bluuebunny/crossref_metadata_2025_split huggingface dataset:
Perceptions of palliative care: Cancer and non-cancer.
Authors: Harle Ingrid , Knott Christine 
Published: November 2017

148 Background: Palliative Medicine consultation is greater for cancer than non-cancer patients. Decreased symptom burden, improved survival time and quality of life, and cost savings are associated with palliative care. Most patients do not receive information about palliative care until end of life, resulting in negative outcomes. We examined perceptions and access to Palliative Medicine for persons living with advanced illnesses. The purpose was to inform the design of palliative care pathways for cancer and non-cancer diagnoses. Methods: Using Interpretive Phenomenological Analysis, patients/caregivers with metastatic cancer, chronic kidney disease, chronic obstructive pulmonary disease and advanced heart failure were interviewed. This qualitative research method explores an individual’s lived illness experience. Interviews addressed care processes, teams, understanding of palliative care and goals of care. Six reviewers read, coded, categorized interview transcripts and extracted themes. Results: Fifty interviews were completed, 36/50 with metastatic cancer or COPD. Despite different diagnoses, themes were similar. Caregiver’s responses reflected the patient’s burden and overall experience. Themes were: focused individual care; multiple dimensions of time; 24/7 home care; physical and psychological impacts; and spirituality. Perceptions about Palliative Medicine remain aligned with end of life. Conclusions: Palliative Medicine remains associated with end of life, regardless of the diagnosis. Majority had limited access to palliative care, despite pursuing information on supportive services. They also expressed high expectations of receiving such information from physicians and other providers. Results are similar to national strategies on palliative care. The project’s findings have informed the design of clinical pathways for early integration of Palliative Medicine for patients with cancer and non-cancer diagnoses.
Does use of the POLST form implicate overall care for patients with advanced cancer syndromes?
Authors: Lebenthal Justin , Barile David , Sedhom Ramy 
Published: November 2017

15 Background: The POLST “Practitioner Orders for Life-Sustaining Treatments” form addresses patient goals, scope of therapies, artificial nutrition, and resuscitation status. In New Jersey, Section A offers a unique opportunity for patients to describe in their own words overall goals of care. We investigated if completion of Section A influences aggressiveness of care at end of life for patients with advanced cancer syndromes. Methods: All POLST forms completed in 2015 at the University Medical Center of Princeton were retrospectively reviewed. Patients 18 years or older, electing for DNAR/DNAI status, were eligible for inclusion. All other responses on the POLST form were collected. Chart review was used to collect admitting diagnosis, referral and/or admission to the intensive care unit, palliative care and hospice use, length of stay, number of readmissions and deaths in the hospital. Discharge summaries were reviewed to assess if advance care planning discussions were documented. Results: 57 charts were reviewed: 34% were female, age 41 to 99 (mean 82), and average LOS was 6 days. 19% preferred “symptom treatment only” on their POLST forms and 70% preferred “limited treatment.” Section A was completed for 34 of 57 patients (60%). Those completing section A were less likely to be referred to the ICU, had a shorten length of stay (5 vs. 9 days), and had fewer unexpected deaths in the hospital. In addition, those completing section A were more likely to utilize both palliative and hospices services. Though physicians rarely documented code status on discharge summaries (38%), all patients with a palliative care consult while hospitalized had advance care planning discussions documented at discharge. Conclusions: Use of the POLST form provides a very natural order for discussion of life sustaining treatments and end-of-life care. Patients completing section A were more likely to utilize palliative care, hospice services, and advance care planning. The benefits of the POLST form extends beyond patient outcomes and may positively impact the care patients with advanced cancer syndromes. The importance of individualized preferences seems logical, but larger studies are needed to validate our findings.
Practice patterns in radiation therapy for bone metastases in multiple histologies.
Authors: Taylor Trent N , Kinchen Catherine Lee , Johnstone Candice Aitken , Robbins Jared R. 
Published: November 2017

151 Background: Radiation therapy (RT) is a common palliative treatment for bone metastasis. Despite copious evidence of palliative equipoise between single and multiple fractions, practice patterns vary widely amongst physicians. We evaluate practice patterns and the impact of treatment regimens on percentage of remaining life spent receiving RT (PRLSRT) and overall survival. Methods: Patients with metastases from Prostate, Lung, Breast, and Kidney to the bone who received RT were identified from the National Cancer Database. The percentage of remaining life spent receiving RT (PRLSRT) was calculated by dividing the elapse days of RT by the number of days they survive from starting RT to death. Results: 43516 patients met the inclusion criteria. The majority were non-small cell lung (64.7%), while breast (13.5%), prostate (11.0%), and kidney (10.8%) had almost equal amounts. Median patient age was 67 years old (18-90). Treated metastatic sites included the spine (61.9%), hip/pelvis (11.2%), and extremity (8.13%). A higher percentage of patients had a PRLSRT over 50% depending on the primary site of their cancer: Lung was the highest (14.4%), followed by kidney (8.9%), breast (6.2%), and prostate (1.4%). Prostate cancer was most often treated with 11+ treatments (38.4%), followed by breast (34.1%), Kidney (33.1%), and finally lung (28.5%) PRLSRT was highest in those who received multiple treatments, with 11.4% of patients receiving 11+ fractions and 11.5% of those receiving 6-10 treatments with a PRLSRT above 50% compared to 1.2% of those receiving a single treatment. Conclusions: Despite the increased burden on patients with more fractions of therapy and the lack of clinical benefit, multiple fractionations remains a common practice , which can impact the way patients spend the end of their lives. More care should be taken to reduce fractionation whenever possible to allow for patient comfort and autonomy.
Implications for the future of palliative care for pancreatic cancer: A retrospective institutional study.
Authors: Basnet Alina , Syed Wajihuddin , Sinha Shreya , Khan Rashad , Kopparthy Pallavi , Madhira Bhaskara Reddy , Huang Danning , Lemke Sheila M. 
Published: November 2017

153 Background: Five year overall survival rate for localized and metastatic pancreatic adenocarcinoma (PAC) is discouraging at 31.5% and 2.7%, respectively. Evidence supports that early palliative care (PC) involvement leads to better quality of life and prolongs OS. Referral to PC is often delayed as it is perceived as an alternative rather than adjunctive care. We conducted a retrospective study to identify different variables that affect PC consultation among patients (pts) with PAC admitted to the hospital and to study the impact of health care utilizations on OS. Methods: A retrospective medical record review of pts with PAC diagnosed/treated at SUNY Upstate University hospital was conducted (2011-2015). Variables like age, sex, race, stage at diagnosis, insurance status, performance status (PS), frequency of hospital admissions, nights spent, procedure visits, blood products used, and time variable to PC referral from diagnosis were collected. OS was calculated using Kaplan Meier analysis. Results: We identified 325 pts with diagnosis of PAC. 86.72% pts had one or more hospital admissions during course of their illness and of these, 15.85% saw PC during initial inpatient admission. 36.23% saw PC later in the course of their illness and 13.96% pts were offered palliative care in first outpatient visit. Median time interval to see palliative care was 75 days (d) from diagnosis, with 25% pts seeing PC 304d from diagnosis. Variables that had significant impact on early palliative care encounter (0-30d) were age > 70, stage IV at diagnosis, PS of 4, medicare insurance, offered PC in first visit (p< 0.001). OS was not statistically significant between groups who had ≥ 1 vs 0 blood products given, < 3 vs ≥ 3 hospital admissions, ≤ 13 vs > 13 nights spent, ≥ 1 vs 0 procedures done, ≤ 3 vs > 3 consults service seen. Median OS for pts with time interval to see PC 0-30d vs > 120d was 33d and 510d respectively with adjusted hazard ratio of 6.252 (95% CI 3.462-11.29). Conclusions: We demonstrated that PC is underutilized with only minority of pts benefiting from it during their cancer treatment. OS was poor in group evaluated by palliative care early than late which could be due to patients with advanced disease and poor PS being referred early.
Novel malignant bowel obstruction (MBO) management program for women with advanced gynecological cancer.
Authors: Lee Yeh Chen , Jivraj Nazlin , O'Brien Catherine , Lau Jenny , Chawla Tanya , Shlomovitz Eran , Buchanan Sarah , Croke Jennifer , Allard Johane P , Dhar Preeti , Laframboise Stephane , Ferguson Sarah E , Dhani Neesha C. , Butler Marcus O. , Ng Pamela , Stuart-McEwan Terri , Savage Pamela , Tinker Lisa Michele , Oza Amit M. , Lheureux Stephanie 
Published: November 2017

158 Background: Malignant bowel obstruction (MBO) is a common and challenging clinical predicament in women with advanced gynecological cancers. However, there is a lack of evidence-based guidelines or innovative approaches to improve patient care and quality of life. We implemented an inter-professional MBO management program incorporating a nurse-led ambulatory symptom management algorithm and multidisciplinary care conferences (MCC) as hallmarks of this program. Methods: Princess Margaret Cancer Centre has piloted an inter-professional MBO management program that supports women with advanced gynecological cancers who are at risk of/have developed MBO. The MBO team includes oncologists (medical, surgical, gynecologic and radiation), palliative care physicians, diagnostic and interventional radiologists, home parenteral nutrition physicians, specialized oncology nurses, dietitians, pharmacists and social workers. Complex MBO cases are discussed at regular MCC to derive treatment consensus. A symptom-driven MBO management algorithm has been devised and all patients are educated with a personalized bowel symptom management and dietary plan. For outpatient care, patients with MBO are proactively monitored by our specialized oncology nurses via phone or an eHealth bowel application to facilitate communication of symptoms and early intervention. Access to community services and home palliative care services are utilized to support care at home. All patients are enrolled into a prospective database to assess care impact and quality. Results: A total of 145 patients have been followed through the MBO management program over 12 months. At time of data cutoff, 14 had MBO (3 inpatients and 11 outpatients) and 22 were deemed at risk of MBO. Majority patients are managed as an outpatient and avoided unnecessary emergency department episodes. Detailed methodology and data analyses will be presented. Conclusions: A successful novel MBO program incorporating inter-professional care model and nurse-led ambulatory symptom management algorithm optimizes patient care in this vulnerable population and foster collaboration in implementing best practice clinical processes.
Development of a serious illness care model implementation framework.
Authors: Nguyen Khue , Schmidt Theresa , Ozcelik Sibel , Bell Janice , Whitney Robin L. 
Published: November 2017

161 Background: Care of individuals with cancer and other serious illness is complex and often results in unmet needs and high costs. Despite growing national interest in innovative care models for serious illness that improve quality and reduce costs, limited information is available to guide health care organizations from program innovation to implementation. Methods: With funding from the Gordon and Betty Moore Foundation, we sought to develop a flexible serious illness care model implementation framework to inform program development, replication, and scaling across a broad range of serious illness populations and settings. A draft framework was developed, guided by review of white papers and peer reviewed evidence and of existing serious illness care programs. Expert panelists—representative of serious illness care providers, policy experts, payers, and researchers—were recruited to review and provide feedback in two rounds of group discussion and additional 1:1 interviews. Results: The resulting framework implementation process begins with setting a vision and completing a local needs assessment. We present a range of evidence-based options for each facet of care model implementation (e.g., possible business models, target populations, services, and outcomes) to guide healthcare organizations in adapting serious illness programs to their local context. Key considerations for encouraging program success include leveraging existing programs and resources, recruiting strong program leaders, engaging staff, assembling experienced multidisciplinary care teams, building strong relationships among team members and with patients/caregivers, and establishing processes for program evaluation and continuous quality improvement. Conclusions: Our framework reflects a growing landscape of care models for cancer and other serious illness, offering a range of potential approaches to program implementation. Next steps include dissemination, framework impact assessment, creating a simulator for payment models, and piloting framework for use with future programs.
Evaluation of an NP-based model of palliative care delivery within an oncology clinic.
Authors: DAmbruoso Sarah F. , Wenger Neil , Coscarelli Anne , Hurvitz Sara A. , Pietras Christopher , Nechrebecki Meghan , Kung Jennie , Callahan Rena Desai , Goldman Jonathan Wade , Peddi Parvin F. , Alexandra Drakaki , Skootsky Samuel A. , Walling Anne Margaret 
Published: November 2017

163 Background: We initiated a nurse practitioner (NP)-based model of palliative care delivery embedded within an oncology clinic guided by a shared mental model (SMM) between palliative care, oncology, and psychosocial oncology clinicians in order to foster best practice collaboration and closed-loop communication between teams. These data represent processes and outcomes three years after initial implementation of the program. Methods: We evaluated program growth as well as advance care planning, hospice use, and utilization in patients with advanced cancer seen by the palliative care NP compared to patients receiving usual care from March 2014 to March 2017 at University-based oncology clinics. We developed a palliative care quality improvement tool integrating administrative and clinical data from multiple sources, including the electronic health record (EHR) and external hospices, using progressive methods of pulling data, such as natural language processing, in order to identify patients with advanced cancer and key process and end of life utilization measures. We used chi square tests to compare care received by the two groups. Results: There was good adoption of the intervention. The number of participating oncologists increased from 2 to 5 and the palliative care NP shifted from part-time to full-time after the first 1.5 years of implementation. Patients enrolled in the NP-based model of palliative care delivery were more likely to have a documented goals of care conversation (74.6% v. 9%, p < 0.01), to be referred for additional psychosocial support (52.5% v. 30.9%, p < 0.01), and to complete physician orders for life sustaining treatment (POLST) (20.3% v. 4.5%, p < 0.01). There was no statistically significant difference in advance directive completion (28.8% v. 23.5%). Among decedents, patients enrolled in the NP-based model were more likely to be enrolled in hospice (50.5% v. 29.1%, p < 0.01). There were non-statistically significant trends toward less hospital (4.6 days v. 5.6 days) and ICU use (1.0 day vs. 1.3 days) in the last 30 days of life. Conclusions: An NP-model of palliative care delivery within an oncology clinic led to important improvements in key palliative care processes and outcomes.
Demographics and disposition of patients in an academic outpatient palliative care practice.
Authors: Zarrabi Ali John , Armstrong Karen , Curseen Kimberly A. , Quest Tammie E. 
Published: November 2017

166 Background: Outpatient PC clinics strive to improve value by improving quality of care for patients while reducing cost. Justifying investment in outpatient PC necessitates characterizing the demographics and disposition of the patients whom these clinics serve. We sought to detail our outpatient palliative care practice in an urban academic medical center in the Southeast to serve a model for other institutions building a financial case for outpatient palliative medicine. Methods: A retrospective analysis from 2014-2017 was conducted on clinical and administrative data from the outpatient supportive oncology cohort at an urban Southern academic center. We performed multivariable logistic regression, t-tests, and chi square analyses to assess associations among variables of interest for patients. Results: Of our outpatient palliative care cohort of 3137 patients, 151 identify as white (51%) and 1377 as black (48%). Among whites 140 (9%) expired and 91% went to hospice compared to 151 (11%) nonwhites expired and 89% nonwhites went to hospice. Furthermore, 21% of non-whites were enrolled in commercial insurance while 79% were enrolled in government insurance compared to 28% whites in commercial insurance and 72% enrolled in government insurance. There were significant correlations among race, age, length of stay (LOS), and discharge disposition (p < 0.05) and race and payer mix (X2= 17.67 df=2, p = .0001). White patients and older patients (P < 0.05) were more likely to enter hospice care compared with minority patients (t = -.655, P < 0.0001). Finally, 2942 patients (94%) received opioid pain medications, and over 90% had > 5 readmissions. Conclusions: In our academic outpatient palliative care clinic we found most patients had governmental insurance, most were prescribed opiates, and older patients and white patients had significantly greater LOS and hospice enrollment compared to black patients. These data illustrate the diversity, payer mix, and disposition to expect when building a case to develop an outpatient palliative care practice in an academic urban medical center.
Models of care for serious illness: What is the evidence?
Authors: Whitney Robin L. , Bell Janice , Nguyen Khue , Schmidt Theresa , Ozcelik Sibel , Matsumoto Cynthia 
Published: November 2017

168 Background: Individuals with cancer and other serious illness may benefit from specialized models of care, including palliative care. However, limited evidence exists to guide real-world implementation of such programs. We reviewed evidence supporting models of care for serious illness as part of a larger effort to develop an implementation framework for serious illness care programs. Methods: We conducted a systematic review, focusing on existing reviews and meta-analyses across a broad range of serious illness population definitions and programs. The quality of evidence was graded and results were synthesized with respect to five outcomes categories (patient and caregiver experience; care and support processes; health outcomes; health service use and costs; and operations), program components associated with success, and implementation considerations. Results: Collectively, 28 reviews were identified, reporting 743 studies, 426 of which were randomized controlled trials. The strongest and most consistent evidence was for reduced health service use and costs (e.g., reduced hospitalization and emergency department use) and for improved patient and caregiver experiences. Few reviews reported on operational outcomes. Program components most frequently reported as associated with success included targeted selection of high-risk patients; face-to-face contact; and transition management. Common recommendations for implementation (reported in 10 of 28 reviews) included attention to relationship building, inclusion of technology-enabled decision support and continuous quality improvement. Conclusions: Compelling evidence exists for improved outcomes across a range of serious illness care models and populations with palliative care needs. Policy attention to payment structures that support feasibility and sustainability of these care models is warranted. Future research might address gaps in the literature, including implementation-related factors, operational outcomes and the relative contribution of individual components associated with program success.
Simultaneous Care clinic (SCC): A three-year monoinstituional experience.
Authors: Stragliotto Silvia , Brunello Antonella , Galuppo Sara , Murgioni Sabina , Dadduzio Vincenzo , Lamberti Evelina , Guglieri Irene , Schiavon Stefania , Nardi Maria Teresa , Procaccio Letizia , Zagonel Vittorina 
Published: November 2017

169 Background: Early palliative care has been shown to improve outcomes in pts with advanced cancer. In accordance with ASCO and AIOM recommendations of implementing palliative care early for pts with metastatic cancer along with active cancer treatment a SCC was set up at Istituto Oncologico Veneto (IOV) in Padova since 2014; Methods: Data of pts referred to the SCC from Mar 2014 to Nov 2016 were retrieved from a prospectively maintained database. Data collected included cancer type, status of disease, PS, ongoing oncological treatment, psychological evaluation, social evaluation, nutritional evaluation, activation of home territorial services and/or Palliative Care services, use of other health services after a first visit and place of death; Results: 533 pts were evaluated by a multidisciplinary team. Overall symptom burden was low with baseline symptom scores highest for fatigue, lack of appetite and depression. Nutritional evaluation revealed 224 pts (42%) with nutritional problems, the most frequent being weight loss (n = 121). Psychological distress was present in 185 pts (35%). Social issues were present in 26 pts (5%) and were dealt with activation of social services (n = 9) or volunteer territorial services (n = 8). Patients deemed in need of home care services after the first access to the SCC were 177 (33%) and for these a formal request for Home Care services activation was sent to the Local Health Territorial Unit. After the first visit 141 patients referred to Emergency Room for intervening problems with median time of 41 days. Globally 290 pts (54%) died with 53% of deaths occurring at home. For pts who were receiving active oncological treatment median time from first-visit in the SCC and death was 126 days. We are also evaluating a score for priority for access to SCC; Conclusions: Early integrated SC may be most effective if targeted to the specific needs of each patient population