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biBackground:/i/bDespite substantial palliative care (PC) needs in people with serious illnesses other than cancer, outpatient PC is less available to these populations.biObjectives:/i/bDescribe the experience, impact, and lessons learned from implementing an outpatient PC service (OPCS) for people with noncancer illnesses.biDesign:/i/bObservational cohort study.biSetting/Subjects:/i/bPatients seen by an OPCS at a United States academic medical center October 2, 2017-March 31, 2021.biMeasurements:/i/bPatient demographics and clinical characteristics, care processes, rates of advance care planning (ACP), and health care utilization.biResults:/i/bDuring the study period, 736 patients were seen. Mean age was 66.7 years, 47.7% were women, and 61.4% were White. Nearly half (44.9%) had a neurologic diagnosis, 19.2% pulmonary, and 11.0% cardiovascular. Patients were most often referred for symptoms other than pain (62.2%), ACP (60.2%), and support for patient/family (48.2%). Three-quarters (74.1%) of visits occurred by video. A PC physician, nurse, social worker, and spiritual care provider addressed nonpain symptoms (for 79.2%), family caregiver needs (70.0%), psychosocial distress (69.9%), ACP (68.8%), care coordination (66.8%), pain (38.2%), and spiritual concerns (27.8%). Rates of advance directives increased from 24.6% to 31.8% (ip/i lt; 0.001) and Physician Orders for Life-Sustaining Treatment forms from 15.6% to 27.3% (ip/i lt; 0.001). Of 214 patients who died, 61.7% used hospice, with median hospice length-of-staygt;30 days. Comparing the six months before initiating PC to the six months after, hospitalizations decreased by 31.3% (ip/i = 0.001) and hospital days decreased by 29.8% (ip/i = 0.02).biConclusions:/i/bOutpatient PC for people with noncancer illnesses is feasible, addresses needs in multiple domains, and is associated with increased rates of ACP and decreased health care utilization. Controlled studies are warranted.

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

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

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

Background: The morbidity and mortality of interstitial lung disease (ILD) is high, despite novel therapeutics. Recognizing unmet needs for symptom management, advance care planning (ACP), and supp...

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

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

Describe the establishment of the palliative care quality network (PCQN) with guidance on how teams can develop similar collaborations.In the current healthcare environment, palliative care (PC) teams must be able to demonstrate value and provide efficient care while supporting the clinicians who provide that care.The PCQN is a national quality improvement (QI) collaborative comprised of specialty PC teams from a diverse range of hospitals across the United States Results: PCQN members identified five core activities to support PC teams. 1) Collection of standardized data: 23 core items and 22 optional data elements document patient demographics, consultation characteristics, processes of care, and clinical outcomes. 2) Data analyses with benchmarking including reports generated in real time providing summary, trend, member comparison, and cross-tab analyses. 3) QI collaborative; QI initiatives have addressed pain management, surrogate decision-making, spiritual screening, and anxiety assessment. 4) Education and personal development provided through monthly conference calls, a listserv, PCQN website, and twice-yearly conferences. 5) Financial analysis; a software program enables PC teams to calculate the financial impact of the care provided.The central tenet of the PCQN is to improve quality of care for patients with serious illness and their families, increase the efficient use of healthcare resources, and support growth and sustainability of PC programs. Building and tending to this community takes time to ensure engagement of all members and remain responsive to evolving needs of patients, families, PC teams, and stakeholders.

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

Background: People with heart failure (HF) have high morbidity and mortality and may benefit from palliative care (PC). Objective: To pilot a randomized, clinical trial of a PC interventio...

The objective of this study is to describe preferences of patients with heart failure (HF) for having advance care planning (ACP) discussions with clinicians and to identify characteristics associated with those preferences.National guidelines call for having ACP discussions with patients with serious illnesses such as HF. Many patients with HF do not discuss ACP with their physician despite wanting to have them.We conducted a cross-sectional cohort study between July 2007 and November 2009 within HF clinics affiliated with a large, urban, academic medical center. Patients with New York Heart Association HF classes II and III were surveyed about whether they had or would like to have discussions with their clinician about what to expect in the future regarding their HF, prognosis, ACP, and their surrogate choice.Patients (n = 104) were on average 53 years old (standard deviation = 14.3; range: 21-84) and had Class II (57%) or Class III (43%) HF. Most patients had discussed what to expect in the future regarding HF (76.5%, 78/102), prognosis (68.0%, 68/100), surrogate choice (90.3%, 93/103), and ACP (46.5%, 47/101). Most of those who did not have these discussions would have liked to discuss expectations regarding their HF (87.5%, 21/24), prognosis (80.6%, 25/31), and ACP (59.6%, 31/52). Men were more likely than women to report having had discussions about their HF (83.6% vs. 62.9%; p = 0.02), prognosis (78.5% vs. 48.6%; p = 0.002), and ACP (56.1% vs. 28.6%; p = 0.01). On average younger patients were more likely to report having discussed what to expect regarding their HF (50 years vs. 59 years; p = 0.007), and to be asked about their spirituality (43 years vs. 56 years; p = 0.0001).Conforming to national guidelines, most patients with HF have discussed ACP with clinicians and most of those who have not, want to. Findings should embolden clinicians to routinely discuss ACP.

Describe the etiology of pain among HF patients and examine the relationship between pain and QoL.Little is known about the etiology of pain in patients with heart failure (HF) and the impact it has on quality of life (QoL).A prospective cohort study of outpatients with NYHA Class II or III HF were surveyed at baseline and at three-month follow-up. The study was conducted in Heart Failure clinics affiliated with a large, urban, academic medical center.Of 104 patients that completed a baseline survey, 73 (70%) completed a follow-up survey. At baseline, 48% of patients reported having pain the previous week. Patients on prescription pain medication (n = 16) had more severe pain (Mean = 4.5 vs. 2.6; p = 0.001). Physician documented pain etiologies included: musculoskeletal (50%, n = 16), cardiac (22%, n = 7), and headache/neurological (22%, n = 7). Linear regression revealed that significant contributions to QoL included HF Class (p = 0.0001), dyspnea (p = 0.0001), and depression (p = 0.01). Pain was not independently associated with QoL (p = 0.17), but moderately correlated with depression (r = 0.49). Although 15% (n = 11) of patients reported a clinically meaningful improvement in pain scores, it was not associated with improvements in QoL (χPain is prevalent and persistent, due largely to non-cardiac causes. Although pain did not predict QOL, it was associated with depression, which did adversely affect QoL. Clinicians should screen for and treat both symptoms.

The number of palliative care consultation services is growing, yet little is known about how program characteristics change over time.Compare changes in the characteristics of palliative care programs and palliative care consultation services in 2007 and 2011.We surveyed all hospitals in California in 2011 and compared palliative care program and palliative care consultation service characteristics with survey results from 2007.There were 41 new palliative care programs since 2007; 17 programs closed between 2007 and 2011. Hospital characteristics associated with the closure of a palliative care program included a hospital size of 1-149 beds versus 150 or more (p=0.03), for-profit status (p=0.001), and having no system affiliation (p=0.0001). The prevalence of palliative care consultation services was 33% in 2007 and 37% in 2011 (p=0.3). At both time periods nearly all palliative care consultation services (98%) were available onsite during weekday business hours and only half were available at other times (p=0.4). There was an increase (p=0.002) in nurse/physician full-time equivalent (FTE; 2007, mean=1.5; 95% confidence interval [CI]=1.3-1.7; 2011, mean=1.9; 95% CI=1.6-2.2) but fewer teams reported having social workers (58% versus 80%, p=0.002) and chaplains (58% versus 77%, p=0.0001) in 2011. Over half of the palliative care consultation services reported seeing less than 50% of patients who would benefit from a consultation (2007: 59%, 2011=50%, p=0.2), yet most also reported struggling to cope with patient volume (2007: 62%; 2011: 66%, p=0.5).Fewer than half of hospitals in California offer a palliative care program and many close over time. Making palliative care consultation services a condition of participation by insurers could make hospital palliative care consultation services universal. Mechanisms need to be established to improve staffing levels, maintain the interdisciplinary nature of palliative care consultation services, and accommodate demand for services.

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

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

The American Academy of Pediatrics recommends that palliative care be available to seriously ill hospitalized children, yet little is known about how these services are structured.The study's aim is to report the prevalence of pediatric palliative care services (PCS) and compare the structure of pediatric PCS to adult PCS within California hospitals.We surveyed 377 hospitals to assess the prevalence, structure, and characteristics of pediatric and adult PCS. Hospitals were categorized as children's hospitals with a pediatric-only PCS, mixed hospitals with pediatric and adult PCS, and hospitals with adult-only PCS.All 8 children's hospitals in the state reported having a pediatric PCS, and 36 pediatric PCSs were in mixed hospitals. Mixed hospitals saw fewer (p=0.0001) children per year (mean=5.6, standard deviation [SD]=3.6) than pediatric-only PCSs (mean=168, SD=73). Pediatric-only PCSs treated more patients for noncancer-related illness (82.5%) than pediatric PCSs in mixed hospitals (34.5%, p=0.03) or adult-only PCSs (52.4%, p=0.001). All PCSs were universally available (100%) during weekday business hours and half were available during weekend business hours. Pediatric-only PCSs had a mean total full-time equivalent (FTE) of 1.9, which was not significantly different (p=0.3) from the total FTE for pediatric PCSs in mixed hospitals (mean=1.1, SD=1.4) or for adult-only PCSs (mean=2.7, SD=2.0). However, in mixed hospitals the adult PCS had a significantly higher (p=0.005) total FTE (mean=2.4, SD=1.3) than the pediatric PCS (mean=1.1, SD=1.4).All children's hospital and a few mixed hospitals offer pediatric PCS. Better understanding of the palliative care needs of seriously ill children in mixed hospitals and assessment of the quality of care provided will help ensure that children seen in these hospitals receive necessary care.

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

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

Although hospital palliative care consultation services (PCCS) can improve a variety of clinical and nonclinical outcomes, little is known about how these services are structured.We surveyed all 351 acute care hospitals in California to examine the structure and characteristics of those hospitals with PCCS.We achieved a 92% response rate. Thirty-one percent (n=107) of hospitals reported having a PCCS. Teams commonly included physicians (87%), social workers (80%), spiritual care professionals (77%), and registered nurses (71%). Nearly all PCCS were available on-site during weekday business hours; 50% were available on-site or by phone in the weekday evenings and 54% were available during weekend daytime hours. The PCCS saw an average of 347 patients annually (median=310, standard deviation [SD]=217), or 258 patients per clinical full-time equivalent (FTE; median=250, SD=150.3). Overall, 60% of consultation services reported they are struggling to cope with the workload. On average, patients were in the hospital 5.9 days (median=5.5, SD=3.3) prior to referral to PCCS, and remained in the hospital for 6 days (median=4, SD=7.9) following the initial consultation. Patient and family meetings were an aspect of the consultation in 74% of cases. Overall, 21% of consultation patients were discharged home with hospice services and 25% died in the hospital.There is variation in how PCCS in California hospitals are structured and in the ways they engage with patients. Ultimately, linking PCCS characteristics and practices to patient and family outcomes will identify best practices that PCCS can use to maximize quality.

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

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

than three days enrolled in hospice before death. Palliative care was involved a median of 5.5 days prior to death. Conclusions. Palliative care services are grossly underutilized for our HIV-infected population despite the large symptom burden these patients suffer and high mortality rate. Implications for research, policy, or practice. Further efforts should be made to integrate palliative care services earlier for this complex patient population.

Objectives 1. Compare changes in staffing, availability, and patient volume of palliative care consultation services between 2007 and 2011. 2. To discuss aspects of palliative care consultation services that have improved or not improved between the two study periods. Background. The number of palliative care consultation services (PCCS) is growing, yet little is known about how program structure and characteristics change over time. Research Objectives. Compare changes in availability, staffing, and patient volume among palliative care consultation services (PCCS) in California hospitals from 2007 to 2011. Method. We surveyed all acute care hospitals in California regarding PCCS in 2007 and 2011. Result. Response rates were 92% (324/351) in 2007 and 96% (361/377) in 2011. There were 26 additional PCCS in 2011 (133) vs. 2007 (107) but no change (p 1⁄4 .4) in overall prevalence: 33% in 2007 vs. 36% in 2011. At both time periods the majority of PCCS (98%) were available onsite during weekday business hours and only half were available during weekend daytime hours (p 1⁄4 .4). There was an increase (p 1⁄4 .002) in nurse/physician FTE (2007: mean 1⁄4 1.5; 95% CI 1⁄4 1.3, 1.7; 2011: mean 1⁄4 1.9, 95% CI1⁄41.6, 2.2), and no change (p 1⁄4 .8) in the number of patients seen per nurse/physician FTE in 2007 (mean1⁄4258, 95% CI1⁄4223,293) and 2011 (mean 1⁄4 265, 95% CI 1⁄4 229,300). Half of PCCS reported seeing fewer than half of patients who would benefit from a consultation (2007 1⁄4 59%, 2011 1⁄4 50%, p 1⁄4 .2), yet the majority also reported struggling to cope with patient volume (2007: 62%; 2011: 66%, p1⁄4 .5). In both surveys, the number of patients per nurse/physician FTE was higher (p 1⁄4 .005) for teams struggling to cope (mean 1⁄4 290, 95% CI 1⁄4 260, 321) compared to those that were not (mean 1⁄4 215, 95% CI 1⁄4 170,260). Conclusion. Despite increased staffing, still only a minority of PCCS have 24/7 availability and most report struggling to cope despite seeing fewer than half of appropriate patients. Implications for Research, Policy, or Practice. Increased staffing is needed to allow hospital PCCS to adequately meet patient needs.

from the ED the prior year; during the pilot there were 163. Physical presence of the PC doctor in the ED was an important factor in generating consults. Implications for research, policy, or practice. Preliminary data suggests that beginning a PC specialist in the ED is likely to bring a variety of benefits to patients, families, ED staff, and the hospital. Further research is warranted and is currently in the planning stages.