bluuebunny/crossref_metadata_2025 huggingface dataset:
End-of-life care decisions using Korean advance directives among cancer patient-caregiver dyads.
Authors: Koh Su-Jin , Kim Shinmi , Kim JinShil
Published: February 2017

11

Background: The Korean advance directives (K-ADs) consist of a value statement, treatment directives (cardiopulmonary resuscitation [CPR], preferences for artificial ventilation, tube feeding, and hospice care). K-ADs can facilitate a patient’s decision-making for end-of-life (EOL) care. This study aims to examine the extent to which patient-caregiver dyads agreed on decisions for EOL care using the K-ADs. Methods: Using a descriptive study design, 81 cancer patients were invited to participate. The final sample consisted of 44 patient-caregiver dyads who completed K-ADs; 36 (44.4%) of the initial 81 patients declined to participate. Results: Patient participants had different cancerdiagnoses: 29.5% colorectal cancer, 29.5% breast, and 15.9% liver/biliary tract cancers; 59% of the sample had advanced stage cancer. Spouse (70.5%) and adult children of the patient (20.4%) were primary caregivers with perceived bonding rated as fair (31.8%) or good (65.9%). Rejection of K-ADs was mainly because of difficulty in deciding EOL care (50%). Comfort in dying was the most common theme of the value statement for patients (73.8%) and caregivers (66.7%). For treatment directives, dyads advocated for hospice care (66.7%) and reduced support for aggressive treatments of CPR or artificial ventilation, k = .43, p = .004 and k = .28, p = .046, respectively. These approaches showed significantly mild to moderate concordance among the dyads. Sixteen out of the 21 dyads identified their spouses as a proxy, with others designating their adult children. Conclusions: The findings of the study are exploratory but suggest the need for ongoing EOL discussion where patient-caregiver dyads are encouraged to participate in the decision-making for EOL care.
Are hospital clinicians aware of legislation surrounding provision of palliative care?
Authors: Wong Aaron Kee Yee
Published: February 2017

118

Background: Many deaths require medical treatment to be withheld or withdrawn. Patients or their substitute decision makers may disagree with these decisions, and sometimes refuse the right to appropriate palliative care. An awareness of legal frameworks surrounding end of life decisions is vital to navigate through these conflicts. Without this, patients suffer unnecessarily. Methods: 542 hospital doctors and nurses were recruited from a large metropolitan public tertiary teaching hospital network involving 5 campuses and 2 medical schools. A questionnaire examined their regarding legislation surrounding end of life care, both in adults with and without capacity. Results: Approximately a quarter of respondents did not believe that the “Not for Resuscitation Form” is legally a medical decision. Most doctors (68%), but not nurses, believed competent patients cannot demand futile treatment. Most clinicians (79% doctors and 85% nurses) erroneously believe that competent patients can refuse appropriate palliative care. There was significant confusion regarding the roles of substitute decision makers. Most clinicians could not find the advance directive. Groups with most correct answers were doctors, had 5-10 years experience, and were in palliative care and critical care specialties. Conclusions: This study confirms poor knowledge regarding legislation surrounding provision of palliative care. An unusually high proportion believed patients could refuse appropriate palliative care. Most clinicians could not locate advance directives. Most nurses believed patients could legally demand futile treatment. Both junior and senior staff had comparably poor knowledge in this area.
Using a values assessment as a bridge to advance care planning: Results of 1286 patient reports.
Authors: Hoverman John Russell , Taniguchi Cynthia , Eagye Kathryn J , Ash-Lee Susan , Kalisiak Angela , Mikan Sabrina Q. , Hartung Nicole
Published: February 2017

12

Background: Recent studies have shown that formal Palliative Care (PC) improves care at the end of life for cancer patients. The role of communication in PC is not defined. Other studies have shown that communication alone can be associated with better end of life outcomes. The US Oncology Network developed and tested a Values Assessment (VA) instrument for routinely broaching difficult topics to facilitate more formal advance care planning (ACP). The results of the first 28 months of the program on over 1200 patients are reported here. Methods: The VA consists of 10 questions of the format “How valuable is it to me to….”, for example “know that I am not a burden to my family, friends or helpers?” Responses were on a 4 point scale from unsure to very valuable. The VA was completed either in person in the clinic or telephonically. VA participation by n = 1286 metastatic cancer patients treated at participating practices from 4/1/2013-7/31/2015 were extracted from the EHR and confirmed by chart review, as were demographic (age, gender, ethnicity), clinical (diagnosis and stage), chemotherapy treatment and outcomes (hospice enrollment and place of death). Demographics and outcomes were compared using the Chi-Squared or Fisher’s Exact Test, or Wilcoxon Rank Sums test for continuous variables. Results: 1268 patients completed the VA. 56.7% were 65 or over. 57.8% went on to complete Advance Directives (AD). 52% had colon or lung cancer. There were 438 deaths of which 431 had a date of last chemotherapy recorded. Of these 431 patients, 78% died at home or inpatient hospice, 14.6% in the hospital. Hospice enrollment with AD was 76.1%, without 60.9%. (p = .008) Median LOS in hospice was 21 days vs. 12.5 (p = .025). Chemotherapy in the last 14 days of life was 7.05% with AD, 13.4% without. The VA was well accepted by patients. Conclusions: A VA as a routine part of practice is feasible and scalable. It can be delivered successfully either face to face or telephonically. It facilitates ACP discussion leading to AD. The results suggest VA and ACP lead to less aggressive care at the end of life.
Evaluation of hematologist/oncologist attributes by physicians and patients: A survey study.
Authors: McIntyre Kaitlin , Patrick Cory , Singal Rakesh , Hansra Damien Mikael
Published: February 2017

124

Background: We aim to compare what attributes are important to hematology/oncology (hem/onc) physicians (MD) and patients (pts). Methods: IRB approval obtained. Pts and MDs at an academic tertiary care medical center were enrolled to complete a survey. Demographics include: age, gender, race, and ethnicity. Clinical info collected: cancer subtype and treating MD. Survey consisted of 5 questions assessing opinions on physician attributes. Patients were asked: “It is important that my doctor” is friendly, is empathetic, is knowledgeable, well dressed, and engaged in research. MDs were asked: “It is important to be” friendly, empathetic, knowledgeable, well dressed, and engaged in research. Answers recorded on a 5 point scale (1 = highly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = highly agree) & converted into 2 categories (1,2,3 = neutral/disagree vs. 4,5 = agree). Fisher’s exact test with 2 sided p-value used to compare significance between MD & pts responses. Results: 1008 pts and 55 MDs enrolled from June 2013 to October 2015. Pt mean age 55, range 18-88 with 45% male & 55% female. 62% of pts were Hispanic vs. 38% not Hispanic. 16% white, 14% black/African American, 2% Asian/Pacific Islander, & 6% other. 21% of pts had hematologic disorders (92% malignant 8% benign) vs. 79% of pts had solid malignancies. Significant difference was seen for research where 93% of pts agree that having a doctor who is engaged in research is important vs. 63% of MDs, p < 0.0001. A majority of pts and MDs agree that friendliness (92% vs. 91% resp., p = 0.6032), empathy (91% vs. 93% resp., p = 1.000), fund of knowledge (95% vs. 94% resp., p = 0.7442), being well dressed (79% vs. 69% resp., p = 0.0901), is important but no significant differences seen. Conclusions: Hem/onc pts and MD agree that friendliness, empathy, fund of knowledge, being well dressed are important attributes in a hem/onc MD. A significantly increased percentage of patients find it important that their hem/onc MD is engaged in research. It is expected that increased hem/onc MD research will not only contribute to society but also it could improve patient satisfaction.
Last year of life of cancer patients who are adolescents and young adults (AYA): Inpatient patterns and disparities in a population-based study.
Authors: Johnston Emily E. , Alvarez Elysia Marie , Saynina Olga , Sanders Lee , Bhatia Smita , Chamberlain Lisa J.
Published: February 2017

126

Background: Cancer is the leading cause of non-accidental death among adolescents and young adults (AYA) in the US. The last year of life involves significant inpatient resources for older patients. We sought to determine the quantity and pattern of inpatient care for AYA cancer decedents in the last year of life to learn their healthcare system impact and groups to target for intervention. Methods: Using the California Office of Statewide Health Planning and Development private administrative database linked to death certificates, we performed a retrospective cross-sectional population-based analysis of patients aged 15-39 with cancer who died between 2000-2011. We calculated the number of admissions, hospital days, and percent of the cohort admitted each day in the last year of life. We determined the bed-day distribution across the population and the clinical and socio-demographic factors associated with high inpatient utilization. Results: The 9562 AYA cancer decedents were 45% non-Hispanic white, 30% Hispanic; 20% had hematologic malignancies, 70% had solid tumors. They were hospitalized, on average, 4.3 times and 40.6 days in the last year of life, increasing 3 months before death. Bed day occupation was skewed: 5% of the patients occupied 20% of the bed days and 18% occupied 50%. Factors associated with increased odds of being a top 5% utilizer were being Hispanic (OR: 1.48, 95% CI: 1.15-1.90, ref: non-Hispanic white), and having Acute Myelogenous Leukemia (AML) (2.7, 1.74-0.67, ref: Acute Lymphoblastic Leukemia (ALL). Factors associated with decreased odds were rural residence (0.39, 0.23-0.67, ref: urban), HMO insurance (0.58, 0.38-0.88, ref: private non-HMO), no hospitalizations at specialty centers (0.72, 0.53-0.97, ref: specialty center only), and having lymphoma or a solid tumor (ORs 0.035-0.39, CI range 0.005-0.56, ref: ALL). Conclusions: AYAs dying of cancer spent 40.6 days in the hospital in their last year of life (more than 1 in 9 days) with higher rates for Hispanics, AML patients, those with urban residence, and those hospitalized at specialty centers. Further research needs to determine what is driving these patterns, if they are preventable, and if they align with patient and family wishes.
The effect of early palliative care consultation for survival in patients with unresectable pancreatic cancer.
Authors: Kosugi Kazuhiro , Omata Fumio , Fujita Yoshiyuki , Hayashi Akitoshi
Published: February 2017

131

Background: Additional early palliative care consultation (EPCC) on standard oncology care (SOC) was reported to prolong survival of patients with metastatic non–small cell lung cancer by one randomized controlled trial. However, its survival benefits for the patients with other advanced cancer have not fully been investigated yet. Pancreatic cancer is one of neoplastic diseases which seldom can be diagnosed in early stage and it is important to know the effectiveness of EPCC. The aim of this study was to determine the effectiveness of EPCC for survival of unresectable pancreatic cancer(UPC). Methods: A retrospective cohort study was conducted in tertiary referral hospital in Tokyo, Japan. 98 patients were diagnosed with UPC between Jan 2004 and February 2007. Candidate variable as predictors for survival analysis included basic characteristics of patients such as age and gender, EPCC, American Joint Committee on Cancer (AJCC) stage, Charlson comorbidity index (CCI), ECOG performance status (PS), and chemotherapy. EPCC was defined as referral to board certified palliative care physician within 30 days after initial diagnosis of UPC. Patients were classified to EPCC with SOC and SOC only group. Bivariate analyses was conducted to compare EPCC with SOC and SOC group. Kaplan-Meier estimates were calculated. Cox proportional hazard model was applied for multivariate analysis. Results: The basic characteristics of patients are described in table. Median estimates of survival [95%CI] were 64 days[21-99] in the group of EPCC with SOC, and 132 days [69-174] in the group of SOC only (P=0.0065, Log-rank test). Adjusted hazard ratio [95% CI] of AJCC stage, chemotherapy, and EPCC was 1.82 [1.02-3.49], 0.41 [0.25-0.70], 2.02 [1.03-3.70], respectively. Conclusions: EPCC may be a significantly poor prognostic factor in the patients with UPC. [Table: see text]
Patterns of intensity of end-of-life care for adolescents and young adults with cancer: A population-based study.
Authors: Johnston Emily E. , Alvarez Elysia Marie , Saynina Olga , Sanders Lee , Bhatia Smita , Chamberlain Lisa J
Published: February 2017

132

Background: Cancer is the leading cause of non-accidental death amongst adolescents and young adults (AYA), aged 15-39, in the U.S. It is critical to understand end of life (EOL) care of AYA cancer decedents, including use of medically intense interventions like intubation. Although desired by some, most patients prefer a natural death. We sought to determine rates of medically intense interventions at end of life for AYA cancer decedents and associated factors. Methods: Using the California Office of Statewide Health Planning and Development private administrative database linked to death certificates, we performed a retrospective population based analysis of patients aged 15-39 with cancer who died between 2000-2010. We used previously defined administrative codes indicative of intense EOL care: intubation, CPR, hospital re-admission, and ICU admission in the last 30 days of life, and location of death. The frequencies of each intense item were calculated and multivariate logistic regression was used to determine clinical (including treatment at specialty center vs non) and socio-demographic factors associated with each item and receipt of ≥ 2 items. Results: The 8,978 AYA cancer decedents were 46% non-Hispanic white, 29% Hispanic, 10% non-Hispanic black, 11% Asian; 21% had hematologic malignancies, 70% had solid tumors, and 9% had secondary neoplasms; 58% were hospitalized only at non-specialty centers in the last 6 months of life. 62% received ≥ 1 medically intense EOL care intervention, and 32% received > 2. Factors associated with > 2 intense EOL care interventions were: non-Hispanic black (OR 1.38, 95% CI 1.16-1.65), Hispanics (1.19, 1.06-1.35), Asians (1.30, 1.10-1.52); those sometimes (2.19, 1.87-2.56) or never (1.44, 1.26-1.65) seen at specialty centers; hematologic malignancies (1.77, 1.57-2.00 ref grp: solid tumors) whereas secondary malignancies were not associated with > 2 intense markers (0.68, 0.56-0.83). Conclusions: Nearly two-thirds of the AYA cancer decedents received medically intense EOL interventions and disparities exist in receipt of such care. Further research needs to determine if the disparities are due to healthcare system, patient preference, or other factors.
Improvements in communication and engagement of advance care planning in adults with metastatic cancer through a targeted team approach.
Authors: Mikan Sabrina Q. , Wilfong Lalan S. , Rhoads Margaret , Cagle Mary Ann , Taniguchi Cynthia B.
Published: February 2017

14

Background: Advance care planning (ACP) continues to be a vital part of comprehensive, person-centered cancer care. A large community oncology practice performed a targeted approach to improve patient engagement of ACP. A process improvement project with three goals was set: increasing ACP referrals, ACP counseling visits and completed Values Assessment (VA) instrument. A leadership team consisting of practice director, physician, nurse manager, and nurse practitioner was developed with ownership of roles and responsibilities. Methods: The ACP leadership team outlined workflows to be tested, followed by evaluating outcomes of each goal over 107 days. Barriers and challenges were identified; ACP education was taught to staff. NP and RNs introduced ACP to patients during ChemoTeaching. Eligible patients were identified weekly by infusion RNs on C1D1, and patients were given the VA. Desk RNs would speak with patients on C1D2 to review symptoms and VA responses. RNs would offer ACP visits to patients. Referrals were made for patients to have one-on-one counseling with NP. Staff was educated about EMR documentation by RN manager. Weekly team phone meetings were held to discuss project status. Results: During the first 53 days of the project, 20 patients were identified at C1D1, 5 VA were completed and 15 ACP visits occurred. After evaluation, weekly communication with clinical staff increased to daily huddles. Daily communication allowed for RNs to identify C1D1 patients and communicate to the full team. During the second 54 days, 94 patients were identified at C1D1, 46 VA were completed, and 27 ACP visits occurred. A 5-fold increase occurred in patient identification; a 9-fold increase in VA completion occurred, and approximately 2-fold increase occurred in ACP counseling. Conclusions: By developing a focused and concerted process on ACP, the cancer center was able to show that patient engagement in the ACP process markedly improved. A navigation process for identifying patients who would benefit from ACP counseling was vital in increasing in the counseling visits. Continual quality improvement by refining processes in the ACP program will benefit patients.
Characteristics of patients with unscheduled versus scheduled visits to outpatient supportive care center (SCC) at a comprehensive cancer center.
Authors: Wong Angelique , Azhar Ahsan , Cerana Maria Agustina , Balankari Vishidha Reddy , Adabala Madhuri , Liu Diane D , Williams Janet L. , Bruera Eduardo
Published: February 2017

144

Background: There is limited literature regarding outpatient palliative care, and even more limited literature describing factors associated with unscheduled visits. Our aim was to identify clinical characteristics of patients who walk-in (present unscheduled) to the outpatient SCC with the hypothesize that the patients who present for unscheduled visits have more severe symptom distress as compared to those patients who present for scheduled appointments. Methods: We compared 183 patients with unscheduled consults (CO) vs a random sample of 361 patients with scheduled CO and 159 patients with unscheduled follow-up (FU) visits vs a random sample of 318 patients with scheduled FU visits. Results: Among 544 total CO visits, unscheduled visits had worse median Edmonton Symptom Assessment Scale (ESAS) symptoms (on a scale from 0 to 10): pain (6.5 vs 4.7, p < .0001), fatigue (p = .002), nausea (p = .017), depression (p = .003), anxiety (p = 0.02), sleep (p = .0002), and overall feeling of well-being (p = 0.0009). There was no statistical difference in shortness of breath, financial distress, nor spiritual pain. Daily opioid dose (MEDD in mg) was significantly higher in unscheduled CO visits (119.7 vs 62.9, p = .0004). Among 344 total FU visits, unscheduled visits had worse median ESAS symptoms: pain (5.7 vs 4.2, p = .0001), fatigue (p = .0006), depression (p = .019), anxiety (p = .014) and higher MEDD (111.3 vs 73.6, p = .0009). There was no difference in type of insurance coverage and better ECOG (p = .015) in unscheduled vs scheduled CO visits. Unscheduled CO visits were more likely to be from outside the Houston area (161/361, 45% vs. 40/133, 30%, p < 0.0001). Conclusions: Patients who are either referred as unscheduled CO visits or who present as unscheduled FU visits have higher levels of physical and psychosocial distress and higher opioid dose. Outpatient palliative care centers need to provide opportunity for walk-in referrals for timely management of these issues.
Embedded palliative medicine model for inpatient solid tumor oncology patients utilizing corounding and consultation criteria: A quality improvement pilot.
Authors: McInnes Susan , Estfan Bassam N. , Montero Alberto J.
Published: February 2017

148

Background: Hospitalized patients (pts) on solid tumor oncology (STO) services have palliative needs including pain management. This quality improvement project sought to establish a new STO-specific co-rounding PM consult service, evaluate the use of consult criteria for STO inpatients, assess the impact/interest in an embedded service, improve access to PM for STO pts and improve palliative education to STO teams. Methods: During October 2015 to January 2016, a new PM consult service was established for the 2 STO inpatient services at Cleveland Clinic. The PM attending physician (MD) rounded with each of the STO teams twice a week. On weekdays, the PM MD chart-screened all STO pts for palliative needs such as uncontrolled pain (2 pain scores ≥ 6 out of 10 in 24 hours), unplanned readmission within 30 days or contact with a PM MD as an outpatient. Other PM needs were assessed on rounds. PM consults were offered for pts who screened positive and were performed if approved by the STO team. STO MDs were surveyed anonymously regarding acceptance of the embedded service. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data regarding pain management during the pilot period was reviewed. Results: Average daily census for the 2 STO teams was 28 pts. There were 282 positive palliative screens in 4 months, 119 of whom were seen in consultation (42%.) The embedded service saw 42-45 new consults per month. The PM team followed 22-35% of all STO inpatients. 14-18 pts/month new to PM were referred to the outpatient PM clinic after discharge. STO MDs indicated strong acceptance of the embedded PM team for pain management, STO team education and coordination of care. All STO MDs wanted the service to continue. HCAHPS pain scores for the entire STO floor improved from a baseline 39th percentile to 98thpercentile. Conclusions: PM was integrated successfully into daily hospital care of STO pts at our institution using a co-rounding model and consult criteria. The service was busy and well received by STO MDs. Continuity with outpatient PM was provided. HCAHPS pain scores improved for the entire STO floor, including pts not directly seen by PM.
Food as medicine: A randomized controlled trial (RCT) of home delivered, medically tailored meals (HDMTM) on quality of life (QoL) in metastatic lung and non-colorectal GI cancer patients.
Authors: Ishaq Omar , Mailhot Vega Raymond , Zullig Lisa , Wassung Alissa , Walters Dorella , Berland Noah , Du Kevin Lee , Ahn Jiyoung , Leichman Cynthia G. , Jill Cohen Deirdre , Gu Ping , Chachoua Abraham , Leichman Lawrence P. , Pearl Karen , Schiff Peter B.
Published: February 2017

155

Background: Malnutrition incidence in cancer approaches 85%, disproportionately burdening those with lung, GI, and advanced stage cancers. Malnourished patients have impaired chemotherapy response, shorter survival, longer hospital stays, and decreased QoL. Home delivered meals are nutritional interventions that improve patient well-being, nutrition, and lower healthcare costs in the elderly but have not been studied as an intervention in cancer patients. HDMTM are nutritionist prescribed home delivered meals tailored to patient’s symptoms, co-morbidities, and health needs. Preliminary data in 211 cancer patients showed with HDMTM 87% ate more than half of meals, 91% lived more independently, 89% ate more nutritiously, and 70% had less fatigue. HDMTM may be a strategy to reduce financial toxicity and healthcare utilization and improve QoL in cancer patients, but no primary data exists evaluating its efficacy. Methods: We sought to develop the first RCT evaluating patient-centered QoL improvement from nutritional intervention with HDMTM in those with metastatic lung and non-colorectal GI cancer. We established a partnership with God’s Love We Deliver, a 501c3 non-profit specializing in HDMTM. Results: We developed a protocol for a single-institution RCT of standard of care (SoC) versus SoC and HDMTM in metastatic lung and non-colorectal GI cancer patients with primary aim comparing QoL between arms at 12 weeks using the FACT-G questionnaire. Sample size is 180. Secondary aims assess HDMTM’s impact on nutritional status, weight, mood, survival, food security, financial toxicity, healthcare utilization, and cost effectiveness. Eligible patients tolerate oral alimentation, have PS 0-3, and newly diagnosed (< 6 weeks) metastatic cancer. All patients have pre-randomization nutritional evaluation by an oncologic dietician. Conclusions: We present the first PRMC reviewed and IRB approved RCT evaluating the efficacy of HDMTM in metastatic cancer patients with primary endpoint of patient reported QoL. Investigating HDMTM expands our knowledge of nutrition as an effective arm of palliative oncology.
Molecular tumor profiling ordering trends in cancer patients.
Authors: Ma Joseph D. , Wang Winnie S , Yau Warren , Hagmann Chelsea , Revta Carolyn , Armstrong Janet M , Roeland Eric
Published: February 2017

165

Background: Molecular tumor profiling may provide information as to whether to initiate or not initiate a targeted therapy. As to the timing of when the tumor profiling is ordered relative to date of diagnosis, date of death, and palliative care (PC) consultations are unknown. The primary objective of this study was to examine molecular tumor profiling ordering trends in the course of cancer illness. Methods: A preliminary, retrospective chart review was conducted in a cohort of patients with a confirmed diagnosis of cancer at an academic, NCI-designated comprehensive cancer center. Patients were identified from a tumor registry and then matched to a next generation sequencing molecular tumor profiling database. The date of palliative care consultation was collected from the electronic medical record. Differences in the date of when tumor profiling was ordered and date of diagnosis, date of PC consultation, and/or date of death were determined. Data were compiled into a single database and descriptive statistical analyses were performed. Results: A cohort of 397 (205 women) cancer patients was included. Metastatic disease was present in 108 (27.2%) patients, with mean±SD age of 58.7 ± 13.5 yrs. One-hundred and nine (27.6%) patients received a PC consultation (n=60 inpatient, n = 49 outpatient). As of February 2016, 119 (30%) patients died, with 58 (48.7%) out of 119 receiving a PC consultation. The difference between date of cancer diagnosis and date of tumor profiling ordered was 2467.4 ± 6865.7 days (n = 376), while the difference between date of tumor profiling ordered and date of death was 229.1 ± 185.7 days (n = 111). The difference between date of cancer diagnosis and date of death was 1507.5 ± 2002.1 days (n = 119). In patients were the tumor profiling was ordered before the PC consultation (n = 29), the difference between date of PC consultation and date tumor profiling ordered was 157.3 ± 258.1 days. In contrast, in patients were the tumor profiling was ordered after the PC consultation (n = 76), the difference was 194.6 ± 168 days. Conclusions: This analysis suggests that molecular tumor profiling is ordered at the end and not at the beginning of a cancer illness. PC consultations are not routinely performed in patients who participate in tumor profiling.
The estimated hospital-wide financial impact of a comprehensive inpatient palliative care (PC) program.
Authors: Isenberg Sarina , Lu Chunhua , McQuade John P , Razzak A. Rab , Gill Natasha , Cardamone Michael A , Torto Deirdre , Langbaum Terry , Holtgrave David R , Smith Thomas J.
Published: February 2017

173

Background: Inpatient PC improves quality of care, patient and family satisfaction, and lowers costs. PC consultation during a cancer hospital stay led to a 14 (if by day 6) to 24% (by day 2) reduction in direct cost, and especially when people had comorbidities. (May, JCO 2015; Health Affairs 2016). We attempted to discern the financial impact of both a PC inpatient unit (PCU) and PC consultations on patients in other inpatient units for a large academic medical center, the Johns Hopkins Hospital (JHH), as we prepared to expand the PCU from 6 to11 beds and increased inpatient PC consultation capacity. Methods: We estimated the savings for an 11 bed PCU based on cost per day from FY 2015 with a 6 bed unit ($444 lower costs per PCU day compared to inpatient stay prior to transfer to the PCU). We then calculated the cost savings for an 11 bed unit operating at 80% occupancy. We estimated the direct cost savings of consultations by adjusting the $/discharge saved (Morrison, Arch Int Med 2008) to 2014 $ (by multiplying the $/discharge saved by 1.4 to adjust for medical inflation). Results: The PCU inpatient stays resulted in projected lower costs of $6.7M over 5 years ($444/day x 3009 days/year, or $~1.3M yearly). IP revenue and margins were small (data not shown). For PC consults of 785 alive discharges ($2197/case) and 97 decedent discharges ($6357/case), total estimated savings in direct costs per case are $2,530,000/year. The PCU allows for additional benefits not calculated in this analysis, including inpatient backfill opportunities, more appropriate ICU bed use, savings from increased referral to hospice (hospice referrals increased 340% in 3 years), and reduced readmission rates from increased PC and hospice use. Conclusions: In addition to improving quality of care and patient satisfaction, the combined IP and consult PC programs contribute to substantially lower charges and costs per day. Backfill revenue, the opportunity for increased revenue from improved patient satisfaction (HCAHPS) scores, and reduced readmission rates will increase this financial impact. [Table: see text]
Template-based high dose rate endobronchial brachytherapy for palliation of previously irradiated obstructive lung lesions.
Authors: Hrycushko Brian A , Chiu Hsienchang , Folkert Michael Ryan
Published: February 2017

174

Background: Local progression after external beam radiation therapy (RT) for lung cancer may result in clinical compromise from bleeding and/or airway obstruction, and additional RT may be precluded by radiation tolerance. High-dose-rate (HDR) endobronchial brachytherapy (EBT) is an effective salvage treatment for airway obstruction and/or bleeding, but requires significant time and resources; planning and treatment are performed bronchoscopically under anesthesia. We sought to reduce procedure and anesthesia time for EBT through template-based planning. Methods: EBT templates were created using the Brachyvision version 11.0.47 treatment planning system for the Varisource iX Ir-192 afterloader. Plans were optimized for dose uniformity at distance from the source following planning criteria of published works. Nine endobronchial centering tube templates were created for treatment lengths from 2-10 cm (1cm intervals) prescribed to 0.5cm distance from the applicator surface. Results: Standard EBT treatment requires a median of 47 minutes (range 44-49 minutes); 5 minutes for applicator placement and fluoroscopic confirmation, 15-17 minutes for plan design and optimization, 20 minutes for quality assurance and plan check, 2-5 minutes for radiation delivery, and 2 minutes for room clearance and applicator removal. Pre-planned templates were evaluated for plan quality, and achieved >90% of the prescription dose for the entire treatment length at the respective treatment depth. Changes to the prescription dose could be achieved through dwell time scaling. Changes to the prescription depth require re-optimization of the plan with the current templates as a base. Use of template-based planning was expected to reduce overall treatment time by 8-9 minutes (16-20% reduction in overall procedure time, 50-56% reduction in treatment planning time); median observed treatment time was 35 minutes (range 32-38 minutes). Conclusions: Template-based HDR EBT treatment plans were developed for the palliative lung cancer program at our institution. Implementation of template-based plans resulted in reduced procedure and operative time, and are now our standard technique.
A provider-based quality improvement intervention aimed at improving appropriateness of radiation therapy regimens for patients with advanced cancer and painful bone metastases.
Authors: Walling Anne M. , Beron Phillip , Wenger Neil , Kupelian Patrick , Kaprealian Tania Betty , McCloskey Susan Ann , King Christopher R. , Steinberg Michael L.
Published: February 2017

176

Background: Although guidelines suggest that shorter course radiation treatments for patients with advanced cancer and painful bone metastases are most appropriate, treatment patterns in the United States are inconsistent with this approach. Methods: We implemented a provider-focused intervention at a university-based radiation oncology practice aimed at improving rates of shorter-course radiation treatments for patients with advanced cancer and painful bone metastases. The intervention involved key leaders of the practice participating in a RAND/UCLA Appropriateness Panel to review the latest guidelines and evidence and judge appropriateness of various treatment regimens as it pertained to their practice. These results were compared to current (7/2012-6/2013) practice patterns and presented to the faculty group. This exercise informed a template-based point of care intervention led by a clinical champion and leadership that focused on key aspects of clinical and patient-centered care including whether the bone metastases were complicated or uncomplicated, patient prognosis, extent of disease, and travel distance for the patient to the treatment site. We compared rates of lower burden treatment regimens (less than 10 fractions) for 81 pre-intervention patients with 107 metastases treated between 7/2012-6/2013 and 75 post-intervention patients with 94 metastases treated between 5/2015-1/2016. Results: Overall, painful bone metastases were treated with less than 10 fractions more often in the post-intervention period (38% v. 63%, p < 0.001). Uncomplicated bone metastases treated with conformal radiation were also more likely to be treated with less than 10 fractions in the post intervention period (19% v. 52%, p < 0.001). One quarter of metastases were treated with SBRT during both the pre and post-intervention periods. Conclusions: Leadership support, provider engagement in integrating guidelines into practice, and a note template with point of care clinical reminders can improve rates of appropriate, low-burden radiation oncology treatments for patients with advanced cancer.
Supportive Oncology Collaborative: Initial impact of supportive oncology screening and care.
Authors: Lo Shelly S. , Wiebe Lauren Allison , Deamant Catherine , Scheu Amy , Roggenkamp Betty , Patel Urjeet , Khosla Pam , Robinson Patricia A. , Penedo Frank J. , Gerhart James , Dale William , Danciu Oana Cristina , Berardi Rosa , Weldon Christine B. , Trosman Julia Rachel
Published: February 2017

180

Background: The Institute of Medicine (IOM) 2013 report recommends supportive oncology care from diagnosis through survivorship, to end of life. The Coleman Supportive Oncology Collaborative (CSOC) developed a city-wide plan to improve supportive oncology. Metrics derived from the Commission on Cancer (CoC), ASCO Quality Oncology Practice Initiative (ASCO-QOPI) and National Quality Forum (NQF) were used to assess the CSOC impact. Methods: Medical records of consecutive cancer patients from 6 practice improvement cancer centers in Chicago (3 academic, 2 safety-net, 1 public) were reviewed for 2 periods: 2014 (n = 843) and Q1 of 2015 (n = 313). Descriptive statistics assessed differences in quality metrics. Results: Significant improvement was achieved in 6 of 8 core supportive oncology metrics (see table). Conclusions: Consolidated metrics are feasible to assess supportive oncology quality. Early data indicate improvement and effectiveness of the collaborative approach. [Table: see text]
How can palliative care specialists best integrate into multidisciplinary oncology care for patients with metastatic breast cancer?
Authors: Kaufmann Tara Laura , Miller Melissa F , Buzaglo Joanne S. , Kamal Arif
Published: February 2017

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Background: Current evidence for palliative care/oncology integration derives from cancers with either very short prognoses or relatively limited treatment options (e.g. pancreas). Little is know about the role of palliative care in metastatic breast cancer, where prognosis may be measured in years and the treatment option portfolio is continuously expanding. Methods: The Cancer Support Community Metastatic Breast Cancer Experience Registry is a voluntary, patient-reported, online registry of patient experiences with cancer. We evaluated data reported by patients from March 2013 to March 2014. The registry includes demographic information and data regarding physical, emotional, social, and financial distress measured using Likert scales. We calculated descriptive statistics and Pearson’s chi-squared. Results: We evaluated 599 patients. The sample median age was 56; 93% were White; 61% had a bachelor’s degree or higher Median time from diagnosis of metastatic cancer was 3 years. Regarding physical distress, over 50% reported “moderate” or higher issues with sleep, nutrition and eating, and fatigue. Depression and anxiety prevalence increased by 15% and 20%, respectively, from pre-treatment to post-treatment. Among social distress, 25% felt alone, 62% worried about burdening their family, and over 50% limited contact with others. 30% or higher desired more assistance with: diagnostic and treatment information, making decisions, managing symptoms and emotions, and managing disruptions to family and work life. Respondents were more likely to have been asked about distress if they received part or all of their care at an academic or comprehensive cancer center (p < 0.001) or treatment through a clinical trial (p = 0.012). Conclusions: We identified a high prevalence of unmet needs across several supportive care domains. These areas of distress should be a targeted focus of palliative care and oncology integration to improve the care of patients with metastatic breast cancer.
Health care utilization and costs at end of life among patients with leukemia or lymphoma in a regional cancer registry-insurance claims linked database.
Authors: McDermott Cara L , Fedorenko Catherine R. , Kreizenbeck Karma L. , Conklin Ted , Smith Bruce , Lyman Gary H. , Ramsey Scott David
Published: February 2017

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Background: End-of-life (EOL) care for persons with hematologic malignancies is variable and often involves high-intensity services at death approaches, which may not reflect patient or family preferences. We characterized healthcare utilization and associated costs in the last 30 days of life among subjects with leukemia or lymphoma to better understand patterns of care in this population. Methods: We linked enrollment and claims records from two regional commercial insurers to Surveillance, Epidemiology, and End Results (SEER) records for patients diagnosed with leukemia or lymphoma in Western Washington state between January 1, 2007 and December 31, 2015. We developed algorithms to characterize EOL care and calculate costs from both the payer and patient perspective for the last 30 days of life. Costs are derived from paid claims for inpatient, outpatient, and pharmacy utilization. Patient out-of-pocket costs are calculated as the difference between allowed and paid claim amounts. Results: See Table. Conclusions: In this analysis, a majority of subjects usedat least one form of high intensity care in the last 30 days of life, and average out-of-pocket costs were considerable. Future research will focus on developing interventions to assess patient and family preferences for intensity of care to better inform the provision of high-value care in this population. [Table: see text]
Prevention of everolimus/exemestane (EVE/EXE) stomatitis in postmenopausal (PM) women with hormone receptor-positive (HR+) metastatic breast cancer (MBC) using a dexamethasone-based mouthwash (MW): Results of the SWISH trial.
Authors: Rugo Hope S. , Beck J. Thaddeus , Glaspy John A. , Peguero Julio Antonio , Pluard Timothy J. , Dhillon Navneet , Hwang Leon C. , Nangia Chaitali Singh , Mayer Ingrid A. , Meiller Timothy F. , Chambers Mark Steven , Warsi Ghulam , Sweetman Robert William , Sabo J. Randy , Seneviratne Lasikas
Published: February 2017

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Background: Stomatitis is a frequent adverse event (AE) associated with mTOR inhibition. In BOLERO-2 patients (pts) receiving EVE/EXE, all grade (Gr) stomatitis was 67%; 33% had Gr ≥ 2 and 8% Gr 3. Median time to ≥ Gr 2 onset was 15.5 days; incidence of new stomatitis (Gr ≥ 2) plateaued at 6 wks. In a meta-analysis, 89% of first stomatitis events occurred within 8 wks. Topical steroids are used to treat aphthous ulcers; anecdotal use as prophylaxis has been reported. Methods: Eligibility included PM women with HR+ MBC prescribed EVE/EXE. Treatment included EVE 10 mg and EXE 25 mg QD, with 10 mL of commercially available 0.5 mg/5 mL dexamethasone oral solution to swish x 2 min and spit QID for 8 wks starting day 1. Pts completed a daily adherence log, including an oral pain (range 0-10) and normalcy of diet score. The primary endpoint was to compare the incidence of Gr ≥ 2 stomatitis at 8 wks with BOLERO-2 results. Secondary endpoints included MW use by average times/day, EVE/EXE dose intensity, incidence of all Gr stomatitis and time to resolution to Gr ≤ 1. Results: 92 women were enrolled; 86 were evaluable for efficacy. Median age was 61 yrs (range 34-87); median dose intensity was 10 (range 3-10) and 25 mg (range 8-25) for EVE and EXE, respectively. 95% of pts used the MW 3-4 times/day (median MW use/day = 3.95, range 1.9-4). At 8 wks, the rate of ≥ Gr 2 stomatitis was 2.4% (2 pts) with a Gr 1 rate of 18.8%. A comparison of stomatitis incidence by grade between BOLERO-2 and SWISH is shown in the table. In the 75 patients with complete ECOG scores, 88% maintained/improved ECOG status. Mean pain scale score was < 1 at all visits; 88% of pts reported a normal diet at 8 wks. 13% discontinued EVE/EXE due to suspected related AEs (most common: rash, 2%; hyperglycemia, 2%; stomatitis, 2%; and pneumonitis, 1%). Conclusions: Prophylactic use of 0.5 mg/5 mL dexamethasone oral solution markedly decreases the incidence and severity of stomatitis in patients receiving EVE/EXE for MBC and should be considered a new standard of oral care in this setting. Clinical trial information: NCT02069093. [Table: see text]
The effect of oncology massage in the treatment and prophylaxis of patient-reported distress during cancer treatment.
Authors: Menendez Alvaro G. , Carvajal Alejandro Ramon , Cobb Regina , Healey Kathi , D'Ambra Diane , Soriano-Pisaturo Maria
Published: February 2017

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Background: Distress (DS) levels are usually elevated across the disease course of cancer patients. Massage Therapy (MT) can improve patient-reported DS levels. We characterize the effect of MT on DS prevention and treatment, and compare the outcomes between single and multiple treatment sessions. Methods: This was a prospective single arm intervention with pre/post assessment using the validated NCCN DS Thermometer for patients on active chemotherapy who agreed to receive at least one MT session over a 10-week period. Results: 62 pts were included. 34/62 (55%) had DS when accruement started (X = 3.82, 6±4, M = 3, SD 2.32). 33/34 (97%) had improvement of DS after 1st session regardless of the type of DS on an average of 25% (p < 0.05). From 1st MT session to beginning of 2nd MT session (5±3 wks), DS had improved in 78% (14/18) of pts on an average of 31% (p < 0.001). 4/18 (22%) reported DS worsening chronically (X = 3.5, M = 3.5). 28/28 (100%) who had no DS reported initially did not develop it by the end of their participation. Conclusions: DS is prevalent among cancer patients and can affect treatment outcomes and overall quality of life. Regardless of type and source of DS, MT resulted in relief of patient-reported DS in a cumulative manner. MT may even appear to delay or prevent the onset of DS. Further studies are needed to determine if the improvement in DS is singularly from the MT intervention the patients received or from the emotional support that the therapist provided. A randomized study is also necessary to determine frequency and total duration of optimal treatment to confirm MT’s prophylactic and therapeutic ability for DS.
Evaluation of the Japanese opioid conversion ratio for switching to methadone for cancer pain control.
Authors: Matsuda Yoshinobu , Okayama Sachiko , Yoshikawa Yoshito , Kobayashi Yoshio
Published: February 2017

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Background: In Japan, oral administration of methadone was approved for patients with cancer pain in March 2013. As methadone exhibits complex pharmacokinetics with individual differences and rare but serious adverse effects, methadone is only prescribed as a fourth-line drug by cancer pain specialists, who must start methadone according to the following table and must not increase methadone dose within 7 days. Aims: To assess the validity of the Japanese opioid conversion ratio. Methods: The clinical characteristics of 60 patients who were prescribed oral methadone between April 2013 and March 2016 were analyzed. Results: The switch from other opioids to methadone was initiated due to refractory pain in the stop-and-go switching. According to the table in Japan, the starting dose of methadone ranged from 15-45mg/day, depending on the previous opioid dose. Fifty cases (11 outpatients, 39 inpatients) were successfully switched to methadone; although 10 cases subsequently exhibited rapid progression of illness and failed due to oral difficulty during the course of dose titration. At the outset, the average oral morphine equivalent daily dose before methadone administration was 155mg (range, 40-660mg) and the starting methadone dose was 10 mg in 2 cases (extremely old age and multi-drug taking), 15 mg in 35 cases, 30 mg in 11 cases and 45 mg in 2 cases. Upon completion of the dose titration according to the Japanese definition, the methadone dose was the same as the starting dose in 21 cases, and was decreased or increased from the starting dose in 5 and 24 cases, respectively. Conclusions: TheJapanese opioid conversion ratio might be better corrected in the near future. For example, it is good to be able to start with 10mg or 20 mg because minute changes might lead the performance of low dose titration in some cases. It should be possible to increase the dose of methadone after 3 or 4 days from the later change based upon the pain severity. [Table: see text]