bluuebunny/crossref_metadata_2025_split huggingface dataset:
Consistent tumor measurement reporting in serial CT scans: A pilot study.
Authors: Wolf Terri P. , Little Dana Ann , Christensen Scott , Perkins Natasha 
Published: February 2017

99 Background: Oncologists in community cancer centers affiliated with the UC Davis Cancer Care Network reported quality concerns with inconsistently measured lesions on serial Computed Tomography (CT) scan reports. Radiologic imaging is an important tool in diagnosis, staging, and assessment of response to therapy in cancer treatment cancer. Accurate assessment of oncologic therapeutic efficacy is dependent on reliable radiology and report quality. The primary objective of this pilot study was to validate oncologist concerns about tumor measurement consistency in radiology reports through an audit. The secondary objective was to identify areas for quality improvement and establish process and time requirements for auditing. Two of four affiliated cancer centers (CC1 and CC2) were selected for a pilot assessment. Methods: CC1 and CC2 identified charts with CT scans in the audit timeframes. Auditors reviewed charts for serial CT scans and measureable disease in the audit date range and created a list of eligible charts. Auditors randomized the list and a sample of 61 (CC1) and 66 (CC2) charts were audited. Auditors reviewed CT orders, radiology reports for consistent lesion measurement, comparison to previous scan, addenda, service dates, radiology facilities, reading radiologist, and medical provider placing order. Results: This audit demonstrated deficiencies with lesion measurement consistency at both CC1 and CC2. At CC1 64% of radiology reports were consistently measured and at CC2 57% were consistently measured. Both CC1 and CC2 had identifiable areas for process and quality improvement. The audit required 86 hours at CC1 and 83 hours at CC2. The audit identified deficiencies in order clarity and information flow from the cancer center to the reading radiologist. At CC1 a radiologist reviewed the audited charts and reported an 85% concurrence with the auditors. A literature search did not provide benchmarks for measurement consistency in radiology reports. Conclusions: Oncologists complaints were verified regarding lesion measurement inconsistencies. This pilot demonstrated the need for quality oversight and implementation of standardized measurement (RECIST) criteria and tumor logs in the non-clinical trial environment.
Developing palliative care capacity in Colombia and Mexico.
Authors: Knaul Felicia Marie , LeBaron Virginia Townsend , Calderon Mariana , Arreola-Ornelas Hector , Bhadelia Afsan , Krakauer Eric Lewis , Leon Marta Ximena , Lohman Diederik , O'Farrill Karla Petersen , De Lima Liliana 
Published: February 2017

103 Background: Access to pain relief and palliative care often is limited or absent in low-and-middle-income countries (LMICs). Consequently, millions of patients with cancer and other serious illnesses in LMICs suffer needlessly. Multiple stakeholders have joined efforts to enhance the delivery of palliative care, develop national plans, and advocate for improved policies and regulations in Colombia and Mexico with applications to other LMICs. Methods: In Mexico and Colombia, efforts to improve access to palliative care focus on regulatory frameworks, finance, delivery, research and capacity-building, as per World Health Organization recommendations. In Colombia, health and educational institutions have partnered with non-governmental organizations to advise the Ministry of Health (MOH) and Senate. In Mexico, a range of governmental, legislative and private institutions are developing a National Palliative Care Plan. Results: Colombia: Laws passed in 2010 and 2013 require palliative care be available for all cancer patients. The allowable length of opioid prescriptions has been extended from 10 to 30 days, strong opioids must be freely available, and the MOH requires at least 1 pharmacy per State be able to dispense opioids 24/7. Mexico: Amendments to the health law introduced palliative care and pain management as a right for people with terminal illness. The government plans a new digital system to make opioid prescribing more efficient and secure, and the pharmaceutical industry is developing systems for monitoring production and supply. Yet, in both countries, palliative care training is mandatory in less than 5% of medical schools and innovative materials are being developed to train practicing primary care personnel. Conclusions: To meet palliative care needs in LMICs, novel approaches are required to develop and implement national plans, train healthcare providers, educate government officials, and advocate for policies that improve equitable access. Exemplary work in Colombia and Mexico illustrate effective strategies to improve palliative care delivery in LMICs.
Implementing values-based advance care planning (ACP) in a community oncology network.
Authors: Taniguchi Cynthia , Neubauer Marcus A. 
Published: February 2017

105 Background: Oncologists often embrace the concept of having discussions with patients regarding end-of-life care. Still, challenges remain with initiating these discussions early in the metastatic setting so that the full ACP process can be satisfied. A framework and infrastructure are needed to systematically initiate and promote the ACP process at a time when metastatic disease is identified and patients are better able to make thoughtful decisions regarding their future care. Methodology is needed for documenting and updating the ACP process within the patient’s health record. Methods: During a 15 month period, 32 independent sites of service within a nationwide community oncology network implemented an electronic health record (EHR)-based program for initiating ACP conversations with patients having a metastatic cancer diagnosis. Patients were identified for program engagement based on clinical criteria populated within the EHR. Identified patients received a brief introduction to ACP by the physician or other clinician and were encouraged to meet with a trained ACP Counselor to engage the full process. ACP Counselors provided guidance to the patient to discover and share personal values and goals for care. Values for care were documented within the EHR. Counselors provided appropriate patient education regarding code status and state-specific advance directives. At end-of-life, practices included hospice and death details within the EHR. Results: For metastatic patients (n = 29,389), ACP counseling was provided for 1,034 individuals (4%). Code status was visible in 3648 health records (12%) and patient values were included for 376 patients (1%). 2,206 patients (8%) transitioned to hospice care during the 14-month period. EHR-based infrastructure allowed for ongoing ACP visibility by the healthcare team. Conclusions: Use of an EHR-based ACP process demonstrates promising outcomes for realizing meaningful delivery of ACP. Essential components are patient identification early in the metastatic trajectory, assessment of patient values for care, thorough patient education regarding code status and advance directive documents, and full visibility of the ACP process within the health record.
Testing a model of caregiver satisfaction with hospice care in the cancer population.
Authors: MacKenzie Meredith A. , Buck Harleah G. , Meghani Salimah H. , Riegel Barbara 
Published: February 2017

107 Background: Caregiver satisfaction with hospice care is a quality measure for hospice organizations and predicts caregiver and patient health, mortality and resource use. Yet contributing factors to caregiver satisfaction are poorly understood and there are no tested models of caregiver satisfaction in the literature to date. To fill this gap, our aim was to develop and test a model of caregiver satisfaction with hospice care in the cancer population. Methods: This was a retrospective cohort study of national data collected by the National Hospice and Palliative Care Organization (NHPCO) using the Family Evaluation of Hospice Care (FEHC) survey in 2011. We utilized a random sample of 1000 cancer caregivers (70,782 available). An initial theoretical model was developed which posited a relationship between demand (as measured by reported patient symptoms) and satisfaction, modified by caregiver internal and external resources. Structural equation modeling was used to test the model and adjustments made to improve model fit. Results: The final model fit the data well (LR=189.08, df=78; RMSEA=0.04; CFI=0.91; SRMR=0.03). Caregiver satisfaction was predicted by demand – higher perception of demand (more patient symptoms) reduces caregiver satisfaction. Patient age, caregiver race, education, relationship to the patient and length of hospice stay modify this relationship directly – black, non-spousal and more highly educated caregivers are less satisfied, along with caregivers of younger patients and those with shorter lengths of stay. Patient and caregiver age, caregiver sex and length of stay influence this relationship by altering caregiver perception of demand. Younger caregiver and patient age, being a female caregiver and longer length of stay increases caregiver demand, decreasing satisfaction. Note that length of stay works both for and against satisfaction. Conclusions: Caregiver satisfaction is a complex perception that depends on caregiver and patient characteristics, as well as hospice care received. Hospice care providers should consider screening caregiver-patient dyads for “high-risk” characteristics and providing additional supportive measures.
The value of advance care planning (ACP) in cancer critical care.
Authors: Portman Diane G. , Lancet Jeffrey E. , Fernandez Hugo Francisco 
Published: February 2017

109 Background: Findings from previous research on the effect of advance directives (ADs) on patient outcomes have been mixed and are limited in the oncology population. A palliative care project in our Cancer Center’s ICU revealed patients with long length of stay (LOS) and ICU death without ADs in place. The Center’s Bone Marrow Transplant (BMT) program has implemented a protocol to obtain ADs pre-transplant. We sought to determine the presence and effect of ADs on end-of-life cost of care (COC) and LOS in critical care patients at our Center. Methods: We compared the 2013 COC and LOS of all ICU patients to the subset of patients for whom ICU care proved futile. The presence of ADs and DNR orders for expired ICU patients were matched to their respective COC and LOS. The COC of floor and ICU care were compared to determine potential cost savings from ICU avoidance. BMT-specific data was reviewed to establish the effect of early ADs on care and LOS. Results: Floor care proved to cost on average $2,000 less per day than ICU care. Thirty-eight percent of ICU patients had ADs. Only 41% of patients who expired in the ICU had an AD. If an AD was present, it was most likely to be a Living Will (LW) with DNR. The daily COC was highest for patients without ADs and lowest for those with LWs with DNR, despite a longer LOS in the LW/DNR group. In the BMT group, AD prevalence was 83% and resulted in earlier discussions about futility and shorter LOS. Conclusions: Obtaining timely ADs with DNR is likely to result in the lowest daily COC for critical patients. The greatest savings is likely to result from early ACP and ICU avoidance. Further study is needed to understand and overcome barriers to timely ACP implementation.
Advance care planning among seniors of a diverse city.
Authors: Belisomo Randi , Gaitan Daniel M. , Eisenstein Amy R. , Mulcahy Mary Frances 
Published: February 2017

117 Background: Advance care planning (ACP) is a system of education, reflection and documentation of health care wishes. Respecting Choices has been successful in implementing ACP throughout Lacrosse County, WI (J Am Geriatr Soc 2010;58:1249–1255)..A single center study in Melbourne, AU, showed that ACP improves end of life (EOL) care, patient and family satisfaction, and reduces stress, anxiety, and depression in surviving relatives (BMJ 2010;340:c1345).We aim to quantify knowledge about ACP, interest in engaging in ACP, and barriers to effective ACP among the older adults of Chicago. The results will provide actionable items to implement an ACP program in a diverse city. Methods: 17 of the 22 City of Chicago senior centers participated in a survey and education forum “Starting the Conversation”. Participants provided demographic information, awareness and knowledge of EOL wishes and advance directives (AD). Data was tabulated and analyzed using descriptive statistics in IBM SPSS Statistics 22 Software. Results: 375 people completed the survey, the average age was 70+8, (range 41 to 93), 93.3% in English, and 6.7% in Spanish. Respondents live alone (44.5%), with a spouse (29.9%) or child (14.4%). 71% have thought about the medical care they would want at the EOL, 60% have discussed their EOL wishes with their loved ones, and 4% with their doctor. 60.5% do not know what an AD is, 25% have an AD, 76% know who would speak for them if they were unable, 58% have discussed their wishes with that person. Using neighborhood demographics, there was no difference in having an AD for predominately African American neighborhoods compared to others (33% and 27%). Respondents from lower income neighborhoods were less likely to think about medical care at the EOL (65% and 77%), less likely to have discussed EOL care (41% and 30% have not discussed EOL care) and less likely to have an AD (19% and 31%). Conclusions: ACP is underutilized in Chicago. The frequency of AD completion among Chicago seniors mirrors that of the US (Am J Public Health. 2013;103(6):e8-e10). Unlike other population studies, no difference was found among racial groups. Participants are aware of EOL wishes, are interested in engaging in these conversations, but lack the knowledge and collaboration of their healthcare team.
Patient-centered prescribing of medications for comorbid illness in older adults with advanced cancer: A qualitative study.
Authors: Tjia Jennifer , Gallagher Julia , Han Paul , Cutrona Sarah L , Mazor Kathleen 
Published: February 2017

122 Background: Polypharmacy is common, burdensome, and potentially harmful in older adults with advanced cancer. According to the IOM, prescribing and coordination of chronic disease medication for these patients is suboptimal. We conducted a qualitative study with patients, caregivers, nurses, and physicians to better understand these issues. Methods: We used semi-structured interviews to explore participants’ views on medication management, care coordination, and communication for advanced cancer patients enrolled in 3 hospice agencies in New England. Eligible hospice patients were aged ≥ 65 yrs, had a diagnosis of cancer, and prescribed ≥5 medications. Family caregivers participated at the patient’s discretion. We also interviewed nurses and physicians to obtain an interdisciplinary perspective on medication coordination and communication. We used content analysis to identify emerging themes. Eighteen (18) patients (mean age 80 yrs [SD 10], 42% female) and 8 caregivers (mean age 63 yrs [SD 16.6], 88% female) were included, along with 10 nurses and 7 physicians from hospice, outpatient oncology and primary care settings. Results: Emerging themes revealed that patients and families were receptive to comprehensive medication reviews upon transition to hospice that assess the ongoing use of longstanding medications for comorbid illness. Effective framing for discussions included a focus on reducing harmful and non-essential medications; a less effective approach emphasized time to benefit (i.e. whether a medication is indicated for active symptom management vs prevention). Hospice nurses reported physician reluctance to discontinue medications, lack of physician confidence in their medication assessments, and lack of prescribing guidelines as barriers to optimizing prescribing. Conclusions: Patients enrolled in hospice for cancer and their families are willing to reassess the ongoing use of chronic medications for comorbid illness; information about medication harms and their impact on quality of life is considered particularly useful. Barriers to optimal prescribing include physician reluctance to discontinue medications and mistrust between providers.
Health services utilization and payments in patients with cancer pain: A comparison of intrathecal drug delivery versus conventional medical management.
Authors: Stearns Lisa , Janjan Nora Anita , Hinnenthal Jennifer A. 
Published: February 2017

125 Background: The financial costs of cancer care are a burden to people diagnosed with cancer, their families, and society. This analysis compared health services utilization and cost in patients receiving either intrathecal drug delivery (IDD) or conventional medical management (CMM) for the treatment of cancer pain. Methods: Using retrospective administrative claims data, patients receiving either IDD or CMM were propensity score-matched 1:1 based on characteristics including, but not limited to, age, gender, cancer type, comorbid conditions, and health care utilization and cost during a six-month baseline period. Follow-up cost and utilization were subsequently compared for up to 12 months. Results: From a sample of 142 IDD patients and 3,188 CMM patients that met all inclusion/exclusion criteria, 73 matched pairs were obtained. Among the matched pairs, the average age was 52.6 years and 70.5% were female. The three most common cancers were leukemia/lymphoma (54.8%), digestive system cancer (40.4%) and breast cancer (24.0%). All patients were continuously enrolled at 2 months, 61% at 6 months, and 35.6% at 12 months; enrollment was not significantly different between groups. At two, six and twelve months follow-up, compared to CMM, IDD patients had a lower average number of inpatient (IP) hospitalizations (two months: 1.12 vs. 1.74 (p=0.0010); six months: 1.72 vs. 2.69 (p=0.0358); twelve months: 2.14 vs. 3.13 (p=0.1476)), and emergency department (ED) visits (two months: 0.47 vs. 1.36 (p<0.0001); six months: 0.98 vs. 2.38 (p=0.0049); 12 months: 1.59 vs. 3.17 (p=0.0611)). Including the cost of the IDD implant procedure, IDD still provided overall savings of $4,123 in IP hospital costs, $6,144 in outpatient hospital costs and $1,902 in ED costs at 12 months. Once all sites of services were considered, IDD saved $3,195 at 12 months relative to CMM. Conclusions: The goal of healthcare reform is to improve health outcomes through more effective therapies and avoid futile care. Through reduced hospital and ED visits, IDD improves health outcomes, and assists healthcare entities to meet current hospital readmission rate criteria and other quality standards.
Integration of oncology and palliative care (PC): A systematic review.
Authors: Hui David , Kim Yu Jung , Zhang Yi , Park Jichan , Strasser Florian , Cherny Nathan , Kaasa Stein , Davis Mellar P. , Bruera Eduardo 
Published: February 2017

13 Background: Both ASCO and ESMO strongly endorse integrating oncology and PC; however, a global consensus on indicators of integration is currently lacking. To better understand what “integration” entails, we conducted a systematic review to identify articles addressing the clinical, education, and administrative indicators of integration. Methods: We searched Ovid MEDLINE and Ovid EMBase between 1948 to 2013 using the search terms “neoplasms”, “integration”, and “Palliative Care” or “Supportive Care”. Two researchers independently reviewed each citation for inclusion, and then extracted the indicators related to integration. The inter-rater agreement was high (kappa=0.96, P<0.001). Results: Our initial search identified 411 publications, and 97 were included in the final sample. 58 (60%) were review articles and 31 (32%) were original articles. The number of articles on integration increased significantly between 1991 and 2013 (P<0.001), with 63 (65%) articles published in 2010 or later. Among these articles, 30 (31%), 16 (16%), 15 (15%) and 8 (8%) articles, respectively, discussed the role of outpatient clinics, community care, PC units, and inpatient consultation teams in integration. 53 (55%) articles addressed various processes for integration, including routine symptom screening (N=16), interdisciplinary teams (N=16), guidelines (N=11), referral criteria (N=10), embedded clinics (N=5) and clinical care pathways (N=5). 31 (32%) mentioned “early” involvement of PC, 11 (11%) provided a specific timing, and 24 (25%) discussed referral criteria. 33 (34%) articles addressed educational strategies for integration, such as training programs (N=13), PC rotations (N=3), and continuing medical education (N=4). 14 (14%) articles described research indicators and 21 (22%) on administrative indicators. No articles specifically defined the term “integration” nor discussed standardized outcomes of integration. Conclusions: Integration was a heterogeneously defined concept. Our systematic review highlighted 40 clinical, educational, research and administrative indicators on integration. This study is part of an international effort to further develop refined and widely endorsed criteria for broad application.
Beyond SPIKES: Key principles to enhance communication in difficult conversations.
Authors: Farrell Tommie Wade , Reed Josh , Roffers Michael 
Published: February 2017

138 Background: The SPIKES protocol for delivering bad news developed by Buckman et al. has been a standard since published. Though helpful those in practice understand that further training is needed for these difficult conversations and for those that follow when deciding on treatment options. What skills can be taught to prepare for these conversations? Methods: At our program Hospice/Palliative and Oncology fellows rotate with the hospital Supportive Care team. They are trained in Three Key Principles after training in the SPIKES protocol: EMOTIONAL ALIGNMENT: aligning team goals with the goals of the patient/family. This includes eliciting the goals of the patient, clarifying the basis of these goals and showing alignment. Example phrases: Tell me what your hopes are for your treatment. What do you feel will happen when you attempt this? Your desire to live as long as possible makes perfect sense. TRANSPARENCY: sharing the ambiguity inherent in care. This includes presenting all options of care, and the variability that exists with all options. Examples: We don't always know exactly what will happen with treatment, but if your goal is to live as long as possible this will possibly extend life by months. If your goal is to maximize time with family, a person may choose to use the services of the hospice team who focus on you being at home. CLARITY: clarifying misconceptions and ensuring that goals and treatment plans match. This includes asking for expectations of treatment, giving accurate expected outcomes, and using language that is clear. Examples: When we say that this treatment is palliative we mean that we don't expect that it will cure, but it may provide on average an extra few months. You have told me you hope to get stronger by doing this treatment. I need to tell you that typically this treatment does not make a person stronger and fatigue is actually a potential side effect. Results: Fellows find these principles helpful in discussing treatment options. They universally evaluate this skill set as being achievable and also report it enhances patient-physician relationships. Conclusions: Applying these key principles is a skill that can enhance communication when making treatment decisions in potentially terminal illness.