potentially stigmatizing behaviors would be affected by (1) their expectation about whether or not their physician would see their disclosures and (2) the assessment method. METHODS One thousand nine hundred fifty-two primary care patients completed a questionnaire assessing human immunodeficiency virus (HIV), alcohol, drug, domestic violence, tobacco, oral health, and seat belt risks; half were told their responses would be seen by the researcher and their physician and half were told that their responses would be seen by the researcher only. Patients were randomly assigned to one of five assessment methods: written, face-to-face, audio-based, computer-based, or video-based. RESULTS Across all risk areas, patients did not disclose differently whether or not they believed their physician would see their disclosures. Technologically advanced assessment methods (audio, computer, and video) produced greater risk disclosure (4%-8% greater) than traditional methods in three of seven risk areas. CONCLUSIONS These findings suggest patients are not less willing to disclose health risks to a research assistant knowing that this information would be shared with their physician and that a number of assessment methods can effectively elicit patient disclosure. Potentially small increases in risk disclosure must be weighed against other factors, such as cost and convenience, in determining which method(s) to use in different health care settings.
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Affiliation(s)
- B Gerbert
- Division of Behavioral Sciences, School of Dentistry, University of California San Francisco, 94111, USA.
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13
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Abstract
OBJECTIVE To develop and test a brief, reliable, and valid HIV-risk screening instrument for use in primary health care settings. DESIGN A two-phase study: (1) developing a self-administered HIV-risk screening instrument, and (2) testing it with a primary care population, including testing the effect of confidentiality on disclosure of HIV-risk behaviors. SETTING Phase 1: 3 types of sites (a blood donor center, a methadone clinic, and 2 STD clinics) representing low and high HIV-seroprevalence rates. Phase 2: 4 primary care sites. PARTICIPANTS Phase 1: 293 consecutively recruited participants. Phase 2: 459 randomly recruited primary care patients. MAIN OUTCOME MEASURE Phase 1: comparison of the responses of participants from low and high HIV-seroprevalence sites. Phase 2: primary care patients' rates of disclosure of HIV-risk behaviors and ratings of acceptability. RESULTS Phase 1: through examining item-confirmation rates, item-total correlations, and comparison of responses from low and high HIV-seroprevalence sites, we developed a final 10-item HIV-risk Screening Instrument (HSI) with an internal consistency coefficient of .73. Phase 2: 76% of primary care patients disclosed at least 1 risky behavior and 52% disclosed 2 or more risky behaviors. Patients were willing to disclose HIV-risk behaviors even knowing that their physician would see this information. Ninety-five percent of our patient participants were comfortable with the questions on the HSI, 78% felt it was important that their doctor know their answers, and 52% wished to discuss their answers with their physician. CONCLUSION Our brief, self-administered HSI is a reliable and valid measure. The HSI can be used in health care settings to identify individuals at risk for HIV and to initiate HIV testing, early care, and risk-reduction counseling, necessary goals for effective HIV prevention efforts.
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Affiliation(s)
- B Gerbert
- Division of Behavioral Sciences, School of Dentistry, University of California, San Francisco 94111, USA
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14
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Abstract
OBJECTIVE To determine whether a brief, multicomponent intervention could improve the skin cancer diagnosis and evaluation planning performance of primary care residents to a level equivalent to that of dermatologists. PARTICIPANTS Fifty-two primary care residents (26 in the control group and 26 in the intervention group) and 13 dermatologists completed a pretest and posttest. DESIGN A randomized, controlled trial with pretest and posttest measurements of residents' ability to diagnose and make evaluation plans for lesions indicative of skin cancer. INTERVENTION The intervention included face-to-face feedback sessions focusing on residents' performance deficiencies; an interactive seminar including slide presentations, case examples, and live demonstrations; and the Melanoma Prevention Kit including a booklet, magnifying tool, measuring tool, and skin color guide. MEASUREMENTS AND MAIN RESULTS We compared the abilities of a control and an intervention group of primary care residents, and a group of dermatologists to diagnose and make evaluation plans for six categories of skin lesions including three types of skin cancer-malignant melanoma, squamous cell carcinoma, and basal cell carcinoma. At posttest, both the intervention and control group demonstrated improved performance, with the intervention group revealing significantly larger gains. The intervention group showed greater improvement than the control group across all six diagnostic categories (a gain of 13 percentage points vs 5, p < .05), and in evaluation planning for malignant melanoma (a gain of 46 percentage points vs 36, p < .05) and squamous cell carcinoma (a gain of 42 percentage points vs 21, p < .01). The intervention group performed as well as the dermatologists on five of the six skin cancer diagnosis and evaluation planning scores with the exception of the diagnosis of basal cell carcinoma. CONCLUSIONS Primary care residents can diagnose and make evaluation plans for cancerous skin lesions, including malignant melanoma, at a level equivalent to that of dermatologists if they receive relevant, targeted education.
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Affiliation(s)
- B Gerbert
- Department of Dental Public Health, School of Dentistry, University of California, San Francisco, 94111, USA
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15
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Gerbert B, Maurer T, Berger T, Pantilat S, McPhee SJ, Wolff M, Bronstone A, Caspers N. Primary care physicians as gatekeepers in managed care. Primary care physicians' and dermatologists' skills at secondary prevention of skin cancer. Arch Dermatol 1996; 132:1030-8. [PMID: 8795541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND DESIGN This study determines (1) the readiness of primary care physicians (PCPs) to triage optimally lesions suspicious for skin cancer, (2) the difference in their abilities from those of dermatologists, and (3) whether accurate diagnosis after viewing slide images transfers to accurate diagnosis after viewing lesions on patients. Seventy-one primary care residents and 15 dermatologists and resident dermatologists diagnosed and selected a treatment/diagnostic plan for skin lesions suspicious for cancer. The lesions were shown on slides, computer images, and patients. Participants' performance was compared with biopsy results of all lesions. RESULTS Dermatologists' scores were almost double those of primary care residents, and primary care residents' performance was positively associated with previous experience in dermatology. Primary care residents failed 50% of the time to diagnose correctly nonmelanoma skin cancer and malignant melanomas, and 33% of the time they failed to recommend biopsies for cancerous lesions. Primary care residents failed to diagnose malignant melanomas 40% of the time; dermatologists failed to do so 26% of the time. Both groups performed better using slide images compared with patients. CONCLUSIONS Primary care residents may not be ready to assume a gatekeeper role for lesions suspicious for skin cancer. Because of the seriousness of missed diagnoses, especially of malignant melanomas, we need to improve the triage skills of PCPs. Future studies should evaluate whether primary care training allows sufficient time for PCPs to learn the necessary skills. Until we can show that PCPs are prepared to triage optimally, managed care plans should reduce the threshold for referrals to dermatologists of potential skin cancers.
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Affiliation(s)
- B Gerbert
- Division of Behavioral Sciences, School of Dentistry, University of California-San Francisco, USA
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