bluuebunny/crossref_metadata_2025_split huggingface dataset:
Variations in use and timing of hospice and palliative care: Differences across health care payers and cancer type.
Authors: Gidwani Risha , Joyce Nina , Kinosian Bruce , Levy Cari , Faricy-Anderson Katherine E. , Ersek Mary , Miller Susan , Mor Vincent 
Published: February 2017

132 Background: Cancer societies recommend cancer patients receive palliative care soon after diagnosis of illness and hospice for at least 3 days before death. While studies suggest receipt of hospice in the last 3 days of life is increasing for patients, the timing of first hospice and first palliative care is currently unknown. It is also not known whether fee-for-service versus capitated healthcare systems differ in their provision of supportive care. We evaluated the timing and frequency of palliative care and hospice use across the Department of Veterans Affairs (VA) and Medicare for dually-eligible Veterans, to understand variations in the use and timing of these services across healthcare systems for the same patient population. Methods: A retrospective evaluation of all VA and Medicare administrative data for the population of Veterans aged 65 or older who died with advanced cancer in 2012. Results: The majority of Veterans received supportive care before death: 67% received hospice and 69% received palliative care. On average, patients had 2 encounters with palliative care before death. Patients with melanoma were most likely to receive palliative care (82%); patients with hematologic malignancies were least likely to receive palliative care (58%). Veterans received VA-based hospice on average 35 days before death (SD = 42), while Veterans receiving Medicare-based hospice did so an average of 25 days before death (SD = 24). However, across both systems, 50% of Veterans were receiving hospice 16 days before death. There were substantial variations in timing of hospice enrollment by cancer type. Of Veterans receiving VA- or Medicare-based hospice, 22% cycled in and out of hospice, meaning they dis-enrolled and re-enrolled in such care. 16% of patients were discharged from hospice before death, with VA more likely to discharge Veterans before death compared with Medicare. Conclusions: There are large variations in healthcare system approaches to timing and use of hospice and palliative care, as well variations by cancer type. VA provides hospice to patients earlier in the disease trajectory, while Medicare is more likely to have patients die while enrolled in hospice.
Pushing palliative care upstream: Integration into a community-based oncology practice.
Authors: Blechman Jennifer , Bull Janet 
Published: February 2017

134 Background: It is now well established that palliative care is an integral part of cancer treatment, recommended by the National Cancer Comprehensive Network for evidence based practices. Palliative care in this setting has been shown to improve symptom burden, enhance quality of life, reduce cost, and extend survival. Partners in Care is a non-profit, community-based hospice/home health agency in Bend OR, and consistent with national trends, receives late oncology referrals to hospice. Partnership with a multispecialty group was established to allow for a palliative care specialist to be embedded into their oncology clinic. Methods: Palliative care consults are offered 2 days/week in the oncology clinic. Triggers have been created to facilitate consultation. Quality metrics have been carefully tracked and include symptom scores, advance care planning, and transition and length of stay for hospice referrals. Financial support has been provided through grant funding from local insurance and community foundations. Results: In the first 10 months, 116 new oncology patients were seen, and had an average 1.9 visits. Documented ACP discussions occurred in 85% patients. Of patients with moderate to severe pain and dyspnea, scores improved by 65% and 50% respectively. Length of stay on hospice increased from 26 to 36 days. All of the patient respondents surveyed would recommend our service to others. Provider respondents 100% strongly agree that objectives were met when they requested a palliative care consult. Conclusions: Palliative care has been successfully integrated into a community-based oncology practice, resulting in increased access to palliative care, increased utilization of and length of stay on hospice, improved symptom management, increased use of ACP, and enhanced patient/family satisfaction. Having palliative care embedded in the clinic has resulted in better coordination of care and ease of communication. Future directions include using QDACT (Quality Data Collection Tool) to better track quality measures, inclusion of a social worker, and alignment with insurers and ACOs for cost support and data analytics.
Engaging the cancer care team in advance care planning.
Authors: Mahmood Tallat , Severson Jane Alcyne , Thompson Laura 
Published: February 2017

14 Background: Engagement of oncologists and their care team is essential to ensure advance care planning (ACP) occurs for cancer patients. However, numerous barriers to ACP exists, including the availability of trained staff with competence and confidence to have discussions with patients as well as resources to ensure ACP is effectively and efficiently integrated into the oncology practice. Methods: A baseline audit to determine the presence of documented ACP discussions for patients with metastatic cancer was conducted, followed by a quality improvement program with subsequent reassessment. The baseline audit identified only 20% (10/50) compliance with documentation of such discussions. Subsequently, we joined the Michigan Oncology Quality Consortium’s (MOQC) ACP Collaborative where the care team (MA, RN, PA, MD) were taught how to request and complete a durable power of attorney, conduct ACP conversations, and document pertinent information in a standard EHR location. Results: A one-year post-intervention audit found that 80% (40/50) of patients with metastatic cancer had an ACP documented in their record - a four fold improvement. A post-implementation staff survey noted that the team improved their understanding of both the legal issues and importance of asking about advance directives as well as using the designated chart location to document. 100% of staff agreed or strongly agreed with the statement “I understand the importance of asking patients about advanced directives”. Staff gained confidence in how to talk to patients about advance directives again with 100% of staff agreeing or strongly agreeing with the statement,” I feel more confident now in how to talk to a patient about advanced directives”. Conclusions: It is critical that all members of the oncology care team understand the importance of ACP and that staff feel confident in how to have discussions with patients. While physician/patient discussion is both necessary and expected, patients often discuss their wishes and fears with others in the practice. It is critical that all members of the team understand the importance of and opportunities where they can both support patients’ wishes and direct patients to their oncologist if necessary for further discussion.
Characteristics of patients referred to embedded rapid access supportive care clinic.
Authors: Yennu Sriram , Lu Zhanni , Williams Janet L. , Arthur Joseph Anthony , Bruera Eduardo 
Published: February 2017

141 Background: ASCO recommends Palliative care and Oncology integration to improve quality care outcomes. There is limited data on the patient (pt) characteristics (PC) for those who access integrated care. Our center created a pilot rapid access supportive care clinic (RASCC) to facilitate same-day consultation. The aim of this study was to determine the PC of pts referred (R) and not referred (NR) to RASCC. We also examined the PC of those who referred early[ER] (within 12 weeks of diagnosis or registration) vs those who have referred late [LR]. Methods: We reviewed pt medical records of all pts R and NR during the pilot period (Aug 01, 2012 to June 30, 2013). To be eligible all pts had advanced Stage IV non-small cell lung cancer with oncologist estimated overall survival (OS) of ≤ 6 months. Results: Of a total of 419 eligible pts seen at the thoracic oncology clinic, 157 (37%) pts were referred to RASCC. R group had a higher symptom distress scores, SDS (Table 1), weight loss, worse PS and OS compared to NR. There was no difference in PC between ER and LR except in the ESAS symptoms and SDS scores were higher in ER than LR, 40(29.5,52) vs 31.5(22.25,40.125), P < .001. Conclusions: R pts had higher symptom burden and worse OS. Similarly ER had a higher SDS than LR suggesting referrals to RASCC were primarily based on symptom burden. [Table: see text]
Barriers to goals of care discussions with patients with advanced cancer and their families: A multicenter survey of oncologists.
Authors: Ethier Josee-Lyne , Paramsothy Thivaher , Gandhi Sonal 
Published: February 2017

15 Background: Early documentation of end-of-life (EOL) preferences in patients with advanced cancer is associated with less aggressive EOL care, however, several barriers to having these discussions exist. Evaluating practitioner-level barriers in the ambulatory oncology setting by adapting an existing survey from the critical care and internal medicine contexts was deemed important. Methods: The previously published “DECIDE” survey was modified to the ambulatory oncology setting and pilot tested. Surveys were then distributed to oncologists in Ontario, Canada via paper and secure online methods. The survey asked physicians to rank on a numerical scale the importance of various barriers to having EOL discussions with patients and their families. Trends were established using descriptive statistics. Analysis by respondent demographic was not completed due to small numbers. Results: A total of 30 out of 79 participants responded to the survey, for a response rate of 38%. Respondents generally ranked patient and family related barriers highest. For instance, patient difficulty accepting prognosis or indicating a desire to be “aggressive” was rated by 69% of respondents as an extremely or very important barrier to initiating EOL discussions. Sixty-three percent of respondents also rated patients’ inflated expectations of further cancer treatment benefit as a very or extremely important barrier to discontinuing active cancer-directed therapies. Patient or family refusal for referral was rated by 47% of respondents as a very or extremely important barrier to early palliative care referral. The majority ( > 85%) of respondents were very or extremely willing to initiate, lead, and finalize the EOL discussions with patients and their families. Conclusions: Oncologists in this study ranked patient and family related barriers to having EOL discussions above all other barriers. Further work is required to better understand such perceived barriers, and compare them to patient preferences and perceptions about EOL planning and cancer care at the end of life. Targeted interventions to address these barriers could then be developed.
Changing focus: Living with advanced cancer—Development of a palliative care transition project.
Authors: Daeninck Paul Joseph , Stenekes Simone , Carpenter-Kellett Tara , Talylor-Brown Jill , Kristjanson Mark , Loewen Ruth , Gingerich Joel Roger 
Published: February 2017

152 Background: The improvement in cancer screening, detection and treatment is changing the illness trajectory and experience for patients. Many cancer patients are living longer with advanced disease as treatment options have expanded. Thus, accurate prognostication is becoming challenging and referral to palliative care programs is often delayed until close to death. This has made the transition to a predominantly palliative approach to care complex to navigate for the health care team, patient and family. Methods: CancerCare Manitoba has undertaken an innovative project “Changing Focus: Living with Advanced Cancer” to enhance communication with primary health care providers (HCPs) and assist patients and caregivers in the transition to a palliative approach to care. The project includes development of an individualized patient treatment summary that provides details of the patient’s cancer treatment and symptoms, identifies the role of the HCPs involved with the patient and family, as well as the expectations for follow up care at the cancer centre and in the community. The transition appointment includes discussion around the treatment summary, standardized follow up care plan, and written information about palliative care, decision making, symptom management, unique issues for caregivers and details about local supports and resources is provided. Results: This presentation will focus on the development and implementation of this project within the cancer centre and throughout the province. Evaluation of this approach is ongoing. Family members and patients will provide feedback using a standardized questionnaire, and ongoing improvement will be built into the evolution of this program. HCPs will also be engaged in evaluation from their perspective. Conclusions: We expect this intervention will allow patients and families better quality of life and possibly improve the interval between the termination of chemotherapy and death.
Integrating outpatient palliative care into a metastatic breast oncology clinic.
Authors: Small Rebecca , Belkora Jeffrey , Jow Alexander , Rabow Michael W. , Majure Melanie Catherine , Melisko Michelle E. , Chien Amy Jo , Rugo Hope S. 
Published: February 2017

154 Background: The Advanced Breast Cancer (ABC) program at UCSF aims to improve metastatic breast cancer outcomes through early integration of palliative and oncologic care. Oncologists now routinely refer stage 4 patients to a palliative care physician and social worker. Thus this initiative translates ASCO policy recommendations into clinical practice. We report early results from our development, implementation, and evaluation of this novel program. Methods: To evaluate ABC, we used the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation and Maintenance), and Rogers’ Diffusion of Innovations theory. Results: Reach: From 10/2014 to 6/2015, 43 women participated out of 64 invited. Decliners’ main reason for refusal was to avoid additional appointments. Effectiveness: 36 patients reported improvements in 13 of 15 quality criteria, including care coordination, emotional support, and propensity to recommend the program. 34 patients responded to ESAS, QUAL-E and Steinhauser Spiritualty Screen questionnaires, with improvement in 10 out of 14 outcomes at 1-2 month follow-up. Improvements included reduction of anxiety, improved quality of life, and decreased nausea. Adoption: Early integration of palliative care is complex and requires additional coordination among busy clinicians. To address this, we embedded a palliative care physician in the oncology clinic two half-days per week; relied on an oncology fellow to facilitate ongoing cross-disciplinary collaboration; and leveraged the program coordinator’s capacity for following up on both project and patient issues. We also instituted a monthly team meeting to review patient cases. Implementation: Overall, our program design succeeded. Challenges included how to best communicate about patient prognosis and reason for referral. We also struggled to determine what patient eligibility criteria should trigger a referral. Maintenance: The program is currently sustained by grants and intramural cancer center funding. We are seeking continued investment. Conclusions: The ABC program demonstrates that early integration of palliative and oncologic care is feasible and associated with the psychosocial benefits previously found in efficacy studies.
Distress factors in the determination of palliative care for ethnically diverse women with gynecologic cancer.
Authors: Falae Adebola , Robinson William , Robinson William R. 
Published: February 2017

16 Background: Versions of the Distress Thermometer have been used and validated widely, but studies of ethnically diverse populations has been limited. A modifed version of the Thermometer is used to understand factors affecting an African American(AA), inner-city population in order to improve access and utilization of palliative care services in a large, ethnically diverse metropolitan area. Methods: A cross-sectional study of women recieving cancer therapy in New Orleans, LA in 2013-14 was conducted. Subjects completed modified Distress Thermometer surveys which captured levels of distress and assessed predefined factors that could impact distress.Demographics were collected, and descriptive and comparative analyses were performed. Results: 49 Caucasian and 34 AA subjects were analyzed. Overall distress rating distributions were similar between the two groups. AA subjects cited family factors as a cause of distress more often than Causasians. (p < 0.006) AA subjects were also more likely to indicate difficulty with partners and overall lack of support as stressing factors than Caucasians. In subjects who reported distress scores greater than 4, AA subjects cited emotional and physical factors more frequently than Caucasians as a cause for distress. (p < 0.05) 11.11% AA subjects vs 3.57% Caucasians cited spiritual factors as a cause of distress. Conclusions: AA women with gynecologic cancer are more likely to cite familial, emotional, physical and perhaps spiritual factors as factors affecting distress than Caucasian women. These findings could be used to target Palliative Care resources more effectively in an ethnically diverse population.
Hospitalizations and emergency department use in cancer clinical trial patients.
Authors: Nipp Ryan David , Powell Elizabeth , Moy Beverly 
Published: February 2017

160 Background: Cancer clinical trials (CTs) often represent the best available treatment for many patients, but little is known about the health care utilization of these patients. We examined correlates of hospitalizations and emergency department (ED) use in cancer CT patients to determine those at greatest risk for these outcomes. Methods: We prospectively collected data on patient characteristics, hospitalizations and ED use among all patients enrolled in cancer CTs at Massachusetts General Hospital in 2014. We calculated the number of hospitalizations and ED visits in the 6-month interval following patients’ CT enrollment. We used linear regression with purposeful selection of covariates to identify factors associated with hospitalizations and ED use. Results: Of 1,218 CT patients (mean age = 58 years; 575 (47%) male), 781 (64%) were married and 851 (70%) had metastatic disease. All cancer types were represented, but hematologic cancers (21%) were most common. Within 6 months following CT enrollment, 519 (43%) and 327 (27%) had at least one hospitalization and ED visit, respectively. At any time during their cancer course, 177 (15%) received a palliative care (PC) consult. Controlling for presence of metastatic disease, PC consults correlated with both hospitalizations and ED visits. Having a hematologic cancer and being unmarried correlated with more hospitalizations and ED visits, respectively. Conclusions: Hospitalizations and ED visits occur in a substantial proportion of cancer CT patients. We need to better understand reasons for these high rates of health care utilization, but the correlations with PC consults suggest that CT patients have unique supportive care needs and that PC services are being targeted to a population particularly in need. [Table: see text]
Characterizing terminal oncology ICU hospitalizations.
Authors: Daly Robert Michael , Hantel Andrew , Polite Blase N. 
Published: February 2017

167 Background: Twenty-five percent of Medicare cancer beneficiaries use the ICU in the last month of life, and 8% of cancer patients expire there. Cancer patients who die in the ICU have worse quality of life compared with those who die at home. Terminal ICU hospitalizations also come at high financial cost, accounting for 80.2% of all terminal hospitalization costs. Our hypothesis is that a significant number of oncology patients suffer avoidable terminal ICU hospitalizations. By better characterizing these hospitalizations, we will provide the knowledge backbone for future interventions. Methods: Using data from the University of Chicago (UC) cancer registry, we identified patients who died in UC adult ICU’s in FY2013. Of the 1,388 oncology deaths, 115 were in the ICU. Of those, 73 were established patients having had at least one visit with a UC oncologist. We performed a chart abstraction to identify patient, clinical, and hospitalization characteristics. Results: The average age of this patient population was 64 years and 71% were men. Solid and hematologic malignancies comprised 71% and 29%, respectively. Of the solid malignancy patients, 54% had metastatic disease. The average duration of the patient-oncologist relationship was 693 days, and 77% had their last oncology appointment within 2 months of index hospitalization. The ECOG performance status was ≥ 2 prior to admission in 51% of patients. These patients had an average of 3 hospitalizations and 15 outpatient visits in the year prior to death. Eighty-one percent did not have advance directives and 86% did not have an outpatient palliative care consult. The average duration in the ICU was 8 days, during which 95% did not have an inpatient palliative care consult, 79% were intubated, and 38% had resuscitation attempted. Conclusions: Most cancer patients who died in the ICU had an advanced stage malignancy and/or poor clinical status prior to admission. In addition, a significant number received intubation and resuscitation. Despite evidence of adequate interaction with the healthcare system, most patients had not had a palliative care consult or advance directives. This study will allow for further exploration of the avoidability of terminal oncology ICU hospitalizations to inform future interventions.
A comparison of QOPI metrics in solid tumor oncology clinic with or without concomitant supportive oncology consultation.
Authors: Huo Ran , Scarborough Bethann , Goldstein Nathan , Smith Cardinale B. 
Published: February 2017

173 Background: The Quality Oncology Practice Initiative (QOPI) is a voluntary quality measurement and improvement program designed to assess practice performance for a series of consensus based and evidenced based measures. Several measures within QOPI pertain to the use of supportive care in the treatment of cancer patients. We hypothesized that patients receiving integrated oncology and palliative care (intervention group) may meet a higher number of quality metrics as compared to patients receiving oncologic care alone (control group). Methods: We conducted a retrospective chart review of patients treated between June of 2013 to June of 2015 from our intervention group and matched these to similar patients within the control group based on tumor type and date of initial visit to oncologic care. We performed bivariate analysis comparing differences in supportive care QOPI measures among the intervention and control group. Results: We identified a total of 200 patients. Patients in the intervention group were younger (p = 0.27) and female (p = 0.21). Among the QOPI metrics, pain was significantly better addressed (p < 0.001) among the intervention group. No significant difference was detected in other QOPI metrics. Of note, the intervention groups had significantly higher rates of enrollment in hospice (p < 0.001) and significantly lower rates of death within the hospital and/or the ICU (p = 0.04). Conclusions: Integrating outpatient palliative care consultation along with standard oncologic care did improve pain being adequately addressed, improved hospice utilization and decreased death within the hospital and ICU. Many of the supportive oncology QOPI metrics can be satisfied by a prompt from the EMR, however adequately addressing pain requires specialized skills. These data support the need for increased primary palliative education regarding pain management for oncologists.