bluuebunny/crossref_metadata_2025_split huggingface dataset:
What’s in the ‘special sauce’ of protocol-driven outpatient palliative care consultations?
Authors: Bagcivan Gulcan , Bakitas Marie , Dionne-Odom J Nicholas , Frost Jennifer , Plunkett Margaret , Lisa A Stephens Lisa A , Bishop Peggy 
Published: February 2017

139 Background: Initial outpatient palliative care consultations (OPCC) in clinics are usually requested for uncontrolled symptoms. The purpose of this substudy was to determine the nature of recommendations made in early PC (EPC) protocol-driven OPCC. Methods: Using a standardized tool, we conducted a content analysis on the assessment and plan components of protocol-driven OPCCs. OPCCs were conducted as a component of the ENABLE [Educate, Nurture, Advise, Before Life Ends] RCT (10/2010-9/2013) consisting of an OPCC and 6 structured weekly telephone coaching sessions and monthly follow up either at study entry (early) or 12 weeks later (delayed). We coded OPCCS for 37 specific recommendations, grouped into 3 categories: general, symptom-specific or advance care planning (ACP). Results: Of 207 study participants, 142 (early = 71; delayed=71) had an OPCC; 65 (31%) did not receive OPCC due to unable (n=35), unknown (n=17), and declined (n = 13). OPCC patients were mostly female (51%), married or living with partner (65%), rural-dwelling (66%), high school graduates (54%), white (99%), Catholic (30%), retired (46%), and had GI cancers (44%). Patients who had OPCCs had statistically ↓ CAGE (p = 0.03), ↑rural-dwelling (p = 0.03), and ↓hospice referral (p = 0.03) at baseline. Median OPCC length was 60 minutes (range 15-105). The most frequent general recommendations were for counselling (34%, n = 48) and medication review (30%, n = 43); symptom-specific recommendations were for pain (16%, n = 23), depression (11%, n = 16), and constipation (8%, n = 11); and ACP were for AD completion (20%, n = 29), identifying surrogate (18%, n = 25), and discussion of illness trajectory (17%, n = 24). There were no significant differences in recommendations between early and delayed group (p > 0.05) except hospice discussion was ↑ in delayed patients (p = 0.02). Conclusions: Protocol driven OPCCs for newly diagnosed advanced cancer patients can prospectively address patients’ needs for additional counseling, symptom control and ACP. Future analyses will focus on relationships regarding overall EPC ‘dose’ and longitudinal patient outcomes.
Snapshot of an outpatient supportive care center at a comprehensive cancer center.
Authors: Pimentel Lindsey E , De la Cruz Maxine Grace , Wong Angelique , Castro Debra , Bruera Eduardo 
Published: February 2017

145 Background: Integration of Palliative Care (PC) in oncology has been found to improve symptom distress, quality of life and survival in patients with advanced cancer. Early integration is most appropriate in the outpatient (OP) setting. However, most PC services in the U.S. do not have an OP component. Our study aims to provide a snapshot of the type of patients that are referred to this novel setting for the delivery of early PC. Methods: We reviewed a day in the SCC to illustrate the structure and process involved in the delivery of outpatient PC. We highlighted 9 patients seen that day to show the variety of patients, scope of services, and the unique roles that PC interdisciplinary team members perform. Results: 41 patients were seen that day in the SCC: 10 scheduled consults, 22 scheduled follow-ups, 9 (22%) same-day unscheduled patients: 4 follow-ups, 1 consult and 4 nurse triages. There were also 31 telephone encounters. Most patients seen were for routine follow-up and symptom assessment. However, 10 presented with worsening symptoms with one needing hospital admission. 21 patients required additional counseling: 2 for hospice transitioning, 12 for psychosocial distress, 7 for opioid education. PC was delivered predominantly by physicians and nurses with collaboration with our pharmacist, counselors, and case manager. Conclusions: Traditionally, PC has been delivered predominantly to patients with advanced disease and to aid in transition to end of life. In recent years, OP centers have dramatically changed the nature of PC work as in our snapshot. In addition to patients regarded as traditional PC patients, such as those transitioning to end of life, there are now patients who come in soon after arrival to a cancer center requiring specialized care to address a variety of symptom and educational needs, thus requiring adaptation of structure and processes to allow access for frequent follow ups and counseling and flexibility for walk-in visits. Our findings suggest that SCC needs to practice in a very different way which requires certain skills and assessment tools that are not conventionally present in traditional oncology clinic setting. More research is needed to identify the type of patients that would benefit most from a PC referral.
Use of an EMR online portal for communication with cancer patients.
Authors: Siegel Craig Stephen , Spies Vicky , Rodin Miriam B. , Tu Yifan 
Published: February 2017

147 Background: Communication with patients about their health care is vital to the physician-patient relationship. This is especially true in oncology where patients receive frequent diagnostic evaluations and their diseases are often active and evolving. In 2009, as part of “meaningful use”, Congress mandated the need to establish an electronic portal for patient communication. We studied factors associated with the use of our online patient portal. Methods: We performed a retrospective chart review of the use of our EMR online portal, MyChart. We assessed whether patients were informed of the existence of the portal and if they had activated and used it. We analyzed whether disparities in age, gender, rural or urban residence, or income impacted patients’ use of this feature. Results: Between January 1, 2014 and December 31, 2015, 1947 patients were seen in the Hematology Oncology Clinic at St. Louis University Hospital. 508 (26.1%) had activated and used MyChart and 1437 (73.9%) had not. Of 1437 patients who had not used MyChart, 110 (7.6%) had not been given the code, 1316 (91.5%) had been given the code but had not activated it, and 13 (0.9%) had declined the code. Patients who activated MyChart were more likely to be less than 65 years old (60.0% vs 40.0% p < .0.0001). Patients who did not activate it were more likely to live in a ZIP code where the median annual income was below the state median, a surrogate for lower income (84.8% vs 15.2%, p < 0.0001). Use of MyChart was not statistically associated with gender or with residence in an urban versus rural location. Conclusions: A large majority of patients in our urban, academic oncology clinic did not access the online communication portal. Use was associated with younger age, and lack of use was associated with residence in a lower income ZIP code. There was no association between use and gender or residence in an urban versus rural location. Future work will attempt to improve provider-patient communication through increasing access to the portal.
Palliative care and health care utilization at the end of life.
Authors: Triplett Daniel P , LeBrett Wendi G , Matsuno Rayna , Hwang Lindsay , Boero Isabel , Roeland Eric , Yeung Heidi , Murphy James Don 
Published: February 2017

152 Background: Palliative care’s role in oncology has expanded, but its impact on aggressiveness of care at the end of life has not been characterized at the population level. Methods: This matched retrospective cohort study examined the effect of an encounter with palliative care on healthcare utilization at the end of life among 6,580 Medicare beneficiaries with advanced prostate, breast, lung, or colorectal cancer. We compared healthcare utilization before and after palliative care consultation to a matched non-palliative care cohort. Results: The palliative care cohort had higher rates of healthcare utilization in the 30 days prior to palliative care consult compared to the non-palliative cohort, with higher rates of hospitalization (risk ratio [RR] 3.33; 95% CI 2.87-3.85), invasive procedures (RR 1.75; 95% CI 1.62-1.88), and chemotherapy administration (RR 1.61; 95% CI 1.45-1.78). The opposite pattern emerged in the interval from palliative care consultation through death, where the palliative care cohort had lower rates of hospitalization (RR 0.53; 95% CI 0.44-0.65), invasive procedures (RR 0.52; 95% CI 0.45-0.59), and chemotherapy administration (RR 0.46; 95% CI 0.39-0.53). Patients with early palliative care consultation had larger absolute reductions in healthcare utilization compared to those with palliative care consultation closer to the end of life. Conclusions: This population-based study found that palliative care substantially decreased healthcare utilization among Medicare beneficiaries with advanced cancer. Given the increasing number of elderly patients with advanced cancer, this study emphasizes the importance of early integration of palliative care alongside standard oncologic care.
The evolving radiation therapist role in a multidisciplinary palliative radiotherapy clinic.
Authors: LeGuerrier Bronwen , Huang Fleur , Spence Winter , Rose Brenda , Middleton Jacqueline , Palen Megan , Thavone Kitta , Ravji Shazma , Danielson Brita Lavender , Fairchild Alysa M. 
Published: February 2017

158 Background: Radiation therapists (MRTT) have been integrated in varying capacities into outpatient palliative radiotherapy (PRT) services across Canada for nearly two decades. We explored the experience of our centre’s MRTTs who have developed an essential role over nine years, from supporting one half-day PRT clinic per week to five full days of clinical, technical, research, and administrative involvement. Methods: An electronic survey was distributed to all 12 MRTTs who contributed to the PRT program (2007-2016), which was later supplemented by in-person semi-structured interviews. Qualitative analysis of the responses was undertaken to discern common themes. These were contextualized within the operational changes to our multidisciplinary clinical model, from pilot to integrated service. Results: Among seven respondents (range of PRT-specific experience: 1-5 years), five answered all questions. From the narratives, three common themes emerged: responsibilities, challenges, and opportunities. Responsibilities identified included: PRT planning/delivery (cited 13 times), patient assessment (12), multidisciplinary collaboration (MDC) (8), research (8), navigation (7), clinic process innovation (5), administration (5), communication (4), and education (2). Challenges described included: lack of support (cited 10 times), lack of shared understanding (5), high workload (5), pushback from colleagues (3), and inadequate staffing (2). However, opportunities outnumbered challenges, in terms of evolution of involvement in MDC (cited 13 times), patient care (8), increased autonomy (6), professional growth (5), role variation (5), scope of practice expansion (2), and being the team’s key contact for referrals (2). The range of MRTT experiences, responsibilities and challenges encountered reflected specific PRT clinical and operational conditions. Conclusions: As our PRT service model has evolved from short-term pilot to fully integrated departmental service, so has the MRTT role. MRTTs contributing to PRT as part of a MDC model are supportive of advancing non-traditional involvement in the holistic palliative care of patients with advanced cancer.
Referral patterns among patients with metastatic breast cancer in an integrated palliative care program.
Authors: Small Rebecca , Belkora Jeffrey , Majure Melanie Catherine , Chien Amy Jo , Melisko Michelle E. , Rugo Hope S. , Rabow Michael W. 
Published: February 2017

163 Background: ASCO recommends palliative care (PC) concurrently with oncologic treatment for patients with metastatic disease and there is emerging data about the benefits of early PC. However, little is known about referral patterns to specialty PC among patients who die of metastatic breast cancer. Methods: After years of offering a stand-alone outpatient PC consult service in our comprehensive cancer center, we established an integrated PC program in breast oncology (the “Advanced Breast Cancer (ABC) Program”) with a care coordinator, PC physician, and co-location with oncology. Among patients who died, we analyzed referral patterns, program participation, and end-of-life quality outcomes from October 2014 through May 2015. Results: 38 of 108 patients (35.2%) referred to and seen in ABC died, with an average of 2.9 PC visits (range 1-17) and 7 months (range 0-20) between referral and death. Reasons for referral among ABC patients who died included: symptom management (15 patients, 39.5%); goals of care discussions (12, 31.6%); psychosocial support (5, 13.2%); discharge referral from the inpatient PC team (4, 10.5%); and new diagnosis of metastatic disease (3, 7.9%). At the time of referral, average time since metastatic diagnosis was 23.6 months (range: 0-106); 10 patients (26.3%) had received > 3 lines of treatment. 15 referred patients (13.9%) died but were not seen by ABC: of those, 6 initiated hospice before they could be seen; 5 initially declined or deferred the referral but then were too sick to be seen in clinic by the time they agreed; and 4 were unwilling to accept extra appointments or did not follow-up to repeated outreach. 24 ABC patients who died (63.2%) were seen early (> 90 days before death), whereas in the year prior to the ABC clinic, among patients who died, only 11 of 44 (25%) who had received PC consultation received it early. 19 of 33 (57.6%) ABC patients for whom data was available utilized hospice, with only 2 (5.3%) using hospice < 3 days. Conclusions: Embedding and integrating a PC practice in breast oncology resulted in patients being seen earlier. Future efforts should be directed at further increases in earlier referrals by oncologists and in facilitating patient acceptance of early referrals.
The I-ONE trial: Integrative oncology education for patient navigators—A randomized pilot trial of web-based distance learning with or without small group retreat.
Authors: Mumber Matthew P. , Beard Karen , Liu Yuan , Kerber Alice S. 
Published: February 2017

171 Background: One of the major barriers to implementation of an integrative oncology (IO) approach is appropriately trained providers. This trial investigated the effectiveness of a mixed method educational program versus web based learning only for oncology patient navigators relative to knowledge and application of IO modalities. Methods: Patient navigators were randomized 1:1 to Web based education only (WEB) vs. WEB plus residential retreat (WEB+R). The trial was conducted as a randomized, two-group, pre-test/post-test design with 4 repeated measures. The primary study outcomes were knowledge and attitudinal beliefs about the perceived efficacy of IO approaches, as well as clinical and personal practices related to IO. Results: 24 patient navigators from varied educational backgrounds and practice settings were randomized to WEB vs. WEB+R. Referrals to complementary therapies increased by 104% immediately after training (p = .013) and by 77.4% 30 days out. (p = .013). There was a statistically significant increase in attitudinal beliefs about the perceived efficacy of IO approaches as measured by the Integrative Medicine Attitude Questionnaire (IMAQ) from baseline to posttest (p = .013). There were no significantly different values between randomized groups in any of the areas surveyed, however internal group pre and post test comparisons had multiple statistically significant improvements in the WEB + R group while there were no such changes in the WEB group, suggesting a trend toward increased educational efficacy for WEB + R that was likely the major driver of entire group educational improvements. Conclusions: Both Web based and Web based plus small group retreat programs were found to be effective in increasing clinical application and attitudinal beliefs about IO in patient navigators. There was a trend toward improved educational efficacy with WEB +R likely related to shared group and personal experience. As IO approaches become part of standard of care, mixed method online plus small group retreat programs would be useful for widespread dissemination of medical knowledge and increased clinical application of IO approaches.
Thirty-day mortality rate in oncology patients treated with palliative radiotherapy.
Authors: Bingham Brian Stewart , Dvorak Tomas , Morris Christopher G. , Yeung Anamaria R 
Published: February 2017

172 Background: Thirty-day mortality is a well-established metric for surgical specialties, but there are limited data available for 30-day mortality after radiation therapy. Our aim was to specifically identify the 30-day mortality of patients treated with palliative radiotherapy for the purposes of establishing a baseline to improve upon. Methods: We retrospectively reviewed the medical records of all patients treated with external-beam radiotherapy (EBRT) from January 1, 2012, to December 31, 2012, who died within 30 days of their last delivered radiation fraction. Patient age, sex, primary disease site, treatment site, fractions planned, and fractions delivered were recorded. Among all patients treated with palliative intent, age (> 70 and < 70 years) and sex were assessed for increased risk of 30-day mortality using a Fisher’s Exact test. Results: Of the 877 patients who received EBRT, 262 were treated palliatively and 615 were treated with curative intent. Of the 262 patients treated palliatively, 33 died within 30 days of the last delivered fraction, resulting in a palliative 30-day mortality rate of 12.6%. Of these 33 patients, the most common primary disease sites were lung (15%), pancreas (12%), and head/neck (12%), and the most common treatment sites were metastases to bone (37%) and brain (24%). In cases of palliative 30-day mortality, 10 or fewer fractions were prescribed 90% of the time and 83% of patients received more than half of their prescribed fractions. Among all patients treated with palliative intent, age (p = 0.0576) and sex (p = 0.5572) were not significantly associated with higher rates of 30-day mortality. Conclusions: We have established a baseline palliative radiation 30-day mortality rate at 12.6%, with the majority of patients receiving less than or equal to 10 radiation fractions and completing most if not all of their intended fractions. This analysis suggests institutional practices that are in line with other published patterns of care, and illustrates how clinical characteristics and 30-day mortality rate can be used to better understand palliative radiotherapy outcomes at a single treatment center.
Predicting hospital readmissions in the oncology population.
Authors: Thirlwell Sarah , Donovan Kristine A. , Turney Mary , Emnett C. Edward , Lamoreaux Amber , Portman Diane G. 
Published: February 2017

177 Background: The 30-day readmission rate is established as an important indicator of quality of care. The LACE index is commonly used in the general medical setting to predict readmission but its ability to predict readmission with sensitivity and specificity in the oncology population has not yet been examined. At our cancer center, palliative care (PC) consultation is associated with an increased risk for readmission but it is not an element in the LACE index. Methods: We sought to characterize the operating characteristics of the LACE Index using receiver operating characteristics analyses to predict unplanned readmissions to our cancer center over a 6-week period beginning March 2016. Data was gathered from chart review to calculate a total LACE score for each unplanned admission. Logistic regression was used to examine the individual components of the LACE index and whether a PC consult improved the performance of the index. Results: A total of 329 patients with unplanned admissions were included. Fifty-nine (17.9%) were readmitted within 30 days of discharge. There was no difference between the median LACE scores of those readmitted compared to those who were not (Md = 10.0; p = .93). Receiver operating characteristic (ROC) curve analyses of LACE scores yielded an area under the curve estimate relative to 30-day readmissions of .45 indicative of poor overall accuracy. ROC analyses also showed that the previously established LACE cutoff score of 10 had sensitivity of .54 and specificity of .57 relative to readmissions. The positive predictive value was .81 and the negative predictive value was .18. In logistic regression analysis, only direct referral center/emergency department visits were an independent predictor of readmission, with a c-statistics of .64 for readmission. The inclusion of a PC consult did not improve the performance of the index. Conclusions: The LACE Index performed poorly in predicting 30-day readmission in the oncology setting; the inclusion of whether a PC consult took place did not improve the index’s utility. Further research is required to create a new tool or enhance existing indices to predict readmission in the oncology population.
Palliative treatment directives for bone metastases: A quality-directed approach to guiding institutional practice.
Authors: Puckett Lindsay , Lee Lucille , Zuvic Petrina , Zhang Isabella Bingchan , Potters Louis , Bloom Beatrice 
Published: February 2017

188 Background: The efficacy of single fraction (fx) radiation treatment (RT) has proven to have equipoise for palliation of bone metastases when compared to courses of 10 fx or more. Despite these data, there has been a slow adoption of this practice in the US and worldwide. Examination of our multicenter practice from 2004 - 2016 showed that single fx RT utilization has remained at 17% and hypofractionationed (HFX) courses (1 or 5 fx) have remained at 71% since 2009. We hypothesized that evidence-based, treatment-guiding directives could improve HFX utilization in this population. Methods: Institutionally, palliative bone metastasis treatments are routinely tracked by a Quality Assurance committee. In 2/2016, two consensus-driven and evidence-based clinical directives were created within our electronic health system for use with either simple or complicated bone metastasis, irrespective of primary histology. The simple and complex directives had default prescriptions of 8 Gy/1fx or 20 Gy/5fx, respectively. The directives were reviewed with physician staff to improve compliance; directives were allowed to be edited at the physician’s discretion if an alternative fx was indicated. The chi-square test was used for analysis. Results: From 1/2009-5/2016, there were 1,781 treatment courses of palliative external beam RT. Following implementation in 2/2016, the new clinical directives were used for 96% of cases and were modified in 12 cases (n = 72). Single fx use increased from 17% to 36% among palliative bone metastasis treatments (p ≤ 0.001) and HFX (1 or 5 fx) utilization increased from 71% to 92% compared to other fractionation schemes (10 fx or other) (p = 0.001). Conclusions: The institution-wide adoption of evidence-based, treatment directives proved to be a straightforward and successful intervention which allowed for rapid adoption and increased utilization of the standard of care. Our early data suggests that this may be a useful approach in the setting of reticence to new treatment paradigms. Further examination of evidence based directives is warranted to address issues of overtreatment in palliation and in standardizing oncologic care.