bluuebunny/crossref_metadata_2025 huggingface dataset:
Entrepreneurial Instant Exporters in the Scottish Arts and Crafts Sector
Authors: McAuley Andrew
Published: November 2018

This article deals with a study of the international behavior of Scottish arts and crafts businesses that are “instant internationals.” The internationalization process is analyzed together with the key influences on rapid internationalization. In what might be regarded as a rather sleepy sector of the economy, it is interesting to find microbusinesses that have gone international in their first year of business. Portraits of three companies are presented to illustrate the internationalization process, the importance of networks, and how, sometimes, the process can be unplanned. The key influences as to why they are instant internationals are classified as (1) product related, (2) personal and psychological, (3) industry related, and (4) cognitive. The analysis identifies the distinguishing features of these firms in relation to their internationalization activities, namely, that the entrepreneurs view themselves as businesspeople rather than craftspeople.
Executive Insights: Corporate Culture and Market Orientation: Comparing Indian and Japanese Firms
Authors: Deshpandé Rohit , Farley John U.
Published: November 2018

The authors examine how organizational dimensions, including corporate culture and market orientation, affect performance in major Indian firms. The research uses a framework (the universal high performance model) developed in the United States and first tested in Japan to assess Indian organizational business-to-business relationships. Although there are some intuitively obvious substantive differences between Indian and Japanese companies, the general pattern of how various factors drive business performance is similar in both countries despite the different economic environments in India and Japan.
Dysregulation of Transcription Factors: A Key Culprit Behind Neurodegenerative Disorders
Authors: Jin Wei , Qazi Talal Jamil , Quan Zhenzhen , Li Nuomin , Qing Hong
Published: November 2018

Neurodegenerative diseases (NDs) are considered heterogeneous disorders characterized by progressive pathological changes in neuronal systems. Transcription factors are protein molecules that are important in regulating the expression of genes. Although the clinical manifestations of NDs vary, the pathological processes appear similar with regard to neuroinflammation, oxidative stress, and proteostasis, to which, as numerous studies have discovered, transcription factors are closely linked. In this review, we summarized and reviewed the roles of transcription factors in NDs, and then we elucidated their functions during pathological processes, and finally we discussed their therapeutic values in NDs.
Ankle fractures: What role does level of insurance play in recovery and outcomes?
Authors: Bakhsh Wajeeh , Childs Sean , Judd Kyle , Soles Gillian , Humphrey Catherine , Gorczyca John , Ketz John
Published: November 2018

Introduction

A number of factors including socioeconomic status have been correlated with post-operative outcomes in orthopedic trauma. The objective of this study is to compare post-operative courses and patient-reported outcomes following operatively managed ankle fractures taking into account a patient's level of insurance coverage.

Methods

A retrospective cohort study was performed at a single level I trauma center. Patients were identified by billing code for operative intervention of ankle fractures (OTA 44) from January 2014 to January 2015. Study outcomes included narcotic refills, compliance with follow-up visits, visual analog scale (VAS) pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) survey data, and perioperative complication rates. Statistical analysis included mean comparison between insurance groups and multivariate regression modeling.

Results

From January 2014 to January 2015, 209 patients met the inclusion criteria (45 patients under/uninsured vs. 164 fully insured). No differences were found amongst demographic data or fracture characteristics. The underinsured group had a higher average number of narcotic prescriptions (2.6 refills vs. 1.5 refills, p < 0.05). The underinsured group also demonstrated a significantly greater number of missed post-operative clinic visits (0.8 vs. 0.3 visits p < 0.05); the total number of post-operative visits were similar (6.4 vs. 6.9, p = 0.38). At one-year follow-up, the underinsured group had higher pain scores (VAS 3.8 vs. 2.1, p < 0.05), and significantly worse PROMIS scores with respect to mood (54 vs. 49.1, p < 0.05), pain (59.6 vs. 55.5, p < 0.05), and functional outcomes (38 vs. 44.7, p < 0.05). There was no difference in perioperative complication rates. Multivariate regression modeling found insurance (p < 0.05), age (p < 0.05), and smoking (p < 0.05) to be significant determinants of post-operative outcomes.

Conclusion

Despite similar demographic and fracture characteristics, patients with decreased insurance coverage demonstrated higher narcotic requirements and missed more appointments. They had worse subjective and objective outcomes. As physician reimbursement becomes increasingly dependent on outcomes, further understanding of the psychosocial factors of this subset of patients is needed to establish realistic expectations and identify avenues for further intervention.
The role of compressibility in computing noise generated at a cavitating orifice
Authors: Tabrizi Amir Bashirzadeh , Wu Binxin
Published: November 2018

The computational fluid dynamics calculation can be accomplished by solving either compressible or incompressible Navier–Stokes equations to determine the flow-field variables of the noise source. The proper assumption depends on both the physical situation and the Mach number. Although in cavitating devices usually we are dealing with low Mach number flow, cavitation is an acoustic phenomenon that can be affected by compressibility. Cavitation behaves acoustically as a monopole and it is mentioned by some researchers that incompressible solution is sufficient to study the dipole sources. However, in order to study the monopole (and quadrupole) sources a compressible solution may be required. In this study, the role of compressibility in computing noise generated at a cavitating single-hole orifice was investigated using large eddy simulation and Ffowcs Williams–Hawkings formulation. The fluid zone downstream of the orifice where the cavitation occurs was evaluated as the acoustic source which generates sound. Time-accurate solutions of the flow-field variables on source surfaces were obtained from both compressible and incompressible flow simulations. Three cases of cavitation were studied and the sound pressure signals far downstream of the orifice were computed by the Ffowcs Williams–Hawkings formulation. For a developed cavitation regime at low frequencies, there is a big discrepancy between the computed values of sound pressure level from compressible and incompressible simulations, and at higher frequencies greater than 6 kHz, both simulation methods provide almost the same values for sound pressure levels. For a super cavitation regime, both compressible and incompressible simulations provide similar values for sound pressure levels at frequencies greater than 2 kHz. The results of this work demonstrate that the compressibility has a significant role in terms of computing noise generated at a cavitating orifice and cannot be ignored, especially when the noise generated by developed cavitation regimes at low frequencies is investigated.
A Conceptual Framework for Non-Disposable Assignments: Inspiring Implementation, Innovation, and Research
Authors: Seraphin Sally B. , Grizzell J. Alex , Kerr-German Anastasia , Perkins Marjorie A. , Grzanka Patrick R. , Hardin Erin E.
Published: November 2018

The concept of “non-disposable assignments” (NDAs), including those referred to as “renewable assignments,” has grown in popularity in recent years in select education circles, particularly alongside an enthusiastic push toward open pedagogy. Unfortunately, little organized literature exists to effectively define, implement, and empirically evaluate what is ultimately an age-old though infrequently applied practice of assigning students a learning activity that provides impact or value outside the traditional student–teacher dyad. In contrast to the often-detested “disposable assignment,” NDAs can be defined by their openness and, accordingly, their ability to reach others, even beyond classroom boundaries. It is this very characteristic that likely underlies anecdotal reports of NDAs’ success at promoting student excitement, engagement, productivity, and achievement. In this report, we briefly review supporting rationale and guides for the implementation and innovative applications of these utilities of open pedagogical practice. Further, we provide a framework for conceptualizing NDAs wherein the openness of assignments can be viewed to influence others across three key dimensions: time, space, and impact/value, or “gravity.” This model is further exemplified through a succinct review of representative NDAs applied at our own institution. Based on this framework, we endeavor to promote a launching ground for empirical research focused on effective practices and learning outcomes for NDAs and, accordingly, support for open pedagogy. Together, the current model and research strategy presents a path for future integration of NDAs in the individual instructor’s open-education toolkit to benefit innovation in the classroom for students and humankind.
Competency adjustment and workload balancing framework in multirobot task allocation
Authors: Lee Dong-Hyun , Zaheer Sheir Afgen , Han Ji-Hyeong , Kim Jong-hwan , Matson Eric
Published: November 2018

This article proposes a framework for competency adjustment and workload balancing in multirobot task allocation. Competency represents the ability of a robot to execute a task in terms of quality and cost, and workload balancing denotes distribution of workload among robots. This framework considers the quality and cost of a robot for a task and adjusts them in accordance with environmental changes. For workload balancing, the framework utilizes the concept of subsidy to encourage participation from the less active members of the robot team. The proposed framework is implemented in a simulated cleaning mission. Simulation results demonstrate that this framework can adjust the competency in accordance with environmental changes and distribute workload among robots in a balanced manner.
Pharmacy Staff Perspectives on Alcohol and Medication Interaction Prevention Among Older Rural Adults
Authors: Zanjani Faika , Allen Hannah , Smith Rachel Vickers , Antimisiaris Demetra , Schoenberg Nancy , Martin Catherine , Clayton Richard
Published: November 2018

Older adults are at high risk for alcohol and medication interactions (AMI). Pharmacies have the potential to act as ideal locations for AMI education, as pharmacy staff play an important role in the community. This study examined the perspectives of pharmacy staff on AMI prevention programming messaging, potential barriers to and facilitators of older adult participation in such programming, and dissemination methods for AMI prevention information. Flyers, telephone calls, and site visits were used to recruit 31 pharmacy staff members who participated in semistructured interviews. A content analysis of interview transcriptions was conducted to identify major themes, categories, and subcategories. The main categories identified for AMI prevention messaging were Informational, Health Significance, and Recommendations. Within barriers to participation, the main categories identified were Health Illiteracy, Personal Attitudes, and Feasibility. The main categories identified for program facilitators were Understanding, Beneficial Consequences, and Practicality. Multimethod dissemination strategies were commonly suggested. This study found positive pharmacy staff perspectives for the planning and implementation of AMI prevention programming, and future development and feasibility testing of such programming in the pharmacy setting is warranted.
Increasing Student Engagement Within the Core Nutritional Sciences Curriculum: A Gameful Learning Approach
Authors: Bridges Dave , Hisamatsu Rina , Anderson Olivia S.
Published: November 2018

Innovative learning strategies are constantly developed to increase student engagement and application of course content to improve learning outcomes. Gameful Learning pedagogy is one such strategy that builds students’ intrinsic motivation, confidence, and engagement to course material by allowing them to choose from a menu of optional assignments to earn points toward a grade. Little is known about student perceptions and outcomes from applying this pedagogy to dietetics and nutritional sciences graduate-level curricula. This article describes the implementation of Gameful Learning to an Accreditation Council for Education in Nutrition and Dietetics–accredited nutritional sciences graduate degree course and evaluates student perceptions and outcomes. Two student cohorts from 2016 (pre–Gameful Learning) and 2017 (implementation of Gameful Learning) who were enrolled in a nutritional sciences graduate-level course were compared. Student teaching evaluations were compared across cohorts. Specific items measuring student perceptions of fairness, knowledge gained, and workload were analyzed. Mann–Whitney nonparametric tests compared groups and Spearman’s rank correlation coefficient measured associations. There was a positive correlation between total points and optional points (Pearson’s r = 0.513, p = .0001). There was an overall increased perception toward the excellence of the course (3.82 to 4.13; 5-point Likert-type scale), improved sense of fairness (3.79 to 4.17; p = .036), and increased perception of workload (2.35 to 2.20; where 1 student indicated more work and 5 indicated less work). Although challenges in workload exist, Gameful Learning strategies aid in improving student outcomes and perceptions of course material by facilitating student autonomy and engagement with course content.
Sustained inflations and avoiding mechanical ventilation to prevent death or bronchopulmonary dysplasia: a meta-analysis
Authors: Fischer Hendrik S. , Schmölzer Georg M. , Cheung Po-Yin , Bührer Christoph
Published: November 2018

Sustained inflations and avoidance of endotracheal mechanical ventilation (eMV) are delivery room interventions aimed at preventing bronchopulmonary dysplasia (BPD). Their effectiveness is the subject of the present meta-analysis.

The databases MEDLINE, EMBASE and CENTRAL were searched for randomised controlled trials (RCTs) of preterm infants that compared: 1) sustained inflations with intermittent positive-pressure ventilation; and 2) a non-intubated strategy of respiratory support with one that prescribed eMV at an earlier stage. Data extraction and analysis followed the standard methods of the Cochrane Collaboration. The primary outcome was death or BPD, defined as need for oxygen or positive pressure treatment at 36 weeks' postmenstrual age.

Avoiding eMV (nine RCTs, 3486 infants) reduced the risk of death or BPD, with a risk ratio of 0.90 (95% CI 0.84–0.97) and a number needed to treat of 35. After sustained inflations (six RCTs, 854 infants), the risk ratio was 0.85 (95% CI 0.65–1.12). A current multicentre RCT of sustained inflations in very preterm infants was halted for increased early mortality in the sustained inflations arm.

While strategies aimed at avoiding eMV had a small but significant impact on preventing BPD, sustained inflations had no effect and may even increase mortality in very preterm infants.
Fatal recurrent VTE after anticoagulant treatment for unprovoked VTE: a systematic review
Authors: van der Wall Sake J. , van der Pol Liselotte M. , Ende-Verhaar Yvonne M. , Cannegieter Suzanne C. , Schulman Sam , Prandoni Paolo , Rodger Marc , Huisman Menno V. , Klok Frederikus A.
Published: November 2018

Current guidelines recommend long-term anticoagulant therapy in patients with unprovoked venous thromboembolism (VTE). The risk of fatal recurrent VTE after treatment discontinuation (versusthat of fatal bleeding during anticoagulation) is of particular relevance in the decision to continue or stop anticoagulation after the first 3 months. Our primary aim was to provide a point-estimate of the yearly rate of fatal recurrent VTE and VTE case-fatality rate in patients with unprovoked VTE after anticoagulation cessation. Data were extracted from both randomised controlled trials and observational studies published before May 1, 2017. The pooled fatality rates were calculated using a random-effects model. 18 studies with low-to-moderate bias were included in the primary analysis, totalling 6758 patients with a median (range) follow-up duration of 2.2 (1–5) years. After anticoagulation cessation, the weighted pooled rate of VTE recurrence was 6.3 (95% CI 5.4–7.3) per 100 patient-years and the weighted pooled rate of fatal recurrent VTE was 0.17 (95% CI 0.047–0.33) per 100 patient-years, for a case-fatality rate of 2.6% (95% CI 0.86–5.0). These numbers are a solid benchmark for comparison to the risks associated with long-term anticoagulation treatment for the decision on the optimal duration of treatment of patients with unprovoked VTE.
Electronic cigarette marketing and smoking behaviour in adolescence: a cross-sectional study
Authors: Hansen Julia , Hanewinkel Reiner , Morgenstern Matthis
Published: November 2018

The aim of this study was to investigate the association between exposure to electronic cigarette (e-cigarette) advertisements and use of e-cigarettes, combustible cigarettes and hookahs.

A cross-sectional survey of 6902 German students (mean age 13.1 years, 51.3% male) recruited in six German states was performed. Exposure to e-cigarette advertisements was measured with self-rated contact frequency to three advertising images. Multilevel mixed-effect logistic regression models were used to assess associations between exposure to e-cigarette advertisement and use of e-cigarettes, combustible cigarettes and hookahs (ever and past 30 days).

Overall, 38.8% of the students were exposed to e-cigarette advertisements; ever-use of e-cigarettes was 21.7%, of combustible cigarettes was 21.8% and of hookahs was 23.2%, and poly-use of all three products was 12.4%. Exposure to e-cigarette advertisements was positively related to ever and past 30-day use of e-cigarettes, combustible cigarettes, hookahs and combined use.

We concluded that a considerable number of German teenagers are exposed to e-cigarette advertisement. There was a clear exposure–behaviour link, indicating that advertising contact was associated with different kinds of “vaping” and also smoking behaviour. Although causal interpretation is not possible due to the cross-sectional design, findings raise concerns about the current tobacco control policies.
The role of employment interruptions and part-time work for the rise in wage inequality
Authors: Biewen Martin , Fitzenberger Bernd , de Lazzer Jakob
Published: November 2018

The incidence of employment interruptions and temporary part-time work has grown strongly among full-time workers, yet little is known about the impact on wage inequality. This is the first study showing that such episodes play a substantial role for the rise in inequality of full-time wages, considering the case of Germany. While there are also strong composition effects of education for males and of age and experience for females, changes in industry and occupation explain fairly little of the inequality rise. Extending the analysis to total employment reveals substantial negative selection into part-time work.

JEL-Classification: J31, J20, J60
Improving PROMs collection rate in an outpatient palliative care clinic.
Authors: Chua Isaac S. , Siegel Jocelyn , Hayne Victoria , McCleary Nadine Jackson
Published: November 2018

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Background: From January 2018 to March 2018, Dana Farber Cancer Institute (DFCI) launched a pilot to collect Patient-Reported Outcomes of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) within the adult palliative care (APC) clinic using smart tablets. We had a limited response rate—only 20% of patients attempted to complete the questionnaire. After the pilot ended on March 2018, smart tablets were discontinued and were replaced with a paper version of PRO-CTCAE from April to June 2018. Our aim was to increase the patient attempt and collection rate of the paper PRO-CTCAE from 20% to 50%. Methods: Our primary outcome measure was the percentage of paper PRO-CTCAE attempted and collected. Eligible patients were established patients scheduled to see a provider in the APC clinic. We implemented several Plan-Do-Study-Act (PDSA) cycles including the implementation of the paper version of the questionnaire, training and educating front desk staff, and posting provider reminders in exam rooms. We used a statistical process control (SPC) chart to track percentage of attempted and collected questionnaires over time and to differentiate between special cause and common cause variation. Results: From April 2018 to June 2018, the PRO-CTCAE collection rate improved from 20% to 48%. Special cause variation was associated with implementation of the paper version of the PRO-CTCAE and increased front desk staff engagement. Increased provider satisfaction was also associated with the paper version of the PRO-CTCAE. Conclusions: Implementing a high-reliability process for collecting patient reported outcome measures in an outpatient palliative care clinic is complex and requires cohesive multi-disciplinary teamwork, a user-friendly patient-facing and provider-facing interface, and a streamlined workflow. The electronic version of PRO-CTCAE will resume in September 2018. We will implement lessons learned from the paper PRO-CTCAE implementation, including ongoing front desk staff engagement and an enhanced provider view in the electronic medical record.
Feasibility of a massive online open course to teach skills in primary palliative care for a global audience.
Authors: Kerkar Ashwini Prafulla , DeNofrio Jan , Tribett Erika Lauren , Ramchandran Kavitha
Published: November 2018

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Background: Palliative Care Always (PCA) is a massive open online course (MOOC), through Stanford Online, that teaches primary palliative care. Our goal was to provide an accessible avenue for palliative care education on a global level. This is to address persistent and considerable gaps in primary palliative care due to lack of specialist trained experts and training opportunities. Methods: A team of providers including palliative care physician, advanced care nurse practitioner, priest and social worker developed 12 modules covering the scope of palliative care across their specialties. Topics ranged from communication of bad news to hospice initiation, while following the case of an oncology patient. Components include (1) Reflection on assigned readings (2) Patient scenes (3) Multiple choice assessments and (4) Group discussions. Participants were surveyed prior to and on completion of the 12-week course. Results: PCA enrolled 721 applicants from 56 countries. Participants from the US represented 51% of the total cohort. Next highest enrollment was from Brazil, India and Canada. Median age was 40 years. 51% of surveyed participants held advanced degrees and 38% held bachelor’s degrees. At the time of enrollment, 70% of participants were employed, 76% of whom worked in healthcare or social assistance industries. 44% of participants identified themselves as having some level of teaching experience. 75% of teachers reported never covering material on palliative care. The most popular reasons for taking the course included general interest, personal growth and relevance to employment. Post assessment surveys showed 95% of enrollees had a positive experience and were satisfied with what they learned; the most useful module was communication of bad news. Conclusions: Based on participant reports, effective palliative care training and exposure on a global level is feasible and acceptable with a MOOC such as PCA. Participants were from diverse backgrounds and found the course relevant and helpful. Future directions include specialty-specific courses, with a Hepatology course currently underway, evaluation of the impact on practice outcomes, and customized cases for individualized training.
Differences in the way patient and partner experience the metastatic disease.
Authors: Bergerot Cristiane Decat , Clark Karen L. , Bergerot Paulo Gustavo , Pedras Renata Nunes , Manhaes Maria Fernanda , Bitz Courtney , Loscalzo Matthew J. , Pal Sumanta K.
Published: November 2018

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Background: In Brazil, 60.5% of patients are diagnosed with an advanced stage of cancer. Patients with incurable cancer and their partners experience high rates of distress. This study aimed to assess problem-related distress among patients with stage IV cancer and their partners. Methods: A descriptive study was conducted at a large public hospital. Patients and their partners completed the 33-item SupportScreen-Couples Distress, on a five Likert scale, which contains questions related to emotional and physical symptoms, relationship issues and concerns around diagnosis, treatment, prognosis, and end-of-life. The McNemar’s test was used to compare rates of problem-related distress between patients and their partners. Results: A total of 64 patients (median 56 yrs old; 57.8% male; 51.6% white; 87.5% Eastern Cooperative Oncology Group < 2) and 64 partners (median 56 yrs old; 53.1% white; 93.8% primary caregiver) were enrolled. Couples were married for a median of 27.3 yrs. Patients reported higher levels of distress related to fatigue (42.1% vs 29.7%; P = 0.02), worry about the future (28.1% vs 20.3%; P = 0.08), sleep problems (28.1% vs 20.3%; P = 0.07) and feeling depressed (26.6% vs 15.6%; P = 0.03) compared to their associated partners. Partners reported more anxiety (37.5% vs 28.1%) and financial concerns (25.1% vs 17.2%) compared to associated patients (P < 0.01 for both). Patients and partners had a similar understanding that curative treatment is unlikely and that the goal of treatment was disease control (51.6% and 56.2%, respectively). Patients (versus their partners) were generally more worried about how their family was coping with their cancer diagnosis (42.2% vs 15.6%) and demonstrated hesitancy in talking about fears related to the end of life (60.9% vs 14.1%) (P < 0.001 for both). Conclusions: We identify key differences in psychosocial issues experience by patients and their partners. Furthermore, patients and partners demonstrate unique concerns related to the spectrum of oncology care. Our findings can be used to tailor unique supportive care interventions for patients and partners.
A pilot study assessing the burden of caregivers of elderly patients at University College Hospital UCH.
Authors: Omoyeni Eunice Nkechi
Published: November 2018

12

Background: Caregiver burden is defined as “the perception of stress and fatigue caused by the sustained effort required in caring for persons with chronic illness or other conditions with special needs for care”. It is a type of stress or strain experienced by caregivers, which is directly/ indirectly related to the challenges/problems they face as a result of the health status of the person cared for. Stucki et al. 2000, described the carers burden as “strain or load borne by a person who cares for a chronically ill, disabled, or elderly family member”. Caregiver burden is response to physical, psychological, emotional, social, and financial stressors associated with the caregiving in a multidimensional way. It is the psychosocial and physical reaction to the imbalance of demands placed on the caregiver by various factors, including personal time, multiple roles, physical and emotional states, financial resources, and formal care resources. The caregiver's perception of the burden, rather than the perception of other family members or healthcare providers, determines the impact of this burden on his or her life. Methods: Caregivers of elderly patients attending the geriatric and medical outpatient’s clinics at UCH completed a caregiver strain index scale, over a 2 month period. Demographic information regarding gender, age, were obtained and scaled questions were ticked. Data was analysed using IBM SPSS statistics 21. Results: Eighty-five participants completed the caregiver strain index scale. The socio-demographic data described age and gender. Most participants fell in the 31 - 40 and 41 - 50 age groups (41.2% for each group). Fifty-eight (68.2%) were females while 27 (31.8%) were males. Most common strain variable was demand on time with percentage 54.1% (46). Twenty-nine (34.1%) had moderate level of stress (4 - 6) , while 32 (37.6%) had mild level of stress, and 17 (20.0%) had high level of stress. One participant had the highest score index was 11 while 13 (15.3%) had scores of 3 and 13 (15.3%) had scores of 5. Conclusions: The study showed that caregivers of elderly patients have high burden in the demand on their time and need supportive/collaborative systems which includes palliative care to help with the task of caring for these elderly ones.
Developing a Delphi survey in MD/APP’s for distress level after supportive care inpatient consults.
Authors: Vidal Marieberta
Published: November 2018

125

Background: Physicians caring for patients with terminal cancer are at particular risk for compromised well-being due to the nature and intensity of the clinical stresses they face. The factors contributing to professional burnout severity included younger age, working in isolation, and working longer hours a shown by a survey conducted by Kamal et al. For patient encounter distress multiple factor have been mention as a source of distress for providers including patient factors, physician factors and environmental factors. No documented evidence of the distress level in palliative care (PC) providers after patient encounter is available. We intend to identify the most common predictors for high distress level after patient encounter in order to identify ways to support our staff. Methods: A group of 28 PC faculty physicians and mid-level providers in the Department of PC at the M. D. Anderson Cancer Center were invited to participate in the study by email with Qualtrics link e-online questionnaire. The questionnaire seek their opinion on the most important interaction or situations that increase their distress level during a PC consult. A 5-point Likert scale of agreement was used, ranging from “strongly disagree” to “strongly agree”. We will conduct the procedure to generate the question prompt sheet with 3 Delphi rounds. Results: After the first round of the Delphi the situations that could cause distress after a consult with more than 80% agreement were identify as: difficult family, manipulative family/patient, angry patient/family, primary team in denial, time of the consult, and number of consults. Situations like patient's terminal diagnosis, patient/family religious beliefs, cultural background, or presence of observer or trainee were less likely consider as source of distress with a less than 20% agreement. Conclusions: For PC specialists situations that affect the communication or rapport with patients as well as amount/burden of clinical work seems to be more a source of distress. Other situations related to uncontrolled symptoms, EOL issues or patient background were less likely a source of distress what could be explain by the expertise of the specialist with these EOL discussions and symptom management.
"Everything that is not curative is now palliative": A nurse perspective.
Authors: Buiting Hilde M. , Botman Femke , Busink Veerle , Oomen Elzbeth , Ho Vincent K.Y.
Published: November 2018

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Background: Advances in oncology increasingly result in protracted disease trajectories for patients with incurable cancer. This phase can be described as advanced / metastatic cancer and in which anti-cancer treatment should control symptoms, slow disease progression, and/or prolong life. It poses new challenges for patients and their doctors; it is unknown how and which disease labels are used by nurses. Methods: Qualitative ethnographic study, based on in-depth interviews with 13 oncology nurses at the day-care unit in a Dutch comprehensive cancer hospital. Results: A substantial number of nurses reported not to know whether patients were treated with a curative or palliative intent, and to follow a patient-centred approach. Other nurses clearly demarcated palliative patients, and some distinguished "real palliative patients" from patients with long-standing incurable cancer. When nurses were explicitly asked about medical terminology, many nurses were not very positive about the term "palliative". They considered this to be an old term, e.g. "Now everything that is not curative is palliative". Moreover, the term "palliative" could have an ambiguous/threatening meaning, especially for patients. Whereas nurses often associated the term "palliative" with alleviating symptoms, for patients this term was frequently associated with the approaching death. Most nurses therefore preferred not to use the term "palliative" in front of the patient; but only amongst nurses themselves. Since nurses had not previously been provoked to think about other terms, they were unsure whether "chronic" was the right term. Some indicated that cancer was rather different compared to other chronic diseases, others felt unsure when to use the term "chronic" at all. Conclusions: According to nurses, the use of specific medical terms such as "chronic" to describe the situation of patients in protracted disease trajectories is unclear. Although they acknowledge differences across the palliative care continuum, they refrain from using the word "palliative" in front of the patient. Nurses’ awareness of the disease stage (curative/palliative/ "chronic") might be important to optimise to patients’ specific needs in every disease phase.
Cost of care, discharge disposition, and survival of advanced cancer patients (ACP) receiving early inpatient palliative care (PC) compared to standard oncologic care (SOC) without palliative care.
Authors: Daugherty Christopher , Johnson Julie , Levine Stacie K. , Wroblewski Kristen , Lane Bradford , Dale William , Malec Monica , Hlubocky Fay J.
Published: November 2018

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Background: PC significantly enhances ACP quality of life, provides symptom control, improves transitions to end-of-life care, and mortality. However, the financial implications, discharge disposition, and survival benefits of early, inpatient PC compared to SOC remains less understood. Methods: Retrospective cohort analysis of ACP receiving either PC or SOC between Jan 2015-Dec 2015 (N=810). ACP cohorts were compared for demographics, costs, disposition, and survival. Financial costs collected included: fixed (overhead expenditures, facility maintenance, hospital property); variable (patient care supplies, diagnostic/therapeutic supplies, medications); operating (fixed, variable, breaking-even costs); direct (labor, materials, commissions, piece-rate wages, manufacturing supplies); indirect (production supervision salaries, quality control, insurance, depreciation). Univariate and multivariate analyses were completed. Results: 468 were admitted to PC and 342 to SOC. In comparison with SOC, PC were more likely to be: younger (61.1±13.2 vs. 62.5±13.0, p=0.02); African American (48% vs. 36%, p=0.0045); female (50% vs. 40%, p=0.005); and have shorter length of inpatient stay (5.7± 4.9 vs. 6.2±6.5, p=0.01). PC had significantly lower costs: direct ($9,478 vs. $10,416, p=0.01); indirect ($9,538 vs. $10,999, p=0.002); fixed ($10,308 vs. $12,076, p=0.001); variable ($8,709 vs. $ 9,339, p=0.02); operating ($19,017 vs. $21,416, p=0.003).Compared with SOC, ACP receiving PC were more likely to be discharged to: home (55% vs.45%, p=0.01); health care facilities (e.g. skilled nursing, inpatient rehabilitation) (36.1% vs. 20%, p=0.04); and hospice (home and inpatient) (7.7% vs. 5.8%, p=0.02). PC had overall greater median survival from the time of discharge (106.8±99.95 vs. 73.8±61.93, p=0.03) compared to SOC. Conclusions: Early PC results in less financial burden and greater cost savings for inpatient ACP including for those who are younger and underserved. These findings provide further evidence for policies arguing that ACP access to routine PC must become a health care priority.
Next steps: Incorporating patient-reported outcomes into palliative care referral for people with advanced breast cancer.
Authors: Li Yun Rose , Marquez Celine Denise , Rugo Hope S. , Rabow Michael W. , Esserman Laura
Published: November 2018

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Background: Specialty palliative care (SPC) has been shown to improve quality of life, reduce unnecessary health care utilization, reduce overall costs, and decrease mortality in some settings for patients with advanced or metastatic cancer, however only a small proportion are being promptly referred. As interventions that respond to patient reported outcomes (PROs) have been shown to improve symptoms and decrease mortality, we hypothesized that the rates of SPC referral would be increased by documenting, tracking, and presenting PROs for oncology visits to referring oncologists. Methods: Over a period of 2 months, 74 English-speaking established patients seen in an advanced breast cancer clinic with an embedded SPC service were approached and completed the study. All patients filled out the electronic, validated PROMIS and PRO-CTCAE PRO questionnaires in the waiting room using a touch screen tablet. Results were presented to the oncologist during the encounter if the CTCAE severity score exceeded 3 in at least 1 domain. Patient demographics, clinical features and PC referrals or appointments were assessed via chart review. Results: At baseline, 9 (12.2%) patients scored a minimum of “severe” (4/5 or 5/5) in at least 1 of the 3 anxiety domains; 17 (23.0%) had moderate-severe pain; and 27 (32.1%) reported fatigue. At study entry, 25 patients (33.8%) had been referred previously to the SPC service; 19 had actually been seen (76% of referred). Of the 63 (85.1%) patients with sufficient follow-up, 13 (20.6%) reported at least “severe” in >1 CTCAE domains, 6 (46.2%) of whom were previously referred to SPC. For the remaining 7 patients, median PROMIS T-score and PRO-CTCAE maximum severity score were 58.3 and 3.2, respectively; none were referred to SPC during the follow up period. Conclusions: The choice to refer (or not to refer) a patient to SPC is complex and tied to patient specific factors such as coordinating additional visits and fear of end of life conversations. To enable greater access to SPC, alternative referral mechanisms, such as group-based or personalized patient education, or automatic referrals triggered by evidence of need, may be required. #YRL/CDM contributed equally.
Disparities in access to palliative care for patients treated for gynecologic oncology.
Authors: Flood Nora , Rivard Colleen
Published: November 2018

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Background: Palliative care intends to improve quality of life for patients with life-threatening illness, but ethnic and linguistic minority patients have worse outcomes with palliative care. Methods: This is a single institution retrospective chart review of patients with an advanced stage or recurrent gynecologic malignancy who were seen in the clinic from 2010 to 2015. Women were defined as being from a minority group if they met one of the inclusion criteria including English not the primary language, race other than white, ethnically Hispanic/Latina, or their country of origin was not the United States. We then compared rates of referral to palliative care between those women who were deemed to be minority women as compared to those who were non-minority. We also compared the time to referral between these two groups. Results: Our study included 277 women of which 20% were categorized as minority. Demographic data between the two groups were well matched with the exception that minority women were diagnosed at a younger age and were more likely to have cervical cancer. Although not statistically significant, more minority women were referred to palliative care than non-minority (79% vs. 89%, p=0.08). In contrast, fewer minority patients were referred to palliative care at least 3 months prior to death when compared to non-minority patients (50% vs. 38%, p =0.10). There was no difference between referral location [inpatients (35% vs. 36%) and outpatients (65% vs. 64%, p=.92)] in minority versus non-minority patients. There was also no significant difference in those patients entering hospice while admitted to the hospital. Minority patients had significantly more cancer-related hospitalizations per year (0.6 vs 1.0, p value 0.02). Conclusions: Our study shows that there is a tendency towards later referral to palliative care for minority patients as compared to non-minority patients. Although more minority patients are referred to palliative care, they are hospitalized for cancer related symptoms at a significantly higher rate suggesting that perhaps their utilization of palliative care services is suboptimal.
Quality improvement pilot of a palliative care model in an outpatient community cancer clinic setting.
Authors: De Vos-Schmidt Diane , DiCarlo Brian Anthony , Katics Matt
Published: November 2018

138

Background: The need for outpatient based palliative care in community cancer clinics has been repeatedly identified, but poorly integrated. Cancer patients benefit from focused attention on the alleviation of symptoms related to either disease or treatment. Methods: A pilot program was developed for use in the outpatient community cancer clinic setting. This program sought to determine feasibility in this setting. It was limited to one medical oncologist and one palliative care APRN. Modifications were made in the electronic medical record to accommodate scheduling, documentation on a palliative care specific progress note and billing. Complete palliative care assessment included: symptom burden assessment, distress analysis using ESAS tool, 10 system physical exam, social, spiritual and emotional history and assessments. Ancillary services of chaplaincy and social services were also available. Home palliative care services were provided by a palliative care accredited home health agency. Initial consult visits were billed 99215, lasting 60 minutes. Follow up visits were billed 99214, lasting 30 min. Family conferences, with the patient present, were billed at the 99215. Results: Sample size was 44 patients: 23% pancreatic cancer, 13% upper gastrointestinal cancers, 13% lung cancer, 11% prostate cancer, 6% each colorectal, ovarian, and hematologic malignancies. The sample size was smaller than anticipated as not all eligible patients were referred. Reports from patients, families, and medical providers were all positive. Conclusions: The program will now be expanded to the entire San Luis Obispo Oncology and Hematology health clinic. This will include five medical oncologist and four advanced practice providers as referral sources. It is anticipated that at least one full time palliative care APRN will be needed. The model was found to be feasible with the additional support of a chaplin, clinic social services, and home health palliative care. The goal is to reduce symptom burden and improve quality of life.
Examining the intersection of palliative care, hospice, and concurrent care in Veterans Affairs (VA).
Authors: Bickel Kathleen Elizabeth , Levy Cari , Corneau Emily , Miller Susan C , Mor Vincent
Published: November 2018

139

Background: The VA advocates for both palliative care and concurrent care (hospice care and cancer-directed treatment). Studies indicate that these policies have increased hospice use and have improved family-reported outcomes and other quality metrics. However, little is known about how palliative care, hospice care and concurrent care may interact to obtain these outcomes. Methods: This was a retrospective cohort study of veterans dying with stage IV non-small cell lung cancer in 2012. VA and Medicare administrative data were used to identify the cohort, chemotherapy and radiation use, hospitalizations, hospice use and length of stay (LOS). Palliative care use was determined by VA data only. Analyses included descriptive statistics, chi-square and analysis of variance. Results: Of the 1763 veterans, 850 (48.2%) received both palliative care and hospice, 392 (22.2%) received hospice only, 241 (13.7%) received palliative care only and 280 (15.9%) received neither. Receipt of cancer-directed treatment or hospitalization in the last 30 days of life was significantly different across these groups (p < 0.0001) and was highest at 65% (182/280) in the neither palliative care or hospice group. In the remaining groups, rates of cancer-directed treatment or hospitalization in the last 30 days were: 39.4% (95/241) in palliative care only, 29.3% (115/392) in hospice only and 23% (198/850) with both palliative care and hospice. Concurrent care was received by 314 veterans (17.8%), 275 also receiving palliative care. Among veterans receiving palliative care and Medicare hospice, concurrent care did not alter hospice utilization rates or LOS: 36.4% (100/275), LOS mean 22.3, median 16.5, range 1-97 and 37.2% (214/575), LOS mean 20.1, median 13, range 1-94, for concurrent care and non-concurrent care respectively. Conclusions: The rates of cancer-directed treatment or hospitalization in the last 30 days of life appeared to be reduced in a continuum from receipt of neither hospice nor palliative care, to receipt of palliative care or hospice alone, followed by receipt of both together. Concurrent care use was facilitated by palliative care without impacting Medicare hospice use or LOS in palliative care recipients.
Randomized trial protocol of bridge intervention for patients with serious mental illness and cancer.
Authors: Fields Lauren , Callaway Catherine A , Park Elyse R. , Nierenberg Andrew A , Greer Joseph , Temel Jennifer S. , Irwin Kelly
Published: November 2018

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Background: Individuals with serious mental illness (SMI) diagnosed with cancer often have disruptions in treatment, leading to premature mortality compared to patients without SMI. To address such gaps in care, we developed and piloted a collaborative care intervention for patients with SMI and cancer (Bridge). We now propose a randomized controlled trial (RCT) to investigate the impact of the Bridge intervention on disruptions in cancer care for patients with SMI. Methods: We will conduct a two-arm RCT (n = 120) comparing Bridge to enhanced usual care (EUC) for patients with SMI (schizophrenia, bipolar disorder, major depressive disorder) and newly diagnosed breast, lung, gastrointestinal, or head/neck cancer. The 12-week Bridge intervention includes: 1) assessment by a psychiatrist with expertise in oncology at cancer diagnosis, 2) involvement of a case manager to promote self-management and care coordination, 3) collaboration between psychiatry and oncology (e.g., joint visits, developing an integrated treatment plan) to address barriers to care, and 4) availability of study clinicians via phone, text, or in-person for consultation and follow-up with patients, caregivers, and oncology and community mental health clinicians. In the EUC arm, study staff will inform the treating oncologist of the psychiatric diagnosis and notify the patient and oncologist of available psychosocial services at enrollment. Patients will be randomized 1:1 to Bridge or EUC, stratified by presence of a caregiver. Identified caregivers will be co-enrolled, and patients without a caregiver will be eligible. We will utilize verbal consent, link study visits to oncology appointments, and personalize frequency and location (e.g., community, clinic, hospital) of contact with patients and caregivers to decrease burden and promote engagement. The primary outcome is the proportion of patients with disruptions in cancer care within 6 months of enrollment, confirmed by oncologists blinded to study arm. Secondary outcomes include clinician assessment of psychiatric illness severity as well as patient and caregiver reported measures (e.g., depression, engagement in care, treatment satisfaction). Results: N/A. Conclusions: N/A. Clinical trial information: NCT03360695.