Quality of palliative and end-of-life care: a quantitative study of temporal trends and differences according to illness trajectories in Quebec (Canada)

BACKGROUND

Our aim was to assess temporal trends and compare quality indicators related to Palliative and End-of-Life Care (PEoLC) experienced by people dying of cancer (trajectory I), organ-failure (Trajectory II), and frailty/dementia (trajectory III) in Quebec (Canada) between 2002 and 2016.

METHODS

This descriptive population-based study focused on the last month of life of decedents who, based on the principal cause of death, would have been likely to benefit from palliative care. Five PEoLC indicators were assessed: home deaths (1), deaths in acute care beds with no PEoLC services (2), at least one Emergency Room (ER) visit in the last 14 days of life (3), ER visits on the day of death (4) and at least one Intensive Care Unit (ICU) admission in the last month of life (5). Data were obtained from Quebec's Integrated Chronic Disease Surveillance System (QICDSS).

RESULTS

The annual percentage of home deaths increased slightly between 2002 and 2016 in Quebec, rising from 7.7 to 9.1%, while the percentage of death during a hospitalization in acute care without palliative care decreased from 39.6% in 2002 to 21.4% in 2016. Patients with organ failure were more likely to visit the ER on the day of death (20.9%) than patients dying of cancer and dementia/frailty with percentages of 12.0% and 6.4% respectively. Similar discrepancies were observed for ICU visits in the last month and ER visits in the last 14 days.

CONCLUSION

PEoLC indicators showed more aggressiveness of care for patients with organ failure and highlight the need for more equitable access to quality PEoLC between malignant and non-malignant illness trajectories. These results underline the challenges of providing timely and optimal PEoLC.

Health equity, care access and quality in headache - part 1

Current definitions of migraine that are based mainly on clinical characteristics do not account for other patient's features such as those related to an impaired quality of life, due to loss of social life and productivity, and the differences related to the geographical distribution of the disease and cultural misconceptions which tend to underestimate migraine as a psychosocial rather than neurobiological disorder.Global differences definition, care access, and health equity for headache disorders, especially migraine are reported in this paper from a collaborative group of the editorial board members of the Journal of Headache and Pain. Other components that affect patients with migraine, in addition to the impact promoted by the migraine symptoms such as stigma and social determinants, are also reported.

Inequitable access to nonpharmacologic pain treatment providers among cancer-free U.S. adults

OBJECTIVE

Using evidence-based nonpharmacologic pain treatments may prevent opioid overuse and associated adverse outcomes. There is limited data on the impact of access-promoting social determinants of health (SDoH: education, income, transportation) on use of nonpharmacologic pain treatments. Our objective was to examine the relationship between SDoH and use of nonpharmacologic pain treatment providers. Our goal was to understand policy-actionable factors contributing to inequity in pain treatment.

METHODS

Based on Andersen's Health Utilization Model, this cross-sectional analysis of 2016-2019 Medical Expenditure Panel Survey data evaluated whether use of outpatient nonpharmacologic pain treatment providers is driven by enabling (i.e., advantageous socioeconomic resources) or need (i.e., perceived disability and diagnosed disease) factors. The study sample (unweighted n = 28,188) represented a weighted N = 81,912,730 noninstitutionalized, cancer-free, U.S. adults with pain interference. The primary outcome measured use of nonpharmacologic providers relative to exclusive prescription opioid use or no treatment (i.e., neither opioids nor nonpharmacologic). To quantify equitable access, we compared the variance-between access-promoting enabling factors versus medical need factors-that explained utilization.

RESULTS

Compared to enabling factors, need factors explained twice the variance predicting pain treatment utilization. Still, the adjusted odds of using nonpharmacologic providers instead of opioids alone were 39% lower among respondents identifying as Black (95% Confidence Interval [CI], 0.49-0.76) and respondents residing in the U.S. South (95% CI, 0.51-0.74). Higher education (95% CI, 1.72-2.79) and income (95% CI, 1.68-2.42) both facilitated using nonpharmacologic providers instead of opioids.

CONCLUSIONS

These findings highlight the substantial influence access-promoting SDoH have on pain treatment utilization.

[Utilization of video consultation in cardiovascular lipid treatment]

BACKGROUND

Video consultation is a possibility for physician-patient communication independent of the location; however, only limited information is available for the possibility of sole use since 2018.

METHODS

After the implementation of video consultation (Viomedi) in lipid consultations at the Medical University Mainz, the patients in the first quarter of 2022 were assessed depending on the possibility, suitability and readiness to participate. Included were patients under lipid management and long COVID patients. After treatment an online survey was carried out on the utilization and appraisal.

RESULTS

Of the 134 patients 29.1% were inclusively treated (3 refusals). All subjects (16 replies) reported having managed (very) well. Advantages were seen in counselling and follow-up. Problems were feared with respect to technology and possible disorders. Data protection aspects played a subordinate role. In comparison to telephone calls, a significant improvement in the physician-patient relationship (p-value = 0.00027), the quality of treatment and information (p-value both = 0.00044), the access to care (p-value = 0.0053) and the communication (p-value = 0.021) was assumed. An improvement in access to care (p-value = 0.021) and the quality of information (p-value = 0.034) was seen in comparison to personal contact. The main problems were a lack of experience, technical requirements, technical problems and unpunctuality of the practitioner. The flexibility, low effort and the pleasant consultation were all praised. All subjects wanted to use the video consultation again.

CONCLUSION

Video consultation can represent a supplement to treatment of patients under lipid management. The correct use requires exact planning and further research.

Procedural and Clinical Outcome Analysis of Monoplane versus Biplane Angiography Suites in Stroke Thrombectomies

BACKGROUND

Thrombectomy is now the standard of care in the treatment of acute ischemic stroke caused by emergent large vessel occlusion. Therefore thrombectomy services have expanded from Comprehensive Stroke Centers to Thrombectomy-Capable Stroke Centers. Stroke interventions at these sites are performed in both biplane and monoplane angiography suites. It has been hypothesized that differences in these systems may affect time to successful reperfusion, with a potentially significant effect on neurologic outcomes. With an increase in TSCs, this study aims to evaluate the safety and efficacy of monoplane thrombectomy versus biplane thrombectomy.

METHODS

Patients who presented with isolated proximal middle cerebral artery M1 occlusions and underwent endovascular thrombectomy from March 2015 to August 2018 at 5 different centers within a single health system were included. Thrombectomy was performed by the same group of experienced neurointerventionalists. The primary endpoint was functional outcome as measured by the modified Rankin scale at 90 days. Secondary endpoints included recanalization grade as measured by the Thrombolysis in Cerebral Infarction score, time to final reperfusion, and incidence of hemorrhagic conversion.

RESULTS

A total of 197 patients were included in this study. Of them, 80.7% underwent thrombectomy on biplane systems. Time to final reperfusion was 10.2 minutes longer in the monoplane group but was not statistically significant (P = 0.252). There was no significant difference in the rates of favorable reperfusion (P = 0.755), hemorrhagic conversion (P = 0.580), or functional outcome at 90 days (favorable modified Rankin Scale 0-2, P = 0.210; favorable modified Rankin Scale 0-3, P = 0.697).

CONCLUSION

Despite perceived advantages of biplane systems in reducing procedural time, our study demonstrates no significant differences between systems. These data support the safety and efficacy of performing thrombectomy on monoplane systems and may also carry implications for reducing patient transfer times and potentially increasing thrombectomy access to areas of the world where biplane suites may not be available. The next step would be a prospective randomized trial comparing both systems in different settings.

Risk Factors for Preventable Emergency Department Use After Outpatient Hand Surgery

PURPOSE

Emergency department (ED) visits for postoperative concerns that could be safely addressed in outpatient clinics have an impact on cost, quality measures, and care workflows. Patient-reported data (PRD) may give unique insights into individual-level factors that predict overuse of health care resources, and guide opportunities for intervention and prevention. We investigated the relationship between preoperative PRD and preventable ED use after outpatient hand surgery to determine whether the preoperative PRD can be used to identify patients at higher odds of having preventable ED visits.

METHODS

All adult patients undergoing outpatient surgery at our hand center between January 1, 2018, and December 31, 2019, were included. Questionnaires, including the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) and pain interference (PI) scales, were completed before surgery. We used our regional health information exchange to identify ED visits within 90 days of surgery.

RESULTS

Our cohort included 2,819 patients. Within 90 days after surgery, 106 (3.8%) had preventable ED visits. Race, insurance status, and transportation issues increased odds of a preventable ED visit. Multivariable models found that each 1-point increase in the preoperative PROMIS UE score was associated with 4% decreased odds of ED presentation (odds ratio, 0.96; 95% confidence interval, 0.94-0.99), and each 1-point increase in the preoperative PROMIS PI score was associated with 4% increased odds of ED presentation (odds ratio, 1.04; 95% confidence interval, 1.0-1.1). Any PROMIS UE or PI scores ≥1SDs worse than population norms increased the probability of a preventable ED visit, independent of other factors.

CONCLUSIONS

Worse preoperative PROMIS UE and PI scores were associated with increased odds of preventable ED visits. Preoperative PRD may allow for identification of outliers at higher risk for preventable ED use, and facilitate preventative interventions.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The Utility of Remote Video Technology in Continuing Neurosurgical Care in the COVID-19 Era: Reflections from the Past Year

Objective

In 2020, the coronavirus disease 2019 (COVID-19) pandemic exposed existing stressors in the neurosurgical care infrastructure in the United States. We aimed to detail innovative technologic solutions inspired by the pandemic-related restrictions that augmented neurosurgical education and care delivery.

Methods

Several digital health and audiovisual innovations were implemented, including use of remote video technology to facilitate inpatient consultations and outpatient ambulatory virtual visits, optimize regional hospital neurosurgical coverage, expand interdisciplinary patient management conferences (i.e., tumor board), and further enhance the neurosurgical resident education program. Enterprise patient experience data were queried to evaluate patient satisfaction following the switch to virtual visits.

Results

Between January 2020 and April 2021, use of virtual visits more than doubled in the Department of Neurosurgery. A survey of 10,772 patients following ambulatory visits showed that virtual visits were equal if not better in providing satisfactory patient care than in-person visits. After switching our interdisciplinary spine tumor board to a virtual meeting, we increased surgeon participation and attendance by 49.29%. Integration of remote audiovisual technology in resident didactics and clinical training improved our ability to provide comprehensive and personalized educational experiences our trainees.

Conclusions

Digital health technology has improved neurosurgical care and comprehensive training at our institution. Investment in the technologic infrastructure required for these remote audiovisual services during the COVID-19 pandemic will facilitate the expansion of neurosurgical care provision for patients across the United States in the future. Governing bodies within organized neurosurgery should advocate for the continued financial and licensing support of these service on a national fiscal and policy level.

Patient-centered medical home care access among adults with chronic conditions: National Estimates from the medical expenditure panel survey

BACKGROUND

The Patient-Centered Medical Home (PCMH) model is a coordinated-care model that has served as a means to improve several chronic disease outcomes and reduce management costs. However, access to PCMH has not been explored among adults suffering from chronic conditions in the United States. Therefore, the aim of this study was to describe the changes in receiving PCMH among adults suffering from chronic conditions that occurred from 2010 through 2015 and to identify predisposing, enabling, and need factors associated with receiving a PCMH.

METHODS

A cross-sectional analysis was conducted for adults with chronic conditions, using data from the 2010-2015 Medical Expenditure Panel Surveys (MEPS). Most common chronic conditions in the United States were identified by using the most recent data published by the Agency for Healthcare Research and Quality (AHRQ). The definition established by the AHRQ was used as the basis to determine whether respondents had access to PCMH. Multivariate logistic regression analyses were conducted to detect the association between the different variables and access to PCMH care.

RESULTS

A total of 20,403 patients with chronic conditions were identified, representing 213.7 million U.S. lives. Approximately 19.7% of the patients were categorized as the PCMH group at baseline who met all the PCMH criteria defined in this paper. Overall, the percentage of adults with chronic conditions who received a PCMH decreased from 22.3% in 2010 to 17.8% in 2015. The multivariate analyses revealed that several subgroups, including individuals aged 66 and older, separated, insured by public insurance or uninsured, from low-income families, residing in the South or the West, and with poor health, were less likely to have access to PCMH.

CONCLUSION

Our findings showed strong insufficiencies in access to a PCMH between 2010 and 2015, potentially driven by many factors. Thus, more resources and efforts need to be devoted to reducing the barriers to PCMH care which may improve the overall health of Americans with chronic conditions.

Contributing factors of frequent use of the emergency department: A synthesis

INTRODUCTION

Overcrowding in emergency departments is an issue that has a negative impact worldwide. As attendance in emergency departments has increased, the ability to provide critical services to patients suffering from actual medical emergencies in a timely manner has decreased as these departments are many times at or over capacity. One patient population whose negative influence has been researched with regard to their impact on the overcrowding issue is that of the frequent user.

METHODS

A search of two electronic databases was conducted to identify factors that frequent users state as their reasoning for using an emergency department. Peer reviewed articles in English were searched for in CINAHL Plus and PubMed, as well as a review of reference lists.

RESULTS

A review of the literature identified two predominant factors related to frequent users in the emergency department: a lack of awareness of medical necessity and issues of access.

DISCUSSION

To address the frequent users in emergency departments, implications for practice need to be explored and implemented. Implications for practice include education of medical necessity for the frequent users, expansion of the pre-hospital role in primary care and inappropriate use prevention, and improvement of access to alternative healthcare services.

Waiting time disparities in breast cancer diagnosis and treatment: a population-based study in France

Waiting times are key indicators of a health's system performance, but are not routinely available in France. We studied waiting times for diagnosis and treatment according to patients' characteristics, tumours' characteristics and medical management options in a sample of 1494 breast cancers recorded in population-based registries. The median waiting time from the first imaging detection to the treatment initiation was 34 days. Older age, co-morbidity, smaller size of tumour, detection by organised screening, biopsy, increasing number of specimens removed, multidisciplinary consulting meetings and surgery as initial treatment were related to increased waiting times in multivariate models. Many of these factors were related to good practices guidelines. However, the strong influence of organised screening programme and the disparity of waiting times according to geographical areas were of concern. Better scheduling of diagnostic tests and treatment propositions should improve waiting times in the management of breast cancer in France.