bluuebunny/crossref_metadata_2025 huggingface dataset:
Exploring racial differences in patient centeredness of care (PCC) during breast cancer (BC) chemotherapy clinic visits.
Authors: Robertson-Jones Tinnikka Angel , Rosenzweig Margaret Quinn , Bender Catherine M. , Connolly Mary , Tissue Madison
Published: November 2017

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Background: Racial disparity in breast cancer survival may be attributed to racial differences in BC treatment dose intensity (dose received/dose prescribed within specific time frame). Poor dose intensity is associated with symptom distress among Black women. Chemotherapy associated symptoms and distress are traditionally assessed by the clinician and reported by the patient during the clinical visit. Poor communication patterns between clinician and patient that do not reflect care that is patient centered may be an important etiology of poor symptom reporting and management influencing BC racial treatment disparity. The purpose of this prospective, comparative pilot study was to qualitatively explore and code for the PCC during the chemotherapy clinical visit of women undergoing BC chemotherapy and compare by race. Methods: Dyads consisting of age-matched Black and White women were recruited. Audio recordings of clinical visits conducted prior to any chemotherapy cycle (except first) infusion were obtained and transcribed. The transcripts were reviewed blindly by two independent coders assigning scores using the Four Habits Coding Scheme, a measure of PCC which includes 23 items coded on five-point scale; lower scores indicate better PCC. Mean scores were tabulated from both coders’ scores and then compared by racial groups using t-test. Results: Matched dyads consisting of 6 Black and 5 White patients undergoing breast cancer chemotherapy were recruited from 1/15/2014 to 12/4/2014 at a 90% recruitment rate. Attrition of one black patient left groups of 5 White (mean age 45) and 5 Black (mean age 47) patients. A total of 15 recordings were analyzed for White and 14 for Black participants. All of the 23 PCC scores were better for White vs. Black women. Black women had worse scores (p < .05) for 6/22 or (27%) of the PCC scores. Conclusions: Qualitatively exploring the PCC during the chemotherapy clinical visits may elucidate reasons for racial disparity in symptom assessment, reporting, management and subsequent distress. These preliminary findings inform future research exploring racial disparity in symptom communication as an etiology of disparity in cancer treatment intensity.
Assessing caregiver satisfaction with care on an acute palliative care unit.
Authors: Mak Ernie , Murphy-Kane Patricia , Zimmermann Camilla
Published: November 2017

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Background: Accreditation Canada has adopted four main values for hospice, palliative, and end-of-life services: dignity and respect; information sharing; partnership and participation; and collaboration . These domains, as well as communication and joint decision-making, are important for satisfaction of caregivers for patients with cancer, and can be measured using the FAMCARE questionnaire. We aimed to assess satisfaction of caregivers for patient admitted to an acute palliative care unit at a comprehensive cancer center in Toronto, Canada. Methods: The FAMCARE questionnaire was administered by a trained volunteer to self-identified caregivers of patients who were admitted for more than five days on the acute palliative care unit. A short, anonymous demographic survey accompanied the FAMCARE questionnaire to gather information on relationship to patient, ethnicity, patient length of stay, and location of residence. The survey package either was completed in the presence of the volunteer, or was left to be completed by the caregiver alone and collected later by the volunteer. Results were reviewed regularly at the quality committee of the palliative care service. Results: From September 2014 to March 2017, 90 caregivers completed the questionnaire. Most caregivers were female (69%), identified as Canadian or Caucasian (57%), and lived in Toronto (63%). In all, 57% were spouses while 31% were children of the patient. Most patients had been admitted between a week and a month (67%). Care was rated as “Satisfied” or “Very satisfied” most of the time on all items (range 81-100%). The availability of nurses and doctors (100% satisfied/very satisfied) and the way tests and treatments were followed-up (99%) were rated highest. Information given about side effects (81%) and referral to specialists (83%) were rated lowest. Conclusions: Despite the nature of the acute palliative care unit, where patients admitted tend to be very ill with complex symptoms and psychosocial issues, caregiver satisfaction was high. Future research will examine whether caregivers of different ethnicities value different aspects of cancer care.
Discussions about hospice among patients with advanced cancer.
Authors: Traeger Lara , Wright Emily M. , El-Jawahri Areej , Gallagher Emily R. , Greer Joseph , Temel Jennifer S.
Published: November 2017

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Background: Timely and effective patient-clinician communication about treatment options at the end of life (EOL) is considered essential to quality care. In this study we examined the timing and nature of first discussions about hospice. We hypothesized that earlier initiation of hospice discussions would be associated with longer hospice length of stay. Methods: We analyzed data from a randomized trial of early palliative care integrated with oncology care versus oncology care alone in patients with newly diagnosed incurable lung or non-colorectal gastrointestinal cancer at the Massachusetts General Hospital (n = 350, enrolled 5/11-7/15). Analysis included patients deceased at 1 year after last enrollment (n = 259). Electronic health records were reviewed to identify first documented hospice discussion with a medical oncology or palliative care clinician. Among hospice enrollees, we tested the association of first hospice discussion with hospice length of stay, adjusting for cancer type and randomized group. We used content analysis to explore the nature of first hospice discussions. Results: Prior to death, 79.9% of patients (54% male; M age = 64 yrs [SD = 11 yrs]) enrolled in hospice. Among hospice enrollees, 8.2% had no documented hospice discussion before enrollment. Range of time from first hospice discussion to hospice enrollment was ≤7 days (40.0%), 8-14 days (12.1%), 15-30 days (13.2%) or > 30 days (34.7%). Greater number of days between first hospice discussion and hospice enrollment was associated with more days on hospice (Beta = .14, SE = .04, p < .001). Almost half of first hospice discussions involved initiation of hospice referral. Discussions that occurred early ( > 30 days before enrollment) were varied, reflecting clinician’s provision of information; discussion of future hospice use; and initiation of dialog about patient/family areas of ambivalence or concern. Conclusions: Earlier initiation of hospice discussions was associated with more subsequent days on hospice and reflected attention to patient/family informational needs, perspectives and concerns about hospice and EOL care. Research is needed to help identify and address factors that facilitate earlier discussions with patients/families about EOL care options.
Autonomy Preference Index and advance care planning preference of patients with incurable cancer and their association with anxiety and depression.
Authors: Colombet Isabelle , Rouquette Alexandra , Urtizberea Miren , Vinant Pascale
Published: November 2017

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Background: Shared decision-making and informed patient choices are promoted in many countries. However, advances in antitumoral treatments are making decisions and communication more complex and the benefit of early discussions on end-of-life care is still unclear, especially in most distressed patients. Using a validated French version of the Autonomy Preference Index (API), we studied the factors associated with the level of preference for participation in medical decision-making (DM), information seeking (IS) and advanced care planning (ACP) in patients with incurable cancer. Methods: The API is a self-administered scale that measures both dimensions of DM and IS on a 0 - 100 scale (100 for maximum participation and desire for information). DM is also assessed against the illness severity, using 3 clinical vignettes of specific diseases of increasing severity, each on a 0 - 10 scale. We designed another clinical vignette, questioning patient’s preference for discussion on “Do Not Resuscitate” order (ACP). 187 consecutive patients visiting the general oncology clinic of a university hospital completed the questionnaire, as well as the anxiety and depression HADS 14-points scales. Results: Patients were aged 65±12, 46% male, 39% with high school level of education. Lung (25%), colorectal (14%), pancreas (12%) ovarian (12%) were the most frequent types of cancer. 175 (95%) patients were receiving chemotherapy, 60 (33%) had anxiety, and 49 (26%) depression. Median (1st-3rdquartiles) of IS and DM were 45.8 (33.3-58.3), 85.4 (78.1-96.9) respectively. According to the ACP vignette, 177 (95%) patients considered important to discuss such decision with their doctor, 130 (71%) considered it possible, and 127 (68%) preferred to decide together with physician, or him/herself after taking physician’s advice. Female, most educated patients had higher DM score. We find no significant correlation between IS or DM scores and HADS. Conclusions: Incurable cancer patients have high expectations of medical information but intermediate or low level of preference for participation in decision making. However, they value the discussion on ACP to express their informed choice.
Metastatic Breast Cancer Collateral Damage (MBCCD) project: Think tank of advocates and provider-survivors.
Authors: Eshraghi Leah , Cooper Ortner Heather , DeHart Jessica Noelle Clague , Stanton Annette , Williamson Timothy , Jorge Alexandra , Obidegwu Nwamaka , Love Susan M.
Published: November 2017

55

Background: From The Health of Women (HOW) Study, we found that participants living with metastatic breast cancer (MBC) had a considerably diminished quality of life (QoL) compared to those with less advanced breast cancer. When faced with MBC, managing and minimizing collateral damage (CD) resulting from sequential and often continuous treatments is crucial to improving QoL. The aim of the MBCCD Project was to characterize the unique experience of MBC to identify and address potential areas of need in this underserved population. Methods: Findings from the MBCCD survey (515 MBC respondents) were presented and discussed at a two-day in-person Think Tank with our Advocate Task Force–10 women and men living with MBC–and 28 provider-survivors. Provider-survivors—consisting of healthcare providers who also had been treated for cancer—represented the full spectrum of providers that MBC patients may need, including nurses, oncologists, and surgeons, to physical therapists, psychologists, social workers, palliative care specialists, and faith leaders. The group was selected to address issues from both perspectives of care to ensure that recommendations would fully address patients’ needs and could be easily implemented in the current health care delivery system. Results: The Think Tank provided multiple opportunities to discuss the survey findings and develop recommendations on ways to educate providers about the needs of MBC patients and help alleviate the CD patients experience. A wide variety of unmet needs were discussed, including increased access to clinical trials, centralized resources for financial assistance, addressing sensitive or non-discussed issues, such as fertility and sexuality, and expanding awareness of palliative care programs. We are in the process of finalizing the recommendations and will disseminate widely to providers, MBC patients, and caregivers. Conclusions: Having a panel of people seated simultaneously on both sides of the cancer diagnosis and treatment conversation resulted in recommendations that did not shy away from addressing complex issues while simultaneously having a high probability for dissemination and implementation within the health care system.
Results of implementing a novel supportive oncology screening tool for comprehensive evaluation of distress and other supportive care needs.
Authors: Khosla Paramjeet , Trosman Julia Rachel , Gerhart James , Patel Urjeet , Lo Shelly S. , Penedo Frank J. , Robinson Patricia A. , Diaz Aidnag , Lillis Teresa , Miranda Harry , Radeke Erika K. , Roggenkamp Betty , Pasquinelli Mary , Feldman Lawrence Eric , Martin Joanna , Kircher Sheetal Mehta , Garcia Sofia F. , Berardi Rosa , Weldon Christine B.
Published: November 2017

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Background: The Institute of Medicine (IOM) 2013 Report recommends that supportive oncology care start at cancer diagnosis; the Commission on Cancer (CoC) Standard 3.2 requires distress screening and indicated action. Screening tools are not standardized and often address only a portion of patients’ supportive oncology needs. Methods: A collaborative of 100+ clinicians, funded by The Coleman Foundation, developed a patient-centric screening tool adapted from NCCN Distress Problem List, IOM report and CoC standards, with validated sub-tools: PHQ-4 for anxiety and depression and PROMIS short forms for pain, fatigue and physical function. Novel treatment/care and other concerns were included. The screening tool was implemented at 4 cancer centers (2 academic, 1 public & 1 safety-net). End points included correlation of PHQ-4 score with other supportive oncology needs. Descriptive statistics, Fisher’s exact test were used. Results: 2805 patients were screened. Average scores were: PHQ4 – Anxiety and Depression 1.8 (mild > 3), Pain 4.5 (mild > 4), Fatigue 8.8 (mild > 6), Physical Function 20.2 (mild < 20), see table for additional items. Higher scores on the PHQ-4 were significantly associated with each of the following: greater pain, fatigue, , nutritional and specific treatment/care concerns, and lower physical function (p<.0001). (See Table). Conclusions: Patients with higher anxiety and depression also have many other supportive oncology concerns. Our results support the use of a comprehensive tool capturing a spectrum of each patient’s unique concerns. This may enable earlier interventions and personalized delivery of supportive care. [Table: see text]
Disruption or innovation? A qualitative study on the use of electronic patient-physician communication in patients with advanced cancer.
Authors: Voruganti Teja , Husain Amna , Grunfeld Eva , Webster Fiona
Published: November 2017

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Background: Clinical management of patients with advanced cancer is complex, involving specialized treatment and multiple healthcare providers in different settings. In this context, care coordination and sharing of contextual information is often inadequate, leading to suboptimal continuity of care. Electronic communication has the potential to address these gaps and engage patients in their own care. We studied a web-based tool which assembles the patient, their caregivers and their healthcare providers in a virtual space for team-based communication. We sought to understand participant perceptions on electronic communication in general, and the added value of the new tool in particular. Methods: We conducted a qualitative descriptive study with participants (patients with advanced cancer, caregivers, cancer physicians) who participated in a 3-month pilot trial evaluating the tool. Interviews were thematically analyzed and the perspectives from patients, caregivers and cancer physicians were triangulated. Results: We identified five themes relating participants’ perspectives on electronic communication to their experience of care: 1) apparent gaps in care; 2) uncertainty in defining the circle of care; 3) relational aspects of communication; 4) incongruence between technology and social norms of patient-physician communication; and 5) appreciation but apprehension about the role of the electronic communication tool for improving the experience of care. Conclusions: The potential of tools for electronic communication to bring together a team of healthcare providers with the patient and caregivers is significant but may pose new challenges to existing team structure and interpersonal dynamics. Patients and physicians were worried about the impact that electronic communication may have on the patient-physician relationship. Implementation approaches which build on the relationship, and integrate the team as a whole, could positively position electronic communication to enhance team-based care.
Outcomes of patients receiving chemotherapy at the end of life.
Authors: Van Metre Laura Jennifer , Scarborough Bethann , Smith Cardinale B.
Published: November 2017

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Background: Chemotherapy within 14 days of death indicates poor quality end-of-life (EOL) care. Despite this, approximately 25% of patients receive EOL chemotherapy. This study identifies determinants of EOL chemotherapy. Methods: We identified patients who died in the hospital within 2 weeks of receipt of chemotherapy in 2012 and conducted a detailed chart review to identify demographic and clinical factors, clinical intent, and cause of death. Provider reasoning and assessments were collected. We identified and grouped cause of death into: treatment related, progression of disease, and sudden/unexpected. We used descriptive statistics to document factors associated with receipt of EOL chemotherapy. Results: Of 41 patients, 73% were male; mean age was 63 years; 71% had a hematological malignancy. Whereas solid tumor patients overwhelmingly died of progression of disease (83%), the majority of hematologic patients died of treatment related causes (62%) such as neutropenic sepsis and graft versus host disease. Furthermore, 41% of hematologic malignancy decedents were undergoing induction therapy. Similarly, though all solid tumor chemotherapy was palliative, 33% was for a new diagnosis. All solid tumor patients had a palliative care consultation, whereas 28% of hematologic malignancy patients did. Only 17% of induction chemotherapy patients received a palliative care consult. 76% of hematologic patients were DNR at time of death, while all solid tumor patients were DNR. Site of death varied with 52% of hematologic patients dying in ICU and 10% on the inpatient hospice unit. No solid tumor patients died in the ICU; 67% died on inpatient hospice. Only 10% of all patients had performance status documented. Clinical reasoning for chemotherapy included: disease modification, bridge to clinical trial or transplant, and palliation of symptoms. Conclusions: Patients with hematologic malignancies who received EOL chemotherapy had high ICU utilization and were less likely to have a palliative care consultation. Clinical intent, including early line therapy, may foster unrealistic clinician expectations. An improved understanding of avoidable causes of receipt of chemotherapy at EOL is important in addressing this gap in quality of care.
A description of cancer directed therapy within 14 days of death in a community cancer institute.
Authors: Newport Kristina , Holliday Rachel , McNaughton Caitlyn , Gehron Emily , Horst Michael , Sivendran Shanthi
Published: November 2017

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Background: It is recommend that no more than 10% of patients receive chemotherapy within 14 days of death. Aggressive end of life interventions like chemotherapy and hospitalization are used as measures of quality. However, cancer care now includes immunotherapy and targeted therapies. It is therefore important to understand how all cancer directed treatments are utilized at end of life, to better define the group of patients for whom they are indicated. Therefore, we sought to describe the people in our institution who received cancer directed therapy in the last two weeks of life. Methods: Adult patients who received cancer directed therapy for any malignancy in a single community cancer institute and died from July 2016-April 2017 were included. Retrospective data collection included clinical cancer stage and type, ECOG performance status (ECOG), last cancer therapy, date of death, dates of treatment, type of treatment, treatment goal, demographics and utilization of ED, hospital, palliative care and hospice. Results: A total of 218 patients were included. 13.7% (30/218) received cancer directed therapy within 14 days of death. Of those patients, only four had ECOG of 3, while 26 had ECOG 0-2. The average duration from treatment to death in this group was eight days, with one patient dying on the day of treatment. The average duration from treatment to death for all patients was 166 days (median 59). 20 patients receiving cancer directed therapy at end of life received chemotherapy, while the remaining 10 received targeted therapy (8) or immunotherapy (2). 40% (8/20) of patients in the chemotherapy group died in hospital as did 50% (5/10) of the remaining patients. Most patients in the overall sample (83%) were being treated with palliative intent. 20% (6/30) of the patients who died within 14 days of treatment were being treated with curative intent. Conclusions: Recommendations regarding cancer directed treatment near end of life need to include non-chemotherapy treatments such as immunotherapy and targeted treatments. Although a small sample size, our data suggest that patients on these treatments receive aggressive end of life care at a similar frequency as those who receive chemotherapy.
End-of-life (EOL) care in medical oncology fellows' clinics.
Authors: Liu Yang , Ramamurthy Chethan , Anari Fern , Varshavsky Asya , Martin James , Kasireddy Vineela , Goldrich Adam , Ghatalia Pooja , Gerson James , Smith Chad , Knollman Hayley Michelle , Tan Carlyn , Egleston Brian L. , Collins Molly , Dotan Efrat , Bauman Jessica Ruth
Published: November 2017

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Background: Medical oncology fellowship training presents a critical time for developing skills necessary for discussing end of life (EOL) care preferences with patients and delivering EOL care. There is little data exploring the delivery of EOL care by fellows in practice. We describe our fellows’ experience and identify areas to improve delivery of EOL care and communication. Methods: We retrospectively reviewed electronic medical records (EMR) of patients at our center with advanced (metastatic or recurrent) solid tumors who received care in fellows’ clinics and died between 7/1/2016 and 6/7/2017. We used Fisher’s exact test to determine associations between variables. Results: We included 103 patients from 46 distinct fellow clinics covered by 16 fellows. 54 (52%) were male; median age was 70 (37-94) years. 42 (40%) had a gastrointestinal malignancy, 31 (30%) had lung cancer. Median duration of advanced cancer was 12 (0.5-120) months. Patients received a median of 2 (1-10) lines of chemotherapy. 10 (10%) received chemotherapy within 14 days of death. 10 (10%) used outpatient palliative care (PC). 48 (47%) had EOL/hospice discussions in the outpatient clinic, while 10 (10%) had code status documented in a clinic encounter, and 20 (19%) had a copy of an advanced directive in the EMR. Median time from EOL discussion to death was 30 days (4-171). 69 (67%) enrolled in hospice and median length of stay on hospice was 18 days (1-142). 58 (56%) were hospitalized and 13 (13%) admitted to the ICU within 30 days of death. Of patients not enrolled in hospice, 8 (8%) died at home without hospice, 23 (22%) died in a hospital or ICU, 3 (3%) died in other or unknown places. Patients who had EOL discussions in clinic were more likely to enter hospice (p = .006) and less likely to be hospitalized (p = 0.016) within 30 days of death. Conclusions: Fellows at our center have significant exposure to outpatient EOL discussions and delivery of EOL care. EOL discussions in clinic were associated with decreased rates of health care utilization within 30 days of death. There were low rates of outpatient code status discussions and documentation of advanced directives, and few patients received outpatient PC, which represent potential areas to enhance fellow training and improve patient EOL care.
Equality during end-of-life cancer care: Trends in aggressiveness of cancer care at the end of life.
Authors: Namireddy Praveen , McLawhorn Vicki , Jonnalagadda Sweta , Muzaffar Mahvish
Published: November 2017

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Background: Aggressive cancer care at the end of life (EOL) can impact quality of life and have major economic burden. The purpose of this study was to portray the aggressiveness of EOL cancer care, and its relation to race, gender and social factors in Eastern North Carolina with high rural and minority population. Methods: This is a retrospective analysis of 401 stage 4 solid tumor patients who died between 2011 and 2014. Aggressiveness of care was calculated by a composite score adopted from Earle et al. Scores range from 0 to 7 with higher scores indicating more aggressive EOL care. 1 point was given to each indicator of aggressiveness in the last 30 days of life: ED visits ≥2,hospital admissions ≥2,any ICU admission,hospitalized days ≥14,new chemotherapy, hospice care ≤ 3 days, and any chemotherapy in the last 14 days. Results: Among the 401 patients, 217 (54%) were white and 178 (44%) were black. The mean composite score of aggressiveness (CSA) for whites was 1.18 and for blacks it was 1.87. (p<0.001).In the last 30 days of death, a higher proportion of blacks had ≥ 2 ED visits 28% vs 13%(p<.0001), ≥ 2 hospital admission 23% vs 13%(p=0.001), any ICU admission 29% vs 16%(p=0.0002), chemotherapy in the last 14 days 30% vs 20%(p=0.001), ≥ 14 hospitalized days 35% vs 21%(p<0.001), and hospital deaths 46% vs 32%(p=0.001) compared to whites. More whites enrolled in hospice compared to blacks 53% vs 45% (p<0.001). Correlation analysis using Fit Y by X model between CSA (score ≤ 3 and >3) and other variables showed statistically significant difference between whites vs blacks p <0.001, females vs males p=0.0006, not married vs married p<0.0001, and no family support vs family support p<0.0001. Conclusions: Male, unmarried and black patients were associated with higher CSA. Patients who were white, married and with family support had high likelihood of enrolling in hospice. [Table: see text]
Lessons from bereaved families: Insights about how the care of patients impacts bereavement.
Authors: Morris Sue Ellen , Block Susan
Published: November 2017

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Background: Feedback from bereaved families, including surveys of family members’ experiences during the patient’s illness and final days, can provide important insights into ways to improve the care of patients with advanced illness and their families. Methods: A convenience sample of 140 bereaved family members from Dana-Farber Cancer Institute (DFCI) completed a survey developed by the authors about their bereavement experiences. Families were asked to describe ways in which the clinical team was helpful in dealing with their loss; what they wished the clinical team had done prior to the death that would have helped in dealing with their loss; and actions taken by the team that were unhelpful or difficult for them in dealing with their loss. The Institutional Review Board at DFCI approved the study. Results: 67% of participants were female and 81% had lost a spouse or partner. The most common responses about ways in which the team was helpful in dealing with their loss included: showing compassion, sending condolence letters or making calls, and offering honest facts and information. Prior to the death of the patient, the most common response about what they wish the team had done was providing more realistic information about prognosis. When asked about actions that were unhelpful or difficult, only 24 responses were given with 50% of participants omitting this question and the remaining stating that there was nothing that the team did that was unhelpful. Of the 24 responses, the most common concerned a lack of contact or contact that was impersonal after the death. Conclusions: This survey demonstrated that families could provide input about ways clinicians can have a positive impact on the bereavement experience of families in caring for the patient before death. Compassion, accurate information, especially about prognosis, and contact with the clinician during early bereavement were highly valued by respondents. The most common unhelpful behavior identified was lack of personal contact following the death of the patient. Improved communication by the clinician, both before and after the patient’s death, has potential to improve the bereavement experience of family members.
Acute care medical interventions in the palliative care unit versus inpatient hospice.
Authors: Vidal Marieberta
Published: November 2017

88

Background: In a survey of different cancer centers in the United States, only 23% reported having dedicated palliative care beds and hospital executives have reported not having further plans for expansion of their program. Barriers that are often cited include poor reimbursement for services, limited institutional support and resources. Patients admitted to an Acute Palliative care unit (APCU) benefit from the multidisciplinary approach that is evident in daily rounds, interdisciplinary team meetings, and family conferences. There could be occasionally misconceptions about the differences between inpatient hospice and an APCU. Even though the psychosocial component of palliative care is extremely important a significant amount of medical interventions also are necessary to provide patients and family with a sense of and optimal care during this time. Methods: A retrospective chart reviewed was performed in 100 consecutives patients admitted to the APCU and inpatient hospice prior to October 2013. From this data we identified the acute medical interventions ordered by the palliative Care specialist tduring the first 5 days of admission. Results: A total of 100 patients from the APCU and 100 patients from inpatient hospice were reviewed. In the APCU 100% of patients had iv fluids vs 7% in inpatient hospice. Antibiotics were given in 52% of APCU patients vs 2% in the inpatient hospice. Steroids were given in 48% of APCU patients vs 30% in inpatient hospices. (See Table). Conclusions: The APCU in comparison to inpatient hospices had higher rate of acute medical interventions with the most common been iv fluids, antibiotics, laboratory and radiologic diagnostic tests. This represent the importance of Acute Palliative Care Units in advanced cancer patients with complicated situations to achieve comfort when transitioning to EOL. [Table: see text]
Acceptability and effects of values-based outpatient advance care planning (ACP) in gastrointestinal (GI) cancers.
Authors: Epstein Andrew S. , O'Reilly Eileen Mary , Volandes Angelo E. , Shuk Elyse , Romano Danielle R. , Breitbart William
Published: November 2017

9

Background: We developed and validated the values questions for the Person-Centered Oncologic Care and Choices (P-COCC) ACP intervention, which combines an informational care goals video with a patient values interview. Herein, we studied (primarily) the acceptability of P-COCC, and (secondarily) its effects on wellbeing and decisional conflict. Methods: Patients (pts): English-speaking with GI cancer, ≤ monthly followup in MSK medical oncology clinics and believed by their oncologist able to complete study measures and survive 1-12 months. Consented pts randomized 2:2:1 to P-COCC vs. video alone (V) vs. usual care (UC). Questionnaires: administered baseline and at next follow-up visit on validated measures of wellbeing, and on follow-up only, decisional conflict. P-COCC arm pts also completed 3 Likert scales (was the intervention helpful, comfortable and recommended to others?); a positive score on ≥1 of 3 indicated acceptability for that pt. Results: During screening from 9/2014-11/2016, 202 pts were approached. 51 (25%) declined participation (most common reason, N = 31 = not wanting to discuss the topic). 151 consented and were randomized; 99 (66% of the 151) completed study measures (most common attrition reason, N = 34 = disease progression or death). Of the 99, 63% male; mean age 61 years; mean ECOG PS 1; most common cancers colorectal, gastroesophageal, and pancreatic. The primary aim was met: Among 33 pts, 32 (97%, 95%CI: 0.84-0.99, p < 0.001) rated P-COCC acceptable. Mean distress scores (0-10) increased (0.43) in the P-COCC arm but decreased in the V (-0.04) and UC (-0.21) arms (p = 0.03 and 0.04, P-COCC vs V and UC, respectively). There were no significant pre-post change scores on other measures of wellbeing (anxiety, depression, stress, acceptance, QOL), or intergroup differences in decisional conflict. Qualitatively, P-COCC interviews revealed pt concerns, and desires for support and QOL. Conclusions: Our values-based ACP paradigm is acceptable but may increase distress in GI cancer outpatients. Further studies are investigating underpinnings and follow-up duration of these results, and ways to best support cancer patients (with any cancers, and regardless of prognosis) in ACP. Clinical trial information: NCT01912131.
Prospective assessment of symptom burden interfering with decision making during the end-of-life phase of high-grade glioma patients.
Authors: Walbert Tobias , Schultz Lonnie , Phillips Joel
Published: November 2017

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Background: To date it is unclear when patients with high grade glioma (HGG) lose their capacity to make decisions during the end-of-life (EoL) phase. EoL symptoms have not been prospectively assessed. The goal of this prospective single center study was to assess the symptom burden in terminal HGG patients with a special focus on symptoms related to decision making capacity during the last 3 months of life. Methods: Patients with HGG, failing 3rd line therapy, showing clinical and/or radiological progression with a Karnofsky Performance Status score < 60 were eligible for enrollment. A baseline MD Anderson Symptom Inventory Brain Tumor Module (MDASI-BT) was performed upon enrollment. Patients or surrogates received bi-weekly telephone calls to repeat the MDASI-BT. Calls continued until death, or refusal to participate. Symptoms were stratified by weeks prior to death. Mixed models were used to assess for symptom and interference changes over time. Overall time effect was tested at the 0.05 level. If significant, pairwise comparisons of the time groups were done. Testing level was set at 0.01 to take into account the large number of comparisons. Results: Symptom scores of 52 patients are available for analysis. Symptoms involved in decision making such as speaking, concentrating, drowsiness (all p < 0.001), and understanding (p < 0.011) started to decline severely 12 weeks prior to death. The cognitive construct (understanding, remembering, speaking, concentrating) was significantly impaired during the last 2 weeks of life and started to deteriorate after week 12 (p < 0.001). The decision making composite score (understanding, speaking, concentrating, fatigue, drowsiness) showed the same pattern (p < 0.001). Overall disease burden also significantly increases within the last 2 weeks of death. Conclusions: Patients with HGG have a high symptom burden during the active EoL phase, increasing significantly during the last 12 weeks prior to death. Symptoms interfering with decision making capacity increase after week 12 and reach their peak 2 weeks prior to death. These findings stress the importance of early initiation of palliative care and advance care planning in patients with HGG.
Impact of palliative care rotation on gynecologic oncology fellows' knowledge, rates of explicit teaching, and perceived competence in palliative care.
Authors: Lefkowits Carolyn , Tamber Anoo , Leahy Janet , Teuteberg Winifred
Published: November 2017

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Background: Impact of a PC rotation on fellows in the primarily surgical specialty of Gynecologic Oncology (GO) has not been described. We aimed to evaluate the impact of a month-long PC rotation on GO fellows’ knowledge, exposure to explicit teaching and perceived competence in PC. Methods: Four years of GO fellows (n = 8) were surveyed before and immediately after a month-long PC rotation about knowledge, explicit teaching and perceived competence across four domains - pain management, non-pain symptom management, out of hospital care and communication/ethics. Knowledge was assessed via 30 multiple choice questions (MCQ). Perceived competence to address 25 PC topics was assessed on a Likert scale (1 to 5). Participants were asked about explicit teaching of 21 PC topics before and during the rotation. The rotation included 5 clinical settings and 7 dedicated didactic strategies beyond routine participation in clinical care. We used medians tests to compare total correct items pre vs post rotation, paired differences pre to post of perceived competence and paired differences pre to during rotation rates of explicit teaching of PC topics. Results: Post-rotation, participants demonstrated significant improvement in knowledge (median MCQ percent correct pre 62% v post 67%; p = 0.01), explicit teaching (median percent items explicitly taught pre 19% v post 91%; p = 0.02) and perceived competence (median percent items competent or better pre 34% v post 100%; p = 0.01). The most highly rated clinical settings were inpatient hospice and inpatient PC consult service. The most highly rated didactic strategies were direct observation of communication skills practice and 10 minute didactics. The educational value of the overall rotation was rated as superior by 100% of participants. Conclusions: After a month-long PC rotation, GO fellows demonstrated significant improvement in knowledge, rates of explicit teaching and perceived competence in PC across all domains examined. Routine incorporation of a dedicated PC rotation should be considered for all gynecologic oncology fellows.
A grounded theory analysis of oncology nurses' perceptions of early palliative care in the context of ambulatory care.
Authors: Mohammed Shan Darrel , Savage Pamela , Zimmermann Camilla
Published: November 2017

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Background: In early palliative care (EPC), palliative supports and resources are provided at an earlier stage in the treatment trajectory. As major care providers, nurses play a pivotal role in ensuring the success of EPC as an emerging model of care delivery. In this study, we examine nurses’ perceptions of EPC in the context of ambulatory oncology care and explore how EPC fits within the broader professional mandate of nursing. Methods: We recruited nurses from several ambulatory care oncology clinics in a tertiary cancer hospital in Ontario, Canada. Nurses participated in semi-structured interviews seeking to qualitatively examine their attitudes and perceptions about EPC. Constructivist grounded theory guided our methods and analysis. Results: A total of 20 nurses that included six staff nurses, ten nurse practitioners, and four advanced practice nurses completed interviews. Participants worked in a variety of clinic settings such as breast, pancreatic, head and neck, and hematology. The core category Perceiving EPC as Synonymous with Fundamental Nursing Care encompasses three subcategories: (1) Prioritizing immediate care needs – recognizing the need for EPC to manage immediate pain and symptom management concerns; (2) Care coordination – viewing EPC as linking resources and organizing interprofessional care; and (3) Safeguarding and preventative care – initiating EPC to protect against difficult transitions between phases of treatment and to prevent being unprepared for active dying. Conclusions: This was the first study to qualitatively examine nurses’ perception of EPC. Nurses not only recognize the value of EPC to ensure good quality care for patients with cancer and their families, but also perceive this care as deeply embedded within the core values of nursing. Recognizing how nurses view EPC has implications for expanding the professional scope of nursing in palliative care and for preparing nurses for the complexities of this work.
Development of a telemedicine palliative care program in a cancer center.
Authors: Kim Youngho Paul , Saldivar Reggie , Sidlow Robert
Published: November 2017

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Background: Inpatient palliative care (PC) teams have increased their presence over the past decade, with over 90% of hospitals having access to PC specialists. However, such growth has not been mirrored in the outpatient setting; this is relevant for patients living far from major medical centers. Memorial Sloan Kettering Cancer Center (MSK) has expanded its ambulatory care footprint beyond New York City (NYC) to sites where PC is not currently available. To address the need for PC delivery to a geographically dispersed patient population, we developed a clinical initiative utilizing telemedicine technology. Methods: The Telemedicine Palliative Care Program (TPCP) was initiated after planning with multiple stakeholders, including clinical, legal, billing, compliance, ambulatory care, information systems, and scheduling departments. The TPCP provides PC consultation and management of patients via a “hub-and-spoke” model, whereby PC specialists are located at the main campus in NYC and patients are scheduled to be seen at one of six regional ambulatory cancer sites within a 50-mile radius. Regional ambulatory sites have video teleconference rooms equipped with Cisco (San Jose, CA) TelePresence MX300 hardware and Jabber software allowing for secure, high fidelity, real-time video communication with clinicians at the main campus who use iPads installed with Jabber software during their consultation sessions. Results: The TPCP is currently active at two regional sites in New York and New Jersey. Patient satisfaction, perception of quality of care, and patient outcomes will be measured. Preliminary results indicate that both patients and providers find this clinical program to be an extremely valuable experience. Conclusions: The technologic infrastructure is now available to deliver telemedicine-enabled PC for cancer patients in a geographically distributed model. Our early experience suggests that our program will help enable the convenient delivery of concurrent PC to cancer patients across a wide geographic area. This innovative clinical initiative has the potential to enable all MSK patients to access high-quality palliative care in a geography-agnostic manner, and eventually deliver such care to patients in their homes.
Factors That Influence FDA Decisions for Postmarketing Requirements and Commitments During Review of Oncology Products
Authors: Hyogo Atsushi , Kaneko Masayuki , Narukawa Mamoru
Published: November 2017

Purpose:

With the recent use of expedited drug development and approval programs for several oncology products in the United States, the importance of postmarketing plans to confirm clinical benefits and safety is increasing. To discuss postmarketing requirements (PMRs) and postmarketing commitments (PMCs) required for oncology products approved in the United States, we investigated the factors that influenced the US Food and Drug Administration (FDA) decisions for PMR/PMCs during FDA review.

Methods:

Characteristics of new drug approvals and PMR/PMCs for oncology products (new molecular entities and new therapeutic biologic products) in the United States between 2008 and 2015 were analyzed.

Results:

Of the 58 oncology products analyzed, PMR/PMCs were required for 54 products. The proportion of approvals that required confirmatory PMR/PMCs was 100% for accelerated approval (AA) and was 39% for regular approval (RA). Median development times for AA and RA were 7.41 and 7.50 years, respectively. Randomization, number of patients, and end point in pivotal studies were identified as key potential factors that influenced the decision to require PMR/PMCs for both confirmatory and clinical safety studies.

Conclusion:

Robustness of the pivotal study design was identified as one of the key factors for the decision by the FDA to require PMR/PMCs—in particular, significant PMR/PMCs, such as those for confirmatory studies. That is, the FDA approved products with surrogate markers and smaller studies but required PMR/PMCs to fully prove the risk-benefit profile in the postmarketing period.
Assurance of Myeloid Growth Factor Administration in an Infusion Center: Pilot Quality Improvement Initiative
Authors: Ramirez Pamela Maree , Peterson Barry , Holtshopple Christine , Borja Kristina , Torres Vincent , Valdivia-Peppers Lucille , Harriague Julio , Joe Melanie D.
Published: November 2017

Purpose:

Four incident reports involving missed doses of myeloid growth factors (MGFs) triggered the need for an outcome-driven initiative. From March 1, 2015, to February 29, 2016, at University of California Irvine Health Chao Infusion Center, 116 of 3,300 MGF doses were missed (3.52%), including pegfilgrastim, filgrastim, and sargramostim. We hypothesized that with the application of Lean Six Sigma methodology, we would achieve our primary objective of reducing the number of missed MGF doses to < 0.5%.

Methods:

This quality improvement initiative was conducted at Chao Infusion Center as part of a Lean Six Sigma Green Belt Certification Program. Therefore, Lean Six Sigma principles and tools were used throughout each phase of the project. Retrospective and prospective medical record reviews and data analyses were performed to evaluate the extent of the identified problem and impact of the process changes. Improvements included systems applications, practice changes, process modifications, and safety-net procedures.

Results:

Preintervention, 24 missed doses (20.7%) required patient supportive care measures, resulting in increased hospital costs and decreased quality of care. Postintervention, from June 8, 2016, to August 7, 2016, zero of 489 MGF doses were missed after 2 months of intervention ( P < .001). Chao Infusion Center reduced missed doses from 3.52% to 0%, reaching the goal of < 0.5%.

Conclusion:

The establishment of simplified and standardized processes with safety checks for error prevention increased quality of care. Lean Six Sigma methodology can be applied by other institutions to produce positive outcomes and implement similar practice changes.
Ultrasound-Guided Dynamic Needle Tip Positioning Technique Versus Palpation Technique for Radial Arterial Cannulation in Adult Surgical Patients: A Randomized Controlled Trial
Authors: Kiberenge Roy K. , Ueda Kenichi , Rosauer Brett
Published: November 2017

BACKGROUND:

Radial arterial cannulation is most commonly done using palpation, but the use of ultrasound has increased the cannulation success rate. This improvement, albeit significant, has not led to a very high success rate especially in trainees. A modified ultrasound technique for vascular cannulation (dynamic needle tip positioning) has been described for peripheral venous cannulation. We therefore assessed the success rate of this technique compared to the palpation technique for radial artery cannulation in adult surgical patients.

METHODS:

We enrolled patients who were having nonemergent operations that required a radial arterial catheter for intraoperative monitoring. Patients were randomized to either palpation or dynamic needle tip positioning technique. Arterial cannulation was performed by anesthesia residents or faculty members. The primary end point was successful cannulation on the first pass. Secondary end points were overall 5-minute success rate and number of attempts within 5 minutes.

RESULTS:

Two hundred sixty patients were evaluated. The first-pass success rate was 83% in the dynamic needle tip positioning technique group (n = 132) and 48% in the palpation group (n = 128; P < .001); relative risk was 2.5; 95% confidence interval, 1.7–3.6. The overall 5-minute success rate was 89% in the dynamic needle tip positioning technique group compared to 65% in the palpation group (P < .001), relative risk was 2.4; 95% confidence interval, 1.2–1.6. The number of skin puncture attempts was significantly more in the palpation group (P < .001). The median cannulation times and interquartile ranges were 81.5 (61–122) seconds in the dynamic needle tip positioning and 76 (48–175) seconds (P = .7) in the palpation group.

CONCLUSIONS:

The use of the ultrasound-guided dynamic needle tip positioning technique increased the first and overall success rates compared to palpation in anesthesia residents and faculty members.