bluuebunny/crossref_metadata_2025 huggingface dataset:
Organizational barriers to receiving quality health care: A qualitative study among lung cancer patients and caregivers.
Authors: Kedia Satish , Ward Kenneth Daniel , Digney Siri Alicia , Jackson Bianca Michelle , Roark Kristina S. , Boyd Stephanie W. , Osarogiagbon Raymond U.
Published: February 2017

76

Background: For lung cancer patients and caregivers, navigating the healthcare system while coping with the complexities of the illness is challenging. We explored organizational barriers to receiving quality healthcare from the perspectives of these stakeholders. Methods: A qualitative study involving 10 focus groups (5 of patients, 5 of caregivers) was conducted. Discussions were guided by a standardized script, recorded for transcription, and analyzed using Dedoose software. Results: 22 patients (10 Males/12 Females; 15 Caucasians and 7 African Americans) and 24 caregivers (6 Males /18 Females; 17 Caucasians and 7 African Americans) shared their experiences. Content analysis showed 5 recurring themes: (1) Insurance Issues: Delays in diagnosis or treatment were reported due to lack of insurance, lag time in insurance approvals and care processing, uncertainty about coverage, and caps for tests and/or office visits. (2) Appointment Scheduling: Participants reported appointment delays and rescheduling, long wait times, cancellations by providers, and inflexibility to accommodate schedules. (3) Provider Communication: Communication was lacking at times in initial diagnosis disclosure, prognosis and treatment preparation, willingness to answer questions in lay terms, and time dedicated to patients during appointments. (4) Patient Education: Participants had inadequate knowledge about lung cancer, treatment options and duration, prognosis, and relied on providers to educate and direct them to credible resources. Many felt confused, frustrated, anxious, or fatalistic. (5) Healthcare System Support: Participants found support within the healthcare system extremely beneficial, when available, for coping with lung cancer, expediting appointments, seeking information, connecting with physicians, and receiving timely diagnosis and treatments. Conclusions: These findings offer valuable insight into lung cancer patients’ and caregivers’ perspectives on organizational barriers to receiving quality care. By identifying these barriers for lung cancer patients and caregivers, better planning and management of effective cancer services can be developed.
EMR optimized oral chemotherapy monitoring program: Adherence and ADR outcomes.
Authors: Carro George W. , Hensing Thomas A. , Brockstein Bruce , Gavin Shannon Maureen , Harper Abigail , Jee Cheryl , Palafox Anna , Schiavo Kathryn , Hui Wendy , Blankenship Amanda , Hughes Brad , Uhlig William J. , Spath Wayne , Hullett Ashton Marie , Marciniak Madelyn , Filippini Jacqueline , Azhar Yousuf
Published: February 2017

77

Background: Utilization of oral anticancer agents (OAA) has drastically increased over the past decade, accounting for more than 70% of new oncology agents approved in 2013. There are many challenges associated with OAA, including monitoring of adverse drug reactions (ADR) and adherence. While few studies estimate adherence of OAA, it is known that a multidisciplinary approach with intensive pharmacist counseling may improve outcomes. Currently, the electronic medical record (EMR) at our institution has many limitations on tracking OAA. In 2007, 1,872 OAA prescriptions were written. The 2014 annualized OAA prescriptions will surpass 5,510, demonstrating a growth of 194%. The purpose of this project is to establish an OAA monitoring program to allow consistent documentation, closer monitoring, and timely management of ADR. Methods: American Society of Clinical Oncology’s Quality Oncology Practice Initiative criteria were utilized to develop a unique monitoring tool, specific for OAA, which was employed via EMR. The monitoring tool assesses the current regimen, ADR, labs, adherence, and drug interactions. The initial analysis focused on testing the tools on two of the most commonly prescribed OAA agents within our institution. New start patients were identified through utilization of an OAA pharmacist verification queue. The pharmacist provided education, intensive follow up, and communicated treatment complications to other healthcare team members. Results: Follow-up calls were placed for 24 capecitabine patients and four erlotinib patients. Over half of the patients required an intervention. For capecitabine, there were seven patients with barriers to adherence. There were two patients who were non-adherent and one patient who was lost to follow-up; therefore, overall adherence rate was 91%. For erlotinib, adherence rate was 100% with no barriers to adherence. Symptom management and education were provided to 16 patients with grade 1 toxicities, and four drug interactions were identified. Conclusions: Oral chemotherapy should be treated with the same intensive monitoring as IV chemotherapy. A multidisciplinary pharmacist driven OAA monitoring program may improve adherence and allow more timely management of ADR.
A review of patient self-reported symptom data with a focus on pain.
Authors: Denny Diane , Nutakki Swetha B. , Alston Kayla , Markman Maurie
Published: February 2017

79

Background: Cancer Treatment Centers of America, Inc (CTCA) is a national network of five hospitals that specialize in the treatment of patients fighting complex or advanced-stage cancer. The Symptom Inventory Tool (SIT) is an assessment tool that captures the patients’ perceived symptom burden. It includes the scientifically validated M. D. Anderson Symptom Inventory core items and is supplemented by CTCA clinician interested ‘custom 8’ (constipation, swelling, mouth soreness, bleeding, sexual interest, family, hope and Quality of Life). Methods: A baseline assessment is administered to new patients. Follow ups are assessed every 21 days or greater. The patients’ answers range from 0 to 10 and a score of 8 or higher was considered a severe symptom. A change of 2 points from baseline to 2nd follow up assessment is considered a clinically significant. Patients who had a severe pain score on a baseline assessment between April 2013 and March 2014 were closely followed. Results: There were 6,836 baseline assessments and 2,961 2nd follow up assessments between April 2013 and March 2014. Fatigue and sleep were the most reported symptoms while bleeding, mouth sores and vomiting were the least reported. Most of the patients had a decrease or stayed unchanged in their symptom scores. The patients who had a significant increase in symptoms at follow up ranged from 6% for bleeding to 28% for fatigue. There were 462 patients who reported severe pain on baseline assessment. Of the 462 patients, 295 patients (63.8%) had improvement in severity by the follow up assessment. After chart review, 447 patients (96.7%) had either improvement by follow up assessment (63.8%) or documented pain intervention (32.9%). Interventions included change to pain medication, addition of a Medtronic pain pump, physical therapy, palliative radiation therapy, cold laser therapy, and integrative therapies such as acupuncture, chiropractic care and massage therapy Conclusions: The SIT was successful in identifying symptom burden and interference with life issues in oncology patients. It has become an integral part of patient care at CTCA in providing exceptional pain and symptom management through the disease process creating visibility and focus.
Quality Oncology Practice Initiative (QOPI) participation as a means to physician engagement, performance improvement, and delivery of safe and high-quality cancer care.
Authors: Chatta Gurkamal S. , Aboulafia David Michael , Brockmeyer Amy , Bumpus Molly , Dimitrova Irina , Goetsch Cathy , Jacobs Andrew , Lin Bruce S. , Malpass Thomas William , Nichols Craig R. , Picozzi Vincent J. , Robinson Nanette , Vishnu Prakash , Rosales Joseph Grant F.
Published: February 2017

80

Background: High quality and safe medical care has been a consistent goal of the medical community at Virginia Mason Medical Center (VMMC). The Am Soc of Clinical Oncology (ASCO) has set out a list of criteria as part of Its Quality Oncology Practice Initiative (QOPI), which are increasingly being adopted as standards for quality measurement in the Oncology community. Our practice at VMMC participated in the QOPI quality metric survey, with the intent of measuring and enhancing cancer care delivery. Methods: We participated in the web-based QOPI quality metric during the September, 2013 and April, 2014 sessions. Chart abstraction was shared by the providers. Following the Sept session, our performance was analyzed, and targeted areas of improvement were collectively identified by all providers. Following the April session, the clinical note format was changed to incorporate a standard template, addressing areas of underperformance. Results: In the September 2013 session, the primary areas of underperformance were assessment of: a) pain, b) emotional distress, c) performance status (PFS), and d) documentation of staging. Following the April 2014 session, we noted improved performance in all these assessments. Thus, pain reporting rates improved from 40.6 to 61.2%; emotional distress screening from 37.3% to 42.8%; PFS documentation from 42.6 to 53.7%; and staging at initial diagnosis from 74.6% to 80.9%. However our areas of underperformance continued to lag 10 to 30% behind QOPI aggregate reporting rates. With the introduction of a structured note in the electronic medical record (EMR), further improvements are expected the results of which will be reported at the time of the meeting. On the positive side, chemotherapy education and discussion of risk/benefit were consistently areas of superior performance in our practice with our reporting rates being 10 to 40% higher than the QOPI aggregate. Conclusions: QOPI participation is a useful tool for improving and sustaining a high level of practice performance in oncology. Structured notes in the EMR maybe indispensable for maintaining a high level of compliance with performance measures.
Continuity of care: A program for multidisciplinary post-treatment surveillance after definitive treatment for head and neck cancer.
Authors: Beadle Beth Michelle , Burke Laura , Hessel Amy Clark
Published: February 2017

82

Background: Patients with head and neck cancers (HNC) are treated with a combination of radiation therapy, chemotherapy, and surgery. With the epidemic of HPV-related oropharynx cancers, patients are younger and healthier; they will require routine surveillance and management of long-term toxicity for many years. There is little data on optimal follow-up and significant duplication of efforts with multiple appointments. Our goal was to create a multidisciplinary post-treatment surveillance program for patients with HNC treated with organ preservation to standardize their evaluation, decompress clinics, reduce duplication of testing, and improve patient satisfaction. Methods: A consensus schema to standardize follow-up was created, consistent with the institutional practice and NCCN guidelines. All services agreed to standardized testing with a rotation between the treating physicians for each follow-up. For the first year, testing occurred at 8 weeks and then every 3 months; for the second year, it occurred every 4 months. Deemed the Continuity of Care (COC) program, patients were identified at the time of tumor board, labeled as eligible at treatment initiation, and followed per its rules on completion. Results: A total of 360 new patients were identified that were eligible for follow-up on COC. In total, 237 (65%) of them had been treated at MD Anderson and reached or surpassed their 3 month follow-up visit. Of these, 209 patients (88%) were following the pathway. Overall, compliance with the pathway has been stable, and follow-up clinics have been streamlined for patients and providers. A 28% reduction in appointment duplications within 3 months of the past appointment has been measured. Conclusions: A model program for surveillance after treatment for HNC was designed and implemented. Patients enrolled had standardized testing and streamlined follow-up appointments during the first two years of surveillance, resulting in a significant decrease in appointment duplication. In addition, significant data was collected in this cohort, allowing for future studies of the optimal utilization of imaging, outcomes, and best practices for this growing group of patients.
Early identification of high-risk neutropenia in the ambulatory setting.
Authors: Nallari Anitha S. , Venepalli Neeta K. , Feldman Lawrence Eric , Chowdhery Rozina A. , Golick Janet
Published: February 2017

87

Background: The University of Illinois Cancer Center (UICC) utilizes nurse (RN) visits for laboratory review and toxicity evaluations for patients (pts) receiving chemotherapy. Upon review of nursing visits, we observed that RN visit documentation for neutropenia was variable without standard language, communication with physicians (MD), or requirement for MD evaluation. We sought to implement an early intervention strategy to prevent morbidity and mortality from high risk neutropenia (HRN). Methods: A multidisciplinary task force of oncology RNs and MDs created actual and ideal process maps, from identification of neutropenia to patient disposition. We developed a Standard Operating Protocol (SOP) involving a HRN checklist (created based on NCCN and ISDA guidelines) and new process for triage of HRN pts. RNs were required to complete the HRN checklist within the electronic health record for all pts with ANC < 1,000. If high risk features were identified, MD evaluation was required within 1 hour of RN call, with SOAP note and attending notification. Results: Over an 8 week period, 17 HRN templates were generated. The process and checklist were adjusted after the first 4 weeks with clinic wide feedback. Within the first 4 weeks, 8 templates were generated (5 MD, 3 RN); no patients met high risk neutropenia criteria and all were discharged home. Within the second 4 weeks, 9 templates were generated (3 MD, 6 RN); 3 HRN pts were identified with two direct admissions and one home discharge with favorable outcomes. Clinic staff reported greater understanding of HRN, increased satisfaction with multidisciplinary interactions, and more comfort with calling MDs for prompt patient evaluation. Conclusions: UICC successfully piloted the creation and implementation of an early identification and intervention strategy for HRN with strong multidisciplinary support. Compared to the prior 6 month period, we found that use of the SOP and checklist resulted in improvement in evaluation of quality and timeliness of HRN pts and prevented morbidity and mortality. Additionally, the checklist provoked critical thinking from end users with more thorough patient evaluations and improved documentation, resulting in aggressive intervention and better outcomes.
Assessing and acting on distress in oncology patients.
Authors: Zerillo Jessica A. , Nahas Myrna Rita , Schnipper Hester Hill , Rosenblatt Laurie , Dowling Holly , Sternberg Scot , Drews Reed , Savarese Diane M. F.
Published: February 2017

89

Background: The American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) set a benchmark that 75% of cancer patients have emotional well-being assessed by the second visit. However, clinicians poorly assess and document emotional well-being. Methods: Our aim was to increase the documented assessment of emotional well-being in an academic medical center's Hematology/Oncology clinic to 75% or greater through a pre/post intervention study design. In fall 2012, clinicians collected baseline QOPI data from the first two visits of a sample of patients with newly diagnosed breast, non-small cell lung and colorectal cancers. Oncology social work and psychiatry implemented the NCCN Distress Thermometer in May 2013. At every provider visit, patients' distress scores were transcribed into a structured field in the electronic record. In spring 2014, clinicians collected post-intervention data. Results: All data used was collected through the routine QOPI chart abstraction process. 142 charts in fall 2012, and 55 charts in spring 2014 met criteria for pre/post assessment, respectively. There was a significant improvement in the assessment of distress (78.2% vs. 64.1%, p=0.01) and in the identification of distress presence (46.5% vs. 27.5%, p=0.01). However, there was better documentation for a plan of action for distress before the intervention (80% vs. 55%, p=0.02). Conclusions: The NCCN Distress Thermometer improved assessment and identification of distress. However, an action plan specifically addressing distress was significantly worse after implementation of the tool. Possible explanations include lack of documentation even if an action was implemented, lack of specificity of the tool to identify the source of the patient's distress so that a therapeutic plan could be targeted, or a failure of the clinician to appreciate the distress score as a valid measure. Further data are needed in order to understand the barriers for clinician documentation of action on patient distress. [Table: see text]
The impact of hospice services in the care of patients with advanced stage non-small cell lung cancer.
Authors: Hildebrand Sara , Tayapongsak Kristy , Stephenson Richard , Streer Nathan Paul
Published: February 2017

104

Background: Prior research has shown that early incorporation of palliative care alongside standard oncological care in metastatic non-small cell lung cancer (NSCLC) patients results in longer survival and less aggressive treatment at the end of life. The purpose of our study was to profile the continuum of care of stage IV NSCLC patients, comparing it to quality indicators for excellence in end-of-life (EOL) cancer care, as defined by the Quality Oncology Practice Initiative and other published studies. Specifically, our aim was to explore the connection between hospice enrollment and end-of-life quality measures. Methods: 197 deceased stage IV NSCLC patients diagnosed between 2008 and 2010 at two separate tertiary care centers within the same county were identified. A retrospective review was conducted, collecting data from electronic medical records regarding antitumor treatment services received, post-diagnosis hospital admissions, palliative care consultations, hospice referrals and enrollments, and circumstances surrounding the patient’s death. The patients were separated into two groups depending on their status of hospice enrollment, and the remainder of the measures compared accordingly. Results: There was no significant difference in number of lines of chemotherapy received and total number of post-diagnosis hospital admissions between the patients who were enrolled in hospice and those who were not. However, the group who received hospice services had a significantly lower number of hospitalizations in the last 30 days of life (p<0.001), emergency department admissions in the last 30 days of life (p<0.01), and intensive care unit admissions in the last 30 days of life (p<0.001). Median survival, measured by the length of time between diagnosis and death, did not differ between the two groups. Conclusions: This study demonstrates that, among patients with metastatic NSCLC, hospice enrollment was associated with optimized end-of-life oncological care, as seen with fewer hospital admissions in the last 30 days of life, without incurring a lower median survival.
Treatment preference discussion in oncology outpatient clinic.
Authors: Nasir Syed Sameer , Ul Haq Mansoor , Pandey Manjari , Ogbeide Osarenren , Ogbata Obiageli Uchenna , Dill Drew Sterling , Ryder Katheryn M , Weir Alva Bowen
Published: February 2017

106

Background: Often end of life discussions are either not held in a timely manner or remain poorly communicated when outpatients are transferred to hospital care. This leads to unwarranted and costly interventions. Methods: In an academic oncology clinic we developed an electronic medical record (EMR) template that listed important information for management decisions, including life expectancy, goals of management and specific patient treatment preferences (ventilator support, tube feedings, transfusions, do-not-resuscitate (DNR) wishes, etc.). The completed note was placed in an easily retrievable location in patients’ electronic charts. Clinic charts were reviewed one week ahead of visits to identify patients who were within the last year of life and a pop up reminder for the treating physician was placed in the EMR. The physicians who admitted our patients to the hospital were educated on utilization of the template notice. We compared the percentage of patients with advanced directives or treatment preference notes before the intervention with the percentage 1½ years after the intervention was begun. We utilized a cross-sectional, self-administered survey to compare in-patient physician responses before and after implementation of the intervention to evaluate the in-hospital utility of the intervention. Results: Easily accessible treatment preference or advanced directive discussions with patients in their last year of life increased from 32% to 55% (p =0.004) with the intervention. Results of the survey also showed improved understanding of patient’s wishes for DNR status (26.9% vs 52.6%, p = 0.08) among admitting physicians. Conclusions: The development of an easily utilized EMR template to record the treatment preferences of patients near the end of life, with an EMR accountability instrument, improved both documentation of discussion and physician understanding of patient treatment preferences when patients were transferred from outpatient to inpatient care. We hypothesize that this intervention will lead to a decline in costly and unwanted interventions for patients near the end of life, and plan to test this hypothesis with further outcomes measures.
“It’s about the conversation”: A multidisciplinary intervention to support advance-care planning.
Authors: Zachariah Finly , Klein Linda , Clifton-Hawkins Nancy , Andrews Becky , McQueary Andrea , Dillard Gaby , Gross Dawn
Published: February 2017

111

Background: A recent California Healthcare Foundation study found that 60% of Californians highly valued “making sure their families are not burdened by tough decisions about their care." However, less than 50% have communicated their end-of-life wishes to their surrogate decision maker. 82% say it is important to have end-of-life wishes in writing, but only 23% say they have done so. At City of Hope National Cancer Medical Center (COH) the advance directive (AD) completion rate is less than 15%. The Department of Supportive Care Medicine Sheri & Les Biller Patient and Family Resource Center (BRC) is leading development of innovative strategies to foster Advance Care Planning (ACP) communication and documentation. Methods: A multi-specialty physician and interdisciplinary team assembled and designed a social media advertised 4-hour interactive event that was held in the BRC. Over 40 staff and volunteers facilitated individualized ACP conversations with the “Go Wish” cards, private consultations with social workers, showed novel COH ACP videos, provided multi-lingual ACP literature and advance directive documents available for completion with Notary support on-site. Results: Over 300 people attended, including patients, caregivers and COH staff. Forty-seven advance directives were completed (24 by patient/caregivers, 23 by COH staff). Twenty-nine Go Wish games were facilitated (2 in Spanish). Of the 52 attendees who completed exit evaluations, 44% were patients, 31% staff, and 11% were caregivers. Respondents reported that the event increased their comfort and likelihood of having conversations about ACP with others. Importantly, 38 of the 52 surveyed, did not have an AD prior to attending the event. Of those 38 attendees, 18 of them completed an AD at the event (or 47%). Conclusions: Advanced care planning is an all too often avoided conversation that results in increased distress of patients, families and providers. By proactively designing opportunities for facilitated conversations in dynamic and public arenas, fear and stigmas are diffused and the true focus and intent of discovering what people wish so the medical team, surrogates and family can ensure their values are honored and met become possible.
A prospective assessment of polypharmacy in the palliative care setting.
Authors: McNeil Michael Joseph , Kamal Arif , Ritchie Christine , Kutner Jean , Abernethy Amy Pickar
Published: February 2017

112

Background: The number of prescribed medications increases substantially in the last year of life aggravating the risk of polypharmacy, adverse reactions and medication non-adherence. What medications do patients with life-limiting illness take? Methods: This was a pre-specified secondary analysis of data from a prospective trial. Eligible participants were adults with a <1-year prognosis taking a statin medication for primary or secondary prevention. Participants were enrolled from 15 sites, randomized to continue or discontinue statin medications, and followed for up to a year. Concomitant medications were recorded at least monthly. For participants with a primary diagnosis of cancer receiving care and with medication data available, prescribed medications were categorized according to the World Health Organization’s (WHO) ‘Guidelines for ATC Classification’ by class and sub-class. An expert panel of palliative care, oncology, geriatrics, and primary care physicians guided categorization. Descriptive statistics were calculated. Results: On average, participants (N=127) were 70 years old (SD 10) and lived 216 days (SD 123) on study; 69% had metastases, 23% had cancer without metastases, 7% had lymphoma, and 1 had leukemia. In total, 49 classes, 156 sub-classes and 283 different medications were prescribed. The five most commonly prescribed medications were: anti-hypertensives, strong opioids, laxatives, gastric protection aids, and anti-emetics. Only 1.2% of medications prescribed were chemotherapy or antineoplastics. Patients took an average of 10.7 (SD 5) number of medications at the time of enrollment and 10.0 (SD 5) medications at death or termination of the study. 31% of patients were on 15 or more medications at any time during the study. Conclusions: Polypharmacy, defined as >10 medicines, is common in the last year of life for people with cancer. Patients commonly receive supportive care medications and drugs for comorbidities like hypertension; antineoplastics are rare. Thoughtful approaches to medication simplification in the palliative care setting are needed.
Targeted therapy at the end of life and the impact on health care utilization.
Authors: Yeung Heidi , Salehi Parsa , Murphy James Don
Published: February 2017

116

Background: The use of targeted therapy has steadily increased over the past decade, though the impact of targeted agents on patterns of care at the end-of-life life remains unknown. The purpose of this study was to explore the influence of targeted therapy on end-of-life care in a large population-based database. Methods: We identified 14,398 patients from the SEER-Medicare linked database with metastatic breast, lung, or colorectal cancer diagnosed between 2000 and 2009 who received conventional cytotoxic chemotherapy or targeted therapy in the last 3 months of life. Multivariate logistic and linear regression models were used to determine the impact of targeted therapy on the following endpoints in the last 3 months of life: emergency department (ED) visits, hospitalizations, and hospice utilization. Analyses were adjusted for differences in patient age, gender, race, comorbidity, socioeconomic status, and geography. Results: Among the whole study cohort 83% of patients received chemotherapy alone, 12% received chemotherapy with targeted therapy, and 5% received targeted therapy alone. The delivery of any targeted therapy in the last 3 months increased across the study period, from 1.5% in 2000 to 28% in 2009. Compared to patients treated with chemotherapy alone, those treated with targeted therapy alone had lower rates of ED visits (adjusted odds ratio [aOR]=0.81, p=0.01), lower rates of hospitalization (adjusted odds ratio [aOR]=0.69, p<0.0001), no difference in overall hospice utilization rates, though had longer stays on hospice (5.1 days longer, p<0.0001). Compared to patients treated with chemotherapy alone, those treated with both chemotherapy and targeted therapy had no difference in ED visits or hospitalization admission rates, though had decreased rates of hospice utilization (aOR = 0.79, p<0.0001), and shorter stays on hospice (2.7 days longer, p<0.0001). Conclusions: This study found that targeted therapy was associated with varying patterns of healthcare utilization at the end-of-life, though these differences could be influenced by unknown confounding variables. Future research should focus on defining the specific impact of targeted therapy on quality of life at the end-of-life.
Early versus late referral to hospice care: A case-control study.
Authors: Voisine Michael , Dahiya Saurabh , Besharatian Behdad , Friderici Jennifer , Stewart James A.
Published: February 2017

127

Background: Hospice care can improve quality of life (QOL) for patients with advanced cancer. Studies suggest that hospice services are offered late in the course of terminal illness; limiting patient comfort and QOL. Limited literature exists on barriers to timely hospice referral. We examined demographic and clinical characteristics associated with late hospice referral. We hypothesized that age, malignancy type, and performance status (PS) may predict late referral to hospice. Methods: Patients were age 18+ cared for by oncologists of Baystate Medical Practices, referred to Baystate Hospice from 1/1/08 to 12/31/2010. Demographics and diagnosis (e.g., breast, lung, GI) were abstracted from the electronic medical record. Referral interval was calculated as date of death minus date of referral. Late referrals (“cases”) were classified as interval quintiles 1 and 2; early referrals (“controls”) quintiles 4 and 5. Fisher’s exact test and Wilcoxon Rank Sum identified demographic and clinical characteristics associated with late referral. Multivariable logistic regression was used to identify independent predictors of late referral. Results: 209 patients met inclusion criteria. The median referral interval was 29 days (IQR 12, 57). In the multivariable model, ECOG score (OR 1.51 95% CI 1.09 2.08); dementia (OR 0.08, 95% CI 0.01, 0.82); CNS cancer (OR 0.14, 95% CI 0.03, 0.73); and unclassified cancer (OR 0.32, 95% CI 0.14, 0.73) independently predicted late referral. Age, race, and sex were not associated in uni- or multivariable comparisons. Conclusions: In this study of 209 patients with advanced cancer enrolled to hospice, malignancy type, dementia, and performance status are associated with late hospice referral. We believe it is important to track timing of referral and look for ways to reduce barriers.
Use of targeted therapy in cancer patients in the end-of-life period.
Authors: Wann Alysson , Ashley David M. , Khasraw Mustafa
Published: February 2017

129

Background: There is limited data on the use of these targeted therapies in patients at the end of life. This study reviews the pattern of use of targeted and potentially futile, toxic and costly therapies at the end of life at an Australian cancer centre. Methods: A retrospective single-centre review covering 12 month period of patients who died < 3 months of starting a targeted agent. We extracted demographics, types of cancers, types of therapy, median age and lines of prior therapy. Results: 478 patients were on targeted therapies during this period. 54 patients, (11.3%) died < 3 months. Of those, the median age was 69 years, men 65%, women 35%. 27 had haematological malignancies (mostly lymphoma and multiple myeloma), 21 had solid tumours (mostly colon and lung cancer). Ten agents were represented with erlotinib, bevacizumab, and rituximab having higher total number of deaths and none on transtuzumab. Treatment lines were first in 64.8%, second in 20.4% and 14.8% had > 2 lines of treatment. Performance status was only documented in 9.3% at start and 11.1% at end of treatment. Symptoms at the start of treatment that can be used to track improvement were only documented in 25 patients (46.3%). Gender, type of cancer, age was found to have no influence on death < 3 months of targeted treatment. Unfortunately we were unable to extract QoL data. Conclusions: In this small single centre descriptive study, the use of targeted therapy in the end of life population was common, mostly in first line treatment. No factors have shown correlation with dying < 3 months of targeted therapies. There is a need to better document performance status and QoL data and also to analyse indicators of when it is appropriate to cease targeted therapies.
Characteristics of patients referred to a community-based palliative care consultation service.
Authors: Alvarez Adriana L. , Samala Renato Verayo , Gupta Mona , Rybicki Lisa A.
Published: February 2017

132

Background: Home-based palliative care programs by multi-disciplinary providers improve patient and caregiver satisfaction, enhance symptom control, increase hospice use, and decrease acute care encounters. We launched a community-based consultation service to deliver high-quality palliative care to patients who are homebound or staying in various post-acute care facilities. The study described the characteristics of our patients, and determined the relationship between certain demographic features and outcomes. Methods: We conducted a restrospective chart review of patients seen on initial consultation and subsequent visits between January 1, 2011 and December 31, 2011. All patient encounters were done by 4 palliative care physicians. Data pertaining to demographics, diagnosis, hospice use, and death were obtained and analyzed. Results: A total of 221 patients were evaluated. The median age was 75 years, 61.1% were female, 51.1% had cancer, 79.1% were seen at home, and 57% possessed advance directives at initial consultation. Almost half (45.2%) of the referrals were made by primary care physicians. Majority (82.4%) of the referrals were for symptom management, while 37.6% were for goals of care discussion. Many patients had several reasons for consultation, as well as multiple symptoms, such as pain (65%), fatigue (54.8%), and dyspnea (22.6%). The mean number of follow-up visits was 0.62 + 1.08. During the study period, 33.5% of patients died, and 42.5% enrolled in hospice. Of the deaths, 48.7% occurred within 30 days of initial consultation, and 50.0% died at home. Age, gender, race and marital status were not related to hospice enrollment, death, and time and site of death. Patients with advance directives were more likely to enroll in hospice (50.0% vs 32.2%, p=0.009), while those seen at home were more likely to die at home rather than in a facility or hospital (61.0% vs 16.9% vs 22.0%, p<0.001). Conclusions: Patients referred to our community-based palliative care consultation service were mostly homebound older adults needing symptom management and goals of care discussion. Our program may have been helpful in providing quality end-of-life care by facilitating hospice enrollment and death at home.
Exploring the palliative care needs of Hispanic immigrant mothers with advanced cancer.
Authors: Saldana Rafael Alonso , Park Eliza , Check Devon , Reeder-Hayes Katherine Elizabeth , Mayer Deborah
Published: February 2017

135

Background: Hispanics are the fastest growing demographic group in the United States and cancer is the leading cause of death in this population. Hispanic immigrants encounter a number of challenges when confronting end-of-life care: geographical and cultural separation from families; language and educational barriers; fear of discrimination; and in the case of undocumented immigrants, fear of deportation. The experiences of Hispanic patients with advanced cancer who are parents of dependent-age children are essentially unknown. Therefore, we used qualitative methods to identify the palliative care and end-of-life needs of this unique population. Methods: We recruited five Spanish-speaking, Hispanic mothers with metastatic cancer to complete a semi-structured interview about their experiences. The interviews addressed coping with advanced illness, sources of distress, parenting changes, medical decision-making strategies, and communication about illness. Data were analyzed using traditional content analysis techniques. Results: Participants were all female, ages 34-43 year old. On average, they had 3.4 children and 8.2 years of education. Common themes were: (1) the financial burden of cancer; (2) low social support for parenting and household responsibilities; (3) lack of perceived role in medical decision-making; (4) and religion as primary source of coping and hope. We also identified several communication barriers in conducting a palliative care study with this population. Conclusions: Future palliative care studies can improve Spanish-speaking Hispanics’ comprehension by incorporating Spanish vocabulary into the interviews and providing greater explanation of concepts such as shared decision-making, cancer staging, palliative care, and hospice. Greater awareness of financial concerns and insufficient social support may help oncology providers and researchers develop interventions to help Hispanic parents with advanced cancer. Further studies are needed to learn more about the unmet needs of end-of-life care for this demographic group.
Feasibility and acceptability of a novel web portal to enhance legacy building for adults with advanced cancer.
Authors: Bernat Jennifer Kim , Johns Shelley A. , Brown Linda F. , Hook Nancy E. , Althouse Sandra , Helft Paul R.
Published: February 2017

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Background: Being diagnosed with advanced cancer is a painful reality encompassing physical, psychosocial, and spiritual challenges as death draws near. Some patients cope resiliently, while others struggle. Dignity therapy (DT) is an empirically supported intervention where patients reflect on meaningful memories and values during interviews. These interviews are transcribed into a legacy project (LP) that can be edited and shared with loved ones. DT has been shown to benefit patients and LP recipients; however, it requires resources to implement and is not widely available in community settings. We developed a narrative intervention based on DT using a novel web portal (ZarpZ) to disseminate the LPs. This pilot assesses the feasibility, acceptability, and efficacy of our intervention to determine if it could be an affordable, user-friendly, and accessible alternative to traditional DT. Methods: Adults (n=16) with advanced-stage solid malignancies participated in a therapist-led intervention including (1) a modified DT session; (2) orientation to ZarpZ; and (3) brief weekly phone calls to aid self-led online LP building. We collected baseline and post-intervention data on primary (acceptability) and secondary (existential well-being, dignity, demoralization, peaceful acceptance of illness, and family communication) outcomes. Results: 69% of participants completed a LP. Participants reported high satisfaction with the LP created (100%) and with the intervention, particularly the home visit with the interventionist (81%). Participants were less satisfied with ZarpZ—only 45% used it. Among ZarpZ users, 40% reported it as somewhat difficult to use. Our sample was not distressed at baseline; thus, post-intervention secondary outcomes did not significantly differ from baseline. Conclusions: Participants found value in the intervention and in the LPs created, but were generally dissatisfied with ZarpZ. Future research should aim to improve usability. Since our sample size was small and participants were not distressed at baseline, we were not able to show significant improvement in secondary outcomes. Future research should examine these outcomes in a larger and more distressed sample.
Effect of dosing interval on pharmacokinetics and safety of fentanyl pectin nasal spray.
Authors: Chen Cuiping , Bujanover Shay , Gupta Anita
Published: February 2017

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Background: Fentanyl pectin nasal spray(FPNS) contains fentanyl citrate and is approved for treatment of breakthrough cancer pain. Nasal delivery allows direct nasal epithelium-to-blood absorption of fentanyl, and thus rapid and effective pain relief. This study evaluated the effect of dosing interval on pharmacokinetics (PK) and safety/tolerability of FPNS. Methods: This was an open-label randomized study in healthy volunteers. Five treatments were administered under naltrexone block to the right nostril, with a ≥3-day washout period: 1 x 100 μg (A); 2 x 100 μg, 4-hr (B), 2-hr (C), and 1-hr apart (D); and 8 x 100 μg consecutively (E). Blood samples were collected and analyzed for plasma fentanyl concentrations. PK data were derived using a non-compartmental model method. Results: 13 subjects were enrolled, 10 (77%) completed the study. For the two-dose regimens, Cmax was higher after the second dose than the first; the increase was statistically significant for the 1- and 2-hr intervals, but not the 4-hr. There were no significant differences in AUC among them. Eight consecutive 100-µg doses resulted in an ~5-fold in Cmax and AUC of those of a single 100-µg dose, suggesting a less than dose proportional increase in rate (peak) and extent (AUC). No new adverse events (AEs) were observed. 53% of subjects reported ≥1 AE, with dizziness (11.9%) and somnolence (4.9%) most common. 12.9% of subjects discontinued due to AEs. All AEs rapidly decreased to sustained low levels after 4–5 weeks. Conclusions: FPNS at 100-800 µg was well tolerated. The shorter the dosing interval, the higher the second Cmax. Dosing interval had no effect on AUC. Exposure plateaued after 8 consecutive 100 µg doses to the same nostril, suggesting an additional safety feature of FPNS. [Table: see text]
Association of lower patient ratings of physician communication with need for symptom management in lung and colorectal cancer patients.
Authors: Walling Anne M. , Keating Nancy Lynn , Kahn Katherine Leslie , Dy Sydney Morss , Malin Jennifer , Arora Neeraj K. , Mack Jennifer W. , Adams John L , Antonio Anna Liza M. , Pantoja Philip , Tisnado Diana M.
Published: February 2017

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Background: Symptoms are prevalent among cancer patients, but little is known about how often patients’ needs for symptom management are met or what factors are associated with unmet needs. Methods: Patients with lung and colorectal cancer from the diverse nationally-representative Cancer Care Outcomes Research and Surveillance cohort completed a survey approximately 4-6 months following diagnosis (n=5,422). We estimated the prevalence of unmet needs for symptom management during the 4 weeks prior to the survey, with unmet needs defined as patients reporting that they wanted but did not receive help for at least one symptom (pain, fatigue, depression, nausea/vomiting, cough, dyspnea, diarrhea). Using a pre-specified conceptual model, we identified patient factors associated with unmet need using multivariable logistic regression with random effects (fixed slopes model with random intercepts for each Primary Data Collection Research site). We also tested whether clinical visits before the interview were associated with unmet need. Results: Overall, 15% (791/5,422) of patients had at least one unmet need for symptom management. Adjusting for patient sociodemographic and clinical factors, African American race, being uninsured or poor, having lung cancer versus colorectal cancer, early- vs. late-stage disease, and the presence of moderate to severe symptoms were associated with greater unmet need (all p<.05). Patients who rated their physicians communication score below 80 (on 1-100 scale) had adjusted rates of unmet need that were more than twice those of patients who rated their physicians with a perfect communication score (23.0% v. 10.0%, OR=3.05, p<0.001). Neither visits with specialty physicians (medical oncology, radiation oncology, surgery, or primary care) nor the total number of outpatient visits in the 28 days before the interview were associated with unmet need (all p>.05). Conclusions: A significant percentage of newly diagnosed lung and colorectal cancer patients report unmet needs for symptom management. Interventions to improve symptom management should consider the importance of physician communication to the experience of disease.
The frequency characteristics and outcomes among cancer patients with delirium admitted to an acute palliative care unit (APCU).
Authors: De La Cruz Maxine Grace Jaucian , Ransing Viraj , Yennu Sriram , Chisholm Gary B. , Bruera Eduardo
Published: February 2017

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Background: Delirium is a common neuropsychiatric condition seen in patients (pts) with severe illness such as advanced cancer. Few studies on delirium frequency and course had been undertaken in pts with advanced cancer. We aimed to determine the frequency, characteristics and outcomes of pts with advanced cancer admitted to an APCU. Methods: Medical records of 609 consecutive pts admitted to the acute palliative care unit from January 2011-December 2011 were retrospectively reviewed. Demographics, Memorial Delirium Assessment Scale (MDAS), Palliative Medicine specialist (PMS) diagnosis of delirium, delirium etiology, subtype, reversibility, late development of delirium, and discharge outcome were collected. Delirium was diagnosed with MDAS score > 7 or by a PMS using DSM-IV TR Criteria. All pts admitted to the APCU had standardized assessments and management of delirium per best practice guidelines in delirium management. Descriptive statistics were used. Results: 317/609 (52%) APCU pts had a diagnosis of delirium; 214/317 (67%) on admission and 103/317 (33%) developed delirium after admission to the APCU. Hyperactive delirium was the most frequent type of delirium 117/317 (37%) followed by hypoactive 101/317 (32%) and mixed type 91/317 (29%). Haloperidol was the most commonly used medication to treat symptoms of delirium 210/317 (66%) followed by chlorpromazine 61/317 (19%). The use of olanzapine, lorazepam and other antipsychotics were minimal. Other interventions included opioid rotation 55/119 (46%), hydration 10/119 (8%), antibiotics 2/119 (2%) and combination treatment of opioid rotation, hydration, correction of electrolytes and antibiotics 52/119 (44%). Counseling of the caregivers and patient when indicated was performed in all cases. Delirium reversed in 98/317 (31%) of episodes. The majority of pts with delirium were discharged to hospice 130/317 (41%). Conclusions: About half of the pts admitted to the APCU had delirium. The predominant type was hyperactive delirium. Reversibility occurred in only a third of cases. Haloperidol was the main pharmacological agent. Pts with delirium were more frequently discharged to hospice.