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Palliative care (PC) benefits critically ill patients but remains underutilized. Important to developing interventions to overcome barriers to PC in the ICU and address PC needs of ICU patients is to understand how, when, and for which patients PC is provided in the ICU.Compare characteristics of specialty PC consultations in the ICU to those on medical-surgical wards.Retrospective analysis of national Palliative Care Quality Network data for hospitalized patients receiving specialty PC consultation January 1, 2013 to December 31, 2019 in ICU or medical-surgical setting. 98 inpatient PC teams in 16 states contributed data. Measures and outcomes included patient characteristics, consultation features, process metrics and patient outcomes. Mixed effects multivariable logistic regression was used to compare ICU and medical-surgical units.Of 102,597 patients 63,082 were in medical-surgical units and 39,515 ICU. ICU patients were younger and more likely to have non-cancer diagnoses (all P0.001). While fewer ICU patients were able to report symptoms, most patients in both groups reported improved symptoms. ICU patients were more likely to have consultation requests for GOC, comfort care, and withdrawal of interventions and less likely for pain and/or symptoms (OR-all P0.001). ICU patients were less often discharged alive.ICU patients receiving PC consultation are more likely to have non-cancer diagnoses and less likely able to communicate. Although symptom management and GOC are standard parts of ICU care, specialty PC in the ICU is often engaged for these issues and results in improved symptoms, suggesting routine interventions and consultation targeting these needs could improve care.

Background and ObjectivesSpecialty palliative care (PC) may benefit patients with dementia by aligning treatment with goals and relieving symptoms. We aimed to compare demographics and processes and outcomes of PC for inpatients with dementia with those with systemic illnesses or cancer.MethodsThis multicenter cohort study included standardized data for hospitalized patients with a primary diagnosis of dementia, systemic illnesses (cardiovascular, pulmonary, hepatic, or renal disease), or cancer among the 98 PC teams submitting data to the Palliative Care Quality Network from 2013 to 2019.ResultsOf 155,356 patients, 4.5% (n = 6,925) had a primary diagnosis of dementia, 32.5% (n = 50,501) systemic illness, and 29.2% (n = 45,386) cancer. Patients with dementia were older (mean 85.5 years, 95% confidence interval [CI] 85.3–85.6) than those with systemic illnesses (mean 73.2, 95% CI 73.0–73.3) or cancer (mean 66.6, 95% CI 66.4–66.7; p < 0.0001). Patients with dementia were more likely to receive a PC consult within 24 hours of admission (52.3% vs systemic illnesses 37.4%; cancer 45.3%; p < 0.0001), more likely to be bed-bound (vs systemic illnesses odds ratio (OR) 2.23, 95% CI 2.09–2.39, p < 0.0001; vs cancer OR 3.45, 95% CI 3.21–3.72, p < 0.0001), and more likely to be discharged alive (vs systemic illnesses OR 2.22, 95% CI 2.03–2.43, p < 0.0001; vs cancer OR 1.51, 95% CI 1.36–1.67, p < 0.0001). Advance care planning/goals of care (GOC) was the primary reason for consultation for all groups. Few patients overall had advance directives or Physician Orders for Life-Sustaining Treatment before consultation. At the time of referral and at discharge, patients with dementia were more likely to have a code status of do not resuscitate/do not intubate (DNR/DNI) (62.6% and 81.0% vs 38.7 and 64.2% for patients with systemic illnesses and 33.4% and 60.5% for patients with cancer; p < 0.0001). Among the minority of patients with dementia that could self-report, moderate-to-severe symptoms were uncommon (pain 6.4%, anxiety 5.8%, nausea 0.4%, and dyspnea 3.5%).DiscussionInpatients with a primary diagnosis of dementia receiving PC consultation were older and more functionally impaired than those with other illnesses. They were more likely to have a code status of DNR/DNI at discharge. Few reported distressing symptoms. These results highlight the need for routine clarification of GOC for patients with dementia.

Background: Patients with cirrhosis have significant morbidity and mortality, as well as substantial symptom burden. Objective: We investigated the relationship between symptom burden and inpatient health care utilization among patients with cirrhosis. Methods: Adult patients with cirrhosis being evaluated for or awaiting liver transplantation at an academic institution in the United States completed the Edmonton Symptom Assessment Scale (ESAS), a validated symptom evaluation tool with total scores ranging from 0 to 90. The outcomes of interest were emergency department (ED) visits, nonelective hospitalizations, hospital days, intensive care unit (ICU) admissions, and 30-day readmissions within 6 months. Adjusted incidence rate ratios (IRRs) were used to examine the relationship between ESAS scores and outcomes. Results: Of 233 patients (43% female, median age 61), the median total ESAS score was 16 (interquartile range 6–30). Higher total scores on the ESAS were associated with increased ED visits, hospitalizations, hospital days, and ICU days (all p

Understanding the unique needs of patients seen in clinic versus at home can help palliative care (PC) teams choose how to maximize available resources.To compare the characteristics and PC needs of patients seen by PC teams in clinic versus at home.We analyzed data from the Palliative Care Quality Network between August 2016 and September 2019 and compared demographics, diagnosis, reason for referral, PC needs, functional status, self-reported symptoms, and patient-reported quality of life.Compared to patients receiving PC in clinic, patients receiving PC at home were more likely to be of age 80 years or older (odds ratio [OR] 7.5, 95% CI 5.0, 10.9, P 0.0001), have lower functional status (mean Palliative Performance Scale score 53% vs. 68%, P 0.0001), and were less likely to screen positive for needing pain management (OR 0.31, 95% CI 0.22, 0.42, P 0.0001) or other symptom management (OR 0.61, 95% CI 0.41, 0.90, P = 0.01). Patients receiving care at home were more likely to be referred for care planning (goals of care discussions or advance care planning) (OR 11.5, 95% CI 8.3, 16.0 P 0.0001) and patient/family support (OR 5.9, 95% CI 4.2, 8.3, P 0.0001).Patients seen by PC teams at home had worse function and were more likely to be referred for care planning, while patients seen in clinic had more PC needs related to pain and symptom management. Despite these differences, both populations have significant PC needs that support routine assessment and require appropriately staffed interdisciplinary teams to address these needs.

OBJECTIVES Although patients with cirrhosis often experience debilitating symptoms, few are referred for palliative care. Frailty is increasingly incorporated in liver transplantation evaluation and has been associated with symptom burden in other populations. We hypothesized that frail patients with cirrhosis are highly symptomatic and thus are likely to benefit from palliative care. METHODS Patients with cirrhosis undergoing outpatient liver transplantation evaluation completed the Liver Frailty Index (grip strength, chair stands and balance) and a composite of validated measures including the Edmonton Symptom Assessment Scale, distress and quality of life (QOL) measures. RESULTS Of 233 patients (median age 61 years, 43% women), 22% were robust, 59% prefrail and 19% frail. Overall, 38% of patients reported ≥1 severe symptoms based on preestablished Edmonton Symptom Assessment Scale criteria. Higher frailty categories were associated with increased prevalence of pain, dyspnea, fatigue, nausea, poor appetite, drowsiness, depression and poor well-being (test for trend, all P < 0.05). Frail patients were also more likely to report psychological distress and poor QOL (all P < 0.01). In univariate analysis, each 0.5 increase in liver frailty index was associated with 44% increased odds of experiencing ≥1 severe symptoms [95% confidence interval (CI), 1.2-1.7, P < 0.001], which persisted (odds ratio, 1.3, 95% CI, 1.0-1.6, P = 0.004) even after adjusting for Model for End Stage Liver Disease-Sodium, ascites, hepatic encephalopathy and age. CONCLUSION In patients with cirrhosis, frailty is strongly associated with physical/psychological symptoms, including pain and depression and poor QOL. Frail patients with cirrhosis may benefit from palliative care co-management to address symptoms and improve QOL.

ObjectiveThis observational study explores the association between palliative care (PC) involvement and high-cost imaging utilisation for patients with cancer patients during the last 3 months of life.MethodsAdult patients with cancer who died between 1 January 2012 and 31 May 2015 were identified. Referral to PC, intensity of PC service use, and non-emergent oncological imaging utilisation were determined. Associations between PC utilisation and proportion of patients imaged and mean number of studies per patient (mean imaging intensity (MII)) were assessed for the last 3 months and the last month of life. Similar analyses were performed for randomly matched case-control pairs (n = 197). Finally, the association between intensity of PC involvement and imaging utilisation was assessed.Results3784 patients were included, with 3523 (93%) never referred to PC and 261 (7%) seen by PC, largely before the last month of life (61%). Similar proportions of patients with and without PC referral were imaged during the last 3 months, while a greater proportion of patients with PC referral were imaged in the last month of life. PC involvement was not associated with significantly different MII during either time frame. In the matched-pairs analysis, a greater proportion of patients previously referred to PC received imaging in the period between the first PC encounter and death, and in the last month of life. MII remained similar between PC and non-PC groups. Finally, intensity of PC services was similar for imaged and non-imaged patients in the final 3 months and 1 month of life. During these time periods, increased PC intensity was not associated with decreased MII.ConclusionsPC involvement in end-of-life oncological care was not associated with decreased use of non-emergent, high-cost imaging. The role of advanced imaging in the PC setting requires further investigation.

Background:Palliative care (PC) is recommended for people with amytrophic lateral sclerosis (ALS), but there is scant literature about how to best provide this care. We describe the structure and impact of a pilot program that integrates longitudinal, interdisciplinary PC into the care of patients with ALS.Methods:Observational cohort study of patients with ALS referred to outpatient PC and seen for at least three PC visits October 2017-July 2020.Results:Fifty-five patients met inclusion criteria. Three-quarters (74.5%) were Caucasian and 78.2% spoke English. Patients were referred for advance care planning (58.2%), support for patient/family (52.7%), and symptoms other than pain (50.9%).Patients had a mean of five scheduled PC visits, the majority occurred by video. A PC physician, nurse, social worker, and chaplain addressed pain (for 43.6% of patients), non-pain symptoms (94.5%), psychosocial distress (78.2%), spiritual concerns (29.1%), care planning (96.4%), and supported family caregivers (96.4%).With PC, the rate of completion of advance directives increased from 16.4% to 36.4% (p=0.001) and Physician Orders for Life-Sustaining Treatment forms from 10.9% to 63.6% (pConclusions:Integrating longitudinal, interdisciplinary PC into the care of patients with ALS is feasible, addresses needs in multiple domains, and is associated with increased rates of advance care planning. Controlled studies are needed to further elucidate the impact of PC on ALS patients, families, and clinicians.

Context Critically ill patients have important palliative care (PC) needs in the intensive care unit (ICU), but specialty PC is often underutilized. Objective To evaluate changes in utilization and reasons for PC consultation over time. Methods Data from a national multi-site network of inpatient PC visits were used to identify patients age ≥18 years admitted to an ICU between 2013 and 2019. Year of ICU admission was the exposure. Primary diagnosis and reason for referral were identified by standardized process measures within the dataset at the time of referral. Trends in primary diagnosis and reason for referral were modeled as a function of year of ICU admission. Results Across 39,515 ICU patients seen by a PC team, overall numbers of consultations from the ICU increased each year. Referrals for patients with cancer decreased from 17.6% (95% CI 13.7%–21.5%) to 14.3% (95% CI 13.2%–14.7%) and for patients with cardiovascular disease increased from 16.8% in (95% CI 16.8%–16.9%) to 18.8% (95% CI 18.8%–18.9%). Reasons for referrals were primarily for goals of care and advance care planning and increased from 74.0% (95% CI 70.0%–78.0%) in 2013 to 80.0% (95% CI 79.4%–80.0%) in 2019 (P Conclusion PC referrals in ICU patients with cancer are decreasing, while those for cardiovascular disease are increasing. Reasons for referrals in the ICU are commonly for goals of care; other reasons, like pain control are uncommon. Early goals of care conversations and further training in advance care planning should be emphasized in the ICU setting.

Background: Telemedicine visits reduce the physical and financial burdens associated with in-person appointments, especially for patients with serious illness. Little is known about patient and caregiver preferences regarding telemedicine visit timing and the discussion of sensitive topics by telemedicine. Objective: To characterize the experience of patients with serious illness and their caregivers receiving palliative care (PC) by telemedicine. Design: Mixed-methods telephone survey. Setting/Subjects: Patients and family caregivers who had at least one telemedicine visit with the outpatient PC team at our urban academic medical center. Results: A total of 35 patients and 15 caregivers were surveyed. Patient mean age was 61 years, 49% had cancer, and 86% were Caucasian. Caregiver mean age was 62 years. Mean satisfaction with PC telemedicine visits was 8.9 out of 10 for patients; 8.8 for caregivers. Patients (97%) and caregivers (100%) felt comfortable discussing sensitive topics over video. Participants felt telemedicine was an acceptable format to discuss most sensitive topics but 53% of caregivers preferred to receive bad news in person. Participants valued the convenience of telemedicine; they had concerns about rapport building and desired a more user-friendly telemedicine platform. Conclusions: Patients with serious illness and their caregivers rated telemedicine visits highly and felt comfortable discussing sensitive topics by video. Concerns included rapport building and telemedicine platform setup and quality. The rapid growth of telemedicine during coronavirus disease 2019 creates an imperative for research to understand the impact on the quality of care and mitigate any negative effects of telemedicine within a diverse population of patients.

Background: While studying the etiology of multiple sclerosis (MS) in children has several methodological advantages over studying etiology in adults, studies are limited by small sample sizes. Objective: Using a rigorous methodological process, we developed the Pediatric MS Tool-Kit, a measurement framework that includes a minimal set of core variables to assess etiological risk factors. Methods: We solicited input from the International Pediatric MS Study Group to select three risk factors: environmental tobacco smoke (ETS) exposure, sun exposure, and vitamin D intake. To develop the Tool-Kit, we used a Delphi study involving a working group of epidemiologists, neurologists, and content experts from North America and Europe. Results: The Tool-Kit includes six core variables to measure ETS, six to measure sun exposure, and six to measure vitamin D intake. The Tool-Kit can be accessed online ( www.maelstrom-research.org/mica/network/tool-kit ). Conclusion: The goals of the Tool-Kit are to enhance exposure measurement in newly designed pediatric MS studies and comparability of results across studies, and in the longer term to facilitate harmonization of studies, a methodological approach that can be used to circumvent issues of small sample sizes. We believe the Tool-Kit will prove to be a valuable resource to guide pediatric MS researchers in developing study-specific questionnaire

Key Points Question How do hospitalized patients with heart failure who are referred to palliative care differ from patients with cancer in their characteristics, reasons for referral, and outcomes of referral? Findings In this cohort study of 57 272 adults, patients with heart failure were referred for palliative care later in their disease course than patients with cancer. Fewer patients with heart failure were referred for symptom management but they had similar rates of symptom improvement after referral. Meaning Hospitalized patients with heart failure are being referred later to palliative care, suggesting that there are opportunities to integrate palliative care earlier in the disease trajectory for symptom management., This cohort study evaluates the processes and outcomes of palliative care consultations for hospitalized patients with heart failure compared with patients with cancer at community and academic hospitals included in the Palliative Care Quality Network., Importance Growing evidence shows that palliative care (PC) improves treatment outcomes in patients with heart failure (HF), but few large-scale studies have prospectively evaluated the processes and outcomes associated with PC consultation for such patients in the real world. Objective To characterize processes and outcomes of PC consultations for hospitalized patients with HF compared with patients with cancer. Design, Setting, and Participants This cohort study of inpatient encounters at community and academic hospitals in the Palliative Care Quality Network enrolled participants between 2013 and 2017. Of a total of 135 197 patients, 57 272 adults with a primary diagnosis of HF or cancer receiving PC consultation were enrolled. Data analysis was performed from April 2018 to December 2019. Exposures Primary diagnosis of HF or cancer. Main Outcomes and Measures Symptom improvement and changes in care planning documentation after PC consultation. Results At the time of consultation, patients with HF were older (mean age, 75.3 years [95% CI, 75.0-75.5 years] vs 65.2 years [95% CI, 65.0-65.3 years]; P

Pain is a common and distressing symptom. Pain management is a core competency for palliative care (PC) teams.Identify characteristics associated with pain and pain improvement among inpatients referred to PC.Thirty-eight inpatient PC teams in the Palliative Care Quality Network entered data about patients seen between December 12, 2012 and March 15, 2016. We examined patient and care characteristics associated with pain and pain improvement.Of patients who could self-report symptoms, 30.7% (4959 of 16,158) reported moderate-to-severe pain at first assessment. Over 40% of these patients had not been referred to PC for pain. Younger patients (P 0.0001), women (P 0.0001), patients with cancer (P 0.0001), and patients in medical/surgical units (P 0.0001) were more likely to report pain. Patients with pain had higher rates of anxiety (P 0.0001), nausea (P 0.0001), and dyspnea (P 0.0001). Sixty-eight percent of patients with moderate-to-severe pain improved by the PC team's second assessment within 72 hours; 74.7% improved by final assessment. There was a significant variation in the rate of pain improvement between PC teams (P 0.0001). Improvement in pain was associated with improvement in anxiety (OR = 2.9, P 0.0001) and dyspnea (OR = 1.4, P = 0.03). Patients who reported an improvement in pain had shorter hospital length-of-stay by two days (P = 0.003).Pain is common among inpatients referred to PC. Three-quarters of patients with pain improve and improvement in pain is associated with other symptom improvement. Standardized, multisite data collection can identify PC patients likely to have marked and refractory pain, create benchmarks for the field, and identify best practices to inform quality improvement.

This cohort study characterizes current practice and trends among patients cared for and outcomes achieved by inpatient specialty palliative care services in the United States., Key Points Question How have the practice and outcomes of inpatient, specialty palliative care in the United States changed over time? Findings During the 5 years examined in this cohort study of 135 197 patients, palliative care teams saw an increasing percentage of patients with diagnoses other than cancer, saw an increasing percentage of patients discharged from the hospital alive, and connected more patients with outpatient supportive services. Meaning These trends suggest that inpatient palliative care teams are reaching a broader group of patients with serious illness and are seeing them earlier in their illnesses, consistent with emerging data and guidelines., Importance Although palliative care (PC) historically focused on patients with cancer and those near the end of life, evidence increasingly demonstrates a benefit to patients with a broad range of serious illnesses and to those earlier in their illness. The field of PC has expanded and evolved rapidly, resulting in a need to characterize practice over time to understand whether it reflects evolving evidence and guidelines. Objective To characterize current practice and trends among patients cared for and outcomes achieved by inpatient specialty PC services in the United States. Design, Setting, and Participants This retrospective cohort study was performed from January 1, 2013, to December 31, 2017, at 88 US hospitals in which PC teams voluntarily participate in the Palliative Care Quality Network (PCQN), a national quality improvement collaborative. A total of 135 197 patients were referred to PCQN teams during the study period. Initial analyses of the study data were conducted from March 3 to March 21, 2018. Exposure Inpatient PC consultation. Main Outcomes and Measures A total of 23 standardized data elements collected by PCQN teams that provided information about the characteristics of referred patients, including age, sex, Palliative Performance Scale score, and primary diagnosis leading to PC consult; reason(s) given for the consultation; and processes of care provided by the PC team, including disciplines involved, number of family meetings held, advance care planning documentation completed, and screened for and intervened on needs. Results A total of 135 197 patients were referred to inpatient PC (51.0% female; mean age, 71.3 years [range, 57.8-82.5 years]) and were significantly debilitated (mean Palliative Performance Scale score, 34.7%; range, 14.9%-56.8%). Cancer was the most common primary diagnosis (32.0%; range, 11.3%-93.9%), although rates decreased from 2013 to 2017 (odds ratio [OR], 0.84; 95% CI, 0.79-0.91; P

ContextAlthough palliative care (PC) has been shown to improve symptoms and end-of-life (EOL) care for patients with cancer, data are lacking on the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease.ObjectivesWe sought to characterize the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease compared with patients with cancer.MethodsWe conducted an observational study using data from the Palliative Care Quality Network (PCQN). The PCQN contains prospectively collected data on 135,197 hospitalized patients receiving PC consultations at 88 PCQN sites between January 2013 and December 2017. The PCQN data set includes patient demographics, processes of care, and patient-level clinical outcomes.ResultsThe cohort included 44,933 patients, of whom 4402 (9.8%) had liver disease and 40,531 (90.2%) had cancer. Patients with liver disease were younger (58.9years vs. 65.2years, P&nbsp

ObjectivesTo compare characteristics and needs of inpatients with neurologic disease to those with cancer referred for palliative care (PC) consultation.MethodsThis prospective cohort study used data collected by the Palliative Care Quality Network from January 2013 until December 2016. We compared demographics, reasons for consultation, discharge disposition, Palliative Performance Scale (PPS) score, and outcomes of care among patients with a primary diagnosis of neurologic disease vs cancer.ResultsThe most common reason for PC consultation in all patients was assistance with goals of care and advanced care planning. PC consultation was less often requested for pain and symptom management in patients with neurologic disease compared to patients with cancer (13.7% vs 43%, odds ratio 0.3) and more often for assistance with transition to comfort measures only and withdrawal of life-sustaining treatment (19.1% vs 7.1%, odds ratio 1.3). Patients with cancer had higher PPS scores (42.1% vs 23.4%) and were more likely to be discharged home from the hospital, while patients with neurologic disease were more likely to die in hospital.ConclusionsPatients with neurologic disease as a reason for PC consultation are more in need of end-of-life care planning and more likely to die in the hospital than those with cancer, suggesting that targeted approaches may best address the needs of each patient population. Our results can direct further research and education in neuropalliative care.

Care planning is a critical function of palliative care teams, but the impact of advance care planning and goals of care discussions by palliative care teams has not been well characterized.To describe the population of patients referred to inpatient palliative care consultation teams for care planning, the needs identified by palliative care clinicians, the care planning activities that occur, and the results of these activities.This was a prospective cohort study conducted between January 1, 2013, and December 31, 2016. Seventy-eight inpatient palliative care teams from diverse US hospitals in the Palliative Care Quality Network, a national quality improvement collaborative. Standardized data were submitted for 73 145 patients.Inpatient palliative care consultation.Overall, 52 571 of 73 145 patients (71.9%) referred to inpatient palliative care were referred for care planning (range among teams, 27.5%-99.4% of patients). Patients referred for care planning were older (73.3 vs 67.9 years; F statistic, 1546.0; P .001), less likely to have cancer (30.0% vs 41.1%; P .001), and slightly more often had a clinical order of full code at the time of referral (54.6% vs 52.1%; P .001). Palliative care teams identified care planning needs in 52 825 of 73 145 patients (72.2%) overall, including 42 467 of 49 713 patients (85.4%) referred for care planning and in 10 054 of 17 475 patients (57.5%) referred for other reasons. Through care planning conversations, surrogates were identified for 10 571 of 11 149 patients (94.8%) and 9026 patients (37.4%) elected to change their code status. Substantially more patients indicated that a status of do not resuscitate/do not intubate was consistent with their goals (7006 [32.1%] preconsultation to 13 773 [63.1%] postconsultation). However, an advance directive was completed for just 2160 of 67 955 patients (3.2%) and a Physicians Orders for Life-Sustaining Treatment form was completed for 8359 of 67 955 patients (12.3%) seen by palliative care teams.Care planning was the most common reason for inpatient palliative care consultation, and care planning needs were often found even when the consultation was for other reasons. Surrogates were consistently identified, and patients' preferences regarding life-sustaining treatments were frequently updated. However, a minority of patients completed legal forms to document their care preferences, highlighting an area in need of improvement.

Context Benzodiazepines (BZDs) are commonly prescribed for relief of dyspnea in palliative care, yet few data describe their efficacy. Objectives To describe the management of moderate-to-severe dyspnea in palliative care patients. Methods Chart review of inpatients with moderate or severe dyspnea on initial evaluation by a palliative care service. We recorded dyspnea scores at follow-up (24 hours later) and use of BZDs and opioids. Results The records of 115 patients were reviewed. The mean age of patients was 64 years and primary diagnoses included cancer (64%, n=73), heart failure (8%, n=9), and chronic obstructive pulmonary disease (5%, n=6). At initial assessment, 73% (n=84) of the patients had moderate and 27% (n=31) had severe dyspnea. At follow-up, 74% (n=85) of patients reported an improvement in their dyspnea, of which 42% (n=36) had received opioids alone, 37% (n=31) had BZDs concurrent with opioids, 2% (n=2) had BZDs alone, and 19% (n=16) had received neither opioids nor BZDs. Logistic regression analysis identified that patients who received BZDs and opioids had increased odds of improved dyspnea (odds ratio 5.5, 95% CI 1.4, 21.3) compared with those receiving no medications. Conclusion Most patients reported improvement in dyspnea at 24 hours after palliative care service consultation. Consistent with existing evidence, most patients with dyspnea received opioids but only the combination of opioids and BZDs was independently associated with improvement in dyspnea. Further research on the role of BZDs alone and in combination with opioids may lead to better treatments for this distressing symptom.

Background/aimPalliative care services (PCS) are recommended to enhance quality of care for hospitalized patients.MethodsWe evaluated the attitudes of liver transplant (LT) providers and perceived barriers to PCS for their patients by conducting a web-based survey of intensive care unit nurses, postgraduate year 1 (PGY1) physician trainees, nurse practitioners, fellows, and attending physicians on the LT service at an academic medical center.ResultsThe response rate was 44% (88/200). Providers agreed that LT and PCS are not mutually exclusive (86%, n = 76). Respondents reported confusion regarding criteria and timing for referral to PCS. Most suggested that referral is appropriate when death is imminent (78%, n = 69). Many providers felt that patients' depression (66%, n = 58) was poorly managed, although few identified that PCS were consulted for depression (28%, n = 25). Overall, 84% (n = 74) identified attending physicians as the main barrier to involving PCS, and attendings (93%, n = 82) were more likely than PGY1 (67%, n = 59) and nurses (55%, n = 48) to describe PCS as end-of-life care (p = 0.03). Nearly all LT providers agreed that patients welcomed goals of care discussions (83%, n = 73), were grateful for PCS (96%, n = 85), and received higher quality care with PCS (96%, n = 85).ConclusionLT providers overwhelmingly report that PCS benefit patients and are consistent with LT goals even while patients are listed for LT. Barriers to PCS include confusion over referral criteria and describing PCS as end-of-life care by attending physicians. PCS teams may expand access for LT patients by establishing clear criteria for PCS referral and targeting educational interventions about palliative care to attendings.

The objective of this cross-sectional questionnaire study was to assess associations of a self-report index of sun protection habit strength with sunscreen use in sporting environments and outdoor physical activity. Participants (n = 234) in field hockey, soccer, tennis and surf sports in Queensland, Australia, completed a self-administered survey on sun protection during organized sport, and during general outdoor physical activity during 2005/2006. The sun protection habit strength index was dichotomized into two categories. Multinomial logistic regression analyses assessed the associations of low versus high sun protection habit strength with three categories of sunscreen use (no or rare use; inadequate use; and adequate use). Compared to participants with low sun protection habit strength, those with high sun protection habit strength had significantly greater odds of any sunscreen use during organized sport and during general outdoor physical activity. This association was strongest for adequate sunscreen use in both settings. In conclusion, this study suggests that the measure of sun protection habit strength is a potentially useful assessment tool for future sun protection studies.

Background Few studies have reported the accuracy of measures used to assess sun-protection practices. Valid measures are critical to the internal validity and use of skin cancer control research. Objectives We sought to validate self-reported covering-up practices of pool-goers. Methods A total of 162 lifeguards and 201 parent/child pairs from 16 pools in 4 metropolitan regions in the United States completed a survey and a 4-day sun-habits diary. Observations of sun-protective behaviors were conducted on two occasions. Results Agreement between observations and diaries ranged from slight to substantial, with most values in the fair to moderate range. Highest agreement was observed for parent hat use (κ = 0.58-0.70). There was no systematic pattern of over- or under-reporting among the 3 study groups. Limitations Potential reactivity and a relatively affluent sample are limitations. Conclusion There was little over-reporting and no systematic bias, which increases confidence in reliance on verbal reports of these behaviors in surveys and intervention research.

Outdoor recreation settings, such as swimming pools, provide a promising venue to assess UVR exposure and sun protection practices among individuals who are minimally clothed and exposed to potentially high levels of UVR. Most studies assessing sun exposure/protection practices rely on self-reported data, which are subject to bias. The aim of this study was to establish the feasibility of conducting a multimethod study to examine the validity of self-reported measures within a swimming pool setting. Data were collected from 27 lifeguards, children and parents in Hawaii. Each participant filled out a survey and a 4 day sun habits diary. On two occasions, researchers assessed observable sun protection behaviors (wearing hats, shirts, sunglasses), swabbed the skin to detect the presence of sunscreen, and subjects wore polysulphone dosimeters to measure UVR exposure. Overall, observed sun protection behaviors were more highly correlated with diary reports than with survey reports. While lifeguards and children reported spending comparable amounts of time in the sun, dosimeter measures showed that lifeguards received twice as much UVR exposure. This study demonstrated the feasibility of implementing a multimethod validity study within a broader population of swimming pools.

BackgroundThe measurement and reporting of the quality of care in the field of palliation has become a required task for many health care leaders and specialists in palliative care. Such efforts are aided when organizations collaborate together to share lessons learned.MethodsThe authors reviewed examples of quality-improvement collaborations in palliative care to understand the similarities, differences, and future directions of quality measurement and improvement strategies in the discipline.ResultsThree examples were identified that showed areas of robust and growing quality-improvement collaboration in the field of palliative care: the Global Palliative Care Quality Alliance, Palliative Care Quality Network, and Project Educate, Nurture, Advise, Before Life Ends. These efforts exemplify how shared-improvement activities can inform improved practice for organizations participating in collaboration.ConclusionsNational and regional collaboratives can be used to enhance the quality of palliative care and are important efforts to standardize and improve the delivery of palliative care for persons with serious illness, along with their friends, family, and caregivers.

To examine the association between tanning bed use and weight concerns, health risk behaviors, and peer influence. The Growing Up Today Study (GUTS) is an ongoing prospective cohort study of adolescents established in 1996. In 1999, a total of 6,373 adolescent females ages 12–18 (offspring of participants in the Nurses Health Study 2) completed the survey. Almost nine percent (8.6%) of the adolescent girls had used a tanning bed 1–9 times and an additional 5.4% had used tanning beds at least 10 times in the past year (frequent users). Logistic regression models revealed that frequent tanning bed use was associated with being highly concerned about weight (OR = 1.5, 95%CI = 1.1, 2.0), frequently dieting to lose weight (OR = 1.5, 95%CI = 1.1, 2.0), using laxatives or vomiting to control weight (OR = 3.6; 95%CI = 2.2–5.8), having friends who placed a lot of importance on being thin (OR = 2.6; 95%CI = 1.3–5.1), smoking cigarettes (OR=1.7, 95%CI = 1.1, 2.6), binge drinking (OR = 2.1, 95%CI = 1.3, 3.1), using recreational drugs (OR = 3.0; 95%CI = 2.4, 3.8), and trying to look like females in the media (sometimes/pretty much: OR = 1.3, 95%CI = 1.0, 1.8). Frequent tanning bed use among adolescent females is associated with a range of health risk behaviors. This effect may be mediated by peer influence and a desire to look like other females in the media. Multi-pronged approaches, particularly those that target attitudes of young females, are needed to combat increased use of tanning beds.

Objectives: To study whether a noninvasive swabbing technique can detect sunscreen use for up to 6 hours, and whether the technique can detect reapplication of sunscreen. Methods: Thirty volunteer office workers were randomly assigned to have one of a variety of sunscreens applied using recommended application techniques, and half were randomly assigned to have sunscreen reapplied after 3 hours. Alcohol-based swabs were used to obtain a sample from participants' arm at 20 minutes, and hourly from 1 to 6 hours post-application. Absorption readings were analyzed using an UV-visible spectrophotometer. Results: The swabbing technique was consistently able to distinguish the sunscreen from control swabs for up to 6 hours. The absorption readings between 20 minutes and 6 hours were significantly higher than control swabs. There were no differences between the group that had sunscreen reapplied and the group that did not. Conclusion: The sunscreen swabbing technique is an effective noninvasive method for detecting a variety of sunscreen products in adults over a 6-hour period. No differences in absorption readings were found with sunscreen reapplication. This procedure will be a useful adjunct to other objective measures of sun protection and UV radiation exposure, resulting in a more accurate picture of the sun protection habits of individuals.

Objective and method: Excessive sun exposure in childhood has been associated with the development of skin cancer, and appropriate levels of sun protection during the early years of a child's life can significantly reduce the risks. A survey of 133 mothers was undertaken in south-east Queensland to examine the levels of sun exposure and skin protection of infants and young children. Results: Among this sample of 133 mothers, use of appropriate skin protection was relatively high for themselves and their children. However, even by six months of age, a third had been sunburnt and 15% had experienced painful sunburn. By three years of age, 82% had been sunburnt and one-third had experienced painful sunburn, though mothers' knowledge levels of sun safety issues were very high. The predictors associated with primary prevention varied across the type of prevention behaviour, but indicated that interventions should focus on susceptibility to sunburn and history of sunburn. Similar programs could be applicable across a broad range of sociodemographic groups, but require attention to mother's country of birth as a factor that significantly influences their use of protection for their young children. Conclusions: Ongoing public education that targets specific groups and settings may contribute to adoption of appropriate sun protective behaviours for young children. Implications: Results of the study provide some of the needed baseline data to assist future skin cancer prevention campaigns for young children and infants. A similar study of levels of sun exposure and skin protection for children during summer is under way.

Identify which populations of patients may warrant further attention when providing palliative care to HF patients. Original Research Background: National guidelines recommend integrating palliative care into Heart Failure (HF) treatment. Few studies examine whether HF patients receive palliative care. Research Objectives: Methods: Patients diagnosed with NYHA class II-III HF were surveyed about whether they had discussed with their clinician what to expect in the future regarding their HF, prognosis, advanced care planning, and their surrogate choice, and if they had not, whether they wanted to have these conversations. Results: Participants (n=102) were on average 53 years old, had HF for 7 years, were 66% male, and had either Class II (57%) or Class III (43%) HF. Most participants reported having had discussions with their provider about what to expect in the future regarding HF (76.5%), prognosis (68.0%), and their surrogate choice (63.4%). Half discussed advanced care planning (46.5%). Of those who reported not having these conversations, most wanted to discuss what to expect in the future with respect to HF (81.5%), prognosis (76.3%), and advanced care planning (56.4%). HF class was not associated with having had or desiring to have discussions on any issue. Men were more likely than women to report discussions about future expectations of HF (83.6% vs. 62.9%; p=0.02), prognosis (78.5% vs. 48.6% p=0.002), and advanced care planning (56.1% vs. 28.6%; p=0.008). Conclusions: Most participants discussed palliative care issues with providers, and most of those who did not wanted to. Our data cannot explain why women are less likely to report these discussions but suggest that clinicians be mindful of this disparity.

BackgroundCommunication about end-of-life issues is difficult across language barriers. Little is known about the experience of health care interpreters in these discussions.ObjectivesObjectives of this study were to: 1) assess the experiences of healthcare interpreters when interpreting discussions about end-of-life issues; 2) identify interpreter characteristics and experiences that may be associated with improved satisfaction and comfort with interpreting these discussions; and 3) describe interpreter training needs.MethodsThe study utilized an electronically administered survey distributed nationally to health care interpreters in the United States. One hundred and forty-two health care interpreters participated. Measurements included general experiences, attitudes, and perceived training needs when interpreting discussions about end-of-life issues.ResultsMost respondents had received a certificate in interpretation (71%, 101/142), completed more than 40 hours of training (89%, 127/142), and had more than 5 years of interpreting experience (65%, 93/142). Overall, 85% (121/142) of respondents had interpreted discussions about end-of-life issues and most interpreted multiple discussions per week. Of those interpreters who had experience with these discussions, the majority (85%, 103/121) reported feeling comfortable, but only half (48%, 58/121) reported that these discussions usually went well. Interpreters who felt clear about their role were more likely than interpreters who did not feel clear about their role to think that discussions went well (51% [57/112] versus 11% [1/9], p=0.02) and to feel comfortable interpreting (88% [98/112] versus 56% [5/9], p=0.01). Eighty percent (97/121) of respondents with experience in end-of-life discussions were personally interested in more specific training for these discussions. Attitudes and perceived training needs did not differ by interpreter demographics or qualifications.ConclusionsThe majority of interpreters have experience with end-of-life discussions but, independent of interpreter training and experience, only half report that these discussions usually go well. Interpreters want and may benefit from targeted educational interventions that could improve the quality of care for vulnerable patients and families in these difficult situations. Health systems and interpreter certification programs should incorporate specific training on how to interpret discussion about end-of-life issues.

Context. In 2000, 17% of California hospitals offered palliative care (PC) services. Since then, hospital-based PC programs have become increasingly common, and preferred practices for these services have been proposed by expert consensus. Objectives. We sought to examine the prevalence of PC programs in California, their structure, and the hospital characteristics associated with having a program. Methods. A total of 351 acute care hospitals in California completed a survey that determined the presence of and described the structure of PC services. Logistic regression identified hospital characteristics associated with having a PC program. Results. A total of 324 hospitals (92%) responded, of which 44% (n ¼141) reported having a PC program. Hospitals most likely to have PC programs were large nonprofit facilities that belonged to a health system, had teaching programs, and had participated in a training program designed to promote development of PC services. Investor-owned sites (odds ratio [OR] ¼ 0.08; 95% confidence interval [CI] ¼ 0.03, 0.2) and city/county facilities (OR ¼0.06; 95% CI¼ 0.01, 0.3) were less likely to have a PC program. The most common type of PC service was an inpatient consultation service (88%), staffed by a physician (87%), social worker (81%), chaplain (76%), and registered nurse (74%). Most programs (71%, n¼ 86) received funding from the hospital and were expected to meet goals set by the hospital or health system. Conclusion. Although the number of hospital-based PC services in California has doubled since 2000, more than half of the acute care hospitals still do not provide PC services. Developing initiatives that target small, public, and investorowned hospitals may lead to wider availability of PC services. J Pain Symptom

Background: Reliance on verbal self-report of solar exposure in skin cancer prevention and epidemiologic studies may be problematic if self-report data are not valid due to systematic errors in recall, social desirability bias, or other reasons. Methods: This study examines the validity of self-reports of exposure to ultraviolet radiation (UVR) compared to objectively measured exposure among children and adults in outdoor recreation settings in 4 regions of the United States. Objective UVR exposures of 515 participants were measured using polysulfone film badge UVR dosimeters on 2 days. The same subjects provided self-reported UVR exposure data on surveys and 4-day sun exposure diaries, for comparison to their objectively measured exposure. Results: Dosimeter data showed that lifeguards had the greatest UVR exposure (24.5% of weekday ambient UVR), children the next highest exposures (10.3% ambient weekday UVR), and parents had the lowest (6.6% ambient weekday UVR). Similar patterns were observed in self-report data. Correlations between diary reports and dosimeter findings were fair to good and were highest for lifeguards (r = 0.38–0.57), followed by parents (r = 0.28–0.29) and children (r = 0.18–0.34). Correlations between survey and diary measures were moderate to good for lifeguards (r = 0.20–0.54) and children (r = 0.35–0.53). Conclusions: This is the largest study of its kind to date, and supports the utility of self-report measures of solar UVR exposure. Impact: Overall, self-reports of sun exposure produce valid measures of UVR exposure among parents, children, and lifeguards who work outdoors. Cancer Epidemiol Biomarkers Prev; 19(12); 3005–12. ©2010 AACR.

Background The aim of this study was to measure ultraviolet radiation (UVR) exposures of lifeguards in pool settings and evaluate their personal UVR protective practices. Methods Lifeguards (n ¼ 168) wore UVR sensitive polysulfone (PS) film badges in wrist bracelets on 2 days and completed a survey and diary covering sun protection use. Analyses were used to describe sun exposure and sun protection practices, to compare UVR exposure across locations, and to compare findings with recommended threshold limits for occupational exposure. Results The measured UVR exposures varied with location, ranging from high median UVR exposures of 6.2 standard erythemal doses (SEDs) to the lowest median of 1.7 SEDs. More than 74% of the lifeguards’ PS badges showed UVR above recommended threshold limits for occupational exposure. Thirty-nine percent received more than four times the limit and 65% of cases were sufficient to induce sunburn. The most common protective behaviors were wearing sunglasses and using sunscreen, but sun protection was often inadequate. Conclusions At-risk individuals were exposed to high levels of UVR in excess of occupational limits and though appropriate types of sun protection were used, it was not used consistently and more than 50% of lifeguards reported being sunburnt at least twice during the previous year. Am. J. Ind. Med. 52:645–653, 2009. 2009 Wiley-Liss, Inc.

PURPOSE.: Approximately, 20.5 million Americans (17.2%) older than 40 years have a cataract in at least one eye, and rates are expected to rise to over 30 million by 2020. Wearing sunglass, especially early in life, may reduce the risk of cataracts. Meanwhile, little is known about the prevalence of wearing sunglasses in the United States, especially in areas with high ultraviolet radiation. The objective of this study was to assess the prevalence and predictors of wearing sunglasses in public outdoor recreation settings. METHODS.: Systematic observations were made at beaches, parks and outdoor public swimming pools in Honolulu, Hawaii on sunny days between November 2005 and June 2007. Observations were conducted independently by two trained observers between 10:00 am and 4:00 pm. During each observation period, each individual in the area was coded for gender, age category, clothing coverage, shade use, and use of sunglasses. RESULTS.: A total of 5171 people were observed by two independent observers, and the inter-rater reliability use of sunglasses was excellent (Cohen kappa = 0.83). Overall, 33.0% of people wore sunglasses. χ analysis revealed that significantly more people (p < 0.001) wore sunglasses at swimming pools (35.1%) and parks (34.8%) compared to beaches (30.4%). Adults (41.6%) were more likely to wear sunglasses than children (12.3%; p < 0.001). Gender was not significantly associated (p = 0.3) with the use of sunglasses (males = 32.7%; females = 33.3%). Those wearing hats were significantly more likely (p < 0.001) to wear sunglasses (46.6%) than those with bare heads (28.4%). CONCLUSIONS.: Direct observation in public outdoor recreation settings reveled that only one third of the population wore sunglasses. Further research should examine the use of sunglasses in other locations and investigate the effectiveness of interventions that promote the wearing of sunglasses in settings with risk for ultraviolet radiation exposure.

Objective: To conduct an assessment of levels of UV radiation (UVR) exposure and the range of sun protection behaviors of beachgoers at a popular vacation destination. Design: Participants completed the sun habits survey prior to entry to the beach and completed an exit survey on leaving regarding their sun protection practices while at the beach. Ambient UVR was monitored using polysulfone dosimeters. Setting: A popular beach for vacationers in Honolulu, Hawaii. Main Outcome Measures: Sun protection practices and UVR. Results: Participants spent an average of 3 hours at the beach and received an estimated UVR dose of 10.4 standard erythemal doses. Latent class analysis identified 3 homogeneous classes with distinct characteristics and sun protection behaviors. Those in class 1 (unconcerned and at low risk) were at least risk of skin cancer, intended to tan, and used the least amount of sun protection. Those in class 2 (tan seekers) had the second highest risk of skin cancer, had the highest proportion of women, became sunburned easily, intended to tan, had used tanning beds in past 30 days, and had the highest proportion of sunscreen coverage and the least clothing coverage. Those in class 3 (concerned and protected) had the highest skin cancer risk, the highest proportion of clothing coverage and shade use, and were more likely to be residents of Hawaii. Conclusions: Beachgoers were exposed to 5 times the UVR dose required to result in erythema among unprotected fair-skinned populations. Latent class analysis was effective in identifying subgroups of beachgoers who would benefit from targeted, population-based interventions aimed at reducing skin cancer risks while enjoying outdoor leisure-time activities.

Background Verbal self-report is the method most often used to assess sunscreen use, but the data may be confounded by recall error and social desirability. Sunscreen swabbing is a non-invasive procedure to objectively assess the presence of sunscreen on the skin. This study examined the agreement between verbal reports of sunscreen use from survey and diary measures and objectively measured sunscreen use. Methods Participants were 564 parents, children aged 5–10 years, and lifeguards at 16 swimming pools in four regions of the U.S. Participants completed self-reported measures, including baseline and final surveys, as well as a 4-day diary and objective swabbing measures of sunscreen presence on 2 separate days. Data were collected in 2006 and analyzed in 2006–2007. Results Levels of sunscreen use were relatively high based on surveys (65.7%); diary data (40.3%); and swabbing measures (59.1%). Agreement between swabbing and diary measures of sunscreen use was fair to good, with κ statistics for children at 0.40, followed by lifeguards at 0.34 and parents at 0.27. Validity coefficients across measures of sunscreen use were higher for lifeguards and parents than for children, and diary measures were higher than surveys. No systematic errors were found across groups or by gender, latitude, study arm, or risk category. Conclusions These findings are comparable to those in other validation studies, including studies of the validity of dietary assessments. Self-reported estimates of sunscreen use by diaries or surveys appear to be as good as objective measures.

Objective To develop, in a collaborative project, core measures of sun exposure and sun protection habits, since the lack of standard outcome measures hampers comparison of population surveys and interventions used in skin cancer prevention research. Design A work group of investigators evaluated available questionnaire measures of sun exposure and protection. Their deliberations led to a proposed set of core questionnaire items for adults, adolescents aged 11 to 17 years, and children 10 years or younger. These core items were used in cognitive testing by the investigators. Cross-site summaries of methods, response samples, and descriptive data were prepared. Setting Nine locations across the United States. Participants The study population comprised 81 individuals. Results No unusual response patterns were detected in any of the respondent groups or for any specific question. Some revisions to the survey items resulted from the need for clarification or emphasis of frames of reference such as adding or underlining key phrases in a question. Conclusions The combination of expert review followed by cognitive interviewing yielded standardized core survey items with good clarity and applicability for measuring sun exposure and sun protection behaviors across a broad range of populations. They are appropriate for studies tracking morbidity and/or mortality and evaluating prevention program effects.

To examine the validity of beachgoers' self-reported sun protection and UV exposure using objective measures.Eighty-eight participants completed a brief survey when they arrived at the beach; their skin was swabbed for the presence of sunscreen, while an observer recorded their clothing worn to the beach and the presence of sunburn. On leaving the beach, an exit survey detailing activities and sun habits while on the beach was completed by the participants, follow-up sunscreen swabs were obtained, and sunburns were recorded. Clothing observations were made for a subgroup (n = 25) of participants during their beach stay.Most participants (38 [44%]) reported spending 2 to 3 hours at the beach, which was consistent with researcher observations (Spearman rank correlation, r = 0.75). Moderate to substantial agreement was achieved between reported use of sunscreen for the day and sunscreen swabs (kappa, 0.54, 0.70, and 0.72 for the face, legs, and arms, respectively). Participants' self-report of clothing worn to the beach had substantial agreement with researcher observation: kappa coefficients ranged from 0.63 for footwear to 0.77 for head wear. Agreement was variable for clothing worn while on the beach, with slight to fair agreement for sunglasses (kappa, 0.11) and footwear (kappa, 0.23) and substantial agreement for upper body clothing (kappa, 0.79). Agreement between self-reported and observed sunburn was consistently lower (kappa, 0.21, 0.33, and 0.39 for the face, legs, and arms, respectively), with participants reporting more sunburn on arrival than was observed.Overall, self-report measures of time outside, sunscreen use, and clothing worn demonstrated good criterion validity when compared with observation and sunscreen swabbing. Sunscreen swabbing proved an effective procedure for detecting sunscreen at a beach setting.

Background. Outpatient palliative care services (OPCS) can improve patient outcomes, yet little is known about their structure and characteristics. Research Objectives. To describe the structure and characteristics of OPCS associated with California hospitals. Method. We surveyed all 377 hospitals in California regarding the structure and characteristics of palliative care services (PCS). Result. Overall 361/377 (96%) hospitals responded. Of the 136 hospitals with an adult PCS, 18% (n 1⁄4 24) have an OPCS. Of the 42 hospitals offering pediatric PCS, 19% (n 1⁄4 8) have an OPCS. On average, adult OPCS see 159 new patients per year (mean visit length 65 minutes) with721 followupvisits (mean length 37minutes). PediatricOPCSsee10newpatientsper year (mean visit length 60 minutes) with 28 follow up visits (mean length 32 minutes). The average staffing of adult OPCS is 2.7 FTE (range: 0.1-14.7) and forpediatricOPCSs 1.5FTE(range: 0.1-4.0). Adult OPCS operate amean of 3.9 days/week compared to 1.1 days/week for pediatric OPCS. Few services provided 24/7 coverage (25% adult, 38% pediatric). Wait times for newly referred patients were 10.7 days for adults and 8.7 days for pediatrics. Most referrals are received from oncology (Adult 1⁄4 47%, Pediatric 1⁄4 43%), the inpatient PCS (Adult 1⁄4 27%, Pediatric 1⁄4 16%), or primary care (Adult 1⁄4 12%, Pediatric 1⁄4 4%). Funding for OPCS is largely through institutional support (Adult 1⁄4 80.0%, Pediatric 1⁄4 62.0%), followed by foundations (Adult 1⁄4 10.3%, pediatric 1⁄4 23.0%), billing (Adult 1⁄4 8.8%, Pediatric 1⁄4 0%), and philanthropy (Adult 1⁄4 0.9%, Pediatric 1⁄4 15.0%). Conclusion. Few California hospitals offer OPCS, though one-fifth offering inpatient PCS also offer OPCS. OPCS care primarily for cancer patients, operate part-time with modest staffing, and are funded primarily by their institution. Implications for Research, Policy, or Practice. Additional research is required to establish the impact of OPCS and their long-term sustainability.

Objective: Primary care physicians are in a unique position to perform skin cancer examinations and provide prevention counseling, given that approximately 40% of office visits to physicians in the United States are to a family practitioner or internist. Compared with family or self-detection, physician detection is associated with an increased probability of detecting thinner melanomas. However, little research has attempted to identify the major obstacles to performing a skin cancer examination and recommending prevention practices. Methods: In the spring of 2002, we surveyed primary care physicians from all 50 states, including family medicine physicians, internists, and general practitioners sampled from the American Medical Association's Medical Marketing Services' database. There were 4 primary outcome variables related to early detection and prevention practices for average-risk patients and patients with risk factors: performing a full-body skin examination; recommending regular skin self-examination; and recommending sun protection practices and avoidance of tanning booths for patients younger than age 35. Results: We received surveys from 380 (60%) of 632 eligible physicians. Nearly 60% of physicians routinely performed full-body examinations with their high-risk patients. In the regression analysis of factors influencing physician examination of high-risk patients, lack of time was the strongest barrier [odds ratio (OR) 0.3 (95% confidence interval (CI) 0.2 to 0.6)]. Physicians using the most information sources [OR 2.5 (95% CI 1.3 to 4.8)] were the most likely to examine their high-risk patients. Physicians whose patients requested a skin examination were more likely to examine their patients compared with physicians whose patients did not request such an examination ( P