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In this observational study, we compared the prognostic ability of an electronic health record (EHR)-derived risk score, the Rothman Index (RI), automatically derived on admission, to the first 24-hour Sequential Organ Failure Assessment (SOFA) score for outcome prediction in the modern cardiac intensive care unit (CICU). We found that while the 24-hour SOFA score provided modestly superior discrimination for both in-hospital and CICU mortality, the RI upon CICU admission had better calibration for both outcomes. Given the ubiquitous nature of EHR utilization in the United States, the RI may become an important tool to rapidly risk stratify CICU patients within the ICU and improve resource allocation.

Rather than early hospice enrollment, most Medicare beneficiaries receive “usual care” in the last months of life, outside of the hospice setting. While care intensity during the last weeks of life has been studied extensively, patterns of symptom management services (SMS) and/or cancer-directed therapies (CDT) received over a 6-month end-of-life period have not. This retrospective study used the Surveillance, Epidemiology, and End Results (SEER)–Medicare database to identify decedents diagnosed with lung cancer at age ≥ 66 years between January 2007 and December 2013 who survived ≥ 6 months from diagnosis. Medicare claims identified receipt of SMS and/or CDT. We created monthly indicators for care content (SMS-only, CDT-only, or both; otherwise full-month hospice or inpatient/skilled nursing). Multinomial logistic regression estimated associations between sociodemographics and comorbidity, with care content in the final month. Between 6 and 1 months before death, full-month hospice and inpatient/skilled nursing increased; CDT decreased from 31.9 to 18.5%; SMS increased from 86.6 to 97.7%. Relative to full-month hospice, the percentage of patients receiving SMS-only was higher for males, unmarried, younger age, and higher comorbidity; the percentage receiving CDT was also higher for males, unmarried, and younger age, but decreased with increasing comorbidity and over calendar time. Among lung cancer decedents observed in the outpatient, nonhospice setting, SMS receipt increased and was nearly universal as death approached. CDT diminished dramatically over the end-of-life period. Associations between sociodemographic characteristics and care setting suggest differences in care preferences or access barriers. Claims represent an important resource for characterizing end-of-life care patterns.

Introduction: An emphasis on patient-centered care has led to a growing interest in collecting PROs in cancer care. Our prior work has demonstrated substantial variation in what types of PROs patients deem most important; although physical symptoms are common, a substantial minority of patients report concerns in non-physical symptom (non-PSx) domains, such as emotional or social health, practical or financial problems, and daily functional activity. Here we report initial findings from a pilot study of a secure web-based tool, called My PROfile, which addresses not only individual symptoms but also non-PSx domains. Methods: We enrolled women who had started a treatment regimen for MBC within the past 6 weeks at Smilow Cancer Hospital of Yale New Haven Hospital or an affiliated care center. Using My PROfile, participants responded to validated surveys and provided PROs addressing physical symptoms as well as non-PSx domains including practical problems, social well-being, emotional well-being, spiritual or religious concerns, alcohol and drug use, daily activities and any other areas of difficulties experienced within the past week. Patients also ranked their top 3 concerns at the time of My PROfile completion. Patients were followed prospectively for 6 months and asked to complete My PROfile as often as desired during that time frame, but at least once prior to each visit with their provider. This information was compiled into a report that was shared with their medical oncology provider prior to the clinic visit. For this analysis, we analyzed the frequency of reporting individual symptoms and domains by patient. Results: A total of 28 patients consented to participate. At the time of data analysis, 9 patients had completed all six months of the pilot. Across the different PRO domains, the majority of patients reported difficulties with physical symptoms (68%) or emotional well-being (50%). Overall, 21% of patients reported physical symptoms only, and 46% of patients reported difficulties with both physical symptoms and non-PSx domains; however, 32% of patients reported difficulties from non-PSx domains only. Approximately 29% of patients reported practical problems (including 21% who noted the impact of treatment on diet/activity and 14% who had concerns about monitoring diet and activity in general). Difficulties with daily activities were reported in 29% of patients (with 18% reporting housework and walking specifically). Difficulties in social well-being were reported by 18% of patients, including 11% who specifically reported concerns with family health. The PRO domain reported by the fewest number of patients (n=1) was alcohol and drug use. The three most common individual symptoms reported were fatigue (57% of patients), pain (54% of patients), and worry (36% of patients). Nearly half (47%) of our respondents (13 out of 28) used My PROfile at least 3 times during follow-up. Among these patients, all but 1 patient reported difficulties with physical symptoms at least twice. Additionally, 23% of these patients reported the non-PSx domains of practical concerns and daily activity concerns more than once during the follow-up period. Conclusion: Although physical and mental health symptoms are commonly reported among patients undergoing systemic treatment for metastatic breast cancer, a substantial minority of patients report non-physical symptom concerns including practical and daily activity-based challenges. Because the specific concerns of interest vary substantially across patients, tools to collect PROs should include additional domains that can significantly affect quality of life in women with MBC. Citation Format: Sarah Mougalian, Maureen Canavan, Renee Capasso, Jenerius Aminawung, Carolyn J. Presley, Cary P Gross. My PROfile: A web-based tool to assess patient reported outcomes (PROs) in women with metastatic breast cancer (MBC): Preliminary results [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-12-09.

BACKGROUND: Patient care ownership improves accountability, clinical skills, and quality of patient care among resident physicians, but appears to be gradually eroding. Research is limited by the lack of a reliable, objective measure of ownership. OBJECTIVE: To validate the Patient Care Ownership Scale, an instrument that measures decision ownership among internal medicine residents. DESIGN: Multi-institutional, cross-sectional study using a 66-item, online survey that queried residents on ownership’s key constructs (advocacy, responsibility, accountability, follow-through, knowledge, communication, initiative, continuity of care, autonomy, self-efficacy, and perceived ownership) as well as mood and burnout. PARTICIPANTS: Internal medicine residents in five geographically diverse residency programs completing an inpatient rotation. MAIN MEASURES: We performed exploratory and confirmatory factor analysis in two randomly split groups to evaluate for subscales and inform item reduction. We conducted reliability testing with Cronbach’s α. We performed bivariate analyses to examine construct validity and identify correlates of ownership. KEY RESULTS: Of the 785 eligible residents, 625 completed the survey (80% response rate); we included responses from 563 in the analysis. We identified three factors corresponding to assertiveness, conscientiousness, and confidence or perceived competence. After iterative item reduction, the 13-item ownership scale demonstrated good reliability (Cronbach’s α = 0.82). Convergent validity was supported by a significant association with perceived ownership (eliminated from the final scale) (r = 0.67, p < 0.001). There was a positive association between ownership and training level (p < 0.01) and prior experience in the intensive care unit (p < 0.001). There were significant, inverse relationships between ownership and self-defined burnout (r = − 0.24, p < 0.001), depression (r = − 0.22, p < 0.001), detachment (r = − 0.26, p < 0.001), and frustration (r = − 0.15, p = 0.02), and significant positive associations between ownership and feeling energetic (r = 0.29, p < 0.001), happy (r = 0.33, p < 0.001), and fulfilled (r = 0.34, p < 0.001). CONCLUSIONS: The Patient Care Ownership Scale is valid in diverse residency program settings. Medical educators and investigators can use our scale to assess interventions aimed at fostering ownership. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06703-x.

PURPOSE: Acute care imposes a significant burden on patients and cancer care costs. We examined whether an advanced practice provider-driven, cancer-specific urgent care center embedded within a large tertiary academic center decreased acute care use among oncology patients on active therapy. MATERIALS AND METHODS: We conducted a quasi-experimental study anchored around the Oncology Extended Care Clinic (OECC) opening date. We evaluated two parallel 4-month periods: a post-OECC period that followed a 5-month run-in phase, and the identical calendar period 1 year earlier. Our primary outcomes included all emergency department (ED) presentations and hospital admissions during the 3-month window following the index provider visit. We used Poisson models to calculate absolute pre-OECC v post-OECC rate differences. RESULTS: Our cohort included 2,095 patients in the pre-OECC period and 2,188 in the post-OECC period. We identified 32.6 ED visits/100 patients and 41.2 hospitalizations/100 patients in the pre-OECC period, versus 28.2 ED visits/100 patients and 26.1 hospitalizations/100 patients post-OECC. After adjusting for age, sex, race and ethnicity, and practice location, we observed a significant decrease of 4.6 ED visits/100 patients during the post-OECC period (95% CI, –8.92/100 to –0.28/100; P = .04) compared with the pre-OECC period. There was no significant association between the OECC opening and hospitalization rate (rate difference: –3.29 admissions/100 patients; 95% CI, –8.24/100 to 1.67/100; P = .19). CONCLUSION: Establishing a cancer-specific urgent care center was significantly associated with a modest decrease in emergency room utilization but not with hospitalization rate. Barriers included clinic capacity, patient awareness, and physician comfort with advanced practice provider autonomy. Optimizing workflow and standardizing clinical pathways can create benchmarks useful for value-based payments.

Introduction: There are currently two recommended radiation strategies for clinical stage III NSCLC: a lower “preoperative” (45–54 Gy) and a higher “definitive/nonsurgical” (60–70 Gy) dose. We sought to determine if definitive radiation doses should be used in the preoperative setting given that many clinical stage III patients planned for surgery are ultimately managed with chemoradiation alone. Methods: Using the National Cancer Database data from 2006 to 2016, we performed a comparative effectiveness analysis of stage III N2 patients who received chemoradiotherapy. Patients were stratified into subgroups across 2 parameters: (1) radiation dose: lower (45–54 Gy) and higher (60–70 Gy); and (2) the use of surgery (i.e., surgical and nonsurgical treatment approaches). Long-term survival and perioperative outcomes were evaluated using multivariable Cox proportional hazards and logistic regression models. Results: A cohort of 961 patients received radiation before surgery including 321 who received a higher dose and 640 who received a lower dose. A higher preoperative dose revealed similar long-term mortality risk (hazard ratio = 0.99, 95% confidence interval: 0.82–1.21, p = 0.951) compared with a lower dose. There was no significant association between radiation dose and 90-day mortality (p = 0.982), 30-day readmission (p = 0.931), or prolonged length of stay (p = 0.052) in the surgical cohort. A total of 17,904 clinical-stage IIIA-N2 patients were treated nonsurgically, including 15,945 receiving higher and 1959 treated with a lower dose. A higher dose was associated with a reduction in long-term mortality risk (hazard ratio = 0.64, 95% confidence interval: 0.60–0.67, p < 0.001) compared with a lower dose. Conclusions: For clinical stage III NSCLC, the administration of 60 to 70 Gy of radiation seems to be more effective than the lower dose for nonsurgical patients without compromising surgical safety for those that undergo resection. This evidence supports the implementation of 60 to 70 Gy as a single-dose strategy for both preoperative and definitive chemoradiotherapy.

This cohort study examines baseline differences in cancer mortality between Medicaid expansion and nonexpansion states.

Clinician expertise has been associated with improved patient outcomes, yet ED clinicians often work in various clinical settings beyond the ED and, therefore, may risk expertise by having less clinical focus. We sought to describe clinical focus among the emergency care workforce nationally.Using the 2017 Medicare Public Use Files (PUF), we performed a cross-sectional analysis of clinicians receiving reimbursement for emergency care EvaluationManagement (E/M) services from Medicare fee-for-service Part B. Clinicians were categorized by type as EM physicians, non-EM physicians, and advanced practice providers (APPs). The primary outcome was the clinical focus of the individual clinician, defined as the proportion of E/M services within the ED setting relative to a clinician's total E/M services across all practice settings.Of 65,710 unique clinicians providing care to Medicare fee-for-service beneficiaries in the ED setting, 39,016 (59.4%) were classified as EM physicians, 8123 (12.4%) as non-EM physicians, and 18,571 (28.5%) as APPs. The individual clinician median focus was 92.8% (interquartile range [IQR]: 87.0, 100.0) for EM physicians, 45.2% (IQR: 5.1, 97.0) for non-EM physicians, and 100.0% (IQR: 96.3, 100.0) for APPs.EM physicians have twice as much clinical focus in comparison to non-EM physicians providing emergency care to Medicare fee-for-service beneficiaries. These findings underscore the importance of diverse training and certification programs to ensure access to clinically focused ED clinicians.

Background Disparities in survival by race/ethnicity, socioeconomic status (SES), and geography in adolescent and young adult (AYA) patients with central nervous system (CNS) tumors have not been well studied. Procedure A retrospective cohort study utilizing the Surveillance, Epidemiology, and End Results (SEER) database was conducted for AYA patients diagnosed with primary CNS tumors. Adjusted hazard ratios (aHR) were calculated using a multivariate Cox proportional hazard model to evaluate the association between race/ethnicity, SES, rurality, and hazard of death. Results All minority groups showed an increased hazard of death with greatest disparities in the high-grade glioma cohort. Lower SES was associated with an increased hazard of death in non-Hispanic White (NHW) patients (aHR 1.12; 95% confidence interval [CI] 1.01-1.24), non-Hispanic Black (NHB) patients (aHR 1.34; 95% CI 1.00-1.80), and patients aged 25-29 years (aHR 1.29; 95% CI 1.07-1.55). Mediation analysis showed an indirect effect of SES on the effect of race/ethnicity on the hazard of death only among NHB patients, with SES accounting for 33.7% of the association between NHB and hazard of death. Rurality was associated with an increased hazard of death for patients in the lowest SES tertile (aHR 1.31; 95% CI 1.08-1.59) and NHW patients (aHR 1.20; 95% CI 1.08-1.34). Conclusions Patients identified as a racial/ethnic minority, patients with a lower SES, and patients residing in rural areas had an increased hazard of death. Further studies are needed to understand and address the biological, psychosocial, societal, and economic factors that impact AYA neuro-oncology patients at highest risk of experiencing poorer outcomes.

Background Several studies have shown improved outcomes in closed compared with open medical and surgical intensive care units. However, very little is known about the ideal organizational structure in the modern cardiac intensive care unit (CICU). Methods and Results We retrospectively reviewed consecutive unique admissions (n=3996) to our tertiary care CICU from September 2013 to October 2017. The aim of our study was to assess for differences in clinical outcomes between an open compared with a closed CICU. We used multivariable logistic regression adjusting for demographics, comorbidities, and severity of illness. The primary outcome was in‐hospital mortality. We identified 2226 patients in the open unit and 1770 in the closed CICU. The unadjusted in‐hospital mortality in the open compared with closed unit was 9.6% and 8.9%, respectively ( P =0.42). After multivariable adjustment, admission to the closed unit was associated with a lower in‐hospital mortality (odds ratio [OR], 0.69; 95% CI: 0.53–0.90, P =0.007) and CICU mortality (OR, 0.70; 95% CI, 0.52–0.94, P =0.02). In subgroup analysis, admissions for cardiac arrest (OR, 0.42; 95% CI, 0.20–0.88, P =0.02) and respiratory insufficiency (OR, 0.43; 95% CI, 0.22–0.82, P =0.01) were also associated with a lower in‐hospital mortality in the closed unit. We did not find a difference in CICU length of stay or total hospital charges ( P >0.05). Conclusions We found an association between lower in‐hospital and CICU mortality after the transition to a closed CICU. These results may help guide the ongoing redesign in other tertiary care CICUs.

BACKGROUND: Primary lung sarcoma (PLS) represents a rare form of lung cancer with outcomes that are poorly defined by small datasets. We sought to characterize clinical and pathological characteristics and associated survival within the surgically managed subgroup of these unusual pulmonary malignancies. METHODS: We performed a retrospective analysis of the National Cancer Database (NCDB), which was queried for cases of surgically managed PLS diagnosed between 2004–2014. Adjusted mortality was evaluated in a multivariable Cox proportional hazards model and compared to surgically manage non-small cell lung cancer (NSCLC) patients from the same time period. RESULTS: A total of 695 patients with surgically managed PLS were identified with 37 different histologic subtypes. The mean age of diagnosis was 57.7 years (range, 18–90 years). A majority of patients underwent surgical resection alone (64.3%) with an estimated 5-year overall survival (OS) of 51%. The multivariable Cox model identified increasing age, Charlson-Deyo score ≥2, high tumor grade, tumor size >5 cm, positive margins, and positive lymph nodes to be associated with higher risk for mortality (P

Background Adjuvant chemotherapy is indicated for patients with resectable stage II and IIIa non-small cell lung cancer. With the revised definition of T4 tumors with nodules in a different ipsilateral lobe, the survival advantage imparted by adjuvant chemotherapy has yet to be defined. We evaluated the role of adjuvant chemotherapy in patients with T4 disease characterized by additional tumor nodules in a different ipsilateral lobe treated with surgical resection. Methods We identified patients with T4 disease and additional tumor nodules in a different ipsilateral lobe treated with surgical resection alone or with adjuvant chemotherapy in the National Cancer Database between 2010 and 2016. The primary outcome was 3-year overall survival (OS). Results A total of 920 patients with T4 tumors and additional tumor nodules in a different ipsilateral lobe were identified. We excluded patients with lymph node metastases, tumors 4 cm or greater, and local invasion. Of the remaining 373 patients, 152 received surgery and adjuvant multiagent chemotherapy whereas 221 received surgery alone. When adjusted for patient, tumor, and treatment factors, the use of adjuvant chemotherapy was associated with improved 3-year OS compared with surgery alone (hazard ratio = 0.572; 95% confidence interval, 0.348-0.940; P = .03). Conclusions Adjuvant chemotherapy in patients with T4 non-small cell lung cancer with additional tumor nodules in a different ipsilateral lobe is associated with improved 3-year OS. Accurate identification of T4 disease is important to define patients in whom adjuvant chemotherapy should be considered. Further prospective study is needed to delineate further the use of adjuvant chemotherapy for this patient population.

Objective Clinician expertise has been associated with improved patient outcomes, yet ED clinicians often work in various clinical settings beyond the ED and, therefore, may risk expertise by having less clinical focus. We sought to describe clinical focus among the emergency care workforce nationally. Methods Using the 2017 Medicare Public Use Files (PUF), we performed a cross-sectional analysis of clinicians receiving reimbursement for emergency care Evaluation & Management (E/M) services from Medicare fee-for-service Part B. Clinicians were categorized by type as EM physicians, non-EM physicians, and advanced practice providers (APPs). The primary outcome was the clinical focus of the individual clinician, defined as the proportion of E/M services within the ED setting relative to a clinician's total E/M services across all practice settings. Results Of 65,710 unique clinicians providing care to Medicare fee-for-service beneficiaries in the ED setting, 39,016 (59.4%) were classified as EM physicians, 8123 (12.4%) as non-EM physicians, and 18,571 (28.5%) as APPs. The individual clinician median focus was 92.8% (interquartile range [IQR]: 87.0, 100.0) for EM physicians, 45.2% (IQR: 5.1, 97.0) for non-EM physicians, and 100.0% (IQR: 96.3, 100.0) for APPs. Conclusion EM physicians have twice as much clinical focus in comparison to non-EM physicians providing emergency care to Medicare fee-for-service beneficiaries. These findings underscore the importance of diverse training and certification programs to ensure access to clinically focused ED clinicians.

This cohort study evaluates different approaches for estimating the population of individuals eligible for Medicaid expansion under the Affordable Care Act in the context of researching changes in cancer care after Medicaid expansion.

Importance Tumor size larger than 4 cm is accepted as an indication for adjuvant chemotherapy in patients with node-negative non-small cell lung cancer (NSCLC). Treatment guidelines suggest that high-risk features are also associated with the efficacy of adjuvant chemotherapy among patients with early-stage NSCLC, yet this association is understudied. Objective To assess the association between adjuvant chemotherapy and survival in the presence and absence of high-risk pathologic features in patients with node-negative early-stage NSCLC. Design, setting, and participants This retrospective cohort study using data from the National Cancer Database included 50 814 treatment-naive patients with a completely resected node-negative NSCLC diagnosed between January 1, 2010, and December 31, 2015. The study was limited to patients who survived at least 6 weeks after surgery (ie, estimated median time to initiate adjuvant chemotherapy after surgery) to mitigate immortal time bias. Statistical analysis was performed from December 1, 2018, to February 29, 2020. Exposures Adjuvant chemotherapy use vs observation, stratified according to the presence or absence of high-risk pathologic features (visceral pleural invasion, lymphovascular invasion, and high-grade histologic findings), sublobar surgery, and tumor size. Main outcomes and measures The association of high-risk pathologic features with survival after adjuvant chemotherapy vs observation was evaluated using Cox proportional hazards regression models. Results Overall, 50 814 eligible patients with NSCLC (27 365 women [53.9%]; mean [SD] age, 67.4 [9.5] years]) were identified, including 4220 (8.3%) who received adjuvant chemotherapy and 46 594 (91.7%) who did not receive adjuvant chemotherapy. Among patients with tumors 3 cm or smaller, chemotherapy was not associated with improved survival (hazard ratio [HR], 1.10; 95% CI, 0.96-1.26; P = .17). For patients with tumors larger than 3 cm to 4 cm, adjuvant chemotherapy was associated with a survival benefit among patients who underwent sublobar surgery (HR, 0.72; 95% CI, 0.56-0.93; P = .004). For tumors larger than 4 cm to 5 cm, a survival benefit was associated with adjuvant chemotherapy only in patients with at least 1 high-risk pathologic feature (HR, 0.67; 95% CI, 0.56-0.80; P = .02). For tumors larger than 5 cm, adjuvant chemotherapy was associated with a survival benefit irrespective of the presence of high-risk pathologic features (HR, 0.75; 95% CI, 0.61-0.91; P = .004). Conclusions and relevance In this cohort study, tumor size alone was not associated with improved efficacy of adjuvant chemotherapy in patients with early-stage (node-negative) NSCLC. High-risk clinicopathologic features and tumor size should be considered simultaneously when evaluating patients with early-stage NSCLC for adjuvant chemotherapy.

Background: Pain is common among patients with cardiopulmonary conditions; however, there are increasing concerns, but limited research, regarding use of opioids for pain in patients with noncancer conditions. Objective: To compare patterns of opioid prescribing among older adults reporting pain with cardiopulmonary conditions and/or cancer. Design: Observational study using data from the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey resource linked to Medicare Part D prescription claims. Setting/Subjects: We identified patients who self-reported moderate-to-severe pain interference with daily activities. Patients were stratified by (1) self-reported history of cardiopulmonary conditions; (2) were within five years of cancer diagnosis; (3) had both conditions; or (4) neither. Measurements: We characterized opioid prescribing within 30 days of survey and one-year follow-up using logistic regression and Cox proportional hazard time-to-event analyses. Results: Of 10,516 patients with moderate-to-severe pain (1758 cardiopulmonary conditions, 3383 cancer, 2861 both, 2514 neither), 46% were aged ≥75 years, 65% were non-Hispanic white, and 10% non-Hispanic black. At survey, 1627 (15.5%) received opioids. Adjusted proportions of opioid use were lower for patients with cardiopulmonary conditions only (14%) compared with cancer only (17%; p

Background The Centers for Medicare and Medicaid Services (CMS) developed risk-adjusted “Star Ratings,” which serve as a guide for patients to compare hospital quality (1 star = lowest, 5 stars = highest). Although star ratings are not based on surgical care, for many procedures, surgical outcomes are concordant with star ratings. In an effort to address variability in hospital mortality after complex cancer surgery, the use of CMS Star Ratings to identify the safest hospitals was evaluated. Methods Patients older than 65 years of age who underwent complex cancer surgery (lobectomy, colectomy, gastrectomy, esophagectomy, pancreaticoduodenectomy) were evaluated in CMS Medicare Provider Analysis and Review files (2013-2016). The impact of reassignment was modeled by applying adjusted mortality rates of patients treated at 5-star hospitals to those at 1-star hospitals (Peters-Belson method). Results There were 105 823 patients who underwent surgery at 3146 hospitals. The 90-day mortality decreased with increasing star rating (1 star = 10.4%, 95% confidence interval [CI] = 9.8% to 11.1%; and 5 stars = 6.4%, 95% CI = 6.0% to 6.8%). Reassignment of patients from 1-star to 5-star hospitals (7.8% of patients) was predicted to save 84 Medicare beneficiaries each year. This impact varied by procedure (colectomy = 47 lives per year; gastrectomy = 5 lives per year). Overall, 2189 patients would have to change hospitals each year to improve outcomes (26 patients moved to save 1 life). Conclusions Mortality after complex cancer surgery is associated with CMS Star Rating. However, the use of CMS Star Ratings by patients to identify the safest hospitals for cancer surgery would be relatively inefficient and of only modest impact.

Background Atypical pulmonary carcinoid tumors represent a subset of non-small cell lung cancer; however, their relative infrequency has left prognosis, management and long-term survival associated with atypical carcinoids, incompletely characterized. Methods Patients aged 18 years or more diagnosed with atypical or typical pulmonary carcinoid between 2010 and 2015 within the National Cancer Database were evaluated. Survival was measured using Kaplan-Meier survival and multivariable Cox proportional hazards regression, adjusting for patient and tumor attributes. Results A total of 816 atypical and 5688 typical carcinoid patients were identified in the cohort. Patients with atypical carcinoids tended to be older, have larger tumors, and later stage disease. The unadjusted overall 5-year survival for atypical carcinoid patients was 84%, 74%, 52%, and 51% for stages I, II, III, and IV, respectively. The unadjusted 5-year survival for typical carcinoids was 93%, 93%, 89%, and 87% for stages I, II, III, and IV, respectively. Nodal upstaging (ie, lymph node metastases identified in surgical specimens of clinically staged N0 patients) was seen in 16% of atypical and 7% of typical carcinoid patients. Increasing age, comorbidities, and stage were identified as significant predictors of mortality for atypical patients in multivariable analysis. Extent of surgical resection (lobectomy vs sublobar) was not identified as a predictor of survival for atypical carcinoid. Conclusions Atypical carcinoid tumors represent a distinct subset of carcinoid tumors, with a tendency toward more aggressive behavior. Further study of the optimal surgical management is warranted.

Importance Insurance status has been linked to important differences in cancer treatment and outcomes in the US. With more than 15 million individuals gaining health insurance through Medicaid expansion, there is an increasing need to understand the implications of this policy within the US cancer population. This review provides an overview of the fundamental principles and nuances of Medicaid expansion, as well as the implications for cancer care. Observations The Patient Protection and Affordable Care Act presented states with an option to expand Medicaid coverage by broadening the eligibility criteria (eg, raising the eligible income level). During the past 10 years, Medicaid expansion has been credited with a 30% reduction in the population of uninsured individuals in the US. Such a significant change in the insurance profile could have important implications for the 1.7 million patients diagnosed with cancer each year, the oncology teams that care for them, and policy makers. However, several factors may complicate efforts to characterize the effect of Medicaid expansion on the US cancer population. Most notably, there is considerable variation among states in terms of whether Medicaid expansion took place, when expansion occurred, eligibility criteria for Medicaid, and coverage types that Medicaid provides. In addition, economic and health policy factors may be intertwined with factors associated with Medicaid expansion. Finally, variability in the manner in which cancer care has been captured and depicted in large databases could affect the interpretation of findings associated with expansion. Conclusions and relevance The expansion of Medicaid was a historic public policy initiative. To fully leverage this policy to improve oncological care and to maximize learning for subsequent policies, it is critical to understand the effect of Medicaid expansion. This review aims to better prepare investigators and their audiences to fully understand the implications of this important health policy initiative.

137 Background: Prior studies indicate that Black patients with cancer are more likely to receive aggressive EOL care, including chemotherapy within 14 days (d) prior to death. However, most studies are limited to specific subgroups, and it is unclear if disparities remain in the immunotherapy era. In this study, we evaluated racial differences in systemic oncologic EOL treatment among a national all-payer cohort of patients treated in routine practice. Methods: We conducted a retrospective cohort study utilizing data from the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database. Patients with confirmed cancer diagnosis, with documented treatment on or after 1/1/2011 and who died between 2015 and 2019, were included. Patients with documented race of White or Black or African American were included. We defined our outcome measures as receipt of any systemic oncologic treatment within 30d or 14d prior to death, and also stratified by mono-chemotherapy (Chemo) and immunotherapy ± targeted therapy (ICI). We used mixed-level logistic regression models to assess the likelihood of receiving each treatment, compared to patients without any EOL treatment, between Black and White patients, adjusted for patient- and practice-level characteristics as fixed effects and a practice-specific random intercept. Race-specific adjusted rates were estimated using stratified analysis. Results: A total of 40,675 White and 5,150 Black patients were included in the analysis. Compared to White patients, Black patients were younger at diagnosis, were more likely to be female and have Medicaid coverage. Black patients were more likely to be treated at practices with higher patient-to-physician ratio (25.8% in highest quintile vs. 18.7%) and with a high proportion (> 10%) of patients with Medicaid (38.1% vs. 31.6%). Compared to White patients within the same practice, Black patients were less likely to receive any EOL treatment within 30d (adjusted odds ratio [aOR]: 0.87; 95% CI: 0.81-0.93) or 14d (aOR: 0.87; 95% CI: 0.80-0.96). Adjusted rates of any EOL treatment within 30d prior to death were 33.8% and 37.6% among Black and White patients, respectively. When stratified by treatment types, Black patients were less likely to receive ICI within 30d prior to death, compared to White patients (aOR: 0.87; 95% CI: 0.76-1.00). Conclusions: Our findings differ from prior studies of oncologic EOL care and suggest that in contemporary practice Black patients are less likely to receive anti-cancer therapy near EOL, largely driven by lower rates of ICI use. Future research should investigate the complex causal pathway underlying observed racial differences among patient and practice-level factors.

253 Background: Among patients with cancer, receipt of systemic oncolytic therapy near the end-of-life (EOL) does not improve outcomes and worsens patient and caregiver experience. Accordingly, the ASCO/NQF measure, Proportion Receiving Chemotherapy in the Last 14 Days of Life, was published in 2012. Over the last decade there has been exponential growth in high cost targeted and immune therapies which may be perceived as less toxic than traditional chemotherapy. In this study, we identified rates and types of EOL systemic therapy in today’s real-world practice; these can serve as benchmarks for cancer care organizations to drive improvement efforts. Methods: Using data from the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database we included patients who died during 2015 through 2019, were diagnosed after 2011, and who had documented cancer treatment. We identified the use of aggressive EOL systemic treatment (including, chemotherapy, immunotherapy, and combinations thereof) at both 30 days and 14 days prior to death. We estimated standardized EOL rates using mixed-level logistic regression models adjusting for patient and practice-level factors. Year-specific adjusted rates were estimated in annualized stratified analysis. Results: We included 57,127 patients, 38% of whom had documentation of having received any type of systemic cancer treatment within 30 days of death (SD: 5%; range: 25% - 56%), and 17% within 14 days of death (SD: 3%; range: 10% - 30%). Chemotherapy alone was the most common EOL treatment received (18% at 30 days, 8% at 14 days), followed by immunotherapy (± other treatment) (11% at 30 days, 4% at 14 days). Overall rates of EOL treatment did not change over the study period: treatment within 30 days (39% in 2015 to 37% in 2019) and within 14 days (17% in 2015 to 17% in 2019) of death. However, the rates of chemotherapy alone within 30 days of death decreased from 24% to 14%, and within 14 days, from 10% to 6% during the study period. In comparison, rates for immunotherapy with chemotherapy (0%-6% for 30 days, 0% -2% for 14 days), and immunotherapy alone or with other treatment types (4%-13% for 30 days, 1%-4% for 14 days) increased over time for both 30 and 14 days. Conclusions: End of life systemic cancer treatment rates have not substantively changed over time despite national efforts and expert guidance. While rates of traditional chemotherapy have decreased, rates of costly immunotherapy and targeted therapy have increased, which has been associated with higher total cost of care and overall healthcare utilization. Future work should examine the drivers of end-of-life care in the era of immune-oncology.

Background Over the last decade, Ethiopia has made impressive national improvements in health outcomes, including reductions in maternal, neonatal, infant, and child mortality attributed in large part to their Health Extension Program (HEP). As this program continues to evolve and improve, understanding the unit cost of health extension worker (HEW) services is fundamental to planning for future growth and ensuring adequate financial support to deliver effective primary care throughout the country. Methods We sought to examine and report the data needed to generate a HEW fee schedule that would allow for full cost recovery for HEW services. Using HEW activity data and estimates from national studies and local systems we were able to estimate salary costs and the average time spent by an HEW per patient/community encounter for each type of services associated with specific users. Using this information, we created separate fee schedules for activities in urban and rural settings with two estimates of non-salary multipliers to calculate the total cost for HEW services. Results In the urban areas, the HEW fees for full cost recovery of the provision of services (including salary, supplies, and overhead costs) ranged from 55.1 birr to 209.1 birr per encounter. The rural HEW fees ranged from 19.6 birr to 219.4 birr. Conclusion Efforts to support health system strengthening in low-income settings have often neglected to generate adequate, actionable data on the costs of primary care services. In this study, we have combined time-motion and available financial data to generate a fee schedule that allows for full cost recovery of the provision of services through billable health education and service encounters provided by Ethiopian HEWs. This may be useful in other country settings where managers seek to make evidence-informed planning and resource allocation decisions to address high burden of disease within the context of weak administrative data systems and severe financial constraints.

Up to 20% of clinical stage I lung cancer patients harbor lymph node metastases that go undetected (missed) during the clinical staging evaluation. We investigated to what degree the addition of invasive nodal staging procedures to imaging, as currently practiced, prevents radiographically occult nodal metastases from being missed during the clinical staging evaluation.Treatment-naive patients, imaged by positron emission tomography and computed tomography, who underwent lobectomy for clinical stage I lung cancer from 2012 to 2017 in The Society of Thoracic Surgeons General Thoracic Surgery Database were studied. Rates of missed nodal metastases (MNM) (ie, nodal metastases in lobectomy specimens undetected during clinical staging evaluation) were determined. Risk factors were assessed with multivariable modeling.Of the 30,685 clinical stage I patients identified, 3895 (12.7%) underwent preoperative endobronchial ultrasound and 3341 (10.9%) underwent mediastinoscopy. Invasive staging was more common with tumors2 cm (66.4% vs 50.2%, P.001) and squamous histology (26.9% vs 16.9%, P.001). MNM were discovered in 14.7% of patients, including 20.1% of patients (95% confidence interval, 18.8%-21.5%) who had undergone endobronchial ultrasound and 18.2% (95% confidence interval, 16.7%-19.6%) who had undergone mediastinoscopy. Hilar nodes were most often "missed" (9.5%). Using cut-points in tumor size, histology, laterality, and age, patients could be stratified into particularly high-risk (25% MNM) and low-risk (6% MNM) cohorts.Substantial risk of occult lymph node metastases persists in patients with clinical stage I lung cancer despite negative invasive nodal staging, positron emission tomography, and computed tomography. In the absence of a thorough surgical nodal evaluation, early-stage lung cancer patients are at risk of under-treatment.

Introduction: Patients with early-stage NSCLC typically must choose between a surgery with superior local control (lobectomy) or one that preserves lung parenchyma (wedge). Recognizing that many patients with cancer have competing mortality risks unrelated to cancer, we investigated whether an established model of predicting life expectancy could be used to identify patients with stage I NSCLC for whom survival after wedge is not different from lobectomy. Methods: A retrospective cohort study using the National Cancer Institute’s Surveillance Epidemiology and End Results—Medicare was performed to evaluate survival among treatment-naive patients, diagnosed 2005–2015, who underwent lobectomy or wedge for stage I (≤2 cm tumors) NSCLC. Comorbidity-related life expectancy (CR-LE) was estimated using a standard life-table approach based on comorbid conditions, sex, and age. Cox models and perioperative complications were stratified by 5-year CR-LE. Results: A total of 4560 patients (median age 74, interquartile range 70–78) were identified. CR-LE was greater than or equal to 5 years for 4016 patients (wedge = 23%). CR-LE was less than 5 years for 544 patients (wedge = 41%). Among patients with CR-LE greater than or equal to 5, wedge resection was associated with higher risk of mortality than lobectomy (hazard ratio: 1.68, 95% confidence interval: 1.52–1.86, p < 0.001). For those with CR-LE less than 5, there was no significant difference in mortality risk between lobectomy and wedge (hazard ratio: 1.19, 95% confidence interval: 0.96–1.47; p = 0.11). CR-LE less than five patients who underwent a lobectomy had higher 90-day mortality compared with wedge (9% versus 4%, p = 0.04). Conclusion: The survival advantage of lobectomy over wedge for stage I NSCLC seems to dissipate among patients with shorter life expectancy owing to age and comorbidities. Wedge resection may be a reasonable option for patients at high risk of dying from non–cancer-related causes.

Mental disorders are disabling and economically costly health conditions. Given limited resources, mental health systems in low- and middle-income countries (LMICs) tend to focus on patients with the most severe conditions, for whom treatment usually relies on use of psychoactive medications; however, inconsistent patterns of use can be ineffective, wasteful, and potentially harmful. Therefore, a greater understanding of prescription practices and medication availability in LMIC is needed. We estimated associations between prescription practices and hospitals and medication availability for patients diagnosed with schizophrenia or delusional disorders (n = 7,296) and patients diagnosed with epilepsy (n = 1,807), the two most common mental and neurological disorders seen at Ghana’s psychiatric hospitals. Among patients with a primary diagnosis of schizophrenia or delusional disorders, 43% were prescribed an anti-psychotic or combination of anti-psychotics and anti-cholinergics. Among patients with...

Background: Despite evidence that enrollment with hospice services has the potential to reduce hospital readmission rates, previous research has not examined exactly how hospitals may promote the appropriate use of hospice and palliative care for their discharged patients. Therefore, we sought to explore the strategies used by hospitals to increase the use of hospice and palliative care for patients at risk of readmission. Methods: We conducted a secondary analysis of qualitative data from a study of hospitals that were participating in the State Action on Avoidable Readmissions (STAAR) initiative, a quality improvement collaborative. We used data attained from 46 in-depth interviews conducted during 10 hospital site visits using a standard discussion guide and protocol. We used a grounded theory approach using the constant comparative method to generate recurrent and unifying themes. Results: We found that a positive effect for hospitals participating in the STAAR initiative was enhanced engagement in efforts to promote greater use of hospice and palliative care as a possible method of reducing unplanned readmissions, the central goal of the STAAR initiative. Hospital staff described strategies to increase the use of hospice and palliative care that included (1) designing and implementing tracking systems to identify patients most at risk of being readmitted, (2) providing education about hospice and palliative care to family, internal and external clinical groups, and (3) establishing closer links to posthospital settings. Conclusion: National efforts to reduce rehospitalizations may result in improved integration of hospice and palliative care for patients who are at risk of readmission.

2 Background: The OCM is a Centers for Medicare and Medicaid Services (CMS) alternative payment model, which seeks to curb costs while improving care for patients receiving systemic cancer therapy. CMS models the expected spending target for each 6-month episode using historical, geographic and clinical factors, including CTr participation. We evaluated the relationship between CTr participation, drug costs and performance in the OCM. Methods: We used claims for OCM episodes attributed to the Yale Cancer Center between July 2016 and July 2018. We stratified episodes by CTr participation and used t-tests and chi-square tests to compare total cost, drug costs (Part B, Part D and novel cancer therapies) and whether observed episode costs were above or below CMS targets. Analyses were conducted for the total sample and among the most common cancer types. Results: Among 9,387 OCM episodes (5,270 unique patients), 815 (8.7%) episodes involved a CTr. Among non-CTr patients, the mean Medicare cost per episode ($32,909) was modestly higher than the mean episode spending target ($31,746; p < 0.001), while in the CTr group, the mean Medicare cost per episode ($36,590) was substantially lower than the mean episode spending target ($48,124 p < 0.001). CTr episode costs were more likely to be under spending targets than non-CTr episodes (66% vs 56%, p < 0.001) overall and in breast, lung, and myeloma cancers, although only statistically significant for lung cancer (76% CTr vs 48% non-CTr, p < .001). Overall, non-CTr had significantly higher mean Part D drug costs per episode ($8,441 vs $3,893, p < 0.001), which was also noted among patients with lung cancer, ovarian cancer and lymphoma. Non-CTr episodes were also associated with higher mean novel therapies cost ($5,736) compared with CTr patient episodes ($4,346, p = 0.013). When comparing the sum of all other expenditures, CTr episodes were significantly associated with higher non-pharmaceutical expenditures than non-CTr episodes ($20,940 vs. $13,323, p < 0.001) overall. Conclusions: Episodes with CTr participation out-performed non-CTr episodes in achieving savings relative to CMS spending targets. Savings were driven by lower drug costs for the CTr episodes, particularly in the categories of Part D and novel cancer therapies. This suggests that CTr enrollment shifts costs for expensive pharmaceuticals away from CMS and toward the CTr study sponsor. Further research should explore whether this finding is generalizable to other cancer centers and payment models.

e19367 Background: The OCM is a Centers for Medicare and Medicaid Services (CMS) alternative payment model, which seeks to curb costs while improving care for patients receiving systemic cancer therapy. CMS models the expected total cost (spending target) for each 6-month episode using historical, geographic and clinical factors including CTr participation. We evaluated the relationship between CTr participation, actual cost of care and performance in the OCM. Methods: We used claims for OCM episodes attributed to the Yale Cancer Center between July 2016 and July 2018. We stratified episodes by CTr participation and used t-tests and chi-square tests to compare total cost, drug costs (Part B and D) and whether actual episode costs were above or below CMS targets. Analyses were conducted for the total sample, and among the most common cancer types. Results: Among 9,387 OCM episodes (5,270 unique patients), 815 (8.7%) episodes involved a CTr. Among non-CTr patients, the mean Medicare cost per episode ($32,909) was modestly higher than the mean episode spending target ($31,746; p < 0.001), while in the CTr group, the mean Medicare cost per episode ($36,590) was substantially lower than the mean episode spending target ($48,124 p < 0.001). Mean drug cost was lower with CTr vs without ($15,650 vs $19,587, p < 0.001). Drug costs also accounted for a lower percentage of total costs for episodes with CTr vs not (41% vs 57%). CTr episodes were more likely to meet spending targets than non-CTr episodes (66% vs 56%, p < 0.001) overall and in breast, lung, and myeloma cancers, although only statistically significant for lung cancer (76% CTr vs 48% non-CTr, p < 0.001). Mean difference between target and actual costs was greater for episodes with CTr (- $11,534) than for episodes without CTr (+ $1,163) (p < 0.001). Conclusions: On average, episodes with CTr participation had substantially lower costs compared with their spending targets, while non-CTr episodes had slightly higher costs compared with their spending targets. While total cost of care was higher for episodes with CTr (as the CMS model predicts), drug costs were significantly lower. As drugs comprise a large proportion of total cost, lower drug costs in CTr episodes likely contribute to savings. Additional research should explore whether other OCM centers with higher rates of CTr participation are more likely to meet spending targets in value-based payment models.

e24009 Background: The use of chemotherapy regimens with varying intensities at specific time points may have an effect on EOL care trajectories among older adults with aLC (IIIB & IV). Methods: Using the Surveillance, Epidemiology, and End Results (SEER)–Medicare registry and claims data, we selected decedents diagnosed with aLC (small cell: SCLC and non-small cell: NSCLC) between 2008 and 2013 who survived ≥6 months (death between 2008 and 2014). Main outcome measures were EOL care trajectories in the 6 months prior to death among patients receiving chemotherapy characterized by intensity levels. A multinomial logit model was used to determine the association between intensity of initial chemotherapy regimen and EOL care trajectory. Results: Our sample (N = 10,594) was mostly NSCLC (77%) of whom only 63% received chemotherapy. Patients receiving chemotherapy were predominantly males (70.4%), age 66-69 years (80%), non-Hispanic white (68.1%) and 78.4% were married. 41 % received treatment prior to EOL-6 and 10.4 % first initiated treatment during EOL-6. The majority of patients received a platinum-based doublet as a first line therapy. Compared to non-cisplatin platinum doublet chemotherapy, patients receiving cisplatin were least likely to be in the decreasing intensity EOL group and most likely to be in increasing intensity EOL group (see table). Conclusions: Among aLC decedents, patients who received cisplatin chemotherapy as compared to non-cisplatin doublet chemotherapy were least likely to be in the decreasing EOL intensity group and most likely to be in the increasing EOL intensity group. EOL care preferences may need to be considered when choosing initial chemotherapy treatment regimens. [Table: see text]

e24008 Background: Medicare decedents often receive intensive care during the last month (mth) of life. There is little information on longer (6-mth) EOL trajectories of care intensity. Area hospice use rates may reflect supply and/or patient and physician preferences, and may influence patterns for individual decedents. Methods: Using SEER-Medicare linked registry and claims data, we selected decedents diagnosed with LC between 2008-2013 who survived ≥6-mths and died between 2008-2014. We linked Dartmouth Atlas data on hospital referral region (HRR) % cancer decedents with hospice use. Each mth we assessed claims to identify cancer-directed (CD) care (chemotherapy or radiation) and pharmacologic or other palliative care services (PCS) and assigned decedents to either CD only, PCS only, concurrent CD & PCS, full-mth inpatient (IP) or full-mth hospice. We ordered monthly care intensity from high to low (IP > CD only > concurrent CD & PCS > PCS only > hospice). Using the indicators arrayed by calendar mth, we assigned each decedent to 1 of 6 trajectories: stable (6-mth continuous) hospice, stable PCS only, stable CD only or concurrent CD & PCS, decreasing intensity, increasing intensity, and mixed (multiple directional shifts). Multinomial logistic regression estimated associations between area hospice rates, socio-demographics, and comorbidity with EOL trajectory, controlling for 1st line therapy, and diagnosis stage. Results: Our sample (N = 24,342) was predominantly male (53.7%), age ≥75 years (59.4%), and non-Hispanic white (80.5%); 19.1% lived in HRRs where ≤50% of cancer decedents received any hospice care. Trajectories were 7% stable hospice, 26% stable PCS only, 4% stable CD; 29% decreasing intensity, 9% increasing intensity, and 26% mixed. Relative to stable hospice, higher HRR-level hospice rates were associated with decreasing EOL intensity; higher age, female, and married were associated with increased probability of stable hospice enrollment); Black, non-Hispanic decedents had higher risk of increasing intensity (aRRR: 1.39, 95% confidence interval: 1.09-1.76, p < .01) and mixed patterns. Conclusions: Among older decedents with LC, only 62% had 6-mth EOL trajectories indicating low- (stable hospice or PCS only) or decreasing intensity, but few received persistent CD care. Area hospice use patterns, demographic characteristics and health status were associated with EOL trajectory. Additional research is needed to identify subgroups at risk of high or increasing intensity trajectories, and interventions that may shift trajectories towards lower intensity at EOL.

Context Older adults with advanced lung cancer experience high symptom burden at end of life (EOL), yet hospice enrollment often happens late or not at all. Receipt of medications to manage symptoms in the outpatient setting, outside the Medicare hospice benefit, has not been described. Objectives We examined patterns of symptom management medication receipt at EOL for older adults who died of lung cancer. Methods This retrospective cohort used the Surveillance, Epidemiology, and End Results—Medicare database to identify decedents diagnosed with lung cancer at age 67 years and older between January 2008 and December 2013 who survived six months and greater after diagnosis. Using Medicare Part B and D claims, we identified monthly receipt of outpatient medications for symptomatic management of pain, emotional distress, fatigue, dyspnea, anorexia, and nausea/vomiting. Multivariable logistic regression estimated associations between medication receipt and patient demographic characteristics, comorbidity, and concurrent therapy. Results Of the 16,246 included patients, large proportions received medications for dyspnea (70.7%), pain (62.5%), and emotional distress (49.4%), with lower prevalence for other symptoms. Medication receipt increased from six months to one month before death. Women and dual Medicaid enrolled were more likely to receive medications for pain, emotional distress, dyspnea, and nausea/vomiting. Receipt of symptom management medications decreased with increasing age and racial/ethnical minorities. Conclusion Symptom management medication receipt was common and increasing toward EOL. Lower use by males, older adults, and nonwhites may reflect poor access or poor patient-provider communication. Further research is needed to understand these patterns and assess adequacy of symptom management in the outpatient setting.

Hospice use has increased substantially during the past decade by an increasingly diverse patient population; however, little is known about patterns of hospice use and how these patterns have changed during the past decade.To characterize Medicare hospice users in 2000 and 2010 and estimate the prevalence of (1) very short (≤1 wk) hospice enrollment; (2) very long (6 mo) hospice enrollment; and (3) hospice disenrollment and how these utilization patterns have varied over time and by patient and hospice characteristics.Cross-sectional analysis of Medicare hospice claims data from 2000 and 2010.All US Medicare Hospice Benefit enrollees in 2000 (N=529,573) and 2010 (N=1,150,194).As of 2010, more than half (53.4%) of all Medicare decedents who used hospice had either very short (≤1 wk, 32.4%) or very long (6 mo, 13.9%) hospice enrollment or disenrolled from hospice before death (10.6%). This represents an increase of 4.9 percentage points from 2000. In multivariable analysis, patients with noncancer diagnoses, the fastest growing group of hospice users, were approximately twice as likely as those with cancer to have very short or long enrollment periods and to disenroll from hospice.The substantial proportion of hospice users with very short or long enrollment, or enrollments that end before death, underscores the potential for interventions to improve the timing and appropriateness of hospice referral so that the full benefits of hospice are received by patients and families.

ObjectiveTo examine whether state-level spending on social and public health services is associated with lower rates of homicide in the USA.DesignEcological study.SettingUSA.ParticipantsAll states in the USA and the District of Columbia for which data were available (n=42).Primary outcome measureHomicide rates for each state were abstracted from the US Department of Justice Federal Bureau of Investigation’s Uniform Crime Reporting.ResultsAfter adjusting for potential confounding variables, we found that every $10 000 increase in spending per person living in poverty was associated with 0.87 fewer homicides per 100 000 population or approximately a 16% decrease in the average homicide rate (estimate=−0.87, SE=0.15, pConclusionsBased on our findings, spending on social and public health services is associated with significantly lower homicide rates at the state level. Although we cannot infer causality from this research, such spending may provide promising avenues for homicide reduction in the USA, particularly among states with lower levels of poverty.

Objectives To examine rates of hospice disenrollment and posthospice hospitalization among patients who are enrolled in hospices that provide continuous home care (CHC) (CHC hospices) compared with patients who are enrolled in hospices that do not offer CHC (non-CHC hospices). Methods We performed a retrospective cohort study among Medicare fee-for-service decedents between July and December 2011, who were 66 years and older and had used hospice in their last 6 months of life. We used propensity score matching to account for potential confounding characteristics of hospices. Generalized estimating equation models were applied to estimate between CHC hospices and non-CHC hospices the associations of hospice disenrollment/hospitalization, adjusted for patient characteristics. We also conducted subgroup analyses to examine how the association might have differed by hospice size, and by the percentage of enrollees who received CHC. Results After matching, we identified 936 pairs of CHC and non-CHC hospices, well balanced in terms of organizational characteristics. In fully adjusted models, compared with non-CHC hospices, CHC hospices had significantly lower disenrollment rates (adjusted rate ratio, 0.73; 95% confidence interval, 0.60-0.87), and lower hospitalization rates (adjusted rate ratio, 0.79; 95% confidence interval, 0.66-0.95). These associations were significantly more pronounced among larger hospices (those with >175 enrollees during study period), and among hospices in which at least 7.3% of enrollees used CHC. Conclusions CHC hospices had significantly lower rates of hospice disenrollment and posthospice hospitalization, suggesting CHC service available may enable higher quality of end-of-life care.

Objectives To characterize the patterns of transitions in care and factors associated with multiple transitions in the last 6 months of life of U.S. decedents (N = 660,132). Design Retrospective study. Setting United States. Participants Medicare beneficiaries aged 66 and older who died from July to December 2011. Measurements Transitions between healthcare settings (e.g., hospital, skilled nursing facility, inpatient hospice, home hospice, home without hospice) in the last 6 months of life. A count variable for number of transitions was summarized, and Sankey diagrams were produced to illustrate the sequences of healthcare transitions. Multivariable analyses were used to identify factors associated with likelihood of having four or more transitions. Results More than 80% decedents (n = 556,437) had at least one transition within the last 6 months of life; 218,731 had four or more transitions within the last 6 months of life. The most-frequent transition pattern (19.3% of all decedents; n = 127,435) was home to hospital, back to home or skilled nursing facility, to hospital again, and then to settings other than hospital, ending with four or more transitions. The average number of transitions in the last 6 months of life varied substantially across states, ranging from 1.8 in Alaska to 3.1 in New Jersey. Transitions became more intensive for decedents approaching death. In multivariable analyses, women, blacks, individuals younger than 85, and individuals without dementia were more likely to have four or more transitions (all P

Background To determine the patterns of alcohol use among households in Trinidad and Tobago (T&T) and to estimate the association between alcohol use and negative psychological, social, or physical events experienced by the household. Methods A convenience sample of 1837 households across T&T. We identified bivariate correlates of alcohol use, and heavy episodic drinking using chi-square and t-test analyses and used multivariable logistic regression to estimate adjusted associations between household alcohol use and experiences within the past 12 months adjusted for sociodemographic covariates. Results One thousand five hundred two households had complete data for all variables (82% response rate). Nearly two thirds (64%) of households included alcohol users; 57% of household that consumed alcohol also reported heavy episodic drinking. Households that reported alcohol consumption were significantly more likely to report illnesses within the households, relationship problems, and behavioral and antisocial problems with children. Among households where a member was employed, those who consumed alcohol were nearly twice as likely (OR = 1.98; 95% confidence interval (CI) 1.03, 3.82) to have a household member call in sick to work and 2.9 times as likely (OR = 2.9; CI 1.19, 7.04) to have a household member suffer work related problems compared with households who reported not consuming alcohol. Conclusions Approximately two thirds of households in T&T reported using alcohol. These households were more likely to report psychological, physical, and social problems. These findings would support efforts to enforce current policies, laws, and regulations as well as new strategies to reduce the impact of harmful alcohol consumption on households in T&T. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4266-z) contains supplementary material, which is available to authorized users.

Accountable care organizations (ACOs) and hospitals are facing additional requirements and financial rewards for improving population health. Therefore, ACOs and hospitals will need tools to understand the relationship between their patients and social determinants and health. We demonstrate the use of hot spotting for identifying geographical sources of high hospital costs and examining links between social determinants of health and these high-cost areas, known as hot spots. In 2012, using hospital data, we generated maps of inpatient costs from 2011 throughout New Haven and within an example neighborhood, Dixwell. We defined hot spots as addresses where costs were in the top 25%. We also overlaid data on concerns and assets in the community. Finally, we calculated the number of concerns and assets that fall within the 250 and 500 ft radii of the defined hot spots. We found that 34 addresses in Dixwell accounted for 70% of total costs for Dixwell. Hot spotting is a straightforward, approachable, and easily understood method for ACOs and hospitals to begin to address population health.

2 Background: Value-based payment programs like the Oncology Care Model (OCM) have focused efforts to reduce costly acute care use through improvements in access and coordination rather than targeting the exponential rise in pharmaceutical pricing. We assessed how participation in OCM affected total cost of cancer care at a large academic cancer center. Methods: Using Medicare claims for Yale-Smilow Cancer Hospital, an NCI-designated cancer center with an academic hub and 10 community practices, we identified episodes for chemotherapy initiated during a historical period (pre-OCM, 2012-2015) and performance period (post-OCM, 2016-2017) following OCM criteria to identify total cost of care. We reported frequency of utilization categories, the mean cost per episode, the proportion of total cost attributed to each utilization category and compared pre- and post-participation periods. Results: There were 8,843 episodes during the historical period and 6,679 episodes during the performance period. The mean total cost per episode increased from $28,645 to $32,666, but this was less than the Medicare-defined expected increase (target price). Between the two periods, the percentage of total episodes decreased for emergency department (ED) use from 36% to 33%, inpatient care from 33% to 29%, and post-acute care from 28% to 25% (p < 0.01). Mean costs of drugs per episode increased by 27% between periods, and from 52% to 58% of total cost of care (p < 0.01). While mean cost per episode for ED, inpatient, and post-acute care remained stable, the mean cost per episode for antineoplastics increased 39% from $10,676 to $14,843. Conclusions: After implementing OCM, we beat the Medicare target largely by decreasing acute care use and stabilizing the cost of hospitalizations and ED; however, actual cost increased largely due to pharmaceutical spending. Because drug costs were the largest proportion of overall cost of care, future value-based models must address the rising cost of pharmaceuticals. [Table: see text]

130 Background: Patients with advLC experience high symptom burden; undertreatment may result in poor quality of life for patients and caregivers. Hospice enrollment often happens late or not at all, yet little is known about EoL outpatient PSM medication use in the non-hospice setting. Methods: Using SEER-Medicare linked registry and claims data, we selected decedents diagnosed with advLC between 2008-2013 who survived ≥6 months (death between 2008-2014). Using non-hospice claims, we identified receipt of oral and parenteral medications to manage symptoms such as pain (any pain medications, any opioids), nausea/ vomiting and dyspnea at 6 (EoL-6) and 1 (EoL-1) months prior to death. Antiemetics were excluded if concurrent with chemotherapy (CTx). T-tests compared sample proportions receiving PSM between EoL-6 and EoL-1. Logistic regression estimated associations between PSM medication receipt at EoL-1 and patient demographic characteristics, comorbidity, and ongoing CTx or radiation. Results: We identified 16,246 decedents: mean age 77 years, 50% male, and 81% non-Hispanic white. PSM medication for individual symptom areas increased from EoL-6 to EoL-1 [Table]. Adjusted results indicate that pain medication receipt was higher for females, and patients with multimorbidity, dual Medicare/Medicaid, higher poverty, living in rural areas, and receiving concurrent radiation but lower among those with increasing age and for non-white race/ethnicity groups. We saw similar trends for PSM using opioids, and for emotional distress, and dyspnea. Conclusions: Among patients with advLC at EoL, medication use for symptom relief was common and increasing toward EoL-1. Lower use by males, older adults, and non-whites may reflect poor access or poor patient-provider communication. Further research is needed to assess adequacy of PSM in the outpatient setting. [Table: see text]

6615 Background: Oncology-specific urgent care clinics (UCC) may play a key role in reducing unscheduled emergency department (ED) visits among patients with cancer. We sought to determine if establishment of an Oncology UCC was associated with lower ED utilization among patients receiving cancer care at Yale’s Smilow Cancer Hospital (SCH) and two nearby, integrated community practices. Methods: SCH opened its UCC in April 2017 to provide supportive care and symptom management for patients with cancer who need acute medical attention outside of regular clinic visits. We identified patients who had at least one visit with an oncology provider during the Pre-UCC period (9/1/16 – 12/31/16) or Post-UCC period (9/1/17 – 12/31/17) and received chemotherapy within a year preceding their provider visit. For each patient, we captured all ED visits in a four-month window starting from their last provider visit in each study period. The ED visit rate for both periods was defined as the total number of ED visits divided by the total number of unique patients in the period. To determine the impact of the UCC on ED utilization, we evaluated the absolute difference in the ED visit rate between the Pre- and Post-UCC period using a two-sample t test. Results: There were 3,754 patients in the Pre-UCC period and 4,734 patients in the Post-UCC period. In the full study sample, the mean age was 62.9 and most common cancer types were Hematologic, Gastrointestinal, and Breast. Prior to opening the UCC, the ED visit rate was 0.27 per unique patient. After opening the UCC, we found a 13.9% relative decrease in the overall ED visit rate from 0.27 to 0.23 (p = 0.02). The SCH patient ED visit rate declined by 12.5% (p = 0.03) and the community practice rate declined by 37.1%; however, the latter decline was not statistically significant, potentially due to a small sample size (p = 0.19). Conclusions: Our study found a decrease in the ED visit rate after the opening of an Oncology UCC. An urgent care strategy for cancer centers may serve as an efficient way to manage patients while minimizing ED use. [Table: see text]

e18310 Background: Cancer care is complex, requiring multidisciplinary care over time and settings. Our implementation strategy for participation in CMS’ Oncology Care Model included the development of a new care management program to provide elderly patients with cancer support and continuity between inpatient and outpatient care with the goal of reducing acute care utilization. With no published models of care coordination in cancer, we launched this program using nurses experience to risk stratify and manage the needs of nearly 2500 patients. To optimize their work, we sought to understand the activity breakdown of their working time and to identify areas that can be managed more efficiently. Methods: Care coordinators are nurses responsible for completing the Institute of Medicine (IOM) care plan, stratifying patients by risk and comorbidity and administering weekly symptom assessment scales to those at high risk for disease and treatment complications. We created, pilot tested and refined a data collection tool that care coordinators could self-report the time they spent in activities of direct and indirect patient care. We performed a desk audit to measure the amount of time that oncology care coordinators spend on various activities and to explore differences in academic center versus care center care coordinators. A total of seven care coordinators self-reported activity specific time for 5 working days. Data were analyzed to assess variation in the proportion of activity time by care coordinator, site of care and day of the week using anova and t-test for the difference in mean activity time. Results: Care coordinators spent the majority of their time in indirect patient care (58%) with the highest percentage of their time specifically on charting/documentation (28%) while only 42% of their time included activities that were direct patient care. We observed no significant difference in the proportion of time spent in direct versus indirect patient care across care coordinators (p = 0.47, day of the week (p = 0.35) or by location of care (p = 0.68). Conclusions: A minority of care coordinators time is spent on providing direct patient care and substantial time is spent on indirect activities including charting and documentation. The efficiency of the care coordination model may be improved by transferring tasks that do not require the clinical expertise of these nurses.

Objective:To determine the association of hypertension (HTN) and its treatment with sexual function in middle-aged and older adults.Methods:We studied a nationally representative sample of community-residing adults aged 57–85 years (n = 3005) from the National Social Health, Life and Aging Project.

Background Adult obesity rates in the United States have reached epidemic proportions, yet vary considerably across states and counties. We sought to explore community-level factors that may be associated with reduced adult obesity rates at the county level. Methods We identified six U.S. counties that were positive deviants for adult obesity and conducted semi-structured interviews with community leaders and government officials involved in efforts to promote healthier lifestyles. Using site visits and in-depth qualitative interviews, we identified several recurrent themes and strategies. Results Participants: 1) developed a nuanced understanding of their communities; 2) recognized the complex nature of obesity, and 3) implemented a county-wide strategic approach for promoting healthy living. This county-wide approachwas used to a) break down silos and build partnerships, b) access community resources and connections, and c) transfer ownership to community members. Conclusions We found that county leaders focused on establishing a county-wide structure to connect and support community-led initiatives to promote healthy living, reduce obesity, and foster sustainability. Findings from this study can help inform county-level efforts to improve healthy living and combat the multi-faceted challenges of adult obesity across the U.S.

Among the four levels of hospice care, continuous home care (CHC) is the most expensive care, and infrequently provided in practice.To identify hospice and patient characteristics associated with the use of CHC and to examine the associations between CHC utilization and hospice disenrollment or hospitalization after hospice enrollment.Using 100% fee-for-service Medicare claims data for beneficiaries aged 66 years or older who died between July and December 2011, we identified the percentage of hospice agencies in which patients used CHC in 2011 and determined hospice and patient characteristics associated with the use of CHC. Using multivariable analyses, we examined the associations between CHC utilization and hospice disenrollment and hospitalization after hospice enrollment, adjusted for hospice and patient characteristics.Only 42.7% of hospices (1533 of 3592 hospices studied) provided CHC to at least one patient during the study period. Patients enrolled with for-profit, larger, and urban located hospices were more likely to use CHC (P 0.001). Within these 1533 hospices, only 11.4% of patients used CHC. Patients who were white, had cancer, and had more comorbidities were more likely to use CHC. In multivariable models, compared with patients who did not use CHC, patients who used CHC were less likely to have hospice disenrollment (adjusted odds ratio 0.21; 95% CI 0.19, 0.23) and less likely to be hospitalized after hospice enrollment (adjusted odds ratio 0.37; 95% CI 0.34, 0.40).Although a minority of patients uses CHC, such services may be protective against hospice disenrollment and hospitalization after hospice enrollment.

Ethiopia implemented an innovative community-based health program, called the health extension program, to enhance access to basic health promotion, disease prevention and selected curative services by establishing health posts in every village, also called kebeles, with average of 5000 people, staffed with two health extension workers (HEWs). This time and motion study was done to estimate the amount of time that HEWs spend on various work duties and to explore differences in urban compared with rural settings and among regions. A total of 44 HEWs were observed for 21 consecutive days, and time and motion data were collected using tablet computers. On average, HEWs were on duty for 15.5 days out of the 21 days of observation period, and on average, they stayed on duty for about 6 hours per day. Out of the total observed work time, the percentages of total time spent on various activities were as follows: providing health education or services (12.8%); participating in meetings and giving trainings (9.3%); conducting community mapping and mobilization (0.8%); recordkeeping, reporting, managing family folders (13.2%); managing commodities and supplies (1.3%); receiving supervision (3.2%); receiving training (1.6%); travel between work activities (15.5%); waiting for clients in the health post (or health centre in urban settings) (24.9%); building relationships in the community (13.3%); and other activities that could not be meaningfully categorized (4%). The proportion of time spent on different activities and the total time worked varied significantly between rural and urban areas and among the regions (at P < 0.05). Findings of this study indicate that only a minority of HEW time is spent on providing health education and services, and substantial time is spent waiting for clients. The efficiency of the HEW model may be improved by creating more demand for services or by redesigning service delivery modalities.

We summarized the recently published, peer-reviewed literature that examined the impact of investments in social services or investments in integrated models of health care and social services on health outcomes and health care spending. Of 39 articles that met criteria for inclusion in the review, 32 (82%) reported some significant positive effects on either health outcomes (N = 20), health care costs (N = 5), or both (N = 7). Of the remaining 7 (18%) studies, 3 had non-significant results, 2 had mixed results, and 2 had negative results in which the interventions were associated with poorer health outcomes. Our analysis of the literature indicates that several interventions in the areas of housing, income support, nutrition support, and care coordination and community outreach have had positive impact in terms of health improvements or health care spending reductions. These interventions may be of interest to health care policymakers and practitioners seeking to leverage social services to improve health or reduce costs. Further testing of models that achieve better outcomes at less cost is needed.

Maternal and neonatal mortality remains high in low- and middle-income countries, with poor quality of intrapartum care as a barrier to further progress.We developed and tested a method of measuring the quality of maternal and neonatal care that could be embedded in a larger national performance management initiative. The tool used direct observations and medical record reviews to score quality in nine domains of intrapartum care. We piloted and evaluated the tool in visits to the 18 lead hospitals that have responsibility to promote and coordinate quality improvement efforts within a hospital cluster in Ethiopia. Between baseline and follow-up assessments, staff from a national quality collaborative alliance provided hospital-based training on labour and delivery services.Ethiopia has invested in hospital quality improvement for more than a decade and this tool was integrated into existing quality improvement mechanisms within lead hospitals, with the potential for scale-up to all government hospitals.Significant improvements in quality of intrapartum care were detected from baseline (June-July 2015) to follow-up (February-March 2016) in targeted hospitals. The overall mean quality score rose from 65.6 (standard deviation, SD: 10.5) to 91.2 (SD: 12.4) out of 110 items (The method was feasible, requiring a total of 3 days and two to three trained data collectors per hospital visit. It produced data that detected substantial changes made during 8 months of national hospital quality improvement efforts. With additional replication studies, this tool may be useful in other low- and middle-income countries.La mortalité maternelle et la mortalité néonatale restent élevées dans les pays à revenu faible et intermédiaire, où la qualité insuffisante des soins pratiqués pendant l'accouchement constitue un frein à la progression dans ce domaine.Nous avons conçu et testé une méthode pour évaluer la qualité des soins dispensés aux mères et aux nouveau-nés, qui pourrait être intégrée à une initiative nationale de gestion des performances de plus grande envergure. Grâce à des observations directes et à l'examen des registres médicaux, notre outil a permis d'attribuer un score de qualité dans neuf domaines de soins intrapartum. Nous avons appliqué et testé notre outil dans le cadre de la visite des 18 hôpitaux principaux ayant chacun la responsabilité de promouvoir et de coordonner les efforts d'amélioration de la qualité au sein d'un groupement d'hôpitaux en Éthiopie. Entre les évaluations de départ et les évaluations ultérieures de suivi, le personnel d'une alliance nationale de collaboration pour la qualité a dispensé des formations dans les hôpitaux sur les services réalisés pendant le travail et l'accouchement.L'Éthiopie investit dans l'amélioration de la qualité de ses hôpitaux depuis plus de dix ans, et cet outil a été intégré aux mécanismes existants d'amélioration de la qualité de ces hôpitaux principaux, avec la perspective de l'étendre éventuellement à tous les hôpitaux gouvernementaux.Des améliorations considérables de la qualité des soins intrapartum ont été constatées entre les données initiales (juin à juillet 2015) et les données de suivi (février à mars 2016) dans les hôpitaux ciblés. Le score global moyen de la qualité est passé de 65,6 (écart type, ET: 10,5) à 91,2 (ET: 12,4) pour les 110 éléments évalués (La méthode était réalisable, nécessitant pour chaque visite trois jours et entre deux et trois collecteurs de données expérimentés. Elle a permis d'obtenir des données reflétant les changements importants survenus en huit mois d'efforts d'amélioration de la qualité des hôpitaux nationaux. Moyennant des études de réitération complémentaires, cet outil pourrait être utile dans d'autres régions à revenu faible et intermédiaire.La mortalidad materna y neonatal sigue siendo alta en países con ingresos bajos y medios, siendo la escasa calidad de atención durante el parto un impedimento para hacer progresos.Se desarrolló y probó un método de cálculo de la calidad de la atención materna y neonatal que podría aplicarse en una gran iniciativa nacional de gestión del rendimiento. La herramienta utilizó observaciones directas y revisiones de historiales médicos para puntuar la calidad en nueve dominios de atención durante el parto. La herramienta se pilotó y evaluó en visitas a los 18 hospitales más importantes con responsabilidad para fomentar y coordinar esfuerzos de mejora de la calidad de un conglomerado de hospitales en Etiopía. Entre las primeras evaluaciones y las de seguimiento, el personal de una colaboración nacional de calidad proporcionó formación hospitalaria sobre el parto.Etiopía ha invertido en mejoras de la calidad de los hospitales durante más de una década y esta herramienta se ha integrado a los mecanismos existentes de mejora de la calidad en los hospitales más importantes, con potencial para llegar a todos los hospitales públicos.Se detectaron mejoras significativas en la calidad de la atención durante el parto desde el principio (junio-julio de 2015) hasta el seguimiento (febrero-marzo de 2016) en los hospitales estudiados. La calidad media general obtuvo una puntuación de 65,6 (desviación estándar, DE: 10,5) a 91,2 (DE: 12,4) de 110 elementos (El método fue viable, necesitando un total de tres días y de dos a tres recopiladores de datos con formación por visita hospitalaria. Se generaron datos que detectaron grandes cambios durante los ocho meses de trabajos de mejora de la calidad de los hospitales. Con otros estudios de reproducción, esta herramienta podría resultar útil en otros países con ingresos bajos y medios.لا يزال معدل وفيات الأمهات وحديثي الولادة مرتفعًا في البلدان المنخفضة والمتوسطة الدخل، بالإضافة إلى ضعف الجودة النوعية للرعاية أثناء الولادة والتي تمثل عائقًا أمام إحراز المزيد من التقدم.قمنا بتطوير واختبار طريقة لقياس الجودة النوعية لرعاية الأمهات وحديثي الولادة يمكن إدماجها في مبادرة وطنية أكبر لإدارة الأداءلقد استثمرت إثيوبيا في تحسين الجودة النوعية للمستشفيات على مدار أكثر من عقد من الزمان، وتم دمج هذه الأداة في آليات تحسين الجودة القائمة داخل المستشفيات الرائدة، مع إمكانية التوسع في جميع المستشفيات الحكومية.تم الكشف عن تحسينات كبيرة في الجودة النوعية للرعاية أثناء الولادة من خط الأساس (يونيه/حزيران – يوليو/تموز 2015) إلى المتابعة (فبراير/شباط – مارس/آذار 2016) في المستشفيات المستهدفة. وارتفع المتوسط العام لنتيجة الجودة النوعية من 65.6 (الانحراف المعياري: 10.5) إلى 91.2 (الانحراف المعياري: 12.4) من بين 110 عناصر (أثبتت الطريقة جدواها، حيث تتطلب الأمر 3 أيام في المجمل، وما بين 2 إلى 3 جامعي بيانات مدربين في كل زيارة إلى المستشفى. وأنتجت الطريقة بيانات كشفت عن التغييرات الجوهرية التي أُجريت خلال 8 أشهر من الجهود الوطنية لتحسين الجودة النوعية في المستشفيات. ومع دراسات النسخ المتماثل، قد تكون هذه الأداة مفيدة في البلدان الأخرى ذات الدخل المنخفض والمتوسط.由于分娩护理质量较差、阻碍进一步发展，导致中低收入国家的孕产妇及新生儿死亡率仍然居高不下。.我们制定并测试了一个衡量孕产妇及新生儿护理质量的方法，该方法可被纳入大型国家绩效管理举措中。该方法采用直接观察与医疗记录审查对九大分娩护理领域的质量进行评分。我们通过拜访 18 家负责在埃塞俄比亚医院集群内部推进并协调质量改进工作的领头医院，试行并评估了该方法。在基础评估至后续评估期间，由国家质量协作组的工作人员提供与产程及分娩服务相关的院内培训。.埃塞俄比亚已投资医院质量改进十余年，且此方法已整合入领头医院的现有质量改进机制，并可能推广至所有政府医院。.我们发现目标医院在基础评估（2015 年 6-7 月）至后续评估（2016 年 2-3 月）期间的分娩护理质量有显著改进。平均质量总分由 65.6（标准偏差，SD： 10.5）上升至 91.2 (SD： 12.4)，评估项共计 110 项 (该方法具有可行性，每次医院访问共计需要 3 天及两至三名经过培训的数据采集员。该方法能够提供监测为期 8 个月的国家医院质量改进工作中所取得的重大变化的数据。通过其它重复性研究，此方法在其它中低收入国家可能会有使用价值。.Материнская и неонатальная смертность в странах с низким и средним уровнем доходов остается высокой, а низкое качество интранатального медицинского обслуживания препятствует дальнейшему прогрессу.Мы разработали и опробовали метод измерения качества медицинского обслуживания для матерей и новорожденных, который можно было бы включить в более масштабную инициативу по управлению эффективностью деятельности на национальном уровне. В качестве инструмента использовались прямые наблюдения и обзоры медицинской документации для оценки качества в девяти областях интранатального медицинского обслуживания. Мы опробовали и оценили этот инструмент при посещении 18 ведущих больниц, которые отвечают за продвижение и координацию мероприятий по повышению качества медицинского обслуживания в кластере больниц в Эфиопии. В период между исходными и последующими оценками сотрудники национального сотрудничества в области качества предоставляли обучение на базе больниц по вопросам родовспоможения.Эфиопия в течение более чем десяти лет осуществляла инвестиции с целью повышения качества медицинского обслуживания в больницах, и этот инструмент был интегрирован в существующие механизмы повышения качества обслуживания в ведущих больницах с возможностью расширения масштабов до применения во всех государственных больницах.Значительные улучшения качества интранатального медицинского обслуживания были выявлены в целевых больницах при сравнении исходных показателей (июнь-июль 2015 г.) и последующих оценок (февраль-март 2016 г.). Общий средний показатель качества вырос с 65,6 (стандартное отклонение, СО: 10,5) до 91,2 (СО: 12,4) из 110 пунктов (Для применения этого метода требовалось в общей сложности три дня и от двух до трех подготовленных специалистов по сбору данных на одно посещение больницы. С помощью этого метода были получены данные, свидетельствующие о существенных изменениях, произошедших в течение 8 месяцев в ходе мероприятий по повышению качества медицинского обслуживания в больницах. При проведении повторных исследований было продемонстрировано, что этот инструмент может быть полезен в других странах с низким и средним уровнем дохода.

Despite increased hospice use over the last decade, end-of-life care intensity continues to increase. To understand this puzzle, we sought to examine regional variation in intensive end-of-life care and determine its associations with hospice use patterns.Using Medicare claims for decedents aged 66 years and above in 2011, we assessed end-of-life care intensity in the last 6 months of life across hospital referral regions (HRRs) as measured by proportion of decedents per HRR experiencing hospitalization, emergency department use, intensive care unit (ICU) admission, and number of days spent in hospital (hospital-days) and ICU (ICU-days). Using hierarchical generalized linear models and adjusting for patient characteristics, we examined whether these measures were associated with overall hospice use, very short (≤7 d), medium (8-179 d), or very long (≥180 d) hospice enrollment, focusing on very short stay.End-of-life care intensity and hospice use patterns varied substantially across HRRs. Regional-level end-of-life care intensity was positively correlated with very short hospice enrollment. Comparing HRRs in the highest versus the lowest quintiles of intensity in end-of-life care, regions with more intensive care had higher rates of very short hospice enrollment, with adjusted odds ratios (AOR) 1.14 [99% confidence interval (CI), 1.04-1.25] for hospitalization; AOR, 1.23 (CI, 1.12-1.36) for emergency department use; AOR, 1.25 (CI, 1.14-1.38) for ICU admission; AOR, 1.10 (CI, 1.00-1.21) for hospital-days; and AOR, 1.20 (CI, 1.08-1.32) for ICU-days.At the regional level, increased end-of-life care intensity was consistently associated with very short hospice use.