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Gruen J, Gandhi P, Gillespie-Heyman S, Shamas T, Adelman S, Ruskin A, Bauer M, Merchant N. Hospitalisations for heart failure: increased palliative care referrals - a veterans affairs hospital initiative. BMJ Support Palliat Care 2023:spcare-2022-004118. [PMID: 36609533 DOI: 10.1136/spcare-2022-004118] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Heart failure (HF) portends significant morbidity and mortality. Integrating palliative care (PC) with HF management improves quality of life and preparedness planning. At a Veterans Affairs hospital, PC was used in 6.5% of patients admitted for HF from October 2019 to September 2020. We sought to increase the percentage of referrals to PC to 20%. METHODS PC referral guidelines were developed and used to screen all HF admissions between October 2020 and May 2021. Point-of-care education on the benefits of PC was delivered to teams caring for patients who met PC referral criteria. Changes were tested using Plan-Do-Study-Act (PDSA) cycles. Results were analysed using run charts. RESULTS During the study period, there were 109 HF admissions in patients who were not already followed by PC. Thirty-one (28%) received a new PC consult. The mean age was 81±9.5 years, median B-type natriuretic peptide was 1202 pg/mL, and mean length of stay was 8±5 days. After our intervention, there was an upward shift in the percentage of new referrals to PC with 6 values above the baseline median, which represents a significant change. CONCLUSIONS Through multiple PDSA cycles, referrals to PC for patients admitted with HF increased from 6.5% to 28%. Point-of-care education was an effective tool to teach medical teams about the benefits of PC. Inpatient teams more consistently and independently considered PC for patients with HF, representing a cultural shift. This quality improvement model may serve as a paradigm to improve the care of HF patients.
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Affiliation(s)
- Jadry Gruen
- Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Parul Gandhi
- Cardiovascular Disease, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Cardiovascular Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sarah Gillespie-Heyman
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Tracy Shamas
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Samuel Adelman
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Andrea Ruskin
- Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Margaret Bauer
- Mental Health, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Naseema Merchant
- Hospital Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Presley CJ, Kaur K, Han L, Soulos PR, Zhu W, Corneau E, O'Leary JR, Chao H, Shamas T, Rose MG, Lorenz KA, Levy CR, Mor V, Gross CP. Aggressive End-of-Life Care in the Veterans Health Administration versus Fee-for-Service Medicare among Patients with Advanced Lung Cancer. J Palliat Med 2022; 25:932-939. [PMID: 35363053 PMCID: PMC9360181 DOI: 10.1089/jpm.2021.0436] [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] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Unlike fee-for-service Medicare, the Veterans Health Administration (VHA) allows for the provision of concurrent care, incorporating cancer treatment while in hospice. Methods: We compared trends of aggressive care at end of life between Medicare and VHA decedents with advanced nonsmall cell lung cancer from 2006 to 2012, and the relation between regional level end-of-life care between Medicare and VHA beneficiaries. Results: Among 18,371 Veterans and 25,283 Medicare beneficiaries, aggressive care at end of life decreased 15% in VHA and 4% in SEER (Surveillance, Epidemiology, and End Results)-Medicare (p < 0.001). Hospice use significantly increased within both cohorts (VHA 28%-41%; SM 60%-73%, p < 0.001). Veterans receiving care in regions with higher hospice admissions among Medicare beneficiaries were significantly less likely to receive aggressive care at end of life (adjusted odds ratio: 0.13, 95% confidence interval: 0.08-0.23, p < 0.001). Conclusions: Patients receiving lung cancer care in the VHA had a greater decline in aggressive care at end of life, perhaps due to increasing concurrent care availability.
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Affiliation(s)
- Carolyn J. Presley
- Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
- Address correspondence to: Carolyn J. Presley, MD, Division of Medical Oncology, The Ohio State University, 1800 Cannon Drive, 13th Floor, Columbus, OH 43210, USA
| | - Kiranveer Kaur
- Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Ling Han
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Pamela R. Soulos
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Weiwei Zhu
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Emily Corneau
- Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, Rhode Island, USA
| | - John R. O'Leary
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Herta Chao
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Connecticut Veterans Health Administration, West Haven, Connecticut, USA
| | - Tracy Shamas
- Connecticut Veterans Health Administration, West Haven, Connecticut, USA
| | - Michal G. Rose
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Connecticut Veterans Health Administration, West Haven, Connecticut, USA
| | - Karl A. Lorenz
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California, USA
- School of Medicine, Stanford University, Stanford, California, USA
| | - Cari R. Levy
- Eastern Colorado VA Healthcare System, Aurora, Colorado, USA
| | - Vincent Mor
- Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Cary P. Gross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut, USA
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Bauer MR, Shamas T, Gillespie-Heyman S, Ruskin A. Feasibility of Safe Opioid Prescribing in Outpatient Palliative Care: A Quality Improvement Project. J Pain Symptom Manage 2021; 62:410-415. [PMID: 33647421 DOI: 10.1016/j.jpainsymman.2021.02.006] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND No guidelines for safe opioid prescribing in palliative care exist, which contributes to limited monitoring of opioid misuse in palliative care. MEASURES Feasibility of a safe opioid prescribing standard operating protocol (SOP) was determined by assessing the percentage of patients in an outpatient cancer center who completed each component of a five-component SOP. INTERVENTION A five-component SOP included: risk stratification for misuse, consent form, prescription drug monitoring program review, urine drug testing, and Naloxone for high-risk individuals. OUTCOMES After one year, compliance rates on four of the of the five-component SOP were greater or equal to 93%. Naloxone co-prescription for high-risk patients never reached over 78%, largely due to clinical decision not to co-prescribe if transition to hospice was imminent. CONCLUSIONS/LESSONS LEARNED Safe opioid prescribing measures are feasible in outpatient palliative care and can facilitate identification of individuals at risk for opioid misuse and prompt early interventions for misuse.
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Affiliation(s)
| | - Tracy Shamas
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | | | - Andrea Ruskin
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
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Affiliation(s)
- Kathleen M Akgün
- VA-Connecticut Healthcare System, West Haven, CT, United States; Yale School of Medicine, New Haven, CT, United States
| | - David Collett
- Mount Sinai Health System, New York, NY, United States
| | - Shelli L Feder
- VA-Connecticut Healthcare System, West Haven, CT, United States; Yale School of Nursing, P.O. Box 27399, West Haven, CT 06516, United States
| | - Tracy Shamas
- VA-Connecticut Healthcare System, West Haven, CT, United States
| | - Dena Schulman-Green
- Yale School of Nursing, P.O. Box 27399, West Haven, CT 06516, United States.
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Presley CJ, Kaur K, Han L, Soulos PR, Zhu W, Corneau E, O'Leary JR, Chao HH, Shamas T, Rose MG, Lorenz K, Levy C, Mor V, Gross CP. Aggressive care at end-of-life in the Veteran’s Health Administration versus fee-for-service Medicare among patients with advanced lung cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.12025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12025 Background: The Veteran’s Health Administration (VHA) allows simultaneous receipt of cancer treatment and hospice care, termed concurrent care, while fee-for-service Medicare does not. Although many physicians who care for patients in the VHA also care for private sector patients, it is unclear whether there is a “spillover” relation between end of life (EOL) care in the VHA and Medicare systems at the regional level. We examined temporal trends, as well as regional-level associations between Medicare and VHA EOL practice for patients with advanced lung cancer. Methods: We conducted a retrospective study on VHA and SEER-Medicare (SM) decedents from 2006-2012 with stage IV non-small cell lung cancer (NSCLC) who received any lung cancer care. Aggressive care (AC) at EOL was defined as any of the following within 30 days of death– intensive care unit (ICU) admission, no-hospice care, cardiopulmonary resuscitation(CPR), mechanical ventilation (MV), > 1 inpatient admission and receipt of chemotherapy. Descriptive statistics were used to compare outcomes. We also analyzed the association between Medicare hospital referral region (HRR) hospice admissions, Medicare HRR EOL spending, and VHA AC use adjusted for patient’s characteristics using a random intercept mixed effect logistic regression model after matching VHA facilities with Medicare facilities in a particular HRR. Results: AC use significantly decreased during the study period, from 46% to 31% among 18,371 Veterans and from 42% to 38% among 25,283 in the SM cohort, (t-test P < .05). Hospice use significantly increased within both cohorts (p < .001). The receipt of chemotherapy at EOL was similar for both cohorts throughout the study period. Veterans who received care in regions with higher hospice admissions among Medicare beneficiaries were significantly less likely to receive AC at EOL (adjusted Odds Ratio (aOR): 0.13 95%CI: 0.08-0.23, P < .001) than veterans in regions with lower Medicare hospice use. Medicare HRR spending at the EOL was not associated with receipt of AC among Medicare beneficiaries (aOR): 1.004 95%CI: 1.00-1.009, P = 0.07). Conclusions: Perhaps due to availability of concurrent care, VHA patients received less aggressive care at EOL as compared to SM patients. At the regional level, greater hospice use among Medicare beneficiaries was significantly associated with reduced AC within the VHA.
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Affiliation(s)
| | | | - Ling Han
- Yale School of Medicine, New Haven, CT
| | | | | | | | | | | | - Tracy Shamas
- Connecticut Veterans Health Administration, West Haven, CT
| | | | - Karl Lorenz
- Center for Innovation to Implementation, VA Palo Alto and Stanford University, Stanford, CA
| | - Cari Levy
- Rocky Mountain Regional VA Medical Center, University of Colorado Denver, Denver, CO
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Presley CJ, Han L, O'Leary JR, Zhu W, Corneau E, Chao H, Shamas T, Rose M, Lorenz K, Levy CR, Mor V, Gross CP. Concurrent Hospice Care and Cancer-Directed Treatment for Advanced Lung Cancer and Receipt of Aggressive Care at the End of Life in the Veteran's Health Administration. J Palliat Med 2020; 23:1038-1044. [PMID: 32119800 DOI: 10.1089/jpm.2019.0485] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Aggressive care at the end of life (EOL) is a persistent issue for patients with stage IV nonsmall cell lung cancer (NSCLC). We evaluated the use of concurrent care (CC) with hospice care and cancer-directed treatment simultaneously within the Veteran's Health Administration (VHA) and aggressive care at the EOL. Objective: To determine whether VHA facility-level CC is associated with changes in aggressive care at the EOL. Design/Setting: Veterans with stage IV NSCLC who died between 2006 and 2012 and received lung cancer care within the VHA. Measurements: The primary outcome was aggressive care at EOL (i.e., hospital admissions, chemotherapy, and intensive care unit) within the last month of life. To compare aggressive care across VHA facilities, we used a random intercept multilevel logistic regression model to examine the association between facility-level CC within each study year (<10%, 10% to 19%, and ≥20%) and aggressive care at the EOL among the decedents as a binary outcome. Results: In total, 18,371 veterans with NSCLC at 154 VHA facilities were identified. Facilities delivering CC for ≥20% of veterans (high CC) increased from 20.0% in 2006 to 43.2% in 2012 (p < 0.001). Overall, hospice care significantly increased and aggressive care at EOL decreased over the study period. However, facility-level CC adoption was not associated with any difference in aggressive care at EOL (adjusted odds ratio high CC vs. low CC: 0.91 [95% CI, 0.79 to 1.05], p = 0.21). Conclusions: Although the VHA adoption of CC increased hospice use among patients with NSCLC, additional measures may be needed to decrease aggressive care at the EOL.
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Affiliation(s)
- Carolyn J Presley
- Department of Internal Medicine, Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ling Han
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - John R O'Leary
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Weiwei Zhu
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Emily Corneau
- Providence Veterans Health Administration Medical Center, Center of Innovation, Providence, Rhode Island, USA
| | - Herta Chao
- Yale University School of Medicine, New Haven, Connecticut, USA.,Connecticut Veterans Health Administration Medical Center, West Haven, Connecticut, USA
| | - Tracy Shamas
- Connecticut Veterans Health Administration Medical Center, West Haven, Connecticut, USA
| | - Michal Rose
- Yale University School of Medicine, New Haven, Connecticut, USA.,Connecticut Veterans Health Administration Medical Center, West Haven, Connecticut, USA
| | - Karl Lorenz
- Department of Medicine, Primary Care and Population Health, Stanford University, Palo Alto, California, USA
| | - Cari R Levy
- Eastern Colorado VA Healthcare System, Aurora, Colorado, USA
| | - Vincent Mor
- Providence Veterans Health Administration Medical Center, Center of Innovation, Providence, Rhode Island, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Cary P Gross
- National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut, USA
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Patwa H, Coffee C, Shamas T. End of life decision making and palliative care services in a multidisciplinary amyotrophic lateral sclerosis clinic. J Neurol Sci 2019. [DOI: 10.1016/j.jns.2019.10.1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
One aspect of palliative medicine that has been underexplored is the perspective of veterans either facing critical life-limiting illness or at the end of life. The needs of veterans differ not only because military culture affects how veterans cope with their illness but also because exposure-related factors (combat and environmental) differ between military branches. In this paper, we describe two cases involving end-of-life care for veterans with combat trauma and describe individualized approaches to their care.
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Affiliation(s)
- Tracy Shamas
- A palliative care advanced practice registered nurse and coordinator of the palliative care consultation team at the VA Connecticut Healthcare System
| | - Sarah Gillespie-Heyman
- A palliative care advanced practice registered nurse and a primary clinician for the palliative care consultation team at the VA Connecticut Healthcare System
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