Differences in the utilization of palliative care support services among patients with metastatic solid tumor cancer in a community oncology setting: A retrospective review

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Background: Palliative care has been underutilized in the setting of advanced cancer despite its established benefit in improving the quality of life in cancer patients. Few studies have evaluated socioeconomic disparities in receiving palliative care in the outpatient oncology setting. We aimed to evaluate for disparities in utilization of palliative care among patients with metastatic solid tumor malignancies at Tennessee Oncology, a large outpatient community oncology practice with an established palliative care program. Methods: We completed a retrospective review of medical records of 1513 patients that were seen in Tennessee Oncology clinics from 12/2020 to 12/2021. We compared the baseline characteristics of patients with metastatic solid tumor malignancies who did and did not receive palliative care. Chi-square and two-sample t-tests were used for data analysis with the 5% significance level using R statistical software. Results: Male patients utilized palliative care less often than female patients (17% versus 24% for females, p =.0002; 95% CI,.05-1.0). Of payer types, Medicare had the least palliative care utilization (14%) compared to commercial (25%) and other payers (23%). Utilization also varied by cancer type, with melanoma (9%), lung cancer (15%) and renal cancer (21%) being least likely to receive palliative care (p <.00005; 95% CI,.19-1.0). We did examine racial differences in palliative care utilization, but those did not reach statistical significance. Conclusions: There are multiple disparities in the utilization of on-site palliative care support services among patients with metastatic solid tumor cancer in this outpatient community oncology setting. Further research is needed to gain insight into why this is, including an in-depth analysis of both patient and provider utilization/referral practices.[Table: see text]

Provider-led advance care planning in community oncology: A successful multidisciplinary quality improvement intervention

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Background: Advanced care planning (ACP) is an important aspect of shared decision making in cancer treatment. Due to its importance, in 2016, Medicare expanded coverage and reimbursement for advance care planning (ACP) services (CPT codes 99497 and 99498). Despite this, ACP has been underutilized in practice. Methods: Tennessee Oncology aimed to increase knowledge and utilization of this service by medical oncologists and advance practice providers and corresponding CPT codes through an educational and quality improvement project. We formed a multidisciplinary team with individuals representing medical oncology providers, palliative care team, billing and accounting, information technology and informatics, nursing, navigation team, and operations. This team created an educational video, incorporating the “PAUSE” framework for addressing advance care planning and its role in community oncology, and details of documentation and billing. We also built in documentation templates into the medical oncology note and created a process to automate the charge capture to avoid additional steps for oncology providers. Results: Prior to this initiative, there was no baseline method to measure ACP and corresponding documentation. After two months of launching our educational video and new documentation templates, 120 documented ACP discussions were completed. ACP documentation was performed by 61 total providers practicing across 16 clinics. Providers completing documentation included both medical oncology (n = 53, 86%) and palliative care (n = 8). Of medical oncology providers, 39 (73%) were physicians and 14 (27%) were advanced practice providers. The three most common cancer diagnoses in ACP encounters were lung (20%), breast (13%), and prostate (8%). Conclusions: This combination of education and automation with multidisciplinary team input helped establish a baseline for ACP measurement that will help identify gaps and improve ACP discussions and documentation in our practice going forward.

Growth and scalability of a palliative care program in a large community oncology practice

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Background: Tennessee Oncology (TO) is a large community oncology practice with over 180 oncology providers spanning over 30 clinics throughout Tennessee and northern Georgia. In 2017, TO began embedding palliative care (PC) providers in clinics. However, the program growth was slow and by the end of 2019, TO offered PC services within only five clinics. In early 2020, TO implemented various initiatives to expand access and improve utilization of palliative care. Methods: In May 2020, TO hired a palliative care physician to grow and oversee the program. TO physician leadership established and communicated the importance of PC to providers and began providing feedback to each provider on utilization of PC for metastatic lung and pancreatic cancer patients. These diseases were selected due to poor prognosis, high morbidity, and known benefit of palliative care. Expansion of telemedicine reimbursement helped our PC team offer in person and telemedicine visits. Increasing demand allowed for expansion of the team and hiring of additional physicians, advanced practice providers (APPs), and a PC nurse coordinator to provide triage, follow-up and scheduling for PC providers. Results: Between the end of 2019 and the end of 2021, the average number of PC visits per quarter (averaged across three quarters) increased from 1,279 to 2,480, representing a growth of 194%. During this time, TO provided over 19,600 PC visits for 3,955 unique patients, of which 53% were female and 47% were male. Of visits provided, 40% were performed through telemedicine. The program has grown from five providers to 11 providers (three physicians, eight APPs). The number of clinics offering in person PC services has grown from five to 13. The three most common malignancies associated with patient visits were lung (16%), breast (10%), and colorectal (7%). Conclusions: Embedding palliative care within a large community oncology practice is feasible and can grow rapidly. A combination of in-person and telemedicine visits can expand reach to improve accessibility across a large patient population.

Real-world patterns of chemotherapy and immunotherapy utilization at end of life in a large community oncology network

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Background: End-of-life anti-neoplastic treatment does not improve quality of life nor prolong survival of advanced cancer patients. It is also not cost-effective. To-date, there has been little data examining real-world patterns of chemotherapy and immunotherapy treatment at end of life. We investigated use of chemotherapy and/or immunotherapy in the last 14 days of life across a community oncology network of 5 practices, 100 sites of care, and 160 oncology providers. Methods: Using a real-time, network-wide database, we identified patients with solid tumor malignancies who died during an episode of active treatment, defined as having received intravenous (IV) chemotherapy and/or immunotherapy within 90 days of death. We then identified patients in this cohort who received IV chemotherapy and/or IV immunotherapy within 14 days of death (TxEoL). We studied TxEoL patterns by cancer type, treatment type, line of therapy, patient age, patient race, and oncology provider years in practice. Statistical significance was assessed using Pearson’s Chi-squared test. Results: 2,858 qualifying solid tumor cancer patients with dates of death between 1/1/2019 and 5/31/2020 were identified. Observed rates of TxEoL were 16.7% for immunotherapy alone vs. 19.6% for chemotherapy +/- immunotherapy (p = 0.09). We found high variation in TxEoL across 132 oncologists that had 5 or more deceased patients (range: 0% to 50%, mean: 19.2%, median: 19.6%). We found no association of TxEOL with physician years in practice, patient age or race. Rates of TxEoL in the first-line setting were significantly higher than in second-line setting or later (23.3% versus 16.4%, p < 0.01). Patients with head and neck, pancreatic, and hepatobiliary malignancies were the most likely to receive TxEoL, while patients with prostate, brain, and ovarian malignancies were the least likely to receive TxEoL. Conclusions: Our data and method identified wide variation in TxEoL patterns across a large community oncology network, suggesting room for provider-level interventions to improve treatment decisions in patients at high risk of death. Studies within our group, such as examining the impact of palliative care referrals on IV anti-cancer treatment in patients potentially facing end of life, are ongoing.

Model for End-Stage Liver Disease Score Predicts Development of First Episode of Spontaneous Bacterial Peritonitis in Patients With Cirrhosis

OBJECTIVE

To examine whether baseline model for end-stage liver disease (MELD) score in patients with cirrhosis and ascites predicts the future development of first spontaneous bacterial peritonitis (SBP) episode.

METHODS

A retrospective case-control study was performed at three academic centers to select patients admitted with first SBP episode (cases) and those with ascites admitted for decompensation without SBP (controls). Medical records from these centers were reviewed between January 1, 2008, and December 31, 2013. Cases and controls were matched (1:2) for age, sex, and race. Conditional logistic recession models were built to determine whether baseline MELD score (within a month before hospitalization) predicts first SBP episode.

RESULTS

Of 697 patients (308, 230, and 159 from centers A, B, and C, respectively), cases and controls were matched in 94%, 89%, and 100% at three respective centers. In the pooled sample, probability of SBP was 11%, 31%, 71%, and 93% at baseline MELD scores less than or equal to 10, from 11 to 20, from 21 to 30, and greater than 30, respectively. Compared with MELD score less than or equal to 10, patients with MELD scores from 11 to 20, 21 to 30, and greater than 30 had six- (3- to 11-), 29- (12- to 69-), and 115- (22- to 598-) folds (95% CI) risk of SBP, respectively. Based on different MELD score cutoff points, MELD score greater than 17 was most accurate in predicting SBP occurrence. Analyzing 315 patients (152 cases) with available data on ascitic fluid protein level controlling for age, sex, and center, MELD score but not ascitic fluid protein associated with first SBP episode with respective odds ratios of 1.20 (1.14 to 1.26) and 0.88 (0.70 to 1.11).

CONCLUSION

Baseline MELD score predicts first SBP episode in patients with cirrhosis and ascites.

Correction: Patients with stage 3 compared to stage 4 liver fibrosis have lower frequency of and longer time to liver disease complications

[This corrects the article DOI: 10.1371/journal.pone.0197117.].

Patients with stage 3 compared to stage 4 liver fibrosis have lower frequency of and longer time to liver disease complications

BACKGROUND AND AIMS

Advanced liver fibrosis is an important predictor of liver disease progression and mortality, and current guidelines recommend screening for complications of cirrhosis once patients develop F3 fibrosis. Our study compared liver disease progression and survival in patients with stage 3 (F3) and stage 4 (F4) fibrosis on liver biopsy.

METHODS

Retrospective study of patients with F3 or F4 on liver biopsy followed for development of liver disease complications (variceal bleeding, ascites, and hepatic encephalopathy); hepatocellular carcinoma, and survival (overall and transplant free survival).

RESULTS

Of 2488 patients receiving liver biopsy between 01/02 and 12/12, a total of 294 (171 F3) were analyzed. Over a median follow up period of 3 years, patients with F4 (mean age 53 years, 63% male) compared to F3 (mean age 49 years, 43% male) had higher five year cumulative probability of any decompensation (38% vs. 14%, p<0.0001), including variceal bleed (10% vs. 4%, p = 0.014), ascites (21% vs. 9%, p = 0.0014), and hepatic encephalopathy (14% vs. 5%, p = 0.003). F4 patients also had lower overall 5-year survival (80% vs. 93%, p = 0.003) and transplant free survival (80% vs. 93%, p = 0.002). Probability of hepatocellular carcinoma in 5 years after biopsy was similar between F3 and F4 (1.2% vs. 2%, p = 0.54).

CONCLUSIONS

Compared to F4 stage, patients with F3 fibrosis have decreased risk for development of liver disease complications and better survival. Prospective well designed studies are suggested with large sample size and overcoming the limitations identified in this study, to confirm and validate these findings, as basis for modifying guidelines and recommendations on follow up of patients with advanced fibrosis and stage 3 liver fibrosis.

Anchoring of self-expanding metal stents using the over-the-scope clip, and a technique for subsequent removal

BACKGROUND AND STUDY AIMS

Standard clips do not consistently prevent the migration of covered self-expanding metal stents (SEMS). The aims of this study were to assess the efficacy and safety of the over-the-scope clip (OTSC) system for anchoring SEMS to the esophagus, and to evaluate a novel OTSC removal technique.

METHODS

This was a single-center, retrospective, cohort study of consecutive patients undergoing SEMS anchoring with OTSC. Removal of the OTSC was accomplished using an inject-and-resect technique.

RESULTS

A total of 12 patients were included. The indications for endoscopic stenting were: tracheo-esophageal fistula (n = 7), postoperative leak or fistula (n = 4), perforation (n = 1). Successful application of the OTSC system was accomplished in all patients (100 %). Stent migration during follow-up (mean 3 weeks, range 2 - 4 weeks) occurred in two patients (16.7 %). After healing of the underlying condition, the stent was removed in six patients (50.0 %). In four patients (33.3 %), the anchored stent was left indefinitely in order to treat the underlying condition. There were no complications associated with deployment of the OTSC or SEMS removal.

CONCLUSIONS

Although endoscopic anchoring of fully covered SEMS with the OTSC was feasible, easy to accomplish, safe, and prevented stent migration in most cases, larger studies are needed to confirm these encouraging early findings. The inject-and-resect technique was safe and efficient for OTSC and stent removal in all cases in which it was attempted.