bluuebunny/crossref_metadata_2025_split huggingface dataset:
Does ACP promote increased hospice utilization? A practice experience among three diverse OCM populations in Texas.
Authors: Mikan Sabrina Q. , Taniguchi Cynthia B. , Wilfong Lalan S. , Hoverman J. Russell 
Published: November 2018

6 Background: A community oncology practice participating in the Oncology Care Model (OCM) has interest in promoting hospice utilization through delivery of proactive advance care planning (ACP) services. This review of data seeks to understand geographic and ethnic variations in Medicare population utilization of ACP program services and timely transition to hospice care at the end of life. The study population included over 43% having stage IV disease at diagnosis; 19% had lung cancer. Methods: Three sites in Texas were selected for review. Site 1: central Texas urban community with primary non-Hispanic population. Site 2: south Texas urban community with primary Hispanic population. Site 3: central/east Texas rural community with primary non-Hispanic population. A 15-month retrospective review of ACP and hospice data was performed for deceased patients having OCM enrollment between January 1, 2017 and March 31, 2018. A total of 224 chart reviews were performed. Results: Little difference in hospice utilization is noted among the various populations, each demonstrating a hospice transition of care for more than 60% of OCM participants reviewed. All sites, however, showed median days in hospice care of five days or less. Formal ACP education was provided for 22% to 27% of urban study populations, while occurring for only 12% of patients seen in the rural setting. Written Advance Directives are captured in the electronic medical record more frequently for non-Hispanic patients when compared to those of Hispanic ethnicity. Formal values and goals for care were not routinely and formally assessed at these study sites, even though a validated tool for assisting with this important component of end-of-life preparedness is available. Conclusions: This study identified notable gaps in service provision to assist patients with end-of-life decision making. Increased efforts to provide ACP counseling services are needed to assist patients and families with ability to consider the additional level of care that is provided when electing hospice care. Overall, work is needed to improve hospice length of stay in all sites reviewed, but particularly among the Hispanic population of south Texas.
Oncologists and medical assistance in dying: Where do we stand?
Authors: Chandhoke Gur , Pond Gregory Russell , Levine Oren Hannun , Oczkowski Simon 
Published: November 2018

64 Background: With the passage of Bill C-14 in June 2016, medical assistance in dying (MAiD) was formally enacted into Canadian law. Since then, approximately 2,000 patients have died with medical assistance across the country, with cancer being the most common qualifying condition. We aimed to understand the views of oncology providers (OPs) regarding MAiD. Methods: We designed and administered an online survey to Canadian OPs’ to assess experience with MAiD, self-perceived knowledge, willingness to participate, and perception of the role of OPs in introducing MAiD as an end-of-life care option. We used complete sampling via the Canadian Association of Medical Oncologists (CAMO) and the Canadian Association of Radiation Oncologists (CARO) membership email lists. The survey was sent to 366 Radiation Oncologists, and 325 Medical Oncologists. Data was collected from April-June 2018. Results were analyzed using descriptive statistics as well as univariate and multivariate analysis. Results: We received 224 responses (response rate 32.4%). 70% of OPs have been approached by patients requesting MAiD. OPs were confident in their knowledge of the eligibility criteria, and previous exposure to MAiD was associated with confidence in this domain (odds ratio [OR]=3.77, 95% CI=2.05-6.94, p value<0.001). OPs were most willing to engage in MAiD with an assessment for eligibility, yet most refer to specialized teams for assessments. A majority of physicians (52.8%) would initiate a conversation of MAiD with a patient under certain circumstances, most commonly the absence of viable therapeutic options, coupled with unmanageable patient distress. Conclusions: In this first national survey of Canadian OP’s regarding MAiD, we found that most OP’s encounter patient requests for MAiD, are confident in knowledge of eligibility, and are willing to act as assessors of eligibility. Many OP’s believe that it is appropriate to present MAiD as a therapeutic option at the end of life under some circumstances. This finding warrants further deliberation amongst national/regional bodies for the development of consensus guidelines in order to ensure equitable access to MAiD for patients who wish to pursue it.
Factors associated with the aggressiveness of end-of-life care for patients dying of cancer in hospitals: A nationwide cohort study.
Authors: Martins-Branco Diogo Alexandre , Lopes Silvia , Canario Rita , Freire João , Feio Madalena , Gonçalves Jose Ferraz , Sousa Gabriela , Lunet Nuno , Gomes Barbara 
Published: November 2018

68 Background: There is growing concern about the aggressiveness of cancer care at the end of life (ACCEoL). Recognizing the most affected patients is a cornerstone to improve this public health unmet need. Our aim is to identify factors associated with ACCEoL for cancer patients dying in hospitals. Methods: Cohort study of adults with ICD9CM diagnosis of cancer, who died in public hospitals in mainland Portugal (Jan'10 - Dec'15), identified from the hospital morbidity database (HMD). HMD provided individual clinical and demographic data. The primary outcome is a composite ACCEoL measure of 16 indicators, expanding an earlier framework, validated by an expert panel. We obtained hospital and area-level variables from a hospital survey and National Statistics. We used multilevel random effects logistic regression modelling (p < 0.05). Results: We included 92,155 patients: median age 73 yo; 61.9% male; 53.0% metastatic. ACCEoL prevalence was 71.1%. The most prevalent indicators were > 14 days in hospital (42.7%) and surgery in last 30 days (27.8%). Older age (p < 0.001), breast cancer (OR 0.83; 95%CI 0.76-0.91) and metastatic disease (0.54; 0.50-0.58) were associated with less ACCEoL. In contrast, higher Deyo-Charlson comorbidity index (p < 0.001), gastrointestinal (GI) and hematological malignancies (p < 0.001), and death at a cancer center (1.31; 1.01-1.72) or hospital with medical oncology (MO) dept. (1.29; 1.02-1.63) were associated with higher ACCEoL. There was no association between existence of hospital palliative care services (HPCS) at the hospital of death and ACCEoL. Conclusions: Our study confirmed that clinical factors related with better understanding of disease course are associated with ACCEoL reduction. Patients with more comorbidities and GI malignancies might represent groups with complex needs, and hematological patients may be at increased risk because of unpredictable prognosis. It is important to better understand how to reduce ACCEoL in cancer centers and hospitals with MO dept.; improvement of HPCS could be an answer as these services are usually under-resourced, thus reaching few.
Community-based palliative care and end-of-life care in elderly patients with pancreatic cancer.
Authors: Lu Zhanni , Ganduglia Cazaban Cecilia M , LeonNovelo Luis G , Yennu Sriram J. , Conway Sadie H , Highfield Linda D , Giordano Sharon Hermes , Zhao Hui 
Published: November 2018

70 Background: No population-based studies have evaluated the impact of community-based palliative care (CBPC) on aggressive end-of-life (EOL) care use and Medicare charges for elderly pancreatic cancer patients. We analyzed the impact of CBPC on aggressive EOL care use in the last 30 days of life and on emergency department (ED) and intensive care unit (ICU) Medicare charges using the SEER-Medicare data. Methods: 12399 elderly pancreatic cancer patients survived for at least 1 month after diagnosis from 2007 to 2013 were identified. CBPC and hospital-based palliative care (HBPC) users were identified by diagnosis codes and place of services and matched by the coarsened exact matching [786:786; age, sex, residence urbanization level, comorbidities, illness duration, palliative care (PC) exposure]. Zero-inflated Poisson and multivariable logistic/linear regression models examined the variations of aggressive EOL care use in the matched patients. Generalized linear regression with a gamma distribution determined how CBPC impacted ED and ICU Medicare charges. Results: 22.1% eligible patients (median age: 76 years) used PC in the 6 years, including 7.7% who used CBPC and 14.5% who used HBPC. The median duration from cancer diagnosis to death of CBPC, HBPC and Non-PC users was 11 months, 6 months and 8 months (P < .001). Matched CBPC users were less likely than HBPC users to be admitted to ICU (risk ratio [RR], 0.64; 95% CI, 0.50-0.81), ED (RR, 0.63; 95% CI, 0.53-0.73), and hospital (RR, 0.50; 95% CI, 0.35-0.72). Compared to matched HBPC users, CBPC users utilized less life-extending care (OR, 0.59; 95% CI, 0.43-0.80) and had shorter hospital (Coef., −0.42; 95% CI, −0.65- −0.18) and ICU stays (Coef., −0.35; 95% CI, −0.59 - −0.10). They tended to die at home (OR, 1.46; 95% CI, 1.19-1.78) and not in ED/ICU/hospital settings (OR, 0.62; 95% CI, 0.45-0.83). CBPC users’ adjusted mean ED and ICU Medicare charges were 0.2% (P = .80) and 1.1% (P < .001) lower than those of Non-PC users and 4.5% (P = .43) and 21.0% (P = .08) lower than those of matched HBPC users. Conclusions: CBPC users utilized less aggressive EOL care than HBPC users, implying CBPC's potential to reduce aggressive EOL care use. Their ICU Medicare charge was lower than that of Non-PC users.
What the HEC? Physician variation and attainable compliance targets in antiemetic prophylaxis.
Authors: Roeland Eric , Ruddy Kathryn Jean , LeBlanc Thomas William , Nipp Ryan David , Binder Gary , Sebastiani Silvia , Potluri Ravi C. , Schmerold Luke M. , Papademetriou Eros , Navari Rudolph M. 
Published: November 2018

74 Background: U.S. National Antiemetic Guidelines recommend upfront triple prophylaxis (NK1 receptor antagonist (RA) + 5HT3 RA + dexamethasone) for patients receiving highly emetogenic chemotherapy (HEC), including carboplatin AUC ≥ 4 per 2017 guidelines. While existing data show gaps in guideline compliance, variation between individual physicians is less studied, and a realistic target compliance rate remains unknown. Methods: In a large electronic health record database (IBM Explorys), we identified HEC courses of therapy initiated from 2012 to 2017. Guideline compliance was defined as triple prophylaxis at chemotherapy initiation. Patient courses for ≥ 7 day cycles of cisplatin or anthracycline + cyclophosphamide (AC), or carboplatin (≥ 14 day cycles as a proxy for AUC ≥ 4) were ascribed to oncologists based on encounter frequency. We then ranked physicians treating ≥ 5 HEC courses and evaluated guideline compliance and individual physician variation. Results: In total, 10,074 HEC courses were identified and attributed to 451 unique physicians. Overall antiemetic guideline compliance with cisplatin and AC averaged 68% and 81% respectively. When ranked by compliance, the top 20% of physicians were 2.5 - 1.5 times as compliant as the bottom 20% (cisplatin 100% vs 40%; AC 100% vs 67%). For cisplatin, 32% of physicians had > 90% compliance; the remaining 68% were evenly distributed from 0 - 90%. For AC, 56% of physicians had > 90% compliance, and another 14% had 80 - 90%; the remaining 30% were evenly distributed. For carboplatin, 62% of physicians had ≤ 10% compliance, and another 17% had 11 - 20%; however, the majority of these data preceded guideline inclusion of carboplatin AUC ≥ 4 as HEC. Rates were independent of course volume per physician. Conclusions: Considerable physician-level variation exists in triple antiemetic prophylaxis guideline adherence for HEC. Hundreds of physicians had > 90% compliance with guidelines, suggesting 90% is a realistic target. However, the majority exhibited substantial gaps in NK1 RA use in HEC, placing patients unnecessarily at risk for CINV. Interventions are needed to bolster triple antiemetic prophylaxis in HEC, perhaps especially for carboplatin.
Results of an educational tool for residents and referring physicians on palliative radiation for bone metastases.
Authors: Desai Nina , Mattes Malcolm David , Bonar Eric , Robertson Grant , Johnstone Candice Aitken 
Published: November 2018

82 Background: Palliative radiation therapy (RT) for painful bone metastases is underutilized in the United States (U.S.), perhaps due to inappropriate use of multi-fraction (MF) regimens over more convenient, less costly, and equally effective single fraction (SF) regimens. Practice patterns may change with improved knowledge of radiation oncology residents (ROR) and non-radiation oncology physicians who refer patients for palliative RT. The aim of this study was to provide evidence-based educational content to these groups, and assess knowledge and views before and after. Methods: In April - June 2017, an electronic educational tool was sent to medical oncology and palliative care physicians, and ROR in the U.S. Multiple choice questions assessed knowledge, and were followed by evidence supporting the correct answer. Likert and sliding scales gaged tool impact. Chi-square and Mann-Whitney tests compared groups and pre/post-test responses. Results: Responses were obtained from 109 (2%) referring physicians (RP) and 135 (21%) ROR. ROR had higher scores than RP for 8 of 9 objective questions. RP were less likely to know that SF and MF are equivalent in terms of pain response (64 v. 91%, p < 0.01) and subsequent analgesic use (86 v. 95%, p = 0.02), or that SF is associated with a higher retreatment rate (27 v. 93%, p < 0.01). ROR were less likely to know that SF and MF are equivalent for patients with a high likelihood of long term survival (25 v. 56%, p < 0.01). After viewing the content, ROR felt more knowledgeable [ mdn 3 (IQR 3 - 4) v. 4 (IQR 3 - 4), p < 0.01], and RP felt more empowered [ mdn 3 (IQR 2 - 4) v. 4 (IQR 3 - 4), p < 0.01]. RP found the survey more helpful, and knew less of the data prior [ mdn 50 (IQR 25 - 75%) v. 80% (IQR 66.3 - 90%), p < 0.01]. Despite knowing the data, ROR preferred SF less than RP at completion (67 v. 85%, p < 0.01). Conclusions: This study demonstrates a need for educational content for multidisciplinary providers on appropriate palliation of bone metastases. Despite ample knowledge, the bias of practicing radiation oncologists for MF is being passed onto residents. Greater knowledge may translate into more effective referral patterns and patient advocacy by RP, and potentially improve utilization of palliative RT in the U.S.
Narrative medicine and reflective practice among providers: Connecting personal experiences with professional action for ACP.
Authors: Hinyard Leslie J. , Wallace Cara L , Ohs Jennifer E , Trees April 
Published: November 2018

9 Background: Increasingly, Narrative Medicine (NM) is utilized in clinical experiences. Critical reflection is a core aspect of NM providing the narrative competence to “recognize, absorb, interpret, and honor” the stories of self and other. This study evaluates the effectiveness of a NM workshop to: 1) develop skills in attending and responding to the stories of others as a part of advance care planning (ACP) conversations and 2) reflect on their own stories of loss in relation to professional practice. Developing narrative skills may help overcome barriers to successful ACP with patients and families. Methods: 29 health care professionals completed a continuing education course on NM principles for end-of-life care. Workshop activities included a close reading on a professional’s story of personal loss and a reflective writing exercise sharing one’s own personal story of loss. Small groups debriefed after each exercise. 24 participants (83%) completed post-workshop surveys including closed and open-ended questions. Results: Mean age of participants was 50.3 (SD 14.7), 87% were female, and 92% White. Social workers represented 71% of the sample with clinicians across several specialty areas. Findings indicate 80% of participants strongly agreed the experience of writing about their own experiences of loss helped develop their communication skills and 88% strongly agreed the experience of listening to stories of others helped develop their communication skills and they would use skills from the workshop in practice. Common themes from qualitative analysis included the usefulness of techniques for framing difficult conversations, patient vulnerability, the importance of active listening, and increased empathy for the storyteller. Common themes reflecting on providers’ personal stories of loss included recognition of prior experience on professional interactions and reported improved skills in authentic interactions and increased capacity for empathy. Conclusions: NM competencies have the potential to enhance communication surrounding ACP. Providers find the NM approach to be a useful framework for engaging in difficult conversations about end-of-life.
Evaluation of a multi-disciplinary, systematic approach to palliative care for patients undergoing active treatment for head and neck cancer.
Authors: Jensen Eleanor , Nuccio Deborah , Stenmark Matthew H. 
Published: November 2018

91 Background: Patients who receive concurrent chemoradiation therapy for head and neck cancer (H&N CA) commonly experience a range of symptoms, including dysphagia, weight loss, and dehydration, which may impact their treatment and prognosis. Treatment of patients with H&N CA often involves multiple specialties, including Surgery, Medical, and Radiation Oncology, and Palliative Care. In January 2017, Kaiser Permanente Colorado (KPCO) began providing early, integrated palliative care for all H&N CA patients (stages I-IV) starting chemoradiation at a single clinic site. This quality improvement program was subsequently evaluated for ease of implementation and, secondarily, to discern impacts on patient care. Methods: Retrospective chart review was performed for patients undergoing treatment in 2017 for H&N CA with concurrent chemoradiation therapy who also received integrated palliative care (n = 16) compared to standard care patients (n = 32) from 2015-2017. Data on rates of unplanned hospitalizations and feeding tube placement, completion of Medical Durable Power of Attorney (MDPOA) and Edmonton Symptom Assessment Scale (ESAS) were extracted from the electronic health record. Descriptive and inferential statistics were used to review data. Assessment of implementation occurred by interviews with the clinical teams. Results: Implementation of the program required intentional work between departments to define roles and reduce unwanted overlap. Standardized nursing assessments of symptom burden were developed. Patients followed in an integrated fashion had increased MDPOA and ESAS completion (38% vs 6%) and decreased hospital admissions (19% vs 53%) and unplanned PEG tube insertions (13% vs 34%). Differences were statistically significant for hospitalizations (p = 0.022) and ESAS completion (p = 0.006). Conclusions: Development of integrated patient management required intentional inter-department team communication and did not disrupt the clinic environment of any department. Lower hospitalization rates may be related to increased monitoring of symptoms. Based on this experience, the program was expanded to other clinical sites within KPCO.
Toxicity and survival of anal cancer patients treated with intensity-modulated radiation therapy
Authors: Ghareeb A , Paramasevon K , Mokool P , van der Voet H , Jha M 
Published: November 2018

Introduction The definitive treatment of anal cancer with chemoradiotherapy spares abdominoperineal resection for salvage treatment but carries a high burden of toxicity. Intensity-modulated radiation therapy has been implemented to reduce toxicity, reduce treatment breaks and improve survival. However, large and long-term studies are lacking. We aimed to investigate the toxicities and long-term survival of anal cancer patients treated with intensity-modulated radiation therapy at James Cook University Hospital, Middlesbrough. Materials and methods We conducted a retrospective analysis of all patients with squamous cell anal cancer treated at James Cook University Hospital between July 2010 and April 2017. All patients were uniformly treated with intensity-modulated radiation therapy-based chemoradiation with curative intent. A subset of these patients was followed-up prospectively by an oncologist for acute and late toxicity. We calculated Kaplan–Meier estimates of survival statistics and compared our results with those of previous trials which used conventional radiotherapy. Results We studied 132 patients, including a toxicity subset of 64, for a median follow-up time of 43 months (range 3–84 months). Eleven patients (8.3%) underwent salvage abdominoperineal resection. Grade 3+ acute non-haematological, gastrointestinal, genitourinary and dermatological toxicity were found in 56.2%, 12.3%, 0% and 50.7% of the toxicity subset (n = 64). Median treatment duration was 37 days. Overall and colostomy-free survival at five years were 68.3% and 85.3%, respectively. Tumour size (P = 0.006) and age (P = 0.002) predicted shorter overall survival. Conclusions Intensity-modulated radiation therapy probably reduces acute gastrointestinal and genitourinary toxicity compared with conventional radiotherapy, while resulting in similar overall and colostomy-free survival. We suggest that further dose escalation may improve survival in patients with T3/T4 tumours.
ANÁLISE DA EFICIÊNCIA DE RESFRIAMENTO DE PAINÉIS POROSOS PREENCHIDOS COM ARGILA EXPANDIDA EM COMPARAÇÃO AOS DE CELULOSE USANDO TÚNEL DE VENTO
Authors: Rosa José Francisco , Tinôco Ilda De Fátima , Fernandes Carlos Magno , Zolnier Sergio , Bueno Mateus Marques 
Published: November 2018

Altas temperaturas do ar, associadass à tipologia aberta e sem isolamento térmico dos alojamentos para animais ainda
constituem grave problema para seu desempenho produtivo. Neste sentido, os sistemas de acondicionamento de
ambientes usuais nas atividades de produção animal brasileira geralmente fazem uso de processos de resfriamento
adiabático evaporativo do ar, utilizando painéis de material poroso umedecido, associado aos sistemas de ventilação em modo túnel. Diante do exposto, este trabalho teve como objetivo comparar a eficiência de placas porosas em argila expandida (cinasita) em relação às do painel de celulose (testemunha) para todas as condições de temperaturas e velocidades das correntes de ar. Foram usados painéis em três espessuras (6 cm, 8,5 cm e 10 cm) e em duas granulometrias, denominadas de granulometria 1 (referência à brita 1) e granulometria 2 (referência à brita 2). Os resultados obtidos foram interpretados com testes de hipóteses de duas médias. Foram encontrados melhores valores de eficiência para os painéis em granulometria 1 em relação à granulometria 2. Também foi verificado bom desempenho para o painel evaporativo de 10 cm de espessura quando a granulometria da argila era a 2.