Search

Palliative care has been one of the most rapidly growing fields of health care in the United States in the past decade. The benefits of palliative care have now been shown in multiple clinical trials, with increased patient and provider satisfaction, equal or better symptom control, more discernment of and honoring choices about place of death, fewer and less intensive hospital admissions in the last month of life, less anxiety and depression, less caregiver distress, and cost savings. The cost savings come from cost avoidance, or movement of a patient from a high cost setting to a lower cost setting. Barriers to expanded use include physician resistance, unrealistic expectations of patients and families, and lack of workforce. The future of palliative care includes more penetration into other fields such as nephrology, neurology, and surgery; further discernment of the most effective and cost-effective models; and establishment of more outpatient services. [ABSTRACT FROM AUTHOR]

Summary: Background: Evidence-based guidelines recommend chemotherapy for medically fit patients with stages II–IV non-small cell lung cancer (NSCLC). Adherence to chemotherapy guidelines has rarely been studied among large populations, mainly because performance status (PS), a key component in assessing chemotherapy appropriateness, is missing from claims-based datasets. Among a large cohort of patients with known PS, we describe first line chemotherapy use relative to guideline recommendations and identify patient factors associated with guideline concordant use. Patients and methods: Insured patients, ages 50+, with stages II–IV NSCLC between 2000 and 2007 were identified via tumor registry (n =406). Chart abstracted PS, automated medical claims, Census tract information, and travel distance were linked to tumor registry data. Chemotherapy was considered appropriate for patients with PS 0–2. Multivariate logit models were fit to evaluate patient characteristics associated with chemotherapy over- and under-use per guideline recommendations. Tests of statistical significance were two sided. Results: Overall compliance with first line chemotherapy guidelines was 71%. Significant (p <0.05) predictors of chemotherapy underuse (19%) included increasing age (odds ratio [OR], 1.09), higher income (OR, 1.02), diagnosed before 2003 (OR, 2.05), and vehicle access (OR, 6.96) in the patient''s neighborhood. Significant predictors of chemotherapy overuse (10%) included decreasing age (OR, 0.92), diagnosed after 2003 (OR, 3.24), and higher income (OR, 1.05) in the patient''s neighborhood. Among NSCLC patients 29% do not receive guideline recommended chemotherapy treatment missing opportunities for cure or beneficial palliation, or receiving chemotherapy with more risk of harm than benefit. Care concordant with guidelines is influenced by age, economic considerations such as income and transportation barriers. [ABSTRACT FROM AUTHOR]

Describes the approach of the American Society of Clinical Oncology (ASC0) in improving the care for cancer patients. Facts on end-of-life issues in the United States; Mission of ASCO; Information on the educational programs of ASCO; Features of the ASCO End of Life Program; Impact of managed care on end of life decisions.

Objective: Social adjustment, including alcohol use, directly affects the success of college students. Due to an increased reliance on computer-delivered alcohol interventions (CDIs) a need has emerged to further investigate alcohol use and web-based interventions. Methods: In-depth focus group interviews were conducted with 51 undergraduate students to elicit information from students on the shared experience of participating in a CDI. Results: Participants identified the influence of gender, culture, parents, and family on alcohol use behavior. A difference in personal factors, previous exposure, and experiences can affect the attitudes, behaviors, and outcomes of a CDI. Conclusion: Multiple approaches geared towards a wide variety of students from different backgrounds and environments are needed to be truly successful in preventing alcohol misuse. [ABSTRACT FROM AUTHOR]

Editorial. References a study in the same issue by Begg et al which contributes data on factors associated with outcomes for patients undergoing major cancer surgery. Patient mortality; Essential data elements needed to identify superior or inferior cancer care; Discussion of process-outcome relationships; The volume-outcome association reported by Begg et al.

The article presents three clinical, economic and political cases focused on data in patients with advanced cancer to show the value of earlier specialty palliative care. Data are used to propose initial priorities for clinicians and policymakers to achieve early integration of palliative care across all populations with serious illness. Improved public and professional awareness of the benefits of palliative care and coordinated action from health professionals and educators is stressed.

Background: Approximately 510 of all cancers and cardiovascular diseases have a significant genetic component. Of the 15 most frequent admission diagnoses for palliative care, at least one third have a significant genetic component which is testable, informative, and potentially life saving to the survivors. Once the patient has died, the chance to test or bank DNA for common inherited conditions such as breast cancer, colon cancer, cardiovascular disease, etc., is gone. Objective: To determine the frequency of genetic conditions for commonly seen palliative care conditions, the availability of testing or DNA banking for future testing, and how genetics assessment is helpful. Design: A case illustration and review of the currently published evidence. Results: Genetic testing fits the accepted model of family-centered palliative care, is ethical, and may lead to life-saving interventions. Risk assessment tools and helpful websites are available. Conclusions: While common genetic conditions should be recognized before end-of-life care, the palliative care health professional may be the only person to recognize the condition before death of the patient and loss of available DNA. [ABSTRACT FROM AUTHOR]

Context: Little attention has been given to social environmental factors associated with advance care planning (ACP) among African Americans or people living with advanced HIV (PLHIV).Objectives: The present study aimed to identify support network factors that affect the likelihood of naming a decision-maker and of talking to family/friends and doctors about ACP among vulnerable PLHIV.Methods: PLHIV were recruited from a large urban HIV clinic. A social support network inventory was used to calculate number of persons available for various types of support. Characteristics of network members were also collected. Multivariable logistic regression models were fit to examine associations between social network factors and ACP discussion, adjusting for age, sex, education, and total number of network members.Results: The sample (N = 370) was mostly African American (95%), male (56%), and 48% had less than a high school education. Almost half the sample (48%) had talked to their family/friends or doctor about ACP, and 34% had named a medical decision-maker. Adjusted analysis revealed that talking about ACP with family/friends was associated with female sex and a larger closer support network who provided health information and physical assistance. Talking to doctors about ACP was associated with larger support networks who provided physical assistance but lower numbers from whom emotional support was received. Naming a decision-maker was associated with greater numbers of network members who provided emotional support, health information, and medication adherence reminders.Conclusion: The findings revealed aspects of family/support network structures and caregiving function associated with ACP in a population with often vital yet vulnerable networks. [ABSTRACT FROM AUTHOR]

Background: Preoperative advance care planning (ACP) may benefit patients undergoing major surgery. Objective: To evaluate feasibility, safety, and early effectiveness of video-based ACP in a surgical population. Design: Randomized controlled trial with two study arms. Setting: Single, academic, inner-city tertiary care hospital. Subjects: Patients undergoing major cancer surgery were recruited from nine surgical clinics. Of 106 consecutive potential participants, 103 were eligible and 92 enrolled. Interventions: In the intervention arm, patients viewed an ACP video developed by patients, surgeons, palliative care clinicians, and other stakeholders. In the control arm, patients viewed an informational video about the hospital's surgical program. Measurements: Primary Outcomes—ACP content and patient-centeredness in patient–surgeon preoperative conversation. Secondary outcomes—patient Hospital Anxiety and Depression Scale (HADS) score; patient goals of care; patient and surgeon satisfaction; video helpfulness; and medical decision maker designation. Results: Ninety-two patients (target enrollment: 90) were enrolled. The ACP video was successfully integrated with no harm noted. Patient-centeredness was unchanged (incidence rate ratio [IRR] = 1.06, confidence interval [0.87–1.3], p = 0.545), although there were more ACP discussions in the intervention arm (23% intervention vs. 10% control, p = 0.18). While slightly underpowered, study results did not signal that further enrollment would have yielded statistical significance. There were no differences in secondary outcomes other than the intervention video was more helpful (p = 0.007). Conclusions: The ACP video was successfully integrated into surgical care without harm and was thought to be helpful, although video content did not significantly change the ACP content or patient–surgeon communication. Future studies could increase the ACP dose through modifying video content and/or who presents ACP. Trial Registration: clinicaltrials.gov Identifier NCT02489799. [ABSTRACT FROM AUTHOR]

Background: Studies report cost-savings from hospital-based palliative care consultation teams compared to usual care only, but drivers of observed differences are unclear. Aim: To analyse cost-differences associated with palliative care consultation teams using two research questions: (Q1) What is the association between early palliative care consultation team intervention, and intensity of services and length of stay, compared to usual care only? (Q2) What is the association between early palliative care consultation team intervention and day-to-day hospital costs, compared to a later intervention?. Design: Prospective multi-site cohort study (2007-2011). Patients who received a consultation were placed in the intervention group, those who did not in the comparison group. Intervention group was stratified by timing, and groups were matched using propensity scores. Setting/participants: Adults admitted to three US hospitals with advanced cancer. Principle analytic sample contains 863 patients (nUC = 637; nPC EARLY = 177; nPC LATE = 49) discharged alive. Results: Cost-savings from early palliative care accrue due to both reduced length of stay and reduced intensity of treatment, with an estimated 63% of savings associated with shorter length of stay. A reduction in day-to-day costs is observable in the days immediately following initial consult but does not persist indefinitely. A comparison of early and late palliative care consultation team cost-effects shows negligible difference once the intervention is administered. Conclusion: Reduced length of stay is the biggest driver of cost-saving from early consultation for patients with advanced cancer. Patient- and family-centred discussions on goals of care and transition planning initiated by palliative care consultation teams may be at least as important in driving cost-savings as the reduction of unnecessary tests and pharmaceuticals identified by previous studies. [ABSTRACT FROM AUTHOR]

Specialist palliative care (PC) often embraces a "less is more" philosophy that runs counter to the revenue-centric nature of most health care financing in the U.S. A special business case is needed in which the financial benefits for organizations such as hospitals and payers are aligned with the demonstrable clinical benefits for patients. Based on published studies and our work with PC programs over the past 15 years, we identified 10 principles that together form a business model for specialist PC. These principles are relatively well established for inpatient PC but are only now emerging for community-based PC. Three developments that are key for the latter are the increasing penalties from payers for overutilization of hospital stays, the variety of alternative payment models such as accountable care organizations, which foster a population health management perspective, and payer-provider partnerships that allow for greater access to and funding of community-based PC. [ABSTRACT FROM AUTHOR]

Purpose This study evaluates outcomes and patterns of care among patients receiving radiation therapy (RT) for bone metastases at a high-volume academic institution. Methods and Materials Records of all patients whose final RT course was for bone metastases from April 2007 to July 2012 were identified from electronic medical records. Chart review yielded demographic and clinical data. Rates of complicated versus uncomplicated bone metastases were not analyzed. Results We identified 339 patients whose final RT course was for bone metastases. Of these, 52.2% were male; median age was 65 years old. The most common primary was non-small-cell lung cancer (29%). Most patients (83%) were prescribed ≤10 fractions; 8% received single-fraction RT. Most patients (52%) had a documented goals of care (GOC) discussion with their radiation oncologist; hospice referral rates were higher when patients had such discussions (66% with vs 50% without GOC discussion, P=.004). Median life expectancy after RT was 96 days. Median survival after RT was shorter based on inpatient as opposed to outpatient status at the time of consultation (35 vs 136 days, respectively, P<.001). Hospice referrals occurred for 56% of patients, with a median interval between completion of RT and hospice referral of 29 days and a median hospice stay of 22 days. Conclusions These data document excellent adherence to American Society for Radiation Oncolology Choosing Wisely recommendation to avoid routinely using >10 fractions of palliative RT for bone metastasis. Nonetheless, single-fraction RT remains relatively uncommon. Participating in GOC discussions with a radiation oncologist is associated with higher rates of hospice referral. Inpatient status at consultation is associated with short survival. [ABSTRACT FROM AUTHOR]

The author discusses aspects of palliative care specialists in oncology. There are three types of palliative care namely primary, secondary, and tertiary palliative care. It advices as to how to do palliative care in office and states that one should always do a symptom and spiritual assessment. It also gives different advices for patients who have less than a year to live and those who still have three to six months to live. It also gives advantages of decision aids and provides conclusions.

This study uses focus group methodology to examine supportive and unsupportive responses experienced by African American and Caucasian cancer patients. Supportive responses included practical assistance, as well as people's willingness to listen, maintain a positive attitude, and pray. Unsupportive responses included others' withdrawal behaviors, patients having to support friends/family as they coped, and family/friends limiting patients' independence. Results reflect ways in which mental health providers, social workers, and health care providers can help patients express support needs, as well as how social networks can be better educated about the types of support valued by patients. [ABSTRACT FROM AUTHOR]

Evidence-based outcomes are commonly used in making decisions about clinical care. For healthcare executives, evidence-based outcomes also can be useful in making decisions about hospital services. Finkler and Ward (2003) suggest a model whereby cost measurement, cost control, and value assessment can be used as nonclinical, evidence-based outcome measures to provide decision support and to guide management decisions. The Finkler and Ward framework is used to understand the financial implications of establishing an inpatient palliative care unit (PCU). A longitudinal study was conducted to examine the nonclinical outcomes associated with opening and operating an inpatient PCU at a large academic medical center during the first four years of the unit's operation. First, the cost of providing inpatient palliative care was measured. Results indicated that the cost per day to care for patients hospitalized in the last 20 days leading up to their death was significantly less on the PCU than on intensive care units and non-PCUs. Average daily total charges exceeded reimbursement on the ICU and non-PCUs, but the cost on the PCU for the same population was equal to or below the average daily total charges. Second, ways to control costs when operating an inpatient PCU were identified and measured. Evidence from one organization suggests that costs can effectively be controlled by admitting patients directly to the PCU and by appropriate use of hospital resources, including staff, ancillary services, and pharmaceuticals. Third, the study assessed the value to the institution of operating an inpatient PCU. Results indicated that the inpatient PCU yielded a cost savings of nearly $1 million by the third year of operations. This study highlights the nonclinical outcomes of one institution's inpatient PCU and provides guidelines for healthcare executives and managers to use in making decisions about adopting such programs. [ABSTRACT FROM AUTHOR]