bluuebunny/crossref_metadata_2025 huggingface dataset:
Determining priority symptoms of women with recurrent ovarian cancers: A Gynecologic Oncology Group study.
Authors: Donovan Heidi AS , Wenzel Lari B. , Ward Sandra , Sereika Susan M. , Edwards Robert P. , Spring Michael , Bender Catherine M , Penson Richard T. , Hagan Teresa
Published: February 2017

101

Background: The purpose of this study is to recommend a core set of priority symptoms to be assessed in research and clinical settings for women with recurrent ovarian cancers. Methods: We used baseline data of 497 women with recurrent ovarian, fallopian, or primary peritoneal cancer participating in a symptom management randomized clinical trial (GOG-0259) to identify a core index of patient-reported priority symptoms. We used the Symptom Representation Questionnaire to assess priority rankings of 28 symptoms based on four criteria: (1) symptom prevalence, (2) patient-reported symptom severity, (3) percentage of women identifying each symptom as one of top three symptoms “I would like to get better control over”, and (4) the association between symptom severity and functional wellbeing as measured by the Functional Assessment of Cancer Therapy - Ovarian. Final priority ranking included all symptoms that were ranked in the top 10 for any of the four criteria. Results: Of the original 28 symptoms, 19 were ranked in the top 10 for at least one criterion: fatigue, sleep disturbance, pain, anxiety, peripheral neuropathy, constipation, abdominal bloating, drowsiness, mood swings, memory problems, weight gain, nausea, sexual concerns, vomiting, hair loss, lymphedema, lack of appetite, shortness of breath, and depression. Fatigue, sleep disturbance, and pain were each ranked one of the top 10 symptoms for all four criteria. Anxiety, peripheral neuropathy, and constipation were each ranked in the top 10 for three of the 4 criteria. Conclusions: We propose a core index of 19 patient-reported symptoms to be systematically assessed among patients with recurrent ovarian cancer. These symptoms are common, severe, poorly managed, and/or interfere with survivors’ functioning and can be efficiently assessed in 1-2 minutes. Systematic assessment in clinical and research settings could advance understanding about the predictors and consequences of poorly managed symptoms and could lead to more proactive, personalized interventions to improve functional well-being in this at-risk patient population.
Randomized trial of inpatient palliative care in patients hospitalized for hematopoietic stem cell transplantation (HCT).
Authors: El-Jawahri Areej , LeBlanc Thomas William , VanDusen Harry , Traeger Lara , Greer Joseph A. , Pirl William F. , Jackson Vicki A. , Telles Jason , Rhodes Alison , Chen Yi-Bin Albert , Temel Jennifer S.
Published: February 2017

103

Background: During HCT, patients experience physical and psychological symptoms that negatively impact their quality of life (QOL). We assessed the impact of an inpatient palliative care intervention on patient QOL, symptom burden, and mood during HCT hospitalization and at 3 months post-HCT. Methods: We randomized 160 patients with hematologic malignancies admitted for autologous or allogeneic HCT to an inpatient palliative care intervention (n=81) integrated with transplant care compared to transplant care alone (n=79). We used the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) to assess QOL, the Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire (PHQ-9) to assess mood, and Edmonton Symptom Assessment Scale (ESAS) to measure symptoms at baseline, week-2, and 3 months post-HCT. We measured post-traumatic stress (PTSD) symptoms using the PTSD checklist at baseline and 3 months post-HCT. We used linear regression models controlling for baseline values to assess the intervention effects on outcomes at week-2 and 3 months post-HCT. Results: Between 8/2014 and 1/2016, we enrolled 160/186 (86%) of potentially eligible patients. At week-2, the intervention led to improvements in QOL, depression, anxiety, and symptom burden. At 3 months post-HCT, the intervention led to improvements in QOL, depression, and PTSD [Table 1]. PHQ-9 scores at week-2 and HADS-anxiety scores at 3 months did not differ significantly. Conclusions: Palliative care improved QOL, depression, anxiety, and symptom burden in patients hospitalized for HCT with notable sustained effects 3 months post-HCT. Involvement of palliative care for patients with hematologic malignancies can improve their outcomes and substantially reduce the morbidity of HCT. Clinical trial information: NCT02207322. [Table: see text]
Changes in opioid type and dose among cancer patients referred to outpatient palliative care.
Authors: Haider Ali , Baidoo Joseph , Meng Yee Choon , Zhukovsky Donna S. , Tanco Kimberson Cochien , Stewart Holly A , Edwards Tonya , Joy Manju P , Kuriakose Leela , Lu Zhanni , Liu Diane D , Williams Janet L. , Bruera Eduardo
Published: February 2017

106

Background: Opioid prescriptions are regulated at both federal and state levels. Examples of such regulations include use of risk evaluation and mitigation strategies (REMS), mandatory sharing of prescription data with state prescription drug monitoring programs and the reclassification of hydrocodone as schedule II opioid in October 2014. One possible consequence of such changes would be earlier referral to palliative care (PC) for opioid management. Alternatively, primary oncologist may treat patients with weak opioids or use strong opioids with lower daily dose. We hypothesized that during the last six years, the number of referrals to outpatient PC has increased and the morphine equivalent daily dose (MEDD) has decreased. Methods: We reviewed 750 randomly selected patients who were seen as a new consultation from the year 2010 to 2015. Data was collected on demographics, cancer type and stage, referring specialty, symptom assessment, cancer pain classification, performance status, opioid type and MEDD. Data were also collected on first subsequent PC visit among eligible patients. MEDD over the 6 years was evaluated using general linear regression method, adjusted for covariates. Results: Hydrocodone was the most common opioid prescribed by the referring team throughout the six-year period. After reclassification, its use declined from 43% in 2014 to 33% in 2015. Tramadol use increased from 9% in 2014 to 19% in 2015 (p < 0.0001). Median MEDD upon referral was 78mg/day in 2010 and progressively decreased to 40mg/day in 2015 (p < 0.0001). Year to year referral increased 24% in the first quarter of 2015 (after hydrocodone rescheduling), compared to 17% in 2014 (p 0.0014). Conclusions: Over the past 6 years, there has been an increase in number of referrals to PC and a decline in MEDD upon referral. Likewise, an increase in weak opioids like tramadol has also been observed. These findings suggest oncologists are sending early referrals before further opioid dose titration and rotations are considered. Further opioid regulations will likely impact the integration of PC services in comprehensive cancer care.
Strategies for introducing outpatient specialty palliative care in gynecologic oncology.
Authors: Hay Casey M. , Lefkowits Carolyn , Bakitas Marie , Crowley-Makota Megan , Urban Renata , Duska Linda R. , Clark Leslie Horn , Creasy Stephanie L. , Schenker Yael
Published: February 2017

111

Background: Concern that patients will react negatively to the idea of palliative care is cited as a barrier to timely referral. Strategies to successfully introduce specialty palliative care to patients have not been well-described. We sought to understand how gynecologic oncologists introduce outpatient specialty palliative care. Methods: We conducted a national qualitative interview study at six geographically diverse academic cancer centers with well-established palliative care clinics between September 2015 and March 2016. Thirty-four gynecologic oncologists participated in semi-structured telephone interviews focusing on attitudes, experiences, and practices related to outpatient palliative care. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine a coding framework. This analysis focuses on practices for introducing palliative care. Results: Mean participant age was 47 years (± 10). Mean interview length was 25 minutes (± 7). Gynecologic oncologists described three main strategies for introducing outpatient specialty palliative care: first establish a strong primary relationship and trust with patients in order to alleviate fear and increase acceptance of referral; focus initial palliative care referral on symptom control to gain a “foot in the door”, facilitate early relationship-building with palliative care clinicians, and dissociate palliative care from end-of-life; and normalize and explain palliative care referral to decrease patient anxiety and confusion. These strategies aimed to decrease negative patient associations and encourage acceptance of early referral to palliative care specialists. Conclusions: Gynecologic oncologists have developed strategies for introducing palliative care services to alleviate patient concerns. Future research should examine patient perception of these strategies and assess impact on rates of acceptance of outpatient specialty palliative care referral.
Are families the barrier? Evaluating attitudes toward early integration of palliative care in pediatric hematopoietic stem cell transplant.
Authors: Levine Deena R. , Baker Justin N.
Published: February 2017

112

Background: The benefits of early integration of palliative care (PC) in oncology have been well established yet, there remain significant barriers to PC integration, especially in the setting of pediatric hematopoietic stem cell transplant (HSCT). HSCT patients are prone to a great degree of treatment related toxicity and are at high risk for morbidity and mortality and, while ideally suited to benefit, inherent factors in this cure oriented field preclude the integration of PC services. Most notably, family receptivity to PC is often perceived as a barrier in HSCT yet there is no data on family attitudes toward PC in this setting. This study aimed to evaluate perceived symptom burden and patient and parent attitudes toward early PC integration in pediatric HSCT. Methods: After IRB approval, development and pre-testing, novel survey tools were administered to HSCT patients and parents. Eligibility criteria included parent of an HSCT recipient < age 10 or patient/parent dyad for patients aged 10-17, time from HSCT > 1 month and < 1 year, English-speaking, and consent/assent. Data was assessed for trends in response content frequencies, percentages and parent/child concordance. Results: Interim analysis of the first 34 participants revealed high levels of perceived symptom related suffering in the first month of HSCT with suffering from: nausea 96%, loss of appetite 88%, diarrhea 88%, pain 83%, depression 79%, anxiety 75%, and constipation 42%. 90% of patients and 71% parents expressed that a great deal or a lot of attention should be paid to quality of life from the start of HSCT. The majority of patient and parent respondents (60/46%) indicated they would likely want to meet with PC early in HSCT and very few reported definite opposition (0% children, 4% parents). Conclusions: Pediatric HSCT patients experience a high degree of symptom related suffering, perceive quality of life as a high priority, and are largely in favor of early PC involvement. Our findings suggest that family receptivity should not be a barrier to early PC in pediatric HSCT and that aggressive cure directed therapy can and should be accompanied by aggressive quality of life directed care through early PC integration.
Blood transfusions at end of life for stem cell transplant patients.
Authors: Wang Winnie S , Ma Joseph D. , Nelson Sandahl H , Revta Carolyn , Buckholz Gary T , Mulroney Carolyn M. , Roeland Eric
Published: February 2017

115

Background: Transfusions are an essential palliative tool in the stem cell transplant (SCT) population. Limited data exist regarding transfusion practices at end-of-life for SCT patients and whether these practices may limit enrollment in hospice. Methods: A retrospective chart review was conducted of deceased patients with hematologic malignancies who underwent SCT at an academic medical center from 2011 to 2015. The primary objective was to determine the difference between the dates of last transfusion and death in patients enrolled and not enrolled in hospice. A secondary objective was evaluation of the number of transfusions between groups. Data were compiled from a single electronic medical record. Descriptive analyses were performed. Days to last transfusion were analyzed using the Wilcoxon-Mann-Whitney test. Number of packed red blood cell (PRBC) transfusions and platelets transfusions on the last day were analyzed using Fisher and chi-squared tests, respectively. Results: A total of 633 SCT were performed from 2011 to 2015 including 39% (n = 245) allogeneic and 61% (n = 388) autologous transplants (n = 29 patients had 2 transplants). Mean ± SD age of SCT patients was 55 ± 13 years. As of January 2016, 20% (n = 119) of these SCT patients have died. Of those that died, 15% (n = 18) were enrolled in hospice. For SCT patients enrolled in hospice, the mean ± SD time of last blood transfusion from death was 42.3 ± 63.4 days, with mean ± SD 0.67 ± 0.77 units of PRBC’s and 0.72 ± 0.75 units of platelets administered. For SCT patients not enrolled in hospice, the mean ± SD time of last blood transfusion from death was 14.2 ± 47.9 days, with mean±SD total 0.69 ± 1.03 units of PRBC’s and 1.14 ± 1 units of platelets administered. Hospice patients had a statistically significant longer number of days until last blood transfusion compared to non-hospice patients (p < 0.001). There was no difference between SCT patients enrolled in hospice and not enrolled in PRBC transfusions (p = 0.069), but there was a significantly higher amount of platelet transfusions in patients not enrolled in hospice (p < 0.005). Conclusions: This data suggests that time to last transfusion may be a significant obstacle for SCT patients when enrolling in hospice, but requires further validation.
The availability/accessibility gap of palliative care and supportive care services at 40 National Cancer Institute-designated cancer centers.
Authors: Hutchins Kathryn , Hamlyn Geoffrey , Johnston Abby , Thomas Rishonda , Tian James , Kamal Arif
Published: February 2017

122

Background: All NCI-designated, comprehensive cancer centers report having consultative palliative care services alongside six other supportive care services. Inaccuracies in the understanding of these services among frontline office staff may undermine their accessibility to patients. We investigated how easily new patients could access these services when first contacting a major cancer center. Methods: We used a ‘mystery shopper’ format to simulate calls made by a family member of a recently diagnosed patient. We used a standardized call script, describing a female patient, age 58, recently diagnosed with inoperable liver cancer. We called each center four times on different days and evaluated quantitative and qualitative components. Descriptive statistics were calculated for each quantitative measure. Results: We placed 160 calls to 40 NCI-designated cancer centers. 38.2% of callers were unable to receive complete information about supportive care services. Overall, only 37.6% of callers (60.8% of those reaching someone who could answer questions) were told all 7 supportive care services were offered. In 9.5% of calls, call recipients gave an answer other than “yes” to whether the cancer center offered palliative care. Callers were told regarding palliative care: that it was for end of life patients only (2 calls), that there weren’t doctors who focused on symptom management (3), its availability depends on review of medical records (2), or that the call recipient was unsure either of the availability of palliative care (10), or did not know what the term meant (2). Availability responses other than “yes” were obtained in the following frequencies: multidisciplinary approach (14.6%), patient navigation (12.1%), genetic assessment (9.5%), psychological services (7.6%), and cancer education services (6.4%). Conclusions: Despite the stated availability of seven key supportive care services, accessibility was limited in one-third of calls. In about 10% of cases where a person was reached, the call recipient was unable to confirm that palliative care was offered. Further research is needed to close the availability vs. accessibility gap in oncology palliative and supportive care.
Oncology patients in the health care safety net: Is it too late for early palliative care?
Authors: Harris Heather A. , Kinderman Anne , Safier Leslie
Published: February 2017

128

Background: Studies have suggested that uninsured and Medicaid patients are more likely to present with late-stage cancer than Medicare patients, and may be more likely to be admitted urgently or emergently. However, studies of palliative care interventions for cancer patients suggest that the greatest impact can be achieved if these services begin “early” (≥ 90 days prior to death). In our urban public hospital, we examined where patients receive their initial cancer diagnosis, and at what stage they are diagnosed, in order to determine how to best implement community-based palliative care services. Methods: Retrospective cohort analysis of cancer patients diagnosed over a five year period. Hospital tumor registry data were used to determine the location of diagnosis (inpatient vs. outpatient), stage and type of cancer at diagnosis, and patient status at the end of the study period (alive vs. deceased). Results: Of the 2,928 patients diagnosed with cancer, 26% of patients (n = 759) were diagnosed while hospitalized. Patients who received their diagnosis while hospitalized were more likely to be diagnosed with stage 3-4 disease (49%, n = 372), vs. stage 0-1 (21%, n = 163). 25% of patients who received their diagnosis in the inpatient setting died within 90 days of initial diagnosis. Patients diagnosed in the outpatient setting were more likely to be diagnosed with stage 0-1 (40%, n = 865), vs. stage 3-4 (32%, n = 688). Patients diagnosed while hospitalized were 2.9 times more likely to be diagnosed with late stage disease, compared to those diagnosed as outpatients (95% CI 2.3-3.5, p < 0.0001). Conclusions: A large minority of patients received their cancer diagnosis while hospitalized, and were more likely to be diagnosed with late-stage disease. Additionally, a significant proportion of these patients died within 90 days of their initial diagnosis. In order to provide "early" palliative care for cancer patients in public hospitals, palliative care programs may need to offer initial consultation visits while patients are hospitalized, and then connect them with prompt outpatient follow-up. Safety net programs with palliative care services for cancer patients should emphasize continuity across inpatient and outpatient settings.
Healthcare utilization among cancer patients prior to hospice.
Authors: Ray Emily Miller , Riedel Richard F. , Rushing Christel N. , Galanos Anthony N.
Published: February 2017

135

Background: The integration of palliative medicine in oncologic care has become increasingly recognized and supported. We have previously reported improved health system and quality of care outcomes for solid tumor patients admitted to our novel, fully-integrated palliative care (PC) and medical oncology inpatient service at Duke University Medical Center (DUMC). In this study, we explored healthcare utilization in patients specifically discharged to hospice pre- and post-PC integration. Methods: We conducted a retrospective cohort study of hospitalized patients on the solid tumor unit at DUMC who were discharged to hospice care between September 1, 2009-June 30, 2010 (pre-PC integration) and September 1, 2011-June 30, 2012 (post-PC integration). Cohorts were compared on the following outcome variables occurring within 30 days prior to discharge to hospice: number of hospitalizations, ICU days, ED visits, invasive procedures, subspecialty consultations, radiologic studies, medical oncology clinic visits, and use of chemotherapy or radiation. Wilcoxon rank-sum and Chi square tests were used for statistical analyses. Results: A total of 296 patients were included (133 pre-PC integration; 163 post-PC integration) in the analyses. Patient characteristics were well matched between cohorts. The overall mean age was 63 years (range 25-96), 62% were Caucasian, 51% were male, and 98% of patients had recurrent or metastatic disease. Of particular note, there were no significant differences noted between cohorts with regards to the resource utilization outcome variables assessed. Conclusions: Understanding healthcare utilization in this patient population is of great interest to clinical providers and policymakers alike. While we have previously demonstrated the benefit of integrating palliative care and medical oncology for reducing hospital readmissions and length of stay, this study shows no significant impact of an integrated approach on the utilization of healthcare resources measured within the 30 days prior to discharge to hospice. This may reflect the aggressive approach to management of symptoms for end-of-life patients, which often involves invasive procedures, use of imaging, and other resources to meet their needs.
Palliative outpatient hot clinic: Rapid access for oncology patients visiting emergency department in a tertiary hospital in Singapore—A 1-year experience.
Authors: Yee Choon Meng , Koh Mervyn Yong Hwang , Lee Jia Fang
Published: February 2017

137

Background: Oncology patients often present with symptoms at Emergency Department (ED). While most patients require admission for further management, some patients can be discharged from ED with outpatient follow-up. However, most patients were given 4 to 6 week appointment. In the light of this service gap, our department collaborated with ED to facilitate rapid access to Palliative Outpatient Hot Clinic (POHC) within 3 working days from ED visit in 2015. Methods: We performed a retrospective review of all patients seen in the ED who satisfied the referral criteria to POHC. The time / date of ED visit and basic demographics of patients were collected. Various outcomes of POHC referral were documented using a pre-determined protocol. Results: 17 out of 68 (25%) patients who attended ED and referred to POHC were included. 11 (64.7%) patients were seen after-office hours. 12 (70.6%) patients were ≥ 60 years old, 14 (82.4%) were male, and 11 (64.7%) had Eastern Cooperation Oncology Group (ECOG) ≤ 2. Among them, 6 (35.3%) patients were known to Palliative Home Care Service and 5 (29.4%) patients were referred after-office hours. The most common oncological diagnosis was gastro-intestinal carcinoma (N=6; 35.3%). 8 (47.1%) patients were receiving oncological treatment. All patients were referred for poor symptom control [Pain (N = 8; 47.1%), dyspnoea (N = 5; 29.4%) and vomiting (N = 1; 5.9%)]. 10 (58.5%) patients were given an appointment with POHC within 3 days. 4 (23.5%), 7 (41.2%) and 10 (58.5%) patients were seen in POHC within 3, 7 and 30 days of ED visit respectively. Among 13 patients who were not seen within 3 days, 7 (53.8%) referrals were screened and rescheduled, 3 (23.1%) were readmitted to hospital; 2 (15.4%) requested to change appointment and 1 (7.7%) defaulted the appointment. 10 (58.5%) patients were eventually seen by POHC. Conclusions: Rapid access to POHC is vital in the partnership with ED to allow the seamless and timely provision of Palliative Care for Oncology patients.
Developing a supportive oncology program in a cancer institute: Needs assessment.
Authors: Martins-Welch Diana , Liberman Tara , D'Olimpio James , Carney Maria
Published: February 2017

141

Background: Cancer patients experience significant symptom and psychosocial burden (Temel JS, et. al. N Engl J Med. 2010 Aug 19; 363(8):733-42. Early palliative care for patients with metastatic non-small-cell lung cancer.). Integration of supportive oncology programs within cancer centers has developed since the findings of Temel and Jackson. Addressing a growing need to manage patients comprehensively, the Northwell Health Divisions of Geriatric and Palliative Medicine and Hematology and Oncology partnered to initiate a community-based supportive oncology program. A needs assessment was completed of the providers staff, and important stakeholders. Methods: A sixteen-question survey was created and distributed to the staff at the cancer center. Questions focused on providers’ need for support in fifteen areas. The target audience included physicians, fellows, mid-level providers, registered nurses, social workers, dietitians, and care navigators. A student intern administered surveys over a six-week period. Results: A total of 61 surveys were collected. Of these, 30 were completed by registered nurses, 13 by physicians, 9 by mid-level practitioners, and 3 by social workers. Physicians expressed the highest level of need (> 4.5/5) related to nutritional status, psychosocial factors and pharmaceutical review. Mid-level providers expressed highest level of need related to pain and depression. Nurses expressed highest level of need related to psychosocial factors, pain, depression, fatigue and pharmaceutical review. The average level of need across all areas and all respondents was 4.2 on a 5 point scale. The biggest challenge identified was lack of time to perform comprehensive assessments of patients. Conclusions: A high level of need for a supportive oncology program was identified. Per our assessment, providing comprehensive care with an emphasis on symptom control, nutritional and psychosocial support, and pharmaceutical review would benefit both providers and patients. Time constraints were identified as an issue by all practitioners and staff. The survey results supported the need for an added level of multi-disciplinary support for oncologists to care for cancer patients in the community.
A model of early integration of palliative care into oncology care for patients with metastatic colorectal cancer.
Authors: Ursem Carling Jade , Cantino Laura , Maravilla Ingrid , Thompson Nicole , Atreya Chloe Evelyn , Bischoff Kara
Published: February 2017

142

Background: Current NCCN guidelines recommend that “institutions should develop processes for integrating palliative care into cancer care.” However, it is not clear what the best method is for implementing this integrated care. Palliative care needs specific to patients with metastatic colorectal cancer (mCRC) and best practices for integration of outpatient palliative and oncologic care in mCRC are not well understood. Methods: We conducted a pre-post prospective cohort study to evaluate the palliative care needs of mCRC patients and the implementation of an integrated palliative care program. In both the control and implementation phase, we enrolled patients with mCRC within 90 days of diagnosis or establishing care for mCRC at UCSF. Patients were surveyed regarding their symptoms, quality of life, psychosocial concerns, functional status and understanding of prognosis. During the control phase, patients received usual oncologic care. Based on survey results from the control phase, we designed a palliative care program to target the needs identified. In the intervention phase, patients are receiving longitudinal palliative care integrated into their usual cancer care. Results: The 30 patients in the control phase reported anorexia, fatigue and poor quality of life as their most common symptoms. Common psychosocial challenges were transportation, insurance/financial and difficulty with treatment decisions. Patients also had unrealistic expectations of their prognosis. In order to improve these identified issues, we designed and implemented an integrated palliative care program that includes weekly multidisciplinary meetings with oncology and palliative care providers and proactive palliative care visits from the time of diagnosis, which occur within the oncology clinic at a time that coincides with oncology visits. Conclusions: Physical symptoms, psychosocial concerns and poor prognostic awareness are common among patients with mCRC. We have implemented an integrated palliative care program to address these needs. Evaluation of the effectiveness of this intervention is ongoing.
A qualitative investigation of mindfulness practice to support advance care planning (ACP).
Authors: Johns Shelley A. , Cottingham Ann H. , Beck-Coon Kathleen A. , Helft Paul R.
Published: February 2017

15

Background: Despite ongoing attempts to increase ACP in the U.S, a national longitudinal study of patients with cancer found no significant change in participation in end-of-life (EOL) discussions or living will completion between 2000-2012. A key barrier to ACP includes emotional discomfort talking about EOL care preferences. Mindfulness practices facilitate emotional regulation through present-centered awareness and non-reactive coping. In this pilot, an intervention combining mindfulness training, mindful communication skill development, and information about ACP was hypothesized to increase ACP in patients with cancer. Methods: The Mindfully Optimizing Delivery of End-of-Life Care (MODEL Care) intervention provided 12 hours of training to 13 patients with advanced-stage cancer and their family CGs (n = 13 dyads). Training included breath awareness, sitting meditation, mindful movement (yoga), mindful communication, and ACP information. Patients reported on participation in ACP behaviors at baseline and 4 weeks post intervention. Patients and CGs participated in semi-structured qualitative interviews after MODEL Care that were recorded, transcribed, and coded for key themes. Results: Compared to baseline, patients made notable improvement in ACP behaviors, including having goals of care conversations with their oncologist (p = .03) and family CG (p = .06). Qualitatively, patients and CGs reported an improved ability to “pause” and effectively manage tender emotions, coupled with improved communication and connection between patient and caregiver: “It kind of reminded us both that we need to make a conscious effort to ensure communication occurs on important things”; “We’ve been more in sync than we ever have been.” Moreover, MODEL Care reportedly facilitated thinking about the future to “do what we need to do” and “get things prepared." Conclusions: The MODEL care intervention improved patient and CG ability in areas foundational to ACP engagement: reduced emotional reactivity, communicating about difficult issues, and understanding relevance of ACP. Findings support the potential use of mindfulness training to support ACP for adults with cancer and their family CGs. Clinical trial information: NCT02367508.
Oncology supportive care clinics as a novel model to integrate oncology and palliative care.
Authors: Kim Yan S , Damle Neha , Greene John D , Baker Jennifer M , Luo Esther J , Escobar Gabriel J
Published: February 2017

154

Background: The integration of oncology with palliative care (PC) has been endorsed by the American Society of Clinical Oncology. Starting in 2012, Kaiser Permanente Northern California (KPNC) began introducing Oncology Supportive Care Clinics (OSCCs) to better provide integrated oncology and PC services. We evaluated the impact of OSCCs on outpatient PC referrals among patients diagnosed with advanced cancers. Methods: We included all adult patients diagnosed with incidental stage IV cancer from 2010-2014 from 19 medical centers within KPNC. We excluded 2 medical centers for inconsistent PC referral tracking. Patients were required to have continuous KPNC coverage during the study period and were followed for a minimum of 12 months after diagnosis or until death. Outcomes included the rate of PC referral following diagnosis and time elapsed from diagnosis to referral. Because the introduction of OSCCs was staggered by medical center, we used a difference-in-differences model to compare the outcomes in medical centers with and without OSCC, before and after OSCC establishment. Results: OSCCs are currently operational at 11 medical centers. A total of 1,7640 patients were included. At centers with OSCCs, the referral rate after OSCC increased from 16.5% to 30.9% (p < 0.01); compared to no change at centers without OSCCs (12.5% before vs. 11.7% after, p = 0.35). There was a decrease in the median time from diagnosis to PC referral at all medical centers, from 163 days (IQR 33-541) to 75 (IQR 20-255) days, p < 0.01, regardless of OSCC presence. Conclusions: The KPNC OSCC model has been successful at increasing PC referrals in patients with stage IV cancers, highlighting the important role healthcare delivery systems have in driving practice change. More research is ongoing to examine patient-centered outcomes associated with receiving OSCC services.
The impact of very early referral on the effectiveness of specialty cancer care management services for oncology patients in active treatment.
Authors: Gratias Eric J. , Lindholm Melissa , Rossof Arthur H. , Weininger Richard B. , Rausa Margaret , Schumacker Pamela , Hartley Steven , Richards Diane , Spangler David , Stern Debra , Reid J. Scott
Published: February 2017

157

Background: Many patients receiving treatment for cancer experience high levels of morbidity and reduction in quality of life. Proactive specialty cancer care management programs can be offered to patients experiencing these challenges. These patients are most often self-identified, referred by a physician, or identified by claims from a commercial or government insurer or vendor. While earlier intervention of case management or palliative care services has been shown to improve outcomes for cancer patients, a variety of logistic challenges frequently interfere with early referral. Methods: All oncology patients obtaining regimen-based chemotherapy prior authorizations were referred for specialty cancer care management via the prior authorization process. Additionally, all oncology patients in active treatment or with active disease whose benefits included care management were eligible through standard referral mechanisms. Patient satisfaction scores were measured every 3 months for all patients enrolled in the program. The medical cost savings value of referral to the specialty cancer care management program was evaluated by comparing patients referred to the program within 30 days of diagnosis (very early referrals) against patients found between 30 and 120 days from the time of diagnosis. Results: Compared with patients referred through standard methods, patients referred to the specialty cancer care management team at the time of chemotherapy authorization resulted in a high percentage of very early referrals. Patients enrolled in specialty cancer case management within 30 days of diagnosis saved an average of $16,000 per surviving participant, or 30% more than patients referred between 30 and 120 days from diagnosis. Overall, patients engaged in specialty cancer case management are highly satisfied. Overall satisfaction with the nurse/case manager was 98%. Conclusions: Early referral of high risk oncology patients to patient-centered care management programs improves the overall patient experience while simultaneously reducing health care costs, and should be strongly considered for all oncology patients with high morbidity or mortality risk.
New primary palliative care (PC) model for community cancer clinics (CCC).
Authors: Santhosh-Kumar Cheruppolil R. , Gray Deborah , Struve Stephanie , Huibregtse Carol , Chen Qiaofang
Published: February 2017

159

Background: Our CCC serving a mixed rural/urban population is part of a large integrated healthcare system in Eastern WI. The closest PC specialist/team is 45 miles away at one of the tertiary care facilities. To fill this service gap we implemented a primary PC model. An initial outpatient palliative care family conference (OFC) and use of cancer nurse navigators (CNN)are hallmarks of this program. Methods: The VLCC, housed in a standalone facility is staffed by two medical oncologists and one radiation oncologist and has an infusion center and a full-fledged radiation oncology unit with support staff, including cancer nurse navigators, research nurses, social workers, a clinical psychologist, a pharmacist, a nutritionist, a therapy dog and a chaplain. Specialized pain management teams and services like acupuncture and hypnotherapy are readily available in the community. The patients have had access to multiple clinical trials since 2004. A team of a physician champion, a CNN and a social worker prioritized the needs and designed a program with support from system leadership. A CNN took additional training in PC. Funding from a research grant provided support for an occupational therapist (OT). Difficulties in communication was identified early as a barrier to integration of PC. OFCs were designed and conducted to discuss multiple domains of palliative care and referrals were made to different services. Pre and post enrollment surveys were administered. The following flow diagram was used (see Table). Results: In 2015, of 334 new patient visits for all stages of cancer, 32 were managed through the new PC model. Patient satisfaction scores were near 100%. Detailed methodology and data analyses will be presented. Conclusions: A successful new model of early integration of PC that is easily replicable in communities without access to specialist PC services is presented. [Table: see text]
Addressing resource allocation for advance care planning discussions in hospital.
Authors: Wong Aaron Kee Yee
Published: February 2017

16

Background: Advance care planning (ACP) is fundamental in quality palliative care. There is no data detailing the demand for ACP discussions in hospitals, nor any standard objective criteria to decide urgency of such discussions. This cross-sectional study addresses this by comparing the ability of two commonly used instruments to detect palliative patients, and to predict death in the current admission. Methods: All inpatients were censored from the largest tertiary hospital in the state on a single inpatient day. 475 patients were followed for 3 months or until discharge or death, whichever earlier. Quan-modified Charlson score (QCS) and the Palliative Prognostic Score (PaP) was identified for each patient. These instruments were chosen based on external validity and ease of scoring. Results: See Table. 134 patients were identified as palliative (using Gold Standards Framework Indicators). 40 patients died. Both instruments were highly specific in detecting palliative patients and deaths but not sensitive, meaning they predicted patients who were palliative or died that admission. PaP>5.6 was most sensitive test to detect death in current admission. Conclusions: Despite poor sensitivity, the most sensitive instrument (QCS) detected many patients requiring ACP discussion on a single day in hospital, highlighting the demand for ACP-trained staff. Secondly, streamlined usage of these instruments may assist in prioritising resource allocation. The QCS could identify patients needing ACP discussions (despite poor sensitivity, still identified many patients), whereas the PaP > 5.6 could refine the prioritisation of such discussions. This strategy could assist in reaching as many patients as possible using current staffing levels. [Table: see text]
PathWell: The development of a triage center and access hub for comprehensive palliative care in oncology.
Authors: Ramchandran Kavitha , Tribett Erika Lauren , Winget Marcy , Webster LaTisha , Valmayor Dorothy , Lunger Jenna , Falconer Patricia
Published: February 2017

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Background: Routine screening to identify palliative care (PC) needs, followed by assessment and management of needs is critical for high-quality cancer care. Our current healthcare system there is poor screening for PC needs, low referral rates to PC services, and unmet needs. In response to these gaps, we developed a dedicated triage center to streamline the assessment of PC needs and better connect patients with appropriate supportive care services. Methods: We identified 24 services at our academic cancer center that provide PC and supportive services. Examples include PC, psycho-oncology, survivorship, nutrition, and social work. Representatives from these groups convened to map service overlap and develop referral structures based on patient need and acuity. A triage hub (PathWell) was established to complete uniform assessments of patient needs and determine appropriate referrals. The hub utilized a centralized scheduling platform, new patient coordinators, and an oncology nurse for assessment and triage. Referrals to the hub were made via EHR, direct patient contact, or prompted by routine distress screening. Results: PathWell launched on February 1, 2016. Referral volume to the hub was 54 in February, 91 in March and 74 in April. Referrals from PathWell were distributed amongst the 24 services, the majority of referrals going to PC, psycho-oncology and nutrition. All programs that were part of the triage center experienced growth in volume; PC 41%, psycho-oncology 14%, nutrition 16%. Conclusions: Partnerships between specialist services and dedicated triage staff can improve early access to resources for PC needs. Early data from PathWell reveals improved assessment and management of patient needs via referrals to appropriate services. The hub has also unveiled important resource gaps (e.g. physical therapy, integrative medicine). These gaps were not previously quantified, and thus not prioritized by leadership. Future state for PathWell includes reporting operational and health-related outcomes, optimizing distress screening, establishing care pathways for patient subtypes (e.g., metastatic disease), and hosting interdisciplinary tumor boards for complex distress management.
Palliative care interventions and end-of-life care outcomes for hepatocellular patients (pts) at two Veterans Affairs (VA) medical centers.
Authors: Wang Zhen , Lee Sarah , Kothadia Sejal , Wang Yucai , Chang Victor Tsu-Shih , Park Yeun-Hee Anna , Olson Ellen , Klein David , Zhong Fengming
Published: February 2017

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Background: Palliative care interventions and their effect on EOL outcomes for liver cancer pts have not been described. We investigated the association between palliative care intervention and EOL care outcomes. Methods: We reviewed the charts of pts with hepatocellular carcinoma and who were seen by palliative care at 2 VA medical centers from 2006 to 2012. We investigated the association between EOL outcomes (number of ER visits, ICU visits, chemotherapy, place of death, number of hospitalizations during their last 30 days), and interventions such as early referral (within 30 days of diagnosis), defined goals of care, holding a family meeting, and symptom assessment and management. The protocol was reviewed by the IRB of both VAs and analyses were done with SAS Studio v3.4. Results: 82 charts were reviewed (30 from EOVA and 52 from BVA). All Pts were men; 30 (39%) were white and 47(61%) African American. Interval from diagnosis to palliative care consult was 68 days (median). 72 (90%) pts were not aware of their diagnosis. 48 (65%) were not aware of prognosis. 65 (88%) had decision making capacity. 32 (39%) pts were DNR/DNI. 60 (86%) pts chose symptom management and 10 (14%) life prolongation. 47 pts (50%) had family meeting. In the last month, 35 pts (48%) had ER visit. 9 pts (12%) had ICU visits, 4 pts (5%) had chemotherapy and 48 pts (71%) had at least 1 hospitalization. 68 (85%) underwent symptom assessment. Most frequently treated symptoms were pain (78%), nausea (27%), constipation (46%), dyspnea (34%). Significant associations were found for early referral and ER admissions (OR = 3.2, p = 0.0178), family meeting and site of death (OR = 0.136 p = 0.0037), family meeting and number of hospitalizations (OR = 0.2652, p = 0.0169). Pts choosing symptom management and who had family meetings associated with hospice/home as place of death (chisq = 5.7368, p = 0.016). Knowledge of prognosis was not associated with site of death. Conclusions: In this population, many palliative care interventions were performed. Early referral, family meetings were significantly associated with site of death, ER admissions, and number of hospitalizations. These results should be replicated in larger studies.
Impact of financial burden on information and opportunity for cancer (ca) patients' (pts) participation (par) in clinical trials (cts).
Authors: Mitchell Edith P. , Dornsife Dana
Published: February 2017

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Background: The degree to which cancer caused financial problems may influence ca pts par in cts and negatively impact quality of life (QoL). Financial burden of cts par, may include finding an appropriate trial, traveling to the trial site, paying for travel, lodging and some medical expenses. The Lazarex Cancer Foundation (LCF) was founded in 2006 with mission to improve care, giving hope, dignity, and life to advanced ca pts by providing assistance with options and costs to cts par, community outreach, and education. LCF developed processes to removing the barriers to cts par by improving equitable access to cancer care, increasing cts enrollment, retention and minority par, and increasing cts referrals. Methods: To determine the extent of benefit of LCF, we conducted a retrospective analysis of LCF beneficiaries participating in cts by reviewing and summarizing the #pts, states and countries of residence, age, type of cancer, location and distance to cts site, type of assistance, and #of advocacy/outreach. Results: From 1/01/2010 – 12/31/2015 1479 pts were assisted; age range 4-86 yrs, median 50-60; 638(43%) male, 790 (53%) female, 51 (3.4%) undeclared. 434 did not give racial/ethnic identity; of 1045, 67 (6.4%) were African American, 108 (10.3%) Hispanic, 38 (3.6) Asian Pacific Islander, other 22 (2.1), and Caucasian 760 (72.7%) –total minority 235 (22.5%). Pts resided in 49 states with largest CA-280, TX-131, MA-119, FL-81. Cts were at 115 sites; 38 NCI CCC, 8 NCI DCC. The most common diagnoses were breast-116, leukemia-87, colorectal-48 and many rare type tumors. The median household income was $75,000. Financial assistance to travel to and living expenses at the cts site was the most frequently identified need. Conclusions: Relieving pts of financial burden allows greater access to and participation in cancer clinical trials. Further research and greater resources are needed to define the patient needs and determine methods to eliminate and remove barriers to enrollment and retention. Future research should investigate coverage thresholds that minimize adverse financial outcomes and identify ca pts at greatest risk for financial toxicity to increase par in cts and enhance QoL.