bluuebunny/crossref_metadata_2025 huggingface dataset:
Do case rates affect physicians' clinical practice in radiation oncology?
Authors: Loy Bryan A. , Shkedy Clive , Tankersley Mark A. , Altonen Brian , Royalty Julie
Published: February 2017

59

Background: Radiation oncology practices and health plans typically engage in fee for service (FFS) contractual relationships, which employ utilization management techniques to manage treatment accordance with recognized guidelines. FFS contracts often result in unpredictable revenue streams for practices and burdensome administrative processes for both practices and payers. Moreover, there are limited mechanisms in FFS arrangements for practices and payers to systematically measure quality. Radiation oncologists and health plans share the common goal of systematically improving quality of patient care while reducing administrative burden. Methods: In 2012, Humana collaborated with a large national radiation therapy provider to implement ‘bundled’ case rate reimbursement instead of FFS. The case rate model was developed with HealthHelp, a radiation oncology quality vendor, and the payments were developed in the context of the appropriate modality for each cancer type. Changes in practice patterns were measured in the Medicare population by average fraction ratios across breast cancer, bone metastases, and prostate cancer. Fraction ratios compare delivered fractions to standards established by the National Comprehensive Cancer Care Network guidelines. A ratio of 1.0 means that the delivered amount met the recommended guideline. Ratios nearer to one (over or under) demonstrate appropriate therapy. Ratios were compared for 2011 vs. 2013 using T-tests. Results: Conversion from a FFS to case rate reimbursement did not coincide with a change in fraction ratios for breast cancer treatment. Fraction ratios for both bone metastases and prostate cancer moved towards the target ratio of 1.0 after the move to case rate reimbursement. Conclusions: After the implementation of case rate reimbursement, fraction ratios improved for bone metastases and prostate cancer, while breast cancer fraction ratios did not change. Future work will evaluate additional markers of quality and practice efficiency measurements. [Table: see text]
Process outcome measures of patients with head/neck, thoracic, and gynecologic malignancies in the MDC clinic.
Authors: Ogata AnnaLyn S. , Conde Francisco A. , Morris Paul , Halford Peter , Chadwick Darlena , Tsuruoka Perry
Published: February 2017

61

Background: Queen’s Medical Center (QMC) was selected as one of 14 sites nationwide to participate in the expansion of the National Cancer Institute’s Community Cancer Centers program in 2010. In 2011, QMC implemented Multidisciplinary Clinics (MDC) to make the treatment of patients with head and neck (H&N), thyroid, thoracic, and GYN malignancies more efficient and seamless. The purpose of this study was to examine the following process outcomes: timeliness of care, adherence to MDC treatment plans and national guidelines, and utilization of ancillary services in H&N, thyroid, thoracic, and GYN MDC. Methods: Retrospective, chart review of patients with H&N, thyroid, thoracic, and GYN malignancies who were seen at the MDC from Jan 2012 to Dec 2012 was conducted. Variables collected were patient demographics, initial date of referral to the MDC, date of first cancer treatment, clinical variables (e.g. cancer diagnosis, co-morbidities, social habits [smoking, drinking, drug use]), and hospital process variables (e.g. reasons for delay in treatment, adherence to national guidelines, and use of ancillary services [e.g. navigation, dietary, survivorship, social work, chaplain, genetic counseling]). Results: 222 charts were reviewed (H&N = 69, Thyroid = 54, Thoracic = 48, Gyn = 51). Ethnic minorities represented over 50% of the sample. For all cancers combined, average time to referral to first treatment was 32 days. Post-hoc analysis showed that patients seen in GYN MDC (mean = 17.5 + 12.3 days) had significantly fewer days from referral to first cancer treatment compared to patients seen in the H&N MDC (mean = 41.3 + 25.6 days), F = 4.3, p = 0.003. For all sites combined, there was 99.5% adherence to the MDC recommended treatment plans, and 100% adherence to NCCN guidelines in the treatment received. Most patients with GYN malignancy (96.1%) were referred to one or more ancillary services followed by H&N (88.4%), thoracic (85.4%), and thyroid (46.3%). Conclusions: Study provided baseline process outcomes for MDC of disease sites which are often less studied in literature. MDC nurse coordinator played a critical role in ensuring efficient and quality patient care. Results can serve as basis for further quality improvement.
Understanding oral chemotherapy use at the end of life: Analysis of a Massachusetts claims database.
Authors: Zerillo Jessica A. , Stuver Sherri Oliver , Fraile Belen , Dodek Anton , Jacobson Joseph O.
Published: February 2017

8

Background: Receipt of chemotherapy in the last 14 days of life is a measure of potential overuse of care. But the appropriateness of oral chemotherapy specifically is not yet described, and there are little available data on utilization of oral chemotherapy at the end of life. Methods: We analyzed results from 200 patients of Dana-Farber Cancer Institute, covered by the Blue Cross/Blue Shield of Massachusetts (BCBSMA) pharmacy benefit, and who died in 2012. We collected data on chemotherapy use in the last 6 months of life. We analyzed oral chemotherapy use in the categories of any oral prescription and timing of first oral prescription. We compared results to intravenous (IV) and any other administration route. Results: Most of our target population had gastrointestinal, thoracic, or breast malignancies. In the last 6 months of life, 75% received some form of chemotherapy, including 23.5% who were prescribed an oral agent. 11 patients were prescribed oral chemotherapy in the last 30 days of life. For 45% (n=5) this was the first oral prescription. In the last 14 days of life, only 5.5% of patients received any chemotherapy, including one patient prescribed an oral agent. Conclusions: The collection of oral chemotherapy utilization data through insurance claims was feasible. Use of any chemotherapy, including oral, sharply declined during the last 30 and 14 days of life, consistent with a shift to palliative end-of-life management. This analysis highlights the need for a more comprehensive understanding of oral chemotherapy use at the end of life. Furthermore, with the growing use of oral chemotherapy, the development of measures to define quality of end-of-life care with these agents is warranted. [Table: see text]
Health risk assessment of head/neck cancer patients.
Authors: Salner Andrew , Dornelas Ellen A
Published: February 2017

81

Background: Effective methods of screening head and neck cancer patients for health risk behaviors are needed. Methods: The present study assessed 452 cancer patients with an assessment that covered the following domains: psychological distress, smoking status, nutritional intake, functional activity level and need for support services. Thirty six out of the 452 patients recruitedfrom radiation oncology carried a diagnosis of head/neck cancer. Results: Patients with head/neck cancer had higher levels of depressive symptoms measured by the Patient Health Questionnaire (PHQ9) with mean scores of 6.3 (SD=4.8) compared to the scores of patients with other cancer diagnoses (mean PHQ9 score= 4.3, SD=5.4) p=.04. Twenty percent of head/neck patients had PHQ9 scores greater than 12 and 52% had a distress thermometer score of >4. Head/neck patients were more likely to be current smokers or have quit since diagnosis (31%) compared to patients with other diagnoses (16%) p=.02. Head/neck patients were more likely to be male 68% (p<.001). When asked if they would like services from any of the following practitioners, 29% requested a nutritionist, 14% requested a social worker and 25% requested integrative medicine services. None of the smokers with head/neck cancer requested services from the smoking cessation counselors compared to 25% of smokers with other cancer diagnoses. In the sample of head/neck patients, 73% of smokers were likely to endorse feeling “worry, fear or nervousness” compared to 33% of non-smokers (p=.04). Referrals were facilitated with an automated email to the clinician within 2 days of the assessment. Conclusions: Head/neck patients in this sample are more likely to have depressive symptoms and to have health risks such as smoking. Smokers are less likely to be receptive to smoking cessation counseling. Cumulatively, these data suggest that the needs of head/neck cancer patients are distinct and this diagnostic group may benefit from enhanced survivorship services both during treatment and to follow.
Mismatch of available cancer therapeutic trials to patient populations in community practices.
Authors: Lai Lily L. , Woo Doni , Chapman Yvonne , Sudan Nimit , Yeon Christina Haeyoung , Trisal Vijay , Waisman James Ross
Published: February 2017

84

Background: Clinical cancer research has consistently been associated with improvements in the quality of cancer care in community practices. We initiated a project to better identify the barriers to enrollment into adult oncology therapeutic trials in a community setting. Methods: Over a 12-month period from June 2013 – May 2014, all consecutive new patients presenting to medical oncologists at two community practices (CP1 and CP2) affiliated with an NCI-designated Comprehensive Cancer Center (NCI CCC) were screened by trained clinical research nurses. Data captured included demographics, diagnoses, stage of disease, previous treatments. Therapeutic trials available through the NCI CCC were matched to the patients. Actual enrollments rates into the trials were calculated. Results: A total of 1,430 new patients was seen in the time period studied (CP1, n=1,088; CP2, n=342). Of these, 912 (CP1, n = 667; CP2, n = 245) patients had a cancer diagnosis. At CP1, 63 therapeutic trials were available through the NCI CCC. 64 (8.3%) patients matched the criteria for any of the available trials, 33 enrolled, 18 declined, 13 failed screening. The accrual rate was 51.5% (33/64) of the patients who matched available trials and 4.9% (33/667) of all new cancer patients. At CP2, 32 (13%) patients matched available trials. The factors associated with the inability to match therapeutic trials with the new patients included: adjuvant treatment status, disease sites, prior treatment requirements, protocol specific tests, protocol specific requirements for correlative studies. Conclusions: Of the 912 new cancer patients treated at 2 community sites affiliated with an NCI CCC, only 10.5% matched available therapeutic trials. Although the enrollment rate into therapeutic trials is high in patients who matched available trials (51.5%), the overall accrual rate of all new cancer patients is 4.9% and consistent with previous studies. Our study highlights the significant mismatch between available trials and clinical populations treated at community sites. We suggest that an improved process to better match patient populations and available trials will improve on clinical trial accruals and efficiencies.
Optimizing smoking cessation resource awareness among patients and providers.
Authors: Ma Laura , Donohue Caitlin C. , Denofrio Tina , Pedulla Lillian Vitale , Haddad Robert I. , Jacobson Joseph O. , Rabinowits Guilherme
Published: February 2017

85

Background: Despite receiving a cancer diagnosis, many patients continue to smoke during treatment, negatively affecting their outcomes and putting them at risk for secondary cancers. We witnessed that limited smoking cessation (SC) discussions were occurring among patients and providers (MDs/NPs) and hypothesized that this was partially due to the providers' lack of awareness of the current SC resources available. Methods: We surveyed the head and neck oncology (HNO) providers at Dana-Farber Cancer Institute to evaluate their awareness about existing SC resources within the community. We performed a 6-month chart review of active smokers to evaluate frequency of documented SC discussions in clinic, and developed several targeted interventions: we educated the HNO providers on available SC resources within the community; developed a SC resource teaching sheet for smoking patients; placed a provider alert page in exam rooms to remind the providers to discuss the SC teaching sheet with the patient; and built a SC discussion template in the electronic medical record to ease documentation. Four weeks post intervention we resurveyed providers and performed chart reviews of active smokers to reevaluate the frequency of SC discussion documentations. Results: Pre-intervention, only 13% of HNO providers were aware of SC resources available within the community and the mean SC discussion documentation was 33%. Post-intervention, 100% of HNO providers became aware of the SC resources available, and the mean SC discussion documentation increased to 76% at 7 weeks. Identification of active smokers in clinic increased from 2-5 smokers per week pre-intervention to 4-13 smokers per week post intervention. Eighty-eight percent of HNO providers felt the intervention prompted them to discuss SC with their patients. Conclusions: The limited number of SC discussions among patients and providers is at least partially due to unawareness of SC resources available within the community. Educating providers, and alerting them to their active smoking patients at the time of their clinic visits, successfully prompted providers to discuss the importance of SC, and empower patients with resources to help them quit.
Utilizing TQM and CQI prinicples in establishing a Type 1 observation unit in a comprehensive cancer center.
Authors: Halm Josiah
Published: February 2017

96

Background: CMS defines Observation Services as outpatient care ordered by a physician and provided in a hospital bed to determine the need for inpatient admission or discharge. Recent CMS rules on Observation stay and 2-midnight rule has created confusion amongst Medicare beneficiaries, providers and hospitals. Two-thirds of US hospitals deliver observation care without using an observation unit. Review of our hospital observation care and a survey of Cancer Centers within the Alliance of Dedicated Cancer Centers revealed that observation care was provided in a bed anywhere in the hospital with unstructured care provided at the discretion of the treating physician. This leads to less favorable outcomes compared to protocol driven and closed observation units (Type 1). Methods: Plan- Institutional stakeholders consisting of administrators, hospitalists, ED physicians, case managers and nurse managers developed an observation services guideline policy and project team. Do- pilot initiated with ED admitting Observation patients to dedicated hospitalist providers and unit. Order sets were developed, education and staff training was provided and target start date set. Baseline and performance measures were developed. Study- impact on ED flow, admissions, ED length of stay, provider satisfaction, diagnoses, patient case-mix, and financial costs. Act– Implemented changes and lessons learned from pilot Results: Before implementation of pilot less than 10 patient per month were placed in observation status (Sept 2011- Aug 2012). After pilot average of 30 patient per month were initially placed in Observation (Sept 2012-April 2014). Approximately 73% of patients placed on observation are discharged and not admitted. Observation counts for approximately 25,000 dollars in professional charges per month. ED LOS decreased to less than 6-hours. Patient satisfaction and ED provider satisfaction scores have improved. Conclusions: Majority of Observation patients are not admitted thus avoiding the higher cost associated with inpatient stays with resulting cost saving. ED wait times have improved leading to less over-crowding with ED physicians having time to see more patients.
Development and implementation of clinical pathways in lung cancer at an academic comprehensive cancer center.
Authors: Tan Sally , Porter Julie M. , Barysauskas Constance , Mach Stacy L. , Rodgers Ed , Elfiky Aymen , Jacobson Joseph O. , Jackman David Michael
Published: February 2017

98

Background: Clinical pathways (CP) is an emerging tool aiming to reduce unwarranted variation and maximize value in cancer care. We describe the preliminary experiences and challenges of developing, implementing and testing pathways at a comprehensive cancer center. Methods: Dana-Farber Cancer Institute (DFCI) partnered with Via Oncology to develop and pilot institution-derived CP in lung cancer. The Via platform tracks usage rate, adherence to the DFCI-designed CP (on-pathway rate), and reasons why off-pathway treatments were chosen. An online satisfaction survey was conducted among providers participating in the pilot. Results: Between 1/27/14 and 5/30/14, 277 chemotherapy treatments were initiated, with 124 new patients. CP was used to generate 98% of new chemotherapy orders; 63% were on-pathway. The most common off-pathway reasons were 1) poor patient performance status and 2) treatment beyond 3rd line. 22 of 41 specialists who participated in the CP pilot at DFCI’s main campus responded to the survey (54% response rate). Respondents ranked the Institute as the stakeholder who most benefits from CP, followed by payers, DFCI network community physicians, DFCI main campus physicians, and patients. Respondents recognized CP reflects appropriate care but are concerned about workflow (Table). Conclusions: Implementation of an institution-derived CP is feasible at a comprehensive cancer center. Physician input into pathway design is essential to build buy-in. Academic specialists perceived more benefit of CP for their community peers and raised concerns about workflow. On-pathway rates were lower than those reported in community settings, due to many potential factors (to be explored with updated data for final presentation). [Table: see text]
Decision making for older adults with advanced cancer: Patient and family member perspectives.
Authors: Hickman Susan Elizabeth , Weaver Michael T. , Habermann Barbara , Helft Paul R.
Published: February 2017

101

Background: The National Cancer Institute and palliative care guidelines emphasize the importance of family member perspectives in end-of-life decision-making for patients with advanced cancer. However, only a handful of studies have examined what role family members play in decisions to continue or discontinue disease-directed therapy. Methods: Thirty-four dyads consisting of a patient (PT) aged 65 and older with metastatic lung, pancreatic, or esophageal cancer and a family member (FM) filled out surveys about goals of care, discussions with the treating oncologist, communication conflict, and decisional uncertainty. Results: Most PTs (60%) understood their cancer was metastatic, and 86% reported they were currently receiving chemotherapy. PTs and FMs (82%) had a shared understanding about current goal of treatment and were more likely to report discussions with the treating oncologist about reasons to continue chemotherapy (90%) than discussions about reasons to discontinue it (53%) (McNemar’s S = 7.0, DF = 1, exact p =.016). However, only a minority of PTs and FMs (26.5%) agree on the preferred course of treatment. FMs (59%) were more likely than PTs (24%) to prefer a course of treatment focused on palliation rather than extending life (Bowker’s S=9.3, DF=3, p=.026). Many patients (44%) were unsure of their preferences. Patients who perceived higher levels of communication conflict with their family reported more decisional uncertainty about their preferred treatment option (r =.49, p =.02). Conclusions: Patients and family members largely share in their understanding of the current treatment goal and recall of discussions with the oncologist about treatment options. However, family members tend to prefer a course of treatment focused on comfort compared to patients, who prefer a course of treatment that extends life as much as possible even if it means having more side effects, pain, or discomfort. Patients who report conflicted communication with family members are more uncertain about their decisions. Findings suggest a need for increased discussion about goals of care and treatment alternatives with advanced cancer patients and their family members.
An innovative model for palliative care at home for 100,000 patients with cancer since 1985 in Italy: A social partnership for a public health system integrated and sustainable.
Authors: Pannuti Raffaella , Varani Silvia , Pannuti Franco
Published: February 2017

113

Background: In Italy, like in most Western countries, the number of elderly people with a chronic disease is constantly increasing and it causes a growth in disability and frailty. However, the Public Health Service is unable to provide all the services needed. Therefore it is necessary to find urgent actions to fill in the gaps of the Public Health Service and to think about appropriate solutions for a sustainable future. Methods: Since 1985, ANT has assisted at home more than 100,000 cancer sufferers, completely free of charge, thanks to its 20 oncological teams in 9 Italian regions. There are currently about 4,000 patients receiving care every day throughout Italy. ANT offers specialized care provided by 400 healthcare professionals, including doctors, nurses, psychologists, nutritionists, physiotherapists, social-health workers, who are able to provide patients with round the clock care, 365 days a year. Results: The quality of the model of ANT home care is supported by the following outcomes: 78% of the patients (ANT National average) choose to die at their own home in contrast with the National average of cancer death at home equal to 57,9%. In the last 30 days of life, 74% of the patients assisted by ANT aren’t admitted to hospital, 12% have an hospitalization lasting less than 7 days and only 14% remain in hospital for over a week. The customer satisfaction, assessed through a questionnaire sent to families about a month after death, shows that 90% of respondents are very satisfied with the assistance received. ANT spends about 2,090 euro for each patient assisted. Given that each patient is cared for an average of 132 days, the cost is about 30 euro a day. This charge is much lower than a recovery for a day in a palliative care residential facility (240 euro) and it is lower also than an admission for a day in a public hospital (780 euro). Conclusions: The situation calls for a change in strategies in health policy, stimulating integration between public and social institutions. The model of ANT home care is an example of a social buffer that offers an integrated health and social assistance able to meet the increasingly complex needs of patients and their families.
A survey to evaluate our physician-trainees' comfort and knowledge in communicating their final good-bye to their terminally ill patient.
Authors: Marcus Joel , El Osta Badi Edmond , Sumrall Bradley , Mott Frank
Published: February 2017

114

Background: Although dealing with end of life (EOL) issues is common and can be stressful in cancer care, very little is taught and written in regards to how healthcare professionals should communicate their final good-bye with their terminally ill patients. There is a wealth of literature available about communicating “bad news”, but a literature review elicited scant data about this topic. Methods: We conducted a pilot survey on 88 house staff physicians to evaluate the frequency, their level of comfort, whether they had prior training and their knowledge about communicating their final good-bye at the EOL and their interest to learn more about this communication skill. Results: 42% were first year trainees across all specialties. 61% encountered at least 1 patient monthly at the EOL. 45% felt comfortable saying good-bye to a patient they were unlikely to see alive again. 54% have expressed interest in learning how to communicate their final good-bye to their patient at the EOL. However, only 5.7% have reported receiving a thorough training and 2.2% endorsed being very knowledgeable in this communication skill. 81% were interested to learn these skills from experienced mentors. Conclusions: Communicating the final good-bye with the terminally ill patient is an important skill that is not routinely taught to our physician-trainees. The majority of them expressed their interest to learn this skill from experienced mentors. Palliative care healthcare professionals can play a pivotal role in our physician training programs by mentoring our trainees on communicating their final good-bye to their terminally ill patient effectively and compassionately. Once implemented, further studies will be needed to assess the impact of experienced mentors on the comfort and knowledge of our physician-trainees in this communication skill.
Considerations for quality improvement in radiation oncology therapy for patients with uncomplicated painful bone metastases.
Authors: Walling Anne M. , Wenger Neil , Kaprealian Tania Betty , Kupelian Patrick , McCloskey Susan Ann , King Christopher R. , Beron Phillip , Steinberg Michael L.
Published: February 2017

118

Background: Although American Society for Radiation Oncology (ASTRO) guidelines support single fraction radiation treatment for uncomplicated bone metastases, it is rarely used. Methods: We used modified RAND/UCLA appropriateness methodology to understand how radiation oncologists make decisions about single fraction treatment to inform quality improvement. We focused on uncomplicated bone metastases (defined by relevant RCT exclusion criteria) without prior irradiation, pathologic fracture, or spinal cord compression. Eight radiation oncologists with varying sub-specialties were provided ASTRO guidelines, a summary table of RCT’s and recent research on current practices. They rated the appropriateness of 8Gy Single Fraction treatment and 4 alternative regimens for clinical cases before and after a panel discussion that also included three palliative care physicians. Clinical cases varied by location of metastases (spine, humeral head, femur, rib), size of metastases, patient prognosis, travel distance to treatment site, and patient age. We report findings based on final median appropriateness ratings and qualitative evaluation of discussion. Results: Single fraction treatment (8Gy) was rated as the most appropriate treatment, regardless of other factors if prognosis was 6 months or less. However, participants noted that prognostic information is often not available at the point of care. Use of greater than 10 fractions was rated as inappropriate regardless of other factors. Older age and travel distance were factors that lead to favoring 8Gy single fraction treatment. There was less consensus concerning single fraction treatment and favoring of other treatment approaches for lesions located on the spine, especially large lesions, and for patients with oligometastases and a longer prognosis where goals may include local tumor control in addition to palliation. Conclusions: Improving specification and communication of prognostic information is an important quality improvement target to enhance the patient-centered nature of care for patients with painful bone metastases.
The serious illness care program.
Authors: Bernacki Rachelle , Block Susan
Published: February 2017

12

Background: Conversations between patients and clinicians about end-of-life care allow patients to prepare and plan for the end of life and are associated with improved outcomes. Objective: To determine the impact of a structured, seven-item conversation guide on anxiety and depression in patients with an estimated prognosis under a year. Methods: A cluster, randomized controlled trial enrolled 81 clinicians and 272 patients (goal of 400 patients) at Dana Farber Cancer Institute. The intervention (integrated into regular clinical care by oncologists) consisted of a system to identify patients and trigger clinician discussions using the checklist, clinician training, and documentation template in the electronic medical record. Adult patients were identified by oncologists using the “surprise” question. Surveys measured key outcomes before and after administration of the checklist (for patients) and after training (for oncologists). Results: 1,299 patients were identified using the surprise question. Of patients contacted, 332 agreed to participate and 254 declined. To date, 62 conversations are complete with a median length of 20 minutes (range: 8-70 min). The mean anxiety level using the GAD-7 score for the participants with complete data prior to the checklist conversation was 4.0 and post-conversation 3.1 (p=0.04). The mean depression score using the PHQ-9 prior to the checklist conversation was 6.3 and post-conversation 5.7 (p=0.2). 51% of patients found the discussion ‘very’ or ‘extremely’ helpful; 21% found the discussion ‘somewhat’ helpful; and 14% ‘slightly’ or ‘not at all’ helpful. The majority of clinicians found the guide simple (79%) and easy to use (78%); 81% reported they would continue its use after the trial. Conclusions: These preliminary data demonstrate that use of the guide is feasible, acceptable to patients and clinicians, and does not lead to increased anxiety or depression. There is a trend towards a significant reduction in anxiety in patients who had the discussion with their oncologists. The Serious Illness Care Program is an acceptable intervention to support clinicians in conducting conversations about end-of-life values and goals with patients, allowing them to articulate their wishes about future medical care. Clinical trial information: NCT01786811.
Palliative prognostic tools for the terminally ill patients with gastric cancer.
Authors: Kang Beodeul , Choi Hye Jin , Rha Sun Young
Published: February 2017

120

Background: Terminally ill patients with gastric cancer have specific gastrointestional symptoms and signs related with cancer progression. To estimate accurate survival expectancy of gastric cancer patients is important for timely decision making of their end of life issues. Methods: We reviewed the 276 patients with terminally ill gastric cancer who were treated at Yonsei Cancer Center between January 2007 and December 2011 and eventually were died. Retrospectively, we conducted the data of clinical signs, symptoms, and laboratory results at the time of cessation of the active treatment. Then, we established the palliative survival estimation model by stratification of risk group. Results: Median palliative survival time from the decision to stop further treatment to death was 42days. In the multivariate Cox regression analysis, 5 parameters were identified as prognostically significant factors: anorexia, dyspnea, hypoalbuminemia, elevated blood urea nitrogen, and elevated serum alkaline phosphatase. We scored each variables as 1-3 for symptom(1:asymptomatic, 2:symptomatic, 3:symptomatic requiring intervention) and 1-2 for lab results(1:normal, 2:abnormal) and summed up each scores. Using the total score, patients were divided into 3 risk groups: low-risk(5-7points), intermediate-risk(8-11points), and poor-risk patients(12point). As a result, median palliative survival for low-risk group(n=110) was 87.0±7.4days, intermediate-risk group(n=158) and poor-risk group(n=8) were 31.0±2.1days and 6.0±2.1days, respectively (p<0.0001). Conclusions: Using multivariate analysis and summation of each prognostic factor score, 3 risk groups were determined. After validation by prospective multicenter trial, this palliative survival time estimation tool will be helpful to inform the accurate survival for terminally ill gastric cancer patients.
Organization, teamwork, and advocacy: Important skills needed by hospice family caregivers who manage medications.
Authors: Tjia Jennifer , Reblin Maija , Lemay Celeste , Clayton Margaret , Ellington Lee
Published: February 2017

121

Background: In the home hospice setting, family caregivers (CGs) often assume medication administration responsibilities traditionally performed by licensed nurses. Little is known about how to assess and support CG medication management skills. As part of an ongoing study of nurse-caregiver interactions in home hospice, we gathered data on CG medication management needs. Methods: A longitudinal, multicenter study of home hospice nurse visits captured audiorecorded communication between nurses and CGs. Participants included patients with cancer and their self-identified CGs who were recruited upon home hospice enrollment. The current sub-study included participants aged ≥65 and their family CGs from 7 hospice agencies. Two investigators independently coded transcriptions of the first audio recorded nurse home visit using a directive content analytic approach to map conversations to a previously published, interview-derived, framework for hospice medication management by CGs. Results: A total of 18 patients (mean age 76.5 [SD 10.7], 56% female) and their CGs (mean age 59.6 [SD13.4], 78% female) were included. Content analysis revealed that CG skills needed for medication management are not limited to drug knowledge. Complicated organizational skills are needed to track medication acquisition and dosing, record the use of short- and long-acting drugs with similar modes of action, and coordinate medication administration by multiple CGs. Teamwork skills are needed to help coordinate medication prescribing between specialist, primary, and hospice physicians. CGs also need symptom management skills regarding the proper selection of medications, as well as skills to manage side effects, inadvertent errors, and possible medication related-emergencies. CGs play a vital role in patient advocacy, alerting providers to the burden and quality of life issues related to medication use, including whether medications have intended or unintended effects, or are potentially unnecessary or causing harm. Conclusions: CGs must have multiple skills to effectively manage medications in home hospice. A systematic approach and intervention is needed to support CGs’ medication management skills.
Interpreting in palliative care: A systematic review of the impact of interpreters on the delivery of palliative care services to cancer patients with limited English proficiency.
Authors: Silva Milagros , Genoff Margaux , Zaballa Alexandra , Stabler Stacy Marie , Gany Francesca , Diamond Lisa
Published: February 2017

123

Background: According to the 2011 U.S. Census 60% of people living in the U.S. speak a language other than English at home, and of these approximately 40% have limited English proficiency (LEP). Language barriers can affect the health outcomes of LEP patients and the use of trained interpreters can improve patient-physician communication. Since effective communication is the cornerstone of delivering adequate palliative care, a systematic review was conducted to determine the impact of interpreters on the delivery of palliative care services to LEP patients with cancer. Methods: We conducted a systematic review of the literature search in all available languages of 6 databases from 1966 and 2013. Studies evaluated interpreter interventions for LEP patients receiving palliative care services. Of 38 references, 11 articles were found by multiple reviewers to meet inclusion criteria. Data were collected on the study design, size, comparison groups, outcomes, and interpreter characteristics. Results: A total of 6 qualitative and 5 quantitative studies assessed the use of interpreters. All studies found that the quality of care provided to LEP patients receiving palliative services is affected by communication. Most studies showed that when no trained interpreters were used, LEP patients and families had inadequate understanding about their diagnosis or prognosis during goals of care conversations, and worse symptom management at end of life including pain and anxiety. Half of the studies concluded that trained interpreters are not utilized adequately and several suggested that pre-meetings between clinicians and interpreters are important to discuss topics and terminology to be used during goals of care conversations. Conclusions: Published studies show worse outcomes during end of life care and goals of care discussions when trained interpreters are not used. Moreover, trained interpreters are not being used appropriately in the field. More clinically relevant studies are needed to improve the quality of care provided to LEP patients and families receiving palliative services.
Improving the final year of life at the institutional level: Quality dying initiative (QDI).
Authors: Myers Jeff , DasGupta Tracey
Published: February 2017

124

Background: For a tertiary academic health sciences and comprehensive cancer centre, care of the dying is a significant element of the institution’s overall patient and family care experience. The aim for this large-scale quality improvement project was to improve the quality of the experience for a patient in the final year of life and their family members. Methods: This is descriptive study involves one institution and the characterization of three distinct patient populations: A - Imminently dying patients for whom care goals have been clarified to be comfort, B - Patients for whom death “this admission” would not be a surprise and C - Among patients being discharged, death “within the next year” would not be a surprise, linking in the outpatient cancer care setting. Results: On average 19 deaths per week are in some way expected for the institution’s acute care setting. Phase 1 of the QDI included a review of evidence and best practices in care of the dying as well as comprehensive plans for both organizational engagement and communications. Phase 2 of the QDI (i.e. “Implementation Phase”) involved interventions for each patient population. A corporate-wide “Comfort Strategy” was developed to address Population A. Components include standardized order sets, standardized interprofessional “Comfort Assessment and Documentation”, the palliative care team’s “Coaching Consult”, a “Family Member Education” process and an evaluation plan that includes an experience survey routinely sent to family members following a patient’s death. The intervention was piloted on and subsequently rolled out to all inpatient oncology units. Interventions for Population B and C are the triggering of Goals of Care and Advance Care Plan discussions respectively. Key metrics have been identified for all three patient populations and are based on care elements considered important by dying patients and their family members. These now comprise a dashboard, which has been endorsed for roll out to all patient care units in the acute care setting. Conclusions: A quality framework can be effectively applied for the institutional context of developing an approach to improving the final year of life for a cancer patient.
Evaluating goals of care meetings for hospitialized cancer patients at risk for critical care.
Authors: Apostol Colleen C. , Waldfogel Julie , Pfoh Elizabeth , List Donald C. , Billing Lynn , Nesbit Suzanne A. , Dy Sydney Morss
Published: February 2017

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Background: Communication about care preferences is vital for care of cancer patients with advanced and refractory disease, particularly when they become ill enough to be at risk for critical care interventions potentially inconsistent with their preferences. It is vital to describe the use of goals of care discussions in patients with advanced/refractory cancer at risk for critical care and evaluate associations between these discussions and outcomes. Methods: Cohort study describing patient/families’ perceptions of goals of care meetings and comparing health care utilization outcomes of patients who did and who did not have discussions. Inpatient units of an academic cancer center included patients who had metastatic solid tumors or relapsed/refractory lymphoma or leukemia and were at risk for critical care (defined as requiring supplemental oxygen and/or a cardiac monitor). Results: Of 86 patients enrolled, 34 (39%) had a reported goals of care discussion. Patients/families reported their needs and goals were addressed moderately to quite a bit during the meetings. Patients with reported discussions were less likely to receive critical care (0% vs 22%, p=0.003) and more likely to be discharged to hospice (48% vs 30%, p=0.04). Only one patient with a goals of care discussion died during the index hospitalization (on comfort care) (3%) compared with 9% among those without discussions (p=0.08). Conclusions: Goals of care meetings should be incorporated into usual care for cancer patients with advanced or refractory disease at risk for critical care during a hospitalization, in order to improve concordance between care received and patient and family preferences. Goals of care meetings for advanced/refractory cancer inpatients at risk for critical care can address patient and family goals and needs and improve health care utilization outcomes. These meetings should be part of routine care in this patient population.
Medical repatriation at end of life: Barriers, facilitation, and fulfillment—A case-series study at a New York public hospital.
Authors: Seetharamu Nagashree , Ma Hilary Y. , Smeltz Robert , Schindewolf Jessica , Empalmado Mariam , Cohen Susan E.
Published: February 2017

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Background: Foreign-born cancer patients frequently desire to return to their home country at the end of life. However, many barriers can make this process challenging. We herein present our recent experience with such patients. Methods: We reviewed charts of terminal cancer patients (pts) who traveled to their homeland at the end of life. Pts’ age, diagnoses, co-morbidities, prior cancer-directed treatment, predicted survival, symptoms, code status, admissions within 4 weeks of travel, oxygen need were noted. Interval between decision to travel and travel date, events during travel, and feedback from families, if available were collected. Results: 17 charts (11 female, 6 male) were analyzed. Mean age was 60 years and the most common diagnosis was thoracic malignancy (70%, 12 pts). All pts had disseminated cancer and had received an average of 2 lines of cancer-directed therapy. All had progressive cancers with expected survival <6 months. All were under the care of medical oncologists, palliative care and social work. The mean interval between decision to travel and travel date was 9 days. 8 were hospitalized at least once in the 4 weeks prior to the day of travel and 6 were cared for as inpatients immediately prior to travel. 11 pts were receiving opioids for pain and 3 were oxygen-dependent. 10 had documented discussions regarding resuscitation and 9 were discharged with New York State out-of –hospital DNR forms. All were discharged with medical records, medication supply and provider contact information. Mean travel distance was 4,099 miles. Provider concerns for decompensation during travel included brain herniation (2), spinal cord compression (3), bleeding (1), and sepsis (2). 16 pts successfully completed their journey. 1 pt died en-route prior to boarding the aircraft. 12 pts/families provided positive feedback about the experience. Conclusions: Return to homeland is an important goal for many terminally ill cancer pts and should be a routine part of end-of-life discussions. Medical repatriation can be accomplished when conducted in a planned, well-coordinated manner. Insights from this review can help us create guidelines that can be readily applied to specific scenarios.
Specialized outpatient palliative care: Results from a representative survey among physicians in Germany.
Authors: Papke Jens Hermann , Lux Eberhard A , Marggraf Kerstin , Fricker Ruth
Published: February 2017

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Background: Specialized ambulatory palliative care (SAPV) allows patients with incurable diseases and limited life expectancy to be cared for until death in their familiar surroundings. In Germany, these services must be prescribed by a physician. Little is known about structure, organization and work pattern within the SAPV teams. Methods: An online survey was carried out between Sept. 2013 and March 2014 with 124 physicians in Germany with regard to aspects related to physicians’ qualification, networks and palliative care teams. Aim of this survey was to evaluate status quo of SAPV from physicians´ viewpoint. Results: All 124 respondents were enrolled in SAPV; 18.3% of them (n=22) were on a direct contract with a health insurance provider. An additional qualification for palliative medicine and for pain therapy was reported by 96.7% and 21.5% of the physicians, respectively. In average, 11.6 physicians are organized in a SAPV-network. The networks comprise general practitioners (in 88.6% of the networks) anesthesiologists (in 62.3%), hematologists/oncologists (in 57.9%) and internists (in 43.9% of the networks) as well as a large proportion of non-medical professions such as pastors, pharmacists, social workers, psychologists and nurses. In most cases, SAPV networks are linked to one or more medical practices, hospitals or welfare institutions. 96% of the respondents assessed the cooperation within the network as “very good”/“good”. Patients admitted to SAPV were mostly suffering from cancer, but also from cardiovascular, neurological and respiratory diseases. The mean duration of care was 26.6 days; 81.4% of them could die in familiar domestic surroundings. On average, one physician is treating 9.7 SAPV-patients at the same time. Documentation requires 25.9% of time spent for medical care. Problems concerning reimbursement were reported by 75.8% of respondents. Conclusions: This survey provides the status quo of the German SAPV concept. Physicians enrolled in SAPV are highly qualified for palliative care and pain therapy. SAPV is a domain of outpatient care sector. While interdisciplinary cooperation within the SAPV networks is good, documentation and reimbursement remains a problem.
Characteristics and outcomes of palliative care patients in intensive care unit.
Authors: Fumis Renata R. L. , Ranzani Otavio Tavares , Martins Paulo Sergio , Schettino Guilherme De Paula Pinto
Published: February 2017

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Background: Despite the growing palliative care movement, most admissions still occur in Intensive Care Units. The aim of this study was to determine the frequency of palliative care patients admitted in an ICU and assessed their outcomes. Methods: This prospective study was conducted in a tertiary private hospital, in an adult medical-surgical ICU with 22-bed in São Paulo, Brazil. Patients or their family member with ICU stay ≥ 48 hours were invited to participate. They were excluded if they had no conditions to answer the questionnaire or if they refuse to participate. During ICU stay we analyzed through the medical records and questionnaire their clinical condition and their oncologic status. We called them by telephonic assessment to assess their survival. Results: From March 2011 to March 2013 a total of 576 ICU patients were analyzed; of these, 280 were oncologic patients and 95 were palliative care. Of total, the majority was male gender (57.8%), median age was 67[54-79] years, SAPS III score was 54±18.4 points, SOFA was 3.1±3.0 and ICU Length of stay (LOS) was 9.0±11.3 days. ICU mortality was 16.5%, 1-month mortality was 22% and 3-months cumulative mortality was 28.6%. We could observe that palliative care patients were in majority cancer patients (75%vs 43.4%,p<0.001), with metastatic disease(81.7 vs 36.3, p<0.001), had greater mean time of initial diagnosis(3.21±3.7 vs 2.17±2.5, p=0.009), had greater ICU LOS (14.2±16.2 days vs 7.96±9.8, p<0.001) greater mean SAPS III (68.5±16.0 vs p<0.001) and SOFA (4.81±3.2 vs 2.81±2.8, p<0.001) when compared with non palliative patients care. They also needed more mechanical ventilation (50.0%vs32.6%, p=0.001), tracheotomy (11.6%vs 5.0%,p=0.014) and vasopressors (54.7% vs 36.8,p=0.001). The ICU mortality was greater (32.6% vs 6.8%, p<0.001), 1-month (60.0% vs 14.0%, p<0.001) and 3-months (73.5% vs 19.1%). Conclusions: Palliative care suffers most in Intensive Care Unit and we observed a high mortality at 3-months after ICU discharge. We recommend more discussions before palliative care patient’s admissions in ICU to better provide them quality of life.