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Gibson LP, Ferrer RA, Meghani SH, Acevedo AM. Potential role of cannabis in ameliorating observed racialized disparities in cancer pain management. J Natl Cancer Inst 2024:djae058. [PMID: 38471103 DOI: 10.1093/jnci/djae058] [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] [Received: 11/01/2023] [Revised: 01/26/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
Cancer-related pain affects a significant proportion of all cancer patients yet remains inadequately managed, particularly among cancer patients from racialized backgrounds. In recent years, there has been increased research and clinical interest in the use of medical cannabis for cancer pain management, including its potential to ameliorate racialized disparities in cancer pain control. Although medical cannabis is not currently an FDA-approved treatment option for cancer-related pain, many oncologists discuss and recommend its use with their patients, underscoring the need for researchers and clinicians to proactively identify barriers to cannabis for cancer pain management that may disproportionately impact racialized cancer patients. In this commentary, we highlight challenges cancer patients from racialized backgrounds may face when incorporating cannabis into their palliative care regimens and discuss opportunities for researchers and clinicians to address these challenges should medical cannabis become a recommended treatment option for cancer pain management. In particular, we identify challenges at the structural (eg, lack of insurance coverage), provider (eg, racialized stereotypes regarding addiction and pain) and individual (eg, internalized stigma) levels and emphasize the importance of multi-level approaches in combating these challenges as the evidence base regarding medical cannabis and its potential harms and therapeutic benefits continues to accumulate.
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Affiliation(s)
- Laurel P Gibson
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, Colorado, USA
| | - Rebecca A Ferrer
- Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences Associate Director, NewCourtland Center for Transitions and Health, ; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amanda M Acevedo
- Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
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Andersen L, Baker KM, Difilippo H, Meghani SH, Porter D, Deng J. The Patient Symptom Experience After Tisagenlecleucel and Lisocabtagene Maraleucel CAR T-Cell Therapy for Lymphoma. Semin Oncol Nurs 2024:151614. [PMID: 38443220 DOI: 10.1016/j.soncn.2024.151614] [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: 10/27/2023] [Revised: 01/21/2024] [Accepted: 02/01/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVES Chimeric Antigen Receptor (CAR) T-cell treatment is associated with several unique toxicities, and the short-term symptom trajectory in the immediately after therapy is well-documented. However, little is known about patients' long-term symptom experience. The study aimed to elicit the symptom experience of adult patients in remission after CAR T-cell therapy for B cell lymphoma. DATA SOURCES A qualitative descriptive design with thematic analysis was utilized. Recruitment occurred at a tertiary academic medical center using the following inclusion criteria: adult recipient of CAR T-cell therapy for B-cell lymphoma between 3 and 12 months prior to enrollment, and currently in remission. Semi-structured interviews were conducted, transcripts were inductively coded, and team members met weekly to ensure rigor. The final sample included 10 patients: Seven received tisagenlecleucel and three received lisocabtagene marleucel and were a median of 169 days post-infusion and 65 years of age. CONCLUSIONS Participants continued to report symptoms, including fatigue, neuropathy, low endurance, insomnia, memory problems, and pain. Most symptoms improved over time. Some symptoms interfered with social activities, work, driving, and physical activity, though participants reported that most symptoms existed prior to CAR T-cell therapy, and overall, found CAR T-cell therapy acceptable. IMPLICATIONS FOR NURSING PRACTICE Patients in remission after CAR T-cell therapy often continue to experience symptoms. Nurses should continue to assess this growing patient population and determine if patients require additional symptom management or support. Further research is needed to understand long-term symptom trajectory and associations with prior lines of therapy and CAR T-cell therapy.
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Affiliation(s)
- Lucy Andersen
- Department of Biobehavioral Health Sciences, School of Nursing, The University of Pennsylvania, Philadelphia, PA.
| | - Kayla M Baker
- Department of Biobehavioral Health Sciences, School of Nursing, The University of Pennsylvania, Philadelphia, PA
| | - Heather Difilippo
- Cell Therapy and Transplant Program, Abramson Cancer Center at the University of Pennsylvania, and Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, School of Nursing, The University of Pennsylvania, Philadelphia, PA
| | - David Porter
- Cell Therapy and Transplant Program, Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA
| | - Jie Deng
- Department of Biobehavioral Health Sciences, School of Nursing, The University of Pennsylvania, Philadelphia, PA
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Yeager KA, Rosa WE, Belcher SM, Lee SM, Lee H, Bruner DW, Meghani SH. A Qualitative Study of the Pain Experience of Black Individuals With Cancer Taking Long-Acting Opioids. Cancer Nurs 2024; 47:E73-E83. [PMID: 36737858 PMCID: PMC10400728 DOI: 10.1097/ncc.0000000000001197] [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: 02/05/2023]
Abstract
BACKGROUND Little is known about the experience of Black individuals with cancer taking long-acting opioids for cancer pain. OBJECTIVE This study aimed to describe the day-to-day experience of living with pain and the experiences of taking opioids for pain management among Black individuals with cancer prescribed with long-acting opioids. METHODS This qualitative descriptive study was part of a larger investigation focused on opioid adherence. Participants (N = 14) were interviewed using a semistructured interview guide. Analysis followed conventional content analysis and constant comparison approaches. Sociodemographics, clinical information, and the Brief Pain Inventory form were collected. RESULTS The majority of the subsample was female (64.3%), not married (78.6%), and with a median age of 52.5 years. Participants were taking either MS Contin (85.7%) or OxyContin (14.3%). The Brief Pain Inventory median "average" pain severity scores and pain interference scores were 5.1/10 (interquartile range [IQR] = 6.1) and 3.5/10 (IQR = 6.7), respectively. Three themes are reported from the analyses: desire for control, barriers to pain relief, and isolation versus connectedness. CONCLUSION Our findings highlight the persistent nature of moderate to severe cancer pain and how pain and its treatment interfere with patients' lives. The findings describe ways that patients learn to manage and exert control over pain despite conflicting attitudes and dealing with opioid stigma. IMPLICATION FOR PRACTICE Clinicians should partner with patients with cancer, especially people of color, who may experience intersecting stigmas related to their cancer pain and opioid use, to best provide an individualized and culturally sensitive pain treatment plan.
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Affiliation(s)
- Katherine A Yeager
- Author Affiliations: Nell Hodgson Woodruff School of Nursing (Drs Bruner, Yeager, and H. Lee and Ms S. Lee); Winship Cancer Institute (Drs Bruner and Yeager); Office of the Senior Vice President for Research (Dr Bruner), Emory University, Atlanta, Georgia; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center (Dr Rosa), New York, New York; School of Nursing (Dr Belcher); Palliative Research Center (Dr Belcher), University of Pittsburgh; Hillman Cancer Center, University of Pittsburgh Medical Center (Dr Belcher), Pennsylvania; and Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania (Dr Meghani), Philadelphia
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Worster B, Meghani SH, Leader AE, Nugent SM, Jones KF, Yeager KA, Liou K, Ashare RL. Toward reducing racialized pain care disparities: Approaching cannabis research and access through the lens of equity and inclusion. Cancer 2024; 130:497-504. [PMID: 37941524 DOI: 10.1002/cncr.35115] [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: 11/10/2023]
Abstract
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.
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Affiliation(s)
- Brooke Worster
- Sidney Kimmel Cancer Center, Department of Medical Oncology, Jefferson Health, Philadelphia, Pennsylvania, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Science, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amy E Leader
- Sidney Kimmel Cancer Center, Department of Medical Oncology, Jefferson Health, Philadelphia, Pennsylvania, USA
| | - Shannon M Nugent
- Department of Psychiatry, Oregon Health and Science University, Portland, Oregon, USA
- Knight Cancer Institution, Oregon Health and Science University, Portland, Oregon, USA
| | - Katie Fitzgerald Jones
- Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine A Yeager
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Kevin Liou
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Rebecca L Ashare
- Department of Psychology, State University of New York at Buffalo, Buffalo, New York, USA
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Meghani SH, Quinn R, Robinson A, Chittams J, Vapiwala N, Naylor M, Cheatle M, Knafl GJ. Trajectories and predictors of high-occurrence pain flares in ambulatory cancer patients on opioids. JNCI Cancer Spectr 2024; 8:pkae003. [PMID: 38268502 PMCID: PMC10880071 DOI: 10.1093/jncics/pkae003] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Pain flares have a substantive impact on the quality of life and well-being of patients with cancer. We identified longitudinal trajectories (clusters) of cancer pain flares in ambulatory patients and sociodemographic and clinical predictors of these trajectories. METHODS In a prospective cohort study using ecological momentary assessment (mEMA), we collected patient-reported daily pain flare ratings data over 5 months and identified predictors and correlates using validated measures. RESULTS The mean age of the sample (N = 270) was 60.9 years (SD = 11.2), 64.8% were female, and 32.6% self-identified as African American. Four pain flare clusters were identified. The "high-occurrence" cluster (23% of patients) experienced 5.5 (SD = 5.47) daily flares, whereas low-moderate clusters (77%) reported 2.4 (SD = 2.74) daily flares (P < .000). Those in the high-occurrence cluster reported higher pain scores (P = .000), increased pain-related interference (P = .000), depressive symptoms (P = .023), lower quality of life (P = .001), and reduced pain self-efficacy (P = .006). Notably, 67.2% of those prescribed opioids as needed (PRN only) were in the high-occurrence pain flare cluster, compared with 27.9% with PRN and around-the-clock opioid prescriptions (P = .024). Individual predictors of high-occurrence pain flares were income below $30 000, unemployment, being African American, lower education level, Medicaid insurance, current opioid misuse (COMM), baseline inpatient hospital stay duration, and PRN-only opioid regimen. In the multiple predictor model, lower education level, unemployment, COMM score, extended inpatient duration, and PRN-only opioid regimen remained significant. CONCLUSION In ambulatory patients with cancer, high occurrence of pain flares may be mitigated by attention to opioid prescription factors and addressing social determinants of health needs of underserved patients.
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Affiliation(s)
- Salimah H Meghani
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan Quinn
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew Robinson
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Jesse Chittams
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Neha Vapiwala
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Naylor
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin Cheatle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George J Knafl
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Levoy K, Ashare RL, Ganta N, O'Connor N, Meghani SH. Caregiver Engagement in Serious Illness Communication in a Long-Term Acute Care Hospital Setting. Am J Hosp Palliat Care 2023:10499091231219799. [PMID: 38100624 DOI: 10.1177/10499091231219799] [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] [Indexed: 12/17/2023] Open
Abstract
CONTEXT Prolonged management of critical illnesses in long-term acute care hospitals (LTACH) makes serious illness communication (SIC), a clinical imperative. SIC in LTACH is challenging as clinicians often lack training and patients are typically unable to participate-making caregivers central. OBJECTIVES This qualitative descriptive study characterized caregiver engagement in SIC encounters, while considering influencing factors, following the implementation of Ariadne Labs' SIC training at a LTACH in the Northeastern United States. METHODS Clinicians' documented SIC notes (2019-2020) were analyzed using directed content analysis. Codes were grouped into four categories generated from two factors that influence SIC-evidence of prognostic understanding (yes/no) and documented preferences (yes/no)-and caregiver engagement themes identified within each category. RESULTS Across 125 patient cases, 251 SIC notes were analyzed. In the presence of prognostic understanding and documented preferences, caregivers acted as upholders of patients' wishes (29%). With prognostic understanding but undocumented preferences, caregivers were postponers of healthcare decision-making (34%). When lacking prognostic understanding but having documented preferences, caregivers tended to be searchers, intent on identifying continued treatment options (13%). With poor prognostic understanding and undocumented preferences, caregivers were strugglers, having difficulty with the clinicians or family unit over healthcare decision-making (21%). CONCLUSION The findings suggest that two factors-prognostic understanding and documented preferences-are critical factors clinicians can leverage in tailoring SIC to meet caregivers' SIC needs in the LTACH setting. Such strategies shift attention away from SIC content alone toward factors that influence caregivers' ability to meaningfully engage in SIC to advance healthcare decision-making.
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Affiliation(s)
- Kristin Levoy
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | - Rebecca L Ashare
- Department of Psychology, State University of New York at Buffalo, Buffalo, NY, USA
| | - Niharika Ganta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nina O'Connor
- Temple Center for Population Health, Temple Health, Philadelphia, PA, USA
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Baker KM, Ulrich CM, Meghani SH. An Integrative Review of Measures of Spirituality in Experimental Studies of Psilocybin in Serious Illness Populations. Am J Hosp Palliat Care 2023; 40:1261-1270. [PMID: 36604312 DOI: 10.1177/10499091221147700] [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] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background: Psilocybin-assisted therapies (PAT) are reemerging as a treatment for complex distress often prompting mystical experiences, enhanced meaning, and spiritual wellbeing. We sought to investigate how measures of spirituality are employed in experimental studies of PAT conducted with seriously ill adults. Methods: We included experimental studies of psilocybin conducted with seriously ill adults, which employed measures that contained spirituality and mysticism concepts within their domains or subdomains. Included studies were peer-reviewed and published in English language (up to December 2021). Results: Seven articles met our inclusion criteria. A total of 12 unique instruments were identified. The most frequently used instruments were the Mystical Experience Questionnaire (MEQ30), the Functional Assessment of Chronic Illness Therapy-Spirituality (FACIT-Sp-12), and the Demoralization Scale (DS-I/II) (used in four studies each), followed by the Persisting Effects Questionnaire (PEQ) (used in three studies). Overall, studies did not consistently define and contextualize spirituality domains and subdomains studied. Conclusions: Despite well-recognized significance of spirituality in PAT, there was considerable heterogeneity in number and types of spirituality measures employed across studies. There also seemed a lack of attention to defining and operationalizing spirituality and its domains and subdomains. This is notable as spirituality and overlapping concepts (eg mystical experiences) contributes substantially to this body of research and patients' therapeutic outcomes. Towards developing more rigorous science of spirituality in PAT research, there is a critical need to evaluate and refine measures of spirituality to enhance their utility and replicability, limit participant burden, and better contextualize spirituality-related findings and outcomes.
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Affiliation(s)
- Kayla M Baker
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics; University of Pennsylvania; Philadelphia, PA; United States
| | - Connie M Ulrich
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences; University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics; University of Pennsylvania; Philadelphia, PA; United States
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences; University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics; University of Pennsylvania; Philadelphia, PA; United States
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Ashare RL, Turay E, Worster B, Wetherill RR, Bidwell LC, Doucette A, Meghani SH. 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. Cannabis 2023; 6:1-12. [PMID: 37484056 PMCID: PMC10361799 DOI: 10.26828/cannabis/2023/000151] [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] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
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.
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Affiliation(s)
- Rebecca L. Ashare
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
- Department of Psychology, University at Buffalo
| | | | - Brooke Worster
- Department of Medical Oncology, Sidney Kimmel Cancer Center/Thomas Jefferson University
| | - Reagan R. Wetherill
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
| | | | | | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences and the NewCourtland Center for Transitions and Health and the Leonard Davis Institute of Health Economics, University of Pennsylvania
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Liou KT, Ashare R, Worster B, Jones KF, Yeager KA, Acevedo AM, Ferrer R, Meghani SH. SIO-ASCO guideline on integrative medicine for cancer pain management: implications for racial and ethnic pain disparities. JNCI Cancer Spectr 2023; 7:pkad042. [PMID: 37307074 PMCID: PMC10336300 DOI: 10.1093/jncics/pkad042] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023] Open
Abstract
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.
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Affiliation(s)
- Kevin T Liou
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rebecca Ashare
- Department of Psychology, State University of New York at Buffalo, Buffalo, NY, USA
| | - Brooke Worster
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Katie F Jones
- Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA
| | - Katherine A Yeager
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Amanda M Acevedo
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Rebecca Ferrer
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Science, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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10
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Wool JR, Chittams J, Meghani SH, Morrison W, Deatrick JA, Ulrich CM. Development of the perceived miscommunication measure in the pediatric intensive care unit. J Pediatr Nurs 2023:S0882-5963(23)00119-7. [PMID: 37270386 DOI: 10.1016/j.pedn.2023.05.011] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE Miscommunication between parents and healthcare providers in the Pediatric Intensive Care Unit (PICU) can affect family-provider relationships and outcomes. This paper reports on the development and psychometric testing of a measure for parent perceived miscommunication, defined as the failure to communicate clearly as perceived by relevant stakeholders in the PICU. DESIGN AND METHODS Miscommunication items were identified through a review of the literature with interdisciplinary experts. In a cross-sectional quantitative survey, the scale was tested with 200 parents of children discharged from a PICU at a large Northeastern Level 1 Pediatric hospital. The psychometric properties of a 6-item miscommunication measure were assessed using exploratory factor analysis and internal consistency reliability. RESULTS Exploratory factor analysis yielded one factor explaining 66.09% of the variance. Internal consistency reliability in the PICU sample was α = 0.89. As hypothesized, there was a significant correlation between parental stress, trust, and perceived miscommunication in the PICU (p < .001). Confirmatory factor analysis supported good fit indices in testing the measurement model (χ2/df = 2.57, Goodness of Fit Index (GFI) = 0.979, Confirmatory Fit Index (CFI) =0.993 and Standardized Mean Residual (SMR) = 0.0136). CONCLUSIONS This new six-item miscommunication measure shows promising psychometric properties including content and construct validity, which can be further tested and refined in future studies of miscommunication and outcomes in PICU. PRACTICE IMPLICATIONS Awareness of perceived miscommunication in the PICU can benefit stakeholders within the clinical environment by recognizing the importance of clear and effective communication and how language affects the parent-child-provider relationship.
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Affiliation(s)
- Jesse R Wool
- University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, USA; Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; La Salle University, 1900 W Olney Ave, Philadelphia, PA 19141, USA.
| | - Jesse Chittams
- University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, USA.
| | - Salimah H Meghani
- University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, USA.
| | - Wynne Morrison
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; University of Pennsylvania, Perelman School of Medicine, USA.
| | - Janet A Deatrick
- University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, USA; Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA.
| | - Connie M Ulrich
- University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, USA; University of Pennsylvania, Perelman School of Medicine, USA.
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Levoy K, Sullivan SS, Chittams J, Myers RL, Hickman SE, Meghani SH. Don't Throw the Baby Out With the Bathwater: Meta-Analysis of Advance Care Planning and End-of-life Cancer Care. J Pain Symptom Manage 2023; 65:e715-e743. [PMID: 36764411 DOI: 10.1016/j.jpainsymman.2023.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/27/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
CONTEXT There is ongoing discourse about the impact of advance care planning (ACP) on end-of-life (EOL) care. No meta-analysis exists to clarify ACP's impact on patients with cancer. OBJECTIVE To investigate the association between, and moderators of, ACP and aggressive vs. comfort-focused EOL care outcomes among patients with cancer. METHODS Five databases were searched for peer-reviewed observational/experimental ACP-specific studies that were published between 1990-2022 that focused on samples of patients with cancer. Odds ratios were pooled to estimate overall effects using inverse variance weighting. RESULTS Of 8,673 articles, 21 met criteria, representing 33,541 participants and 68 effect sizes (54 aggressive, 14 comfort-focused). ACP was associated with significantly lower odds of chemotherapy, intensive care, hospital admissions, hospice use fewer than seven days, hospital death, and aggressive care composite measures. ACP was associated with 1.51 times greater odds of do-not-resuscitate orders. Other outcomes-cardiopulmonary resuscitation, emergency department admissions, mechanical ventilation, and hospice use-were not impacted. Tests of moderation revealed that the communication components of ACP produced greater reductions in the odds of hospital admissions compared to other components of ACP (e.g., documents); and, observational studies, not experimental, produced greater odds of hospice use. CONCLUSION This meta-analysis demonstrated mixed evidence of the association between ACP and EOL cancer care, where tests of moderation suggested that the communication components of ACP carry more weight in influencing outcomes. Further disease-specific efforts to clarify models and components of ACP that work and matter to patients and caregivers will advance the field.
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Affiliation(s)
- Kristin Levoy
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana.
| | - Suzanne S Sullivan
- School of Nursing (S.S.S.), University at Buffalo, State University of New York, Buffalo, New York
| | - Jesse Chittams
- BECCA (Biostatistics, Evaluation, Collaboration, Consultation & Analysis) Lab, Office of Nursing Research (J.C.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Ruth L Myers
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana
| | - Susan E Hickman
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences (S.H.M.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics (S.H.M.), University of Pennsylvania, Philadelphia, Pennsylvania
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12
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Bader CE, Flynn DM, Buckenmaier CC, McDonald CC, Meghani SH, Glaser D, Polomano RC. Patterns of Change in Pain-related Physical, Mental, and Social Health Outcomes in a Military Population. Pain Manag Nurs 2023; 24:265-272. [PMID: 36746698 DOI: 10.1016/j.pmn.2023.01.002] [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] [Received: 04/29/2022] [Revised: 12/08/2022] [Accepted: 01/05/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Military persons frequently experience pain conditions stemming from noncombat and combat injuries. This study assessed the patterns of change over time and the associations of pain intensity and interference with physical, mental, and social health domains in a military sample. METHODS A secondary analysis of Pain Assessment Screening Tool and Outcomes Registry (PASTOR) was conducted using data collected over 10 months. Participants selected for analysis completed ≥3 assessments with an interval of ≥14 days between assessments. The Defense and Veterans Pain Rating Scale (DVPRS) measured average and worst pain intensity, and Patient-Reported Outcomes Measurement Information System (PROMIS®) T-scores measured pain and health outcomes. RESULTS The sample (N = 190) majority reported being active duty (96%); serving in the U.S. Army (93%); and being enlisted (86%). The percent difference from assessment one to assessment three showed improvement for DVPRS average pain (-4.85%) and worst pain (-2.16%), and PROMIS Pain Interference T-score (-1.98%). Improvements were observed for all PROMIS outcomes except depression. The Defense and Veterans Pain Rating Scale average and worst pain intensity and PROMIS pain interference were strongly correlated with physical function. Multilevel models showed that an increase in average and worst pain, and pain interference were associated with a decrease in satisfaction with social roles. CONCLUSION Analysis identified patterns of change over time in physical, mental, and social health outcomes, as well as associations important to understanding the complexities of pain. This work has implications for pain management nursing in ambulatory settings where ongoing collection and analyses of multivariable outcomes data can inform clinical care.
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Affiliation(s)
- Christine E Bader
- Special Assistant to the Dean, Graduate School of Nursing, Uniformed Services University of the Health Sciences.
| | - Diane M Flynn
- Department of Rehabilitative Medicine, Madigan Army Medical Center, Tacoma, Washington
| | - Chester C Buckenmaier
- Professor Emeritus, Department of Anesthesiology, Uniformed Services University of the Health Sciences
| | - Catherine C McDonald
- Associate Professor, University of Pennsylvania, School of Nursing, Perelman School of Medicine at the University of Pennsylvania, Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Salimah H Meghani
- Professor & Craig M. Wasserman Term Chair of Palliative Care, Department of Biobehavioral Health Sciences, Associate Director, NewCourtland Center for Transitions and Health, Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Dale Glaser
- Principal, Glaser Consulting, Lecturer and Adjunct Faculty at San Diego State University/University of San Diego/University of California San Diego
| | - Rosemary C Polomano
- Associate Dean for Practice, Professor of Pain Practice, University of Pennsylvania, School of Nursing, Professor of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania
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13
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Andersen L, McHugh M, Ulrich CM, Meghani SH, Deng J. A systematic review of coping skill interventions to reduce anxiety and depressive symptoms among adults with hematologic malignancies. Eur J Oncol Nurs 2022; 61:102224. [PMID: 36375304 PMCID: PMC9714520 DOI: 10.1016/j.ejon.2022.102224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Received: 08/26/2022] [Accepted: 10/08/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with hematologic malignancies experience anxiety and depressive symptoms from diagnosis through survivorship. The aim of this systematic review is to determine if coping skill interventions can reduce anxiety and depressive symptoms for persons with hematologic cancer. METHODS Databases including PubMed, Embase, CINAHL, APA PyschInfo, Scopus, and Cochrane were searched in June of 2021 for coping skill interventional studies with adult patients with hematologic cancer and outcomes of anxiety and depressive symptoms. Search terms, definitions, and inclusion/exclusion criteria were guided by the Transactional Model of Stress and Coping, and quality appraisal utilized the Johns Hopkins Evidence Based Practice Appraisal tool. The study was registered in PROSPERO under "CRD42021262967." RESULTS Eleven studies met inclusion criteria with ten studies evaluating anxiety symptoms and nine studies evaluating depressive symptoms. Of ten studies with 449 participants evaluating anxiety, five studies showed significant reduction (p < 0.05), three found small to moderate effect size reductions not reaching statistical significance (p > 0.05), and only two showed no reduction in anxiety symptoms. Of nine studies with 429 participants evaluating depressive symptoms, three had significant reductions (p < 0.05), three reported small to moderate effect size reductions not reaching statistical significance (p > 0.05), and three found no effect on depressive symptoms. Coping interventions that were problem-focused as opposed to emotion-focused were most effective for both anxiety and depressive symptoms. CONCLUSION This systematic review finds evidence that problem-focused coping interventions reduce anxiety symptoms among patients with hematologic malignancies, with mixed evidence for reduction of depressive symptoms. Nurses and other clinicians caring for patients with hematologic cancers may employ coping skill interventions as a potential way to mitigate anxiety and depressive symptoms. PROSPERO REGISTRATION ID CRD42021262967.
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Affiliation(s)
- Lucy Andersen
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA; The NewCourtland Center for Transitions and Health, Philadelphia, PA, USA.
| | - Molly McHugh
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA; The NewCourtland Center for Transitions and Health, Philadelphia, PA, USA
| | - Connie M Ulrich
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA; The NewCourtland Center for Transitions and Health, Philadelphia, PA, USA
| | - Salimah H Meghani
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA; The NewCourtland Center for Transitions and Health, Philadelphia, PA, USA
| | - Jie Deng
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA
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14
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Jones KF, Cousin L, Meghani SH. Underrecognition of Symptoms During Breast Radiotherapy. JAMA Oncol 2022; 8:1509-1510. [PMID: 35951332 DOI: 10.1001/jamaoncol.2022.3239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts
| | | | - Salimah H Meghani
- New Courtland Center for Transitions and Health, Leonard Davis Institute of Health Economics, Department of Biobehavioral Health Sciences, University of Pennsylvania, Philadelphia
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15
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Starr LT, Ulrich C, Perez GA, Aryal S, Junker P, O’Connor NR, Meghani SH. Hospice Enrollment, Future Hospitalization, and Future Costs Among Racially and Ethnically Diverse Patients Who Received Palliative Care Consultation. Am J Hosp Palliat Care 2022; 39:619-632. [PMID: 34318700 PMCID: PMC8795236 DOI: 10.1177/10499091211034383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 11/16/2022] Open
Abstract
BACKGROUND Palliative care consultation to discuss goals-of-care ("PCC") may mitigate end-of-life care disparities. OBJECTIVE To compare hospitalization and cost outcomes by race and ethnicity among PCC patients; identify predictors of hospice discharge and post-discharge hospitalization utilization and costs. METHODS This secondary analysis of a retrospective cohort study assessed hospice discharge, do-not-resuscitate status, 30-day readmissions, days hospitalized, ICU care, any hospitalization cost, and total costs for hospitalization with PCC and hospitalization(s) post-discharge among 1,306 Black/African American, Latinx, White, and Other race PCC patients at a United States academic hospital. RESULTS In adjusted analyses, hospice enrollment was less likely with Medicaid (AOR = 0.59, P = 0.02). Thirty-day readmission was less likely among age 75+ (AOR = 0.43, P = 0.02); more likely with Medicaid (AOR = 2.02, P = 0.004), 30-day prior admission (AOR = 2.42, P < 0.0001), and Black/African American race (AOR = 1.57, P = 0.02). Future days hospitalized was greater with Medicaid (Coefficient = 4.49, P = 0.001), 30-day prior admission (Coefficient = 2.08, P = 0.02), and Black/African American race (Coefficient = 2.16, P = 0.01). Any future hospitalization cost was less likely among patients ages 65-74 and 75+ (AOR = 0.54, P = 0.02; AOR = 0.53, P = 0.02); more likely with Medicaid (AOR = 1.67, P = 0.01), 30-day prior admission (AOR = 1.81, P = 0.0001), and Black/African American race (AOR = 1.40, P = 0.02). Total future hospitalization costs were lower for females (Coefficient = -3616.64, P = 0.03); greater with Medicaid (Coefficient = 7388.43, P = 0.01), 30-day prior admission (Coefficient = 3868.07, P = 0.04), and Black/African American race (Coefficient = 3856.90, P = 0.04). Do-not-resuscitate documentation (48%) differed by race. CONCLUSIONS Among PCC patients, Black/African American race and social determinants of health were risk factors for future hospitalization utilization and costs. Medicaid use predicted hospice discharge. Social support interventions are needed to reduce future hospitalization disparities.
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Affiliation(s)
- Lauren T. Starr
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Connie Ulrich
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine,
Philadelphia, Pennsylvania
| | - G. Adriana Perez
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Subhash Aryal
- BECCA (Biostatistics * Evaluation * Collaboration *
Consultation * Analysis) Lab, University of Pennsylvania School of Nursing,
Philadelphia, Pennsylvania
| | | | - Nina R. O’Connor
- University of Pennsylvania Perelman School of Medicine,
Philadelphia, Pennsylvania
| | - Salimah H. Meghani
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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16
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Worster B, Ashare R, Meghani SH, Smith D, Case AA, Selvan P, Shimada A, Garber GD, Leader A. Prevalence and perceptions of cannabis use among racially diverse patients with cancer pain: Results from a multi-site survey. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.12125] [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
12125 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]
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Affiliation(s)
| | | | | | | | | | | | - Ayako Shimada
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | | | - Amy Leader
- Thomas Jefferson University Hospital, Philadelphia, PA
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17
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Janevic MR, Mathur VA, Booker SQ, Morais C, Meints SM, Yeager KA, Meghani SH. Making Pain Research More Inclusive: Why and How. J Pain 2022; 23:707-728. [PMID: 34678471 PMCID: PMC9018873 DOI: 10.1016/j.jpain.2021.10.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/28/2021] [Accepted: 10/05/2021] [Indexed: 02/09/2023]
Abstract
Current knowledge about mechanisms and interventions for pain has largely been derived from samples that are healthier, wealthier, younger, and more likely to be White than the general population. Failure to conduct inclusive pain research not only restricts generalizability and application of findings, but also hampers the discovery of mechanisms and the development of measures and interventions that are valid across population subgroups. Most of all, inclusive practices are critical to ensure that underrepresented groups derive equitable benefit from pain research. Here, we provide guidance for the pain research community on how to adopt inclusive research practices. We define "inclusion" to encompass a range of identities and characteristics, including racialized group/ethnicity, disability status, gender identity, sexual orientation, and age. We first describe principles relevant to promoting inclusion in pain research, including attention to: 1) stakeholder engagement; 2) structural factors underlying inequities; 3) the limitations of "disparity" research; 4) intersectionality; and 5) universal design. Next, we provide checklists with practical strategies for making studies more inclusive at each stage of the research process. We conclude by calling for system-level changes to ensure that the future of pain research is socially just, scientifically productive, and responsive to the needs of all people. PERSPECTIVE: This paper offers guidance on promoting inclusion of underrepresented groups in pain research. We describe principles relevant to conducting more inclusive research; eg, attention to stakeholder engagement, structural factors, and universal design. We provide checklists with practical strategies for inclusion at each stage of the research process.
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Affiliation(s)
| | - Vani A. Mathur
- Department of Psychological & Brain Sciences, Texas A&M University
| | - Staja Q. Booker
- College of Nursing, Department of Biobehavioral Nursing Science University of Florida
| | - Calia Morais
- Department of Community Dentistry and Behavioral Science, University of Florida
| | - Samantha M. Meints
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | | | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences; New Courtland Center for Transitions and Health; Leonard Davis Institute of Health Economics, University of Pennsylvania
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18
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Levoy K, Wool J, Ashare RL, Rosa WE, Barg FK, Meghani SH. "It's Rougher on Me Than It Is on Him": Family Caregiver-Generated and Prioritized Illness Concerns While Patients Undergo Cancer Treatments. JCO Oncol Pract 2022; 18:e525-e536. [PMID: 34735272 PMCID: PMC9014424 DOI: 10.1200/op.21.00164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Research eliciting patients' illness concerns has typically focused later in the cancer continuum, rather than during cancer treatments. Family caregiver concerns are overlooked during this time. Less is known about how patients and caregivers prioritize concerns during cancer treatments, which holds potential for improving supportive oncology care (ie, primary palliative care). The purpose of this study was to elicit and compare which domains of supportive oncology are of highest importance to patients and caregivers during cancer treatments. METHODS Freelisting, a cognitive anthropology method, was used to elicit concerns in order of importance. Freelist data were analyzed using Smith's salience index. Qualitative interviews were conducted with a caregiver subsample to add explanatory insights. RESULTS In descending order, pain, death, fear, family, and awful were salient Freelist items for patients (n = 65), whereas sadness, time-consuming, support, anger, tired, death, and frustration were salient for caregivers (n = 24). When integrated with supportive oncology domains, patients' concerns reflected a prioritization of the physical (pain) and emotional (death, fear, and awful) domains, with less emphasis on social (family) aspects. Caregivers' prioritized the emotional (sadness, anger, death, and frustration) and social (time-consuming and support) domains, with less emphasis on the physical (tired) aspects. CONCLUSION Our findings suggest that enhancing primary palliative care delivery by oncology teams requires systems thinking to support both the patient and caregiver as the primary unit of care. Primary palliative care may be improved by prioritizing interventions that address physical concerns among patients as well as key social concerns among caregivers to support the complex caregiving role while patients undergo cancer treatments.
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Affiliation(s)
- Kristin Levoy
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN,Center for Aging Research, Regenstrief Institute, Indianapolis, IN,Kristin Levoy, PhD, MSN, RN, Department of Community and Health Systems, Indiana University School of Nursing, 600 Barnhill Dr, Indianapolis, IN 46202; e-mail:
| | - Jesse Wool
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA,NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA,Nursing Operations Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Frances K. Barg
- Department of Family and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA,NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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19
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Walker SL, Levoy K, Meghani SH. Use of complementary and integrative health in cancer pain management among patients undergoing cancer treatments: a qualitative descriptive study. Support Care Cancer 2022; 30:5147-5156. [PMID: 35237857 DOI: 10.1007/s00520-022-06928-4] [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: 10/20/2021] [Accepted: 02/19/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pain is a common symptom in patients undergoing cancer treatment. Despite recommendations for the stronger integration of complementary and integrative health (CIH) in cancer pain management, little is known about the individual experience of using this approach for cancer pain, particularly in certain populations such as African Americans. OBJECTIVE This study aimed to describe the experiences of using CIH for pain in African American and White patients with cancer undergoing cancer treatments. METHODS A secondary analysis of qualitative descriptive data from a subsample of patients with cancer in a parent study of their illness concerns was employed. Atlas.ti 8.0 was used for data management and qualitative analysis. Counts of participant-endorsed themes were tabulated to discern differences in themes by group. RESULTS Of 32 participants (16 African American, 16 White), 22 reported CIH usage for cancer pain management, with equal distribution between groups (11 each). Three themes emerged: Approach to, Reasons for, and Barriers to CIH Use. Psychological approaches were most common (n = 15). Nutritional, physical, and combination approaches were less common and more often employed by White participants. Reasons for CIH use were to reduce opioid consumption or for an opioid adjuvant. Personal limitations and access issues contributed to Barriers to CIH use. CONCLUSIONS Both African American and White patients used CIH for pain management while undergoing cancer treatments. However, some preferential differences in CIH approaches by race surfaced. Further research into these differences may uncover new ways of addressing disparities in cancer pain management with CIH.
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Affiliation(s)
- Suzanne L Walker
- Abramson Cancer Center, Penn Presbyterian Medical Center, Philadelphia, PA, USA.
| | - Kristin Levoy
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA.,Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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20
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Jones KF, Laury E, Sanders J, Starr LT, Rosa WE, Booker SQ, Wachterman M, Jones CA, Hickman S, Merlin JS, Meghani SH. Author Response to Reader's Comments to Fitzgerald Jones et al., Top Ten Tips Palliative Care Clinicians Should Know About Delivering Antiracist Care to Black Americans (DOI: 10.1089/jpm.2021.0502). J Palliat Med 2022; 25:347-348. [PMID: 35230905 PMCID: PMC9022451 DOI: 10.1089/jpm.2021.0673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA.,Address correspondence to: Katie Fitzgerald Jones, MSN, APRN, William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA
| | - Esther Laury
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania, USA
| | - Justin Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren T. Starr
- New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Staja Q. Booker
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, Florida, USA
| | - Melissa Wachterman
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Christopher A. Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan Hickman
- Department of Community and Health Systems, Indiana University School of Nursing, Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences, New Courtland Center for Transitions and Health, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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21
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Jones KF, Laury E, Sanders JJ, Starr LT, Rosa WE, Booker SQ, Wachterman M, Jones CA, Hickman S, Merlin JS, Meghani SH. Top Ten Tips Palliative Care Clinicians Should Know About Delivering Antiracist Care to Black Americans. J Palliat Med 2022; 25:479-487. [PMID: 34788577 PMCID: PMC9022452 DOI: 10.1089/jpm.2021.0502] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 01/05/2023] Open
Abstract
Racial disparities, including decreased hospice utilization, lower quality symptom management, and poor-quality end-of-life care have been well documented in Black Americans. Improving health equity and access to high-quality serious illness care is a national palliative care (PC) priority. Accomplishing these goals requires clinician reflection, engagement, and large-scale change in clinical practice and health-related policies. In this article, we provide an overview of key concepts that underpin racism in health care, discuss common serious illness disparities in Black Americans, and propose steps to promote the delivery of antiracist PC.
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Affiliation(s)
| | - Esther Laury
- Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania, USA.,Address correspondence to: Esther Laury, PhD, RN, Merck Sharp & Dohme Corp., US Outcomes Research, 351 N. Sumneytown Pike, North Wales, PA 19454, USA
| | - Justin J. Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren T. Starr
- New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Staja Q. Booker
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, Florida, USA
| | - Melissa Wachterman
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Christopher A. Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan Hickman
- Department of Community and Health Systems, Indiana University School of Nursing, Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Rosa WE, Parekh de Campos A, Abedini NC, Gray TF, Huijer HAS, Bhadelia A, Boit JM, Byiringiro S, Crisp N, Dahlin C, Davidson PM, Davis S, De Lima L, Farmer PE, Ferrell BR, Hategekimana V, Karanja V, Knaul FM, Kpoeh JDN, Lusaka J, Matula ST, McMahon C, Meghani SH, Moreland PJ, Ntizimira C, Radbruch L, Rajagopal MR, Downing J. Optimizing the Global Nursing Workforce to Ensure Universal Palliative Care Access and Alleviate Serious Health-Related Suffering Worldwide. J Pain Symptom Manage 2022; 63:e224-e236. [PMID: 34332044 PMCID: PMC8799766 DOI: 10.1016/j.jpainsymman.2021.07.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [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: 03/04/2021] [Revised: 06/21/2021] [Accepted: 07/22/2021] [Indexed: 11/16/2022]
Abstract
CONTEXT Palliative care access is fundamental to the highest attainable standard of health and a core component of universal health coverage. Forging universal palliative care access is insurmountable without strategically optimizing the nursing workforce and integrating palliative nursing into health systems at all levels. The COVID-19 pandemic has underscored both the critical need for accessible palliative care to alleviate serious health-related suffering and the key role of nurses to achieve this goal. OBJECTIVES 1) Summarize palliative nursing contributions to the expansion of palliative care access; 2) identify emerging nursing roles in alignment with global palliative care recommendations and policy agendas; 3) promote nursing leadership development to enhance universal access to palliative care services. METHODS Empirical and policy literature review; best practice models; recommendations to optimize the palliative nursing workforce. RESULTS Nurses working across settings provide a considerable untapped resource that can be leveraged to advance palliative care access and palliative care program development. Best practice models demonstrate promising approaches and outcomes related to education and training, policy and advocacy, and academic-practice partnerships. CONCLUSION An estimated 28 million nurses account for 59% of the international healthcare workforce and deliver up to 90% of primary health services. It has been well-documented that nurses are often the first or only healthcare provider available in many parts of the world. Strategic investments in international and interdisciplinary collaboration, as well as policy changes and the safe expansion of high-quality nursing care, can optimize the efforts of the global nursing workforce to mitigate serious health-related suffering.
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Affiliation(s)
- William E Rosa
- Department of Psychiatry and Behavioral Sciences (W.E.R.), Memorial Sloan Kettering Cancer Center, New York, USA.
| | - Amisha Parekh de Campos
- University of Connecticut School of Nursing (A.P.D.C.), Storrs & Hospice Program, Middlesex Health, Connecticut, USA
| | - Nauzley C Abedini
- Division of Gerontology and Geriatric Medicine (N.C.A.), Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Tamryn F Gray
- Harvard Medical School (T.F.G.), Department of Psychosocial Oncology and Palliative Care, Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Afsan Bhadelia
- Harvard T.H. Chan School of Public Health (A.B.), Boston, Massachusetts, USA
| | | | - Samuel Byiringiro
- Johns Hopkins University School of Nursing (S.B.), Baltimore, Maryland, USA
| | - Nigel Crisp
- All-Party Parliamentary Group on Global Health (N.C.), House of Lords, Nursing Now Global Campaign, London, UK
| | | | - Patricia M Davidson
- The Vice-Chancellor's Unit (P.M.D.), University of Wollongong, New South Wales, Australia
| | - Sheila Davis
- Partners In Health (S.D., C.M.), Boston, Massachusetts, USA
| | - Liliana De Lima
- International Association for Hospice & Palliative Care (L.D.L.), Houston, Texas, USA
| | - Paul E Farmer
- Department of Global Health and Social Medicine (P.E.F.), Harvard Medical School, Boston, Massachusetts, USA
| | - Betty R Ferrell
- Division of Nursing Research and Education (B.R.F.), Department of Population Sciences, City of Hope Medical Center, Duarte, California, USA
| | - Vedaste Hategekimana
- Pain Free Hospital Initiative (V.H.), Rwanda Biomedical Center and Ministry of Health, Butaro, Rwanda
| | - Viola Karanja
- Partners In Health Liberia (V.K., J.D.N.K, J.L.), Harper, Maryland County, Liberia
| | - Felicia Marie Knaul
- University of Miami Institute for Advanced Study of the Americas (F.M.K.), Coral Gables, Florida, USA
| | - Julius D N Kpoeh
- Partners In Health Liberia (V.K., J.D.N.K, J.L.), Harper, Maryland County, Liberia
| | - Joseph Lusaka
- Partners In Health Liberia (V.K., J.D.N.K, J.L.), Harper, Maryland County, Liberia
| | - Samuel T Matula
- University of Botswana School of Nursing (S.T.M.), Gabarone, Botswana
| | - Cory McMahon
- Partners In Health (S.D., C.M.), Boston, Massachusetts, USA
| | - Salimah H Meghani
- University of Pennsylvania School of Nursing (S.H.M.), Philadelphia, Pennsylvania, USA
| | - Patricia J Moreland
- Emory University Nell Hodgson Woodruff School of Nursing (P.J.M.), Atlanta, Georgia, USA
| | | | - Lukas Radbruch
- Department of Palliative Medicine (L.R.), University Hospital Bonn, Bonn, Germany
| | - M R Rajagopal
- Trivandrum Institute of Palliative Sciences (M.R.R.), Trivandrum, Kerala, India
| | - Julia Downing
- International Children's Palliative Care Network (J.D.), Makerere University, Kampala, Uganda
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23
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Knafl GJ, Meghani SH. Regression Modeling of Individual-Patient Correlated Discrete Outcomes with Applications to Cancer Pain Ratings. OJS 2022; 12:456-485. [PMID: 36033966 PMCID: PMC9410526 DOI: 10.4236/ojs.2022.124029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Purpose: To formulate and demonstrate methods for regression modeling of probabilities and dispersions for individual-patient longitudinal outcomes taking on discrete numeric values. Methods: Three alternatives for modeling of outcome probabilities are considered. Multinomial probabilities are based on different intercepts and slopes for probabilities of different outcome values. Ordinal probabilities are based on different intercepts and the same slope for probabilities of different outcome values. Censored Poisson probabilities are based on the same intercept and slope for probabilities of different outcome values. Parameters are estimated with extended linear mixed modeling maximizing a likelihood-like function based on the multivariate normal density that accounts for within-patient correlation. Formulas are provided for gradient vectors and Hessian matrices for estimating model parameters. The likelihood-like function is also used to compute cross-validation scores for alternative models and to control an adaptive modeling process for identifying possibly nonlinear functional relationships in predictors for probabilities and dispersions. Example analyses are provided of daily pain ratings for a cancer patient over a period of 97 days. Results: The censored Poisson approach is preferable for modeling these data, and presumably other data sets of this kind, because it generates a competitive model with fewer parameters in less time than the other two approaches. The generated probabilities for this model are distinctly nonlinear in time while the dispersions are distinctly non-constant over time, demonstrating the need for adaptive modeling of such data. The analyses also address the dependence of these daily pain ratings on time and the daily numbers of pain flares. Probabilities and dispersions change differently over time for different numbers of pain flares. Conclusions: Adaptive modeling of daily pain ratings for individual cancer patients is an effective way to identify nonlinear relationships in time as well as in other predictors such as the number of pain flares.
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Affiliation(s)
- George J Knafl
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, USA
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Tarbi EC, Gramling R, Bradway C, Meghani SH. "If it's the time, it's the time": Existential communication in naturally-occurring palliative care conversations with individuals with advanced cancer, their families, and clinicians. Patient Educ Couns 2021; 104:2963-2968. [PMID: 33992483 PMCID: PMC8578593 DOI: 10.1016/j.pec.2021.04.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/25/2021] [Accepted: 04/22/2021] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To explore how patients with advanced cancer, their families, and palliative care clinicians communicate about existential experience during palliative care conversations. METHODS We analyzed data from the Palliative Care Communication Research Initiative (PCCRI) - a multisite cohort study conducted between 2014 and 2016 involving hospitalized adults with advanced cancer who were referred for inpatient palliative care consultations at two academic medical centers. We used a qualitative descriptive approach paired with inductive content analysis to analyze a random subsample of 30 patients from the PCCRI study (contributing to 38 palliative care conversations). RESULTS We found existential communication to be woven throughout palliative care conversations, with key themes related to: 1) time as a pressing boundary; 2) maintaining a coherent self; and 3) connecting with others. CONCLUSION Communication about existential experience is omnipresent and varied in palliative care conversations between individuals with advanced cancer, their families, and clinicians. PRACTICE IMPLICATIONS Clinicians can recognize that discussion of time, routines of daily life, and relationships in the clinical context may hold profound existential relevance in palliative care conversations. Understanding how patients and families talk about existential experience in conversation can create opportunities for clinicians to better meet these needs.
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Affiliation(s)
- Elise C Tarbi
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, USA; NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, USA.
| | - Robert Gramling
- Department of Family Medicine, University of Vermont College of Medicine, Burlington, USA
| | - Christine Bradway
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, USA
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, USA
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25
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Meghani SH, Quinn R, Ashare R, Levoy K, Worster B, Naylor M, Chittams J, Cheatle M. Impact of Cannabis Use on Least Pain Scores Among African American and White Patients with Cancer Pain: A Moderation Analysis. J Pain Res 2021; 14:3493-3502. [PMID: 34764689 PMCID: PMC8577564 DOI: 10.2147/jpr.s332447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/25/2021] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Salimah H Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan Quinn
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca Ashare
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Psychology, State University of New York at Buffalo, Buffalo, NY, USA
| | - Kristin Levoy
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis, IN, USA
- Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA
| | - Brooke Worster
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mary Naylor
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jesse Chittams
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin Cheatle
- Department of Psychiatry and Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Rosa WE, Buck HG, Squires AP, Kozachik SL, Huijer HAS, Bakitas M, Boit JM, Bradley PK, Cacchione PZ, Chan GK, Crisp N, Dahlin C, Daoust P, Davidson PM, Davis S, Doumit MAA, Fink RM, Herr KA, Hinds PS, Hughes TL, Karanja V, Kenny DJ, King CR, Klopper HC, Knebel AR, Kurth AE, Madigan EA, Malloy P, Matzo M, Mazanec P, Meghani SH, Monroe TB, Moreland PJ, Paice JA, Phillips JC, Rushton CH, Shamian J, Shattell M, Snethen JA, Ulrich CM, Wholihan D, Wocial LD, Ferrell BR. American Academy of Nursing Expert Panel consensus statement on nursing's roles in ensuring universal palliative care access. Nurs Outlook 2021; 69:961-968. [PMID: 34711419 PMCID: PMC8717680 DOI: 10.1016/j.outlook.2021.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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] [Received: 02/15/2021] [Revised: 05/26/2021] [Accepted: 06/12/2021] [Indexed: 01/19/2023]
Abstract
The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.
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Affiliation(s)
- William E Rosa
- Palliative Care & End-of-Life Expert Panel; Global Nursing & Health Expert Panel; Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) Health Expert Panel.
| | - Harleah G Buck
- Palliative Care & End-of-Life Expert Panel; Expert Panel on Aging
| | | | | | - Huda Abu-Saad Huijer
- Palliative Care & End-of-Life Expert Panel; Global Nursing & Health Expert Panel
| | | | | | | | | | | | | | | | | | - Patricia M Davidson
- Palliative Care & End-of-Life Expert Panel; Global Nursing & Health Expert Panel
| | | | | | | | - Keela A Herr
- Palliative Care & End-of-Life Expert Panel; Expert Panel on Aging
| | | | - Tonda L Hughes
- Global Nursing & Health Expert Panel; Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) Health Expert Panel
| | | | | | | | | | | | | | | | | | | | | | | | - Todd B Monroe
- Palliative Care & End-of-Life Expert Panel; Expert Panel on Aging
| | - Patricia J Moreland
- Palliative Care & End-of-Life Expert Panel; Global Nursing & Health Expert Panel
| | | | - J Craig Phillips
- Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) Health Expert Panel
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Rosa WE, Buck HG, Squires AP, Kozachik SL, Huijer HAS, Bakitas M, Boit JM, Bradley PK, Cacchione PZ, Chan GK, Crisp N, Dahlin C, Daoust P, Davidson PM, Davis S, Doumit MAA, Fink RM, Herr KA, Hinds PS, Hughes TL, Karanja V, Kenny DJ, King CR, Klopper HC, Knebel AR, Kurth AE, Madigan EA, Malloy P, Matzo M, Mazanec P, Meghani SH, Monroe TB, Moreland PJ, Paice JA, Phillips JC, Rushton CH, Shamian J, Shattell M, Snethen JA, Ulrich CM, Wholihan D, Wocial LD, Ferrell BR. International consensus-based policy recommendations to advance universal palliative care access from the American Academy of Nursing Expert Panels. Nurs Outlook 2021; 70:36-46. [PMID: 34627615 DOI: 10.1016/j.outlook.2021.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Received: 02/15/2021] [Revised: 05/26/2021] [Accepted: 06/17/2021] [Indexed: 12/24/2022]
Abstract
The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. On behalf of the Academy, these evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. Through improved palliative nursing education, nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative care nurses worldwide, nurses can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations. Part II herein provides a summary of international responses and policy options that have sought to enhance universal palliative care and palliative nursing access to date. Additionally, we provide ten policy, education, research, and clinical practice recommendations based on the rationale and background information found in Part I. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter.
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Affiliation(s)
- William E Rosa
- Palliative Care & End-of-Life Expert Panel; Global Nursing & Health Expert Panel; Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) Health Expert Panel.
| | - Harleah G Buck
- Palliative Care & End-of-Life Expert Panel; Expert Panel on Aging
| | | | | | - Huda Abu-Saad Huijer
- Palliative Care & End-of-Life Expert Panel; Global Nursing & Health Expert Panel
| | | | | | | | | | | | | | | | | | - Patricia M Davidson
- Palliative Care & End-of-Life Expert Panel; Global Nursing & Health Expert Panel
| | | | | | | | - Keela A Herr
- Palliative Care & End-of-Life Expert Panel; Expert Panel on Aging
| | | | - Tonda L Hughes
- Global Nursing & Health Expert Panel; Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) Health Expert Panel
| | | | | | | | | | | | | | | | | | | | | | | | - Todd B Monroe
- Palliative Care & End-of-Life Expert Panel; Expert Panel on Aging
| | - Patricia J Moreland
- Palliative Care & End-of-Life Expert Panel; Global Nursing & Health Expert Panel
| | | | - J Craig Phillips
- Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) Health Expert Panel
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Magan KC, Hirschman KB, Starr LT, Meghani SH. Longitudinal Trajectories and Correlates of Post-Caregiving Depressive Symptoms in Former Caregivers of Persons With Alzheimer's Disease or a Related Dementia. Am J Hosp Palliat Care 2021; 39:725-736. [PMID: 34477008 DOI: 10.1177/10499091211042836] [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] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite the end of caregiving responsibilities, caregivers' depressive symptoms continue following the death of the care recipient with Alzheimer's disease or a related dementia (ADRD). However, long-term patterns of depressive symptoms among ADRD caregivers following the care recipient's death remain poorly understood. PURPOSE To explore longitudinal trajectories and correlates of depressive symptoms in former caregivers of persons with ADRD following the care recipient's death. METHODS Using the modification of Cooper's framework presented by Whittemore and Knafl, an integrative review was conducted in 4 stages: problem identification, literature search, data evaluation, and data analysis. The literature search was performed using CINAHL, PubMed, and PsycINFO databases. Articles were included if they were published in English between January 1994 and March 2021, reported in peer-reviewed sources, and described findings of original research related to factors, correlates, or longitudinal patterns of depressive symptoms in former family caregivers following the death of the care recipient with ADRD. RESULTS Longitudinal trajectories of depressive symptoms were categorized into 3 overarching themes: (1) gradual reduction of depressive symptoms during the first year post-caregiving; (2) failure of depressive symptoms to fully resolve after the first year post-caregiving; and (3) individualized depressive symptom trajectories. Correlates of post-caregiving depressive symptoms were categorized into 3 themes: (1) caregiver personal characteristics; (2) extrinsic factors; and (3) coping resources. CONCLUSION These findings indicated that screening for depression and psychosocial support are high priorities during the first year post-caregiving to facilitate early identification of at-risk caregivers and improve mental health outcomes in this population.
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Affiliation(s)
| | - Karen B Hirschman
- NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren T Starr
- NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
BACKGROUND Caring for patients with serious illness may severely strain clinicians causing distress and probable poor patient outcomes. Unfortunately, clinician distress and its impact historically has received little attention. RESEARCH PURPOSE The purpose of this article was to investigate the nature of clinician distress. RESEARCH DESIGN Qualitative inductive dimensional analysis. PARTICIPANTS AND RESEARCH CONTEXT After review of 577 articles from health sciences databases, a total of 33 articles were eligible for analysis. ETHICAL CONSIDERATIONS This study did not require ethical review and the authors adhered to appropriate academic standards in their analysis. FINDINGS A narrative of clinician distress in the hospital clinician in the United States emerged from the analysis. This included clinicians' perceptions and sense of should or the feeling that something is awry in the clinical situation. The explanatory matrix consequence of clinician distress occurred under conditions including: the recognition of conflict, the recognition of emotion, or the recognition of a mismatch; followed by a process of an inability to feel and act according to one's values due to a precipitating event. DISCUSSION This study adds three unique contributions to the concept of clinician distress by (1) including the emotional aspects of caring for seriously ill patients, (2) providing a new framework for understanding clinician distress within the clinician's own perceptions, and (3) looking at action outside of a purely moral lens by dimensionalizing data, thereby pulling apart what has been socially constructed. CONCLUSION For clinicians, learning to recognize one's perceptions and emotional reactions is the first step in mitigating distress. There is a critical need to understand the full scope of clinician distress and its impact on the quality of patient-centered care in serious illness.
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Affiliation(s)
- Anessa M Foxwell
- 6572University of Pennsylvania School of Nursing, Philadelphia, USA; Perlman Center for Advanced Medicine, Philadelphia, USA
| | | | - Connie M Ulrich
- 6572University of Pennsylvania School of Nursing, Philadelphia, USA; Leonard Davis Institute for Health Economics, USA
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Meghani SH, Levoy K, Magan KC, Starr LT, Yocavitch L, Barg FK. "I'm Dealing With That": Illness Concerns of African American and White Cancer Patients While Undergoing Active Cancer Treatments. Am J Hosp Palliat Care 2021; 38:830-841. [PMID: 33107324 PMCID: PMC8424597 DOI: 10.1177/1049909120969121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/17/2022] Open
Abstract
BACKGROUND National oncology guidelines recommend early integration of palliative care for patients with cancer. However, drivers for this integration remain understudied. Understanding illness concerns at the time of cancer treatment may help facilitate integration earlier in the cancer illness trajectory. OBJECTIVE To describe cancer patients' concerns while undergoing cancer treatment, and determine if concerns differ among African Americans and Whites. METHODS A 1-time, semi-structured qualitative interview was conducted with a purposive subsample of cancer patients participating in a larger study of illness concerns. Eligible patients were undergoing cancer treatments and had self-reported moderate-to-severe pain in the last week. Analysis encompassed a qualitative descriptive approach with inductive thematic analysis. RESULTS Participants (16 African American, 16 White) had a median age of 53 and were predominantly females (72%) with stage III/IV cancer (53%). Illness concerns were largely consistent across participants and converged on 3 themes: symptom experience (pain, options to manage pain), cancer care delivery (communication, care coordination and care transitions), and practical concerns (access to community and health system resources, financial toxicity). CONCLUSIONS The findings extend the scope of factors that could be utilized to integrate palliative care earlier in the cancer illness trajectory, moving beyond the symptoms- and prognosis-based triggers that typify current referrals to also consider diverse logistical concerns. Using this larger set of concerns aids anticipatory risk mitigation and planning (e.g. care transitions, financial toxicity), helps patients receive a larger complement of support services, and builds cancer patients' capacity toward a more patient-centered treatment and care experience.
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Affiliation(s)
- Salimah H. Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | - Kristin Levoy
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | | | - Lauren T. Starr
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing; Philadelphia, Pennsylvania
| | | | - Frances K. Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania
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Schatz AA, Oliver TK, Swarm RA, Paice JA, Darbari DS, Dowell D, Meghani SH, Winckworth-Prejsnar K, Bruera E, Plovnick RM, Richardson L, Vapiwala N, Wollins D, Hudis CA, Carlson RW. Bridging the Gap Among Clinical Practice Guidelines for Pain Management in Cancer and Sickle Cell Disease. J Natl Compr Canc Netw 2021; 18:392-399. [PMID: 32259777 DOI: 10.6004/jnccn.2019.7379] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 11/12/2019] [Indexed: 11/17/2022]
Abstract
Opioids are a critical component of pain relief strategies for the management of patients with cancer and sickle cell disease. The escalation of opioid addiction and overdose in the United States has led to increased scrutiny of opioid prescribing practices. Multiple reports have revealed that regulatory and coverage policies, intended to curb inappropriate opioid use, have created significant barriers for many patients. The Centers for Disease Control and Prevention, National Comprehensive Cancer Network, and American Society of Clinical Oncology each publish clinical practice guidelines for the management of chronic pain. A recent JAMA Oncology article highlighted perceived variability in recommendations among these guidelines. In response, leadership from guideline organizations, government representatives, and authors of the original article met to discuss challenges and solutions. The meeting featured remarks by the Commissioner of Food and Drugs, presentations on each clinical practice guideline, an overview of the pain management needs of patients with sickle cell disease, an overview of perceived differences among guidelines, and a discussion of differences and commonalities among the guidelines. The meeting revealed that although each guideline varies in the intended patient population, target audience, and methodology, there is no disagreement among recommendations when applied to the appropriate patient and clinical situation. It was determined that clarification and education are needed regarding the intent, patient population, and scope of each clinical practice guideline, rather than harmonization of guideline recommendations. Clinical practice guidelines can serve as a resource for policymakers and payers to inform policy and coverage determinations.
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Affiliation(s)
- Alyssa A Schatz
- National Comprehensive Cancer Network, Plymouth Meeting, Pennsylvania
| | | | - Robert A Swarm
- National Comprehensive Cancer Network, Plymouth Meeting, Pennsylvania.,Washington University School of Medicine, St. Louis, Missouri
| | - Judith A Paice
- National Comprehensive Cancer Network, Plymouth Meeting, Pennsylvania.,American Society of Clinical Oncology, Alexandria, Virginia.,Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Deepika S Darbari
- American Society of Hematology, Washington, DC.,Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Deborah Dowell
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Eduardo Bruera
- American Society of Clinical Oncology, Alexandria, Virginia.,University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Lisa Richardson
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Neha Vapiwala
- University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Dana Wollins
- American Society of Clinical Oncology, Alexandria, Virginia
| | | | - Robert W Carlson
- National Comprehensive Cancer Network, Plymouth Meeting, Pennsylvania
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Abstract
Parents are commonly responsible for making health care decisions for their seriously ill children in the pediatric intensive care unit (PICU); however, the factors influencing their decisions may vary. This integrative review examined the empirical literature between 2013 and 2018 to understand factors pertaining to parents' decision-making about serious illness care of their children in the PICU. Seventeen studies met the inclusion criteria with three key findings. First, parent-clinician communication in the PICU is critical; second, most parents want to be the final decision-maker for their critically ill child; and third, parents' emotions, support systems, and the child's clinical status impact decision-making. Parental perspectives are important to consider when discussing serious illness care decisions for critically ill children. Further inquiry is needed into how the parent-clinician encounter impacts the decision-making process and subsequent outcomes in this population.
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Affiliation(s)
- Jesse Wool
- University of Pennsylvania, Philadelphia, USA
- Children's Hospital of Philadelphia, PA, USA
| | - Sharon Y Irving
- University of Pennsylvania, Philadelphia, USA
- Children's Hospital of Philadelphia, PA, USA
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Starr LT, O'Connor NR, Meghani SH. Improved Serious Illness Communication May Help Mitigate Racial Disparities in Care Among Black Americans with COVID-19. J Gen Intern Med 2021; 36:1071-1076. [PMID: 33464466 PMCID: PMC7814859 DOI: 10.1007/s11606-020-06557-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Lauren T Starr
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | - Nina R O'Connor
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Meghani SH, Persico AL, Fudin J, Knafl GJ. Gaps in the Use of Long-Acting Opioids Within Intervals of Consecutive Days Among Cancer Outpatients Using Electronic Pill Caps. Pain Med 2021; 22:687-693. [PMID: 32935134 DOI: 10.1093/pm/pnaa273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE This study describes individual cancer patients' nonuse of extended-release or long-acting (ER/LA) opioids, including periods of gap between opioid doses taken. DESIGN Secondary analysis of a three-month observational study of prescribed ER/LA opioids monitored using electronic pill caps. SETTING Two outpatient oncology clinics of a large health system in the Mid-Atlantic region. PARTICIPANTS Inclusion was based on self-identified African Americans and whites, at least 18 years old, diagnosed with solid tumors or multiple myeloma. For the current analysis, the additional inclusion criterion was prescription of an oral ER/LA opioid for cancer pain to be taken around the clock. METHODS The electronic monitoring period for each study participant was partitioned into intervals of days between days with one or more openings (using medication event monitoring systems) representing rates of ER/LA opioid nonuse over consecutive days and over time. RESULTS Of the sample (N = 109), two-thirds of the cancer patients had some nonuse of prescribed ER/LA opioids, with one in four having nonuse during 31.5-87.5% of their electronic-monitoring periods. Nonuse over periods of five or more, six or more, and seven or more consecutive days occurred for 37.6%, 34.9%, and 30.3% of the participants, respectively. CONCLUSIONS About one in three ambulatory cancer patients in this study had substantial gaps between days of ER/LA opioid use, potentially resulting in risk of overdose depending upon the prescribed ER/LA opioid type, dose, and length of the time the opioid was stopped and resumed at the previous dose. This phenomenon has received little to no attention in the opioid safety discourse.
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Affiliation(s)
- Salimah H Meghani
- Department of Biobehavioral Health Sciences; New Courtland Center for Transitions and Health; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Jeffrey Fudin
- Samuel S. Stratton Department of Veterans Affairs Medical Center, Albany, New York, USA.,Albany College of Pharmacy and Health Sciences, Albany, New York, USA.,Western New England University, Springfield, Massachusetts, USA.,Remitigate Therapeutics, Delmar, New York, USA
| | - George J Knafl
- The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Tarbi EC, Gramling R, Bradway C, Broden EG, Meghani SH. "I Had a Lot More Planned": The Existential Dimensions of Prognosis Communication with Adults with Advanced Cancer. J Palliat Med 2021; 24:1443-1454. [PMID: 33534644 DOI: 10.1089/jpm.2020.0696] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 01/17/2023] Open
Abstract
Background: Communication about prognosis is a key ingredient of effective palliative care. When patients with advanced cancer develop increased prognostic understanding, there is potential for existential distress to occur. However, the existential dimensions of prognosis communication are underexplored. Objective: To describe the existential dimensions of prognosis communication in naturally-occurring palliative care conversations. Methods: This study was an explanatory sequential mixed methods design. We analyzed a random subset of patients from the Palliative Care Communication Research Initiative (PCCRI) parent study (n = 34, contributing to 45 palliative care conversations). Data were based on audio-recorded and transcribed inpatient palliative care conversations between adults with advanced cancer, their families, and palliative care clinicians. We stratified the study sample by levels of prognosis communication, and qualitatively examined patterns of existential communication, comparing the intensity, frequency, and content, within and across levels. Results: Existential communication was more common, and of stronger intensity, within conversations with higher levels of prognosis communication. Conversations with more prognosis communication appeared to exhibit a shift toward the existential and away from the more physical nature of the serious illness experience. Conclusion: Existential and prognosis communication are intimately linked within palliative care conversations. Results highlight the multiplicity and mutuality of concerns that arise when contemplating mortality, drawing attention to areas of palliative care communication that warrant future research.
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Affiliation(s)
- Elise C Tarbi
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Robert Gramling
- Department of Family Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Christine Bradway
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Elizabeth G Broden
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Rosa WE, Riegel B, Ulrich CM, Chittams J, Quinn R, Meghani SH. The Association Between Analgesic Treatment Beliefs and Electronically Monitored Adherence for Cancer Pain. Oncol Nurs Forum 2021; 48:45-58. [PMID: 33337438 DOI: 10.1188/21.onf.45-58] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 01/17/2023]
Abstract
OBJECTIVES To determine whether clusters based on analgesic treatment beliefs among patients with cancer predict objective analgesic adherence. SAMPLE & SETTING 207 patients with cancer in the outpatient setting who were aged 18 years or older, self-identified as White or African American, were diagnosed with solid tumor or multiple myeloma, and were prescribed at least one around-the-clock analgesic prescription for reported cancer pain. METHODS & VARIABLES This study is a secondary analysis of an existing dataset. General linear modeling with a backward elimination approach was applied to determine whether previously identified analgesic treatment belief clusters, as well as sociodemographic, clinical, and pain variables, were associated with adherence behaviors. RESULTS Significant explanatory factors were experiential in nature and included sociodemographic, clinical, and pain-related variables, explaining 21% of the variance in analgesic adherence. Analgesic belief clusters were not predictive of adherence. IMPLICATIONS FOR NURSING Future research should examine sociodemographic and other clinical factors, as well as the influence of analgesic treatment beliefs, to better understand adherence behaviors among patients with cancer.
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Knafl GJ, Meghani SH. Modeling Individual Patient Count/Rate Data over Time with Applications to Cancer Pain Flares and Cancer Pain Medication Usage. OJS 2021; 11:633-654. [PMID: 35938069 PMCID: PMC9351387 DOI: 10.4236/ojs.2021.115038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this article is to investigate approaches for modeling individual patient count/rate data over time accounting for temporal correlation and non-constant dispersions while requiring reasonable amounts of time to search over alternative models for those data. This research addresses formulations for two approaches for extending generalized estimating equations (GEE) modeling. These approaches use a likelihood-like function based on the multivariate normal density. The first approach augments standard GEE equations to include equations for estimation of dispersion parameters. The second approach is based on estimating equations determined by partial derivatives of the likelihood-like function with respect to all model parameters and so extends linear mixed modeling. Three correlation structures are considered including independent, exchangeable, and spatial autoregressive of order 1 correlations. The likelihood-like function is used to formulate a likelihood-like cross-validation (LCV) score for use in evaluating models. Example analyses are presented using these two modeling approaches applied to three data sets of counts/rates over time for individual cancer patients including pain flares per day, as needed pain medications taken per day, and around the clock pain medications taken per day per dose. Means and dispersions are modeled as possibly nonlinear functions of time using adaptive regression modeling methods to search through alternative models compared using LCV scores. The results of these analyses demonstrate that extended linear mixed modeling is preferable for modeling individual patient count/rate data over time, because in example analyses, it either generates better LCV scores or more parsimonious models and requires substantially less time.
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Affiliation(s)
- George J. Knafl
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- ,
| | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Belcher SM, Watkins Bruner D, Hofmeister CC, Kweon J, Meghani SH, Yeager KA. Characterizing Pain Experiences: African American Patients With Multiple Myeloma Taking Around-the-Clock Opioids. Clin J Oncol Nurs 2020; 24:538-546. [PMID: 32945786 PMCID: PMC10432153 DOI: 10.1188/20.cjon.538-546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 11/17/2022]
Abstract
BACKGROUND Despite known disparities by race, studies to date have not focused on pain characterization among African American patients with multiple myeloma. OBJECTIVES This study aimed to characterize the pain experience, beliefs about pain and pain control, and additional symptoms among African American patients with multiple myeloma taking around-the-clock opioids. METHODS This study employed secondary analysis of baseline data from a completed longitudinal study of opioid adherence. Descriptive statistics were used to characterize the sample, pain experience, beliefs regarding pain and pain control, and related symptoms. FINDINGS Participants (N = 34) experienced everyday pain and additional symptoms, and half experienced depression. Pain management barriers included dislike of pills, fear of addiction, and bothersome side effects from pain and medication. Additional larger studies can incorporate multilevel factors contributing to high symptom burden.
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Starr LT, Ulrich CM, Junker P, Appel SM, O'Connor NR, Meghani SH. Goals-of-Care Consultation Associated With Increased Hospice Enrollment Among Propensity-Matched Cohorts of Seriously Ill African American and White Patients. J Pain Symptom Manage 2020; 60:801-810. [PMID: 32454185 PMCID: PMC7508853 DOI: 10.1016/j.jpainsymman.2020.05.020] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 05/04/2020] [Accepted: 05/14/2020] [Indexed: 11/28/2022]
Abstract
CONTEXT African Americans are less likely to receive hospice care and more likely to receive aggressive end-of-life care than whites. Little is known about how palliative care consultation (PCC) to discuss goals of care is associated with hospice enrollment by race. OBJECTIVES To compare enrollment in hospice at discharge between propensity-matched cohorts of African Americans with and without PCC and whites with and without PCC. METHODS Secondary analysis of a retrospective cohort study at a high-acuity hospital; using stratified propensity-score matching for 35,154 African Americans and whites aged 18+ admitted for conditions other than childbirth or rehabilitation, who were not hospitalized at end of study, and did not die during index hospitalization (hospitalization during which first PCC occurred). RESULTS Compared with African Americans without PCC, African Americans with PCC were 15 times more likely to be discharged to hospice from index hospitalization (2.4% vs. 36.5%; P < 0.0001). Compared with white patients without PCC, white patients with PCC were 14 times more likely to be discharged to hospice from index hospitalization (3.0% vs. 42.7%; P < 0.0001). CONCLUSION In propensity-matched cohorts of seriously ill patients, PCC to discuss goals of care was associated with significant increases in hospice enrollment at discharge among both African Americans and whites. Research is needed to understand how PCC influences decision making by race, how PCC is associated with postdischarge hospice outcomes such as disenrollment and hospice lengths of stay, and if PCC is associated with improving racial disparities in end-of-life care.
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Affiliation(s)
- Lauren T Starr
- University of Pennsylvania School of Nursing, NewCourtland Center for Transitions and Health, Philadelphia, Pennsylvania, USA; University of Pennsylvania Perelman School of Medicine, Center for Bioethics, Philadelphia, Pennsylvania, USA.
| | - Connie M Ulrich
- University of Pennsylvania School of Nursing, NewCourtland Center for Transitions and Health, Philadelphia, Pennsylvania, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Paul Junker
- Program for Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Scott M Appel
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Nina R O'Connor
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Salimah H Meghani
- University of Pennsylvania School of Nursing, NewCourtland Center for Transitions and Health, Philadelphia, Pennsylvania, USA
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Starr LT, Ulrich CM, Appel SM, Junker P, O'Connor NR, Meghani SH. Goals-of-Care Consultations Are Associated with Lower Costs and Less Acute Care Use among Propensity-Matched Cohorts of African Americans and Whites with Serious Illness. J Palliat Med 2020; 23:1204-1213. [PMID: 32345109 PMCID: PMC7469692 DOI: 10.1089/jpm.2019.0522] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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] [Accepted: 02/17/2020] [Indexed: 01/20/2023] Open
Abstract
Background: African Americans receive more aggressive end-of-life care than Whites. Little is known about how palliative care consultation to discuss goals-of-care ("PCC") is associated with acute care utilization and costs by race. Objective: To compare future acute care costs and utilization between propensity-matched cohorts of African Americans with and without PCC, and Whites with and without PCC. Design: Secondary analysis of a retrospective cohort study. Setting/Subjects: Thirty-five thousand one hundred and fifty-four African Americans and Whites age 18+ admitted for conditions other than childbirth or rehabilitation, who were not hospitalized at the end of the study, and did not die during index hospitalization (hospitalization during which the first PCC occurred). Measurements: Accumulated mean acute care costs and utilization (30-day readmissions, future hospital days, future intensive care unit [ICU] admission, future number of ICU days) after discharge from index hospitalization. Results: No significant difference between African Americans with or without PCC in mean future acute care costs ($11,651 vs. $15,050, p = 0.09), 30-day readmissions (p = 0.58), future hospital days (p = 0.34), future ICU admission (p = 0.25), or future ICU days (p = 0.30). There were significant differences between Whites with PCC and those without PCC in mean future acute care costs ($8,095 vs. $16,799, p < 0.001), 30-day readmissions (10.2% vs. 16.7%, p < 0.0001), and future days hospitalized (3.7 vs. 6.3 days, p < 0.0001). Conclusions: PCC decreases future acute care costs and utilization in Whites and, directionally but not significantly, in African Americans. Research is needed to explain why utilization and cost disparities persist among African Americans despite PCC.
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Affiliation(s)
- Lauren T. Starr
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Center for Bioethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Connie M. Ulrich
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Center for Bioethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott M. Appel
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Paul Junker
- Program for Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Nina R. O'Connor
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Liou KT, Hung TKW, Meghani SH, Epstein AS, Li QS, Romero SAD, Cohen RB, Mao JJ. What if Acupuncture Were Covered by Insurance for Pain Management? A Cross-Sectional Study of Cancer Patients at One Academic Center and 11 Community Hospitals. Pain Med 2020; 20:2060-2068. [PMID: 31329938 DOI: 10.1093/pm/pnz087] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE In response to the national opioid crisis, governmental and medical organizations have called for broader insurance coverage of acupuncture to improve access to nonpharmacologic pain therapies, especially in cancer populations, where undertreatment of pain is prevalent. We evaluated whether cancer patients would be willing to use insurance-covered acupuncture for pain. DESIGN AND SETTING We conducted a cross-sectional survey of cancer patients with pain at one academic center and 11 community hospitals. METHODS We used logistic regression models to examine factors associated with willingness to use insurance-covered acupuncture for pain. RESULTS Among 634 cancer patients, 304 (47.9%) reported willingness to use insurance-covered acupuncture for pain. In univariate analyses, patients were more likely to report willingness if they had severe pain (odds ratio [OR] = 1.59, 95% confidence interval [CI] = 1.03-2.45) but were less likely if they were nonwhite (OR = 0.59, 95% CI = 0.39-0.90) or had only received high school education or less (OR = 0.46, 95% CI = 0.32-0.65). After adjusting for attitudes and beliefs in multivariable analyses, willingness was no longer significantly associated with education (adjusted OR [aOR] = 0.78, 95% CI = 0.50-1.21) and was more negatively associated with nonwhite race (aOR = 0.49, 95% CI = 0.29-0.84). CONCLUSIONS Approximately one in two cancer patients was willing to use insurance-covered acupuncture for pain. Willingness was influenced by patients' attitudes and beliefs, which are potentially modifiable through counseling and education. Further research on racial disparities is needed to close the gap in utilization as acupuncture is integrated into insurance plans in response to the opioid crisis.
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Affiliation(s)
- Kevin T Liou
- Bendheim Integrative Medicine Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tony K W Hung
- Department of Hematology-Oncology, Olive View-UCLA Medical Center, Sylmar, California
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew S Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Q Susan Li
- Bendheim Integrative Medicine Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sally A D Romero
- Bendheim Integrative Medicine Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Roger B Cohen
- Division of Hematology-Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jun J Mao
- Bendheim Integrative Medicine Center, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
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Rosa WE, Gray TF, Chow K, Davidson PM, Dionne-Odom JN, Karanja V, Khanyola J, Kpoeh JDN, Lusaka J, Matula ST, Mazanec P, Moreland PJ, Pandey S, de Campos AP, Meghani SH. Recommendations to Leverage the Palliative Nursing Role During COVID-19 and Future Public Health Crises. J Hosp Palliat Nurs 2020; 22:260-269. [PMID: 32511171 PMCID: PMC8018720 DOI: 10.1097/njh.0000000000000665] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [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: 01/03/2023]
Abstract
With the daily number of confirmed COVID-19 cases and associated deaths rising exponentially, social fabrics on a global scale are being worn by panic, uncertainty, fear, and other consequences of the health care crisis. Comprising more than half of the global health care workforce and the highest proportion of direct patient care time than any other health professional, nurses are at the forefront of this crisis. Throughout the evolving COVID-19 pandemic, palliative nurses will increasingly exercise their expertise in symptom management, ethics, communication, and end-of-life care, among other crucial skills. The literature addressing the palliative care response to COVID-19 has surged, and yet, there is a critical gap regarding the unique contributions of palliative nurses and their essential role in mitigating the sequelae of this crisis. Thus, the primary aim herein is to provide recommendations for palliative nurses and other health care stakeholders to ensure their optimal value is realized and to promote their well-being and resilience during COVID-19 and, by extension, in anticipation of future public health crises.
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Affiliation(s)
- William E Rosa
- William E. Rosa, PhD, MBE, ACHPN, FAANP, FAAN, is Robert Wood Johnson Foundation Future of Nursing Scholar, University of Pennsylvania School of Nursing, Philadelphia. Tamryn F. Gray, PhD, RN, is research fellow, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts. Kimberly Chow, RN, ANP-BC, ACHPN, is nurse practitioner, Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York. Patricia M. Davidson, PhD, RN, FAAN, is dean and professor, Johns Hopkins University School of Nursing, Baltimore, Maryland. J. Nicholas Dionne-Odom, PhD, MSN, MA, ACHPN, FPCN, is assistant professor, University of Alabama at Birmingham School of Nursing; and codirector, Caregiver and Bereavement Support Services, UAB Center for Palliative and Supportive Care. Viola Karanja, BSN, RN, is deputy executive director, Partners in Health Liberia, Harper. Judy Khanyola, MSc, RCHN, is Chair, Nursing and Midwifery, University of Global Health Equity, Butaro, Rwanda. Julius D. N. Kpoeh, ASN, RN, is senior clinical mentor, Partners in Health Liberia, Harper. Joseph Lusaka, BSc HM, DCM, PA, is clinical manager, Pleebo Health Centre, Liberia. Samuel T. Matula, PhD, RN, PCNS-BC, is lecturer, University of Botswana, Gaborone. Polly Mazanec, PhD, AOCN, ACHPN, FPCN, FAAN, is research associate professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. Patricia J. Moreland, PhD, CPNP, FAAN, is assistant clinical professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia. Shila Pandey, MSN, AGPCNP-BC, ACHPN, is nurse practitioner, Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York. Amisha Parekh de Campos, PhD, MPH, CHPN, Robert Wood Johnson Foundation Future of Nursing Scholar, University of Connecticut, Storrs; quality and education coordinator, Hospice Program, Middlesex Health, Connecticut. Salimah H. Meghani, PhD, MBE, RN, FAAN, is professor and term chair of Palliative Care, University of Pennsylvania School of Nursing, Philadelphia
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Starr LT, Ulrich CM, Junker P, Huang L, O’Connor NR, Meghani SH. Patient Risk Factor Profiles Associated With the Timing of Goals-of-Care Consultation Before Death: A Classification and Regression Tree Analysis. Am J Hosp Palliat Care 2020; 37:767-778. [DOI: 10.1177/1049909120934292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Early palliative care consultation (“PCC”) to discuss goals-of-care benefits seriously ill patients. Risk factor profiles associated with the timing of conversations in hospitals, where late conversations most likely occur, are needed. Objective: To identify risk factor patient profiles associated with PCC timing before death. Methods: Secondary analysis of an observational study was conducted at an urban, academic medical center. Patients aged 18 years and older admitted to the medical center, who had PCC, and died July 1, 2014 to October 31, 2016, were included. Patients admitted for childbirth or rehabilitationand patients whose date of death was unknown were excluded. Classification and Regression Tree modeling was employed using demographic and clinical variables. Results: Of 1141 patients, 54% had PCC “close to death” (0-14 days before death); 26% had PCC 15 to 60 days before death; 21% had PCC >60 days before death (median 13 days before death). Variables associated with receiving PCC close to death included being Hispanic or “Other” race/ethnicity intensive care patients with extreme illness severity (85%), with age <46 or >75 increasing this probability (98%). Intensive care patients with extreme illness severity were also likely to receive PCC close to death (64%) as were 50% of intensive care patients with less than extreme illness severity. Conclusions: A majority of patients received PCC close to death. A complex set of variable interactions were associated with PCC timing. A systematic process for engaging patients with PCC earlier in the care continuum, and in intensive care regardless of illness severity, is needed.
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Affiliation(s)
- Lauren T. Starr
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Center for Bioethics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Connie M. Ulrich
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Junker
- Program for Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Liming Huang
- BECCA Lab, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Nina R. O’Connor
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Salimah H. Meghani
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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44
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Rosa WE, Meghani SH, Stone PW, Ferrell BR. Opportunities for Nursing Science to Advance Patient Care in the Time of COVID-19: A Palliative Care Perspective. J Nurs Scholarsh 2020; 52:341-343. [PMID: 32725813 PMCID: PMC7323245 DOI: 10.1111/jnu.12570] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 11/29/2022]
Affiliation(s)
- William E Rosa
- Robert Wood Johnson Foundation Future of Nursing Scholar, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Salimah H Meghani
- Professor & Term Chair of Palliative Care, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Patricia W Stone
- Centennial Professor of Health Policy, Director, Center for Health Policy, Director, Center for Improving Palliative Care for Vulnerable Adults with MCC (CIPC), Columbia University School of Nursing, New York, NY
| | - Betty R Ferrell
- Professor and Director of Nursing Research, City of Hope Medical Center, Duarte, CA
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45
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Kang Y, Meghani SH, Bruner DW, Yeager KA. Factors Associated with Depression in African American Patients Being Treated for Cancer Pain. Pain Manag Nurs 2020; 21:410-415. [PMID: 32513560 DOI: 10.1016/j.pmn.2020.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 02/17/2020] [Accepted: 03/17/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Among cancer patients in the United States, African American cancer patients have the highest mortality rate and shortest survival rate. Although depression is known as a predictor of mortality in cancer and a potential barrier to health care utilization, research on depression in African American patients is limited. Cancer pain can interfere with an individual's ability to cope with depression. AIMS To identify factors that are associated with a positive screening of depressive symptoms assessed by the PHQ-8 in African American patients treated for cancer pain. DESIGN Secondary data analysis of a cross-sectional study of opioid adherence. SETTING Medical oncology, palliative care, and radiation oncology clinics in Atlanta, Georgia. PARTICIPANTS/SUBJECTS African American patients with cancer pain in the parent study. METHODS Independent samples t-test was used to assess variable correlations with and without depressive symptoms. Adjusted logistic regression was conducted to identify factors that were associated with presence of depressive symptoms. RESULTS Mean patient age was 55.6 years, and nearly 38% had a PHQ-8 score of >10 indicating presence of moderate to severe depressive symptoms. Participants with depressive symptoms had significantly higher means for anxiety and pain interference with mood than those without depressive symptoms. Factors that were significantly associated with depressive symptoms were anxiety, pain interfering with mood, and lack of involvement with a religious congregation. CONCLUSIONS The findings of this study help to identify African American cancer patients at risk for depression and demonstrates the need for increased screening for depression in this underserved population.
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Affiliation(s)
- Youjeong Kang
- University of Utah College of Nursing, Salt Lake City, Utah.
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
| | - Deborah W Bruner
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Katherine A Yeager
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
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Rosa WE, Chittams J, Riegel B, Ulrich CM, Meghani SH. Patient Trade-Offs Related to Analgesic Use for Cancer Pain: A MaxDiff Analysis Study. Pain Manag Nurs 2020; 21:245-254. [PMID: 31648906 PMCID: PMC7170763 DOI: 10.1016/j.pmn.2019.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/05/2019] [Accepted: 07/26/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE Many patients with cancer pain deviate from prescribed analgesic regimens. Our aim was to elicit the trade-offs patients make based on their beliefs about analgesic use and rank utilities (importance scores) using maximum difference (MaxDiff) scaling. We also investigated if there were unique clusters of patients based on their analgesic beliefs. METHODS This was a secondary analysis of a three-month, prospective observational study. Patients (N = 207) were self-identified African Americans and Whites, >18 years, diagnosed with multiple myeloma or solid tumor, and were prescribed at least one around-the-clock analgesic for cancer pain. MaxDiff analysis allowed us to identify patients utilities. Second, a cluster analysis assisted in ranking how analgesic beliefs differed by groups. Third, clusters were described by comparing key sociodemographic and clinical variables. RESULTS Participants' beliefs were a significant factor in choices related to analgesic use (chi-square = 498.145, p < .0001). The belief, 'Pain meds keep you from knowing what is going on in your body', had the highest patient endorsement. Two distinct clusters of patients based on analgesic beliefs were identified; 'knowing body' was ranked as top priority for both clusters. The belief that cancer patients become addicted to analgesics was moderately important for both clusters. Severity of side effects was the only key variable significantly different between clusters (p = .043). CONCLUSIONS Our findings support tailored pain management interventions that attend to individual beliefs about cancer pain and analgesic use. Future research should explore the relationship between analgesic utilities, actual analgesic taking behaviors, and how they impact patients' cancer pain outcomes.
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Affiliation(s)
- William E Rosa
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania.
| | - Jesse Chittams
- BECCA Lab, Office of Nursing Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Barbara Riegel
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Connie M Ulrich
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Salimah H Meghani
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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47
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Schatz AA, Oliver TK, Swarm RA, Paice JA, Darbari DS, Dowell D, Meghani SH, Winckworth-Prejsnar K, Bruera E, Plovnick RM, Richardson L, Vapiwala N, Wollins D, Hudis CA, Carlson RW. Bridging the Gap Among Clinical Practice Guidelines for Pain Management in Cancer and Sickle Cell Disease. JCO Oncol Pract 2020; 16:e433-e442. [PMID: 32255722 DOI: 10.1200/jop.19.00675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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
Opioids are a critical component of pain relief strategies for the management of patients with cancer and sickle cell disease. The escalation of opioid addiction and overdose in the United States has led to increased scrutiny of opioid prescribing practices. Multiple reports have revealed that regulatory and coverage policies, intended to curb inappropriate opioid use, have created significant barriers for many patients. The Centers for Disease Control and Prevention, National Comprehensive Cancer Network, and ASCO each publish clinical practice guidelines for the management of chronic pain. A recent JAMA Oncology article highlighted perceived variability in recommendations among these guidelines. In response, leadership from guideline organizations, government representatives, and authors of the original article met to discuss challenges and solutions. The meeting featured remarks by the Commissioner of Food and Drugs, presentations on each clinical practice guideline, an overview of the pain management needs of patients with sickle cell disease, an overview of perceived differences among guidelines, and a discussion of differences and commonalities among the guidelines. The meeting revealed that although each guideline varies in the intended patient population, target audience, and methodology, there is no disagreement among recommendations when applied to the appropriate patient and clinical situation. It was determined that clarification and education are needed regarding the intent, patient population, and scope of each clinical practice guideline, rather than harmonization of guideline recommendations. Clinical practice guidelines can serve as a resource for policymakers and payers to inform policy and coverage determinations.
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Affiliation(s)
| | | | - Robert A Swarm
- National Comprehensive Cancer Network, Plymouth Meeting, PA.,Washington University School of Medicine, St. Louis, MO
| | - Judith A Paice
- National Comprehensive Cancer Network, Plymouth Meeting, PA.,ASCO, Alexandria, VA.,Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Deepika S Darbari
- American Society of Hematology, Washington, DC.,Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | | | | | - Eduardo Bruera
- ASCO, Alexandria, VA.,University of Texas MD Anderson Cancer Center, Houston, TX
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48
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Meghani SH, Wool J, Davis J, Yeager KA, Mao JJ, Barg FK. When Patients Take Charge of Opioids: Self-Management Concerns and Practices Among Cancer Outpatients in the Context of Opioid Crisis. J Pain Symptom Manage 2020; 59:618-625. [PMID: 31711967 DOI: 10.1016/j.jpainsymman.2019.10.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 08/08/2019] [Revised: 10/19/2019] [Accepted: 10/23/2019] [Indexed: 12/13/2022]
Abstract
CONTEXT With concerns about opioid prescribing practices prominent in the professional and lay literature, there is less focus on patients' self-management of opioids for cancer pain and potential safety risks. OBJECTIVES To investigate reports of opioid self-management practices and concerns among patients undergoing active cancer treatments-a group excluded from the scope of most policy initiatives on prescription opioids. METHODS This sequential multimethod study used freelisting (n = 65) and open-ended semistructured interviews with a racially diverse subgroup (n = 32). Adult ambulatory patients with solid malignancies or multiple myeloma and pain (≥4 on a scale of 0-10) were recruited from an urban National Cancer Institute-designated cancer center in Philadelphia. Freelists were analyzed using consensus analysis and semistructured interview data were analyzed using thematic analysis. RESULTS In freelisting, "pain relief" emerged as the primary term in relation to taking pain medications preceding "addiction" concerns. In interviews, patients described several heuristics and some potentially unsafe practices to minimize opioid use to a self-defined "normal." These included reducing opioid dose by cutting pills; self-tapering off opioids; using extended-release/long-acting opioids on an as-needed basis; mixing over-the-counter, nonopioid analgesics; and using illicit drugs to avoid "harder medicines" (opioids). Many patients preferred nonopioid treatments for pain but invariably faced access barriers. Some described assuming stewardship of their prescribed opioids and felt that oncology clinicians are quick to prescribe opioids without providing workable alternatives. CONCLUSIONS Risks related to self-management of opioids among cancer outpatients, including potential overdose risks, need urgent attention. Interventions are needed for improving clinician-patient communication, patient education, safety, and access to effective nonopioid alternatives.
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Affiliation(s)
- Salimah H Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Jesse Wool
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jessica Davis
- School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine A Yeager
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Jun J Mao
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Frances K Barg
- School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Family and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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49
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Nugent SM, Meghani SH, Rogal SS, Merlin JS. Medical cannabis use among individuals with cancer: An unresolved and timely issue. Cancer 2020; 126:1832-1836. [PMID: 32012232 DOI: 10.1002/cncr.32732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Shannon M Nugent
- Department of Psychiatry, Oregon Health and Science University, Portland, Oregon.,Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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50
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Corey KL, McCurry MK, Sethares KA, Bourbonniere M, Hirschman KB, Meghani SH. Predictors of psychological distress and sleep quality in former family caregivers of people with dementia. Aging Ment Health 2020; 24:233-241. [PMID: 30588830 PMCID: PMC6663657 DOI: 10.1080/13607863.2018.1531375] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 05/13/2018] [Revised: 08/01/2018] [Accepted: 09/29/2018] [Indexed: 10/27/2022]
Abstract
Objectives: The stress-related psychological symptoms experienced by informal family caregivers do not always improve or resolve after the death of the care recipient. The purpose of this study was to explore the independent associations of sociodemographic variables, personality and coping, environmental variables, and caregiver guilt with the sleep quality and psychological distress of former family caregivers of individuals with dementia following care recipient's death.Method: A cross-sectional, correlational study was conducted with a sample of 171 former family caregivers of people with dementia. Participants completed an online survey comprised of six instruments and demographic items. Caregiver personal variables (e.g. personality and coping), environmental variables, guilt, psychological distress (depressive and anxiety symptoms), and sleep quality were evaluated using psychometrically validated measures.Results: In bivariate analysis, post-caregiving guilt was significantly associated with depressive and anxiety symptoms (p < 0.01). After controlling for covariates, dysfunctional coping and neuroticism explained 32% of the variance in depressive symptoms (R2 = .52, ΔR2 = .32, F(5, 165) = 36.24, p < .001) and 24% of the variance in anxiety symptoms (R2 = .41, ΔR2 = .24, F(5, 165) = 22.65, p < .001), while dysfunctional coping, pre-loss depression, and extraversion accounted for 16% of the variance in sleep quality (R2 = .30, ΔR2 = .16, F(6, 164) = 11.44, p < .001).Conclusion: This study demonstrates the critical role of personal variables, including personality traits, coping strategies, and pre-loss depression, in explaining psychological distress and sleep quality in this sample of former dementia caregivers.
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Affiliation(s)
- Kristin L. Corey
- NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Mary K. McCurry
- Department of Adult Nursing, University of Massachusetts Dartmouth, Dartmouth, MA, United States
| | - Kristen A. Sethares
- Department of Adult Nursing, University of Massachusetts Dartmouth, Dartmouth, MA, United States
| | - Meg Bourbonniere
- College of Nursing, University of Rhode Island, Kingston, RI, United States
| | - Karen B. Hirschman
- NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Salimah H. Meghani
- NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
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