bluuebunny/crossref_metadata_2025_split huggingface dataset:
Defining the denominator for measuring quality of end-of-life care in children with cancer: Results of a nominal group technique.
Authors: Johnston Emily E. , Tefera Raba , Ananth Prasanna Janaki , Martinez Isaac , Porter Amy , Snaman Jennifer Malia , Thienprayoon Rachel , Asch Steven M , Bhatia Smita , O'Beirne Ronan 
Published: October 2023

227 Background: National Quality Forum (NQF)-endorsed end-of-life (EOL) quality measures helped identify disparities in quality of EOL care in adults with cancer. In adults, those quality measures apply to all adults dying with cancer or those with Stage III or IV disease. Quality measures for EOL care for children with cancer were recently developed. However, identifying the denominator for EOL quality measures in children with cancer is more nuanced than in adults. Therefore, we utilized the Nominal Group Technique to determine to whom these EOL quality measures should be applied (i.e., the denominator). Methods: In a series of Nominal Groups, panelists answered the question: "Which children, diagnoses, conditions, or prognoses should be included when examining the quality of EOL care for children with cancer?" In each group, individuals first proposed answers to the group and then selected the 5 options they thought best answered the question. Five points were assigned to the statement that was the best answer, 4 the second best, etc. A team developed a framework of themes and subthemes based on the responses and coded each statement, with multiple meetings to develop consensus. Results: We conducted 5 separate Nominal Groups with a total of 44 participants. Most identified as female (88%) and Non-Hispanic White (86%). Seventy-nine percent were pediatric palliative care, pediatric oncology, pediatric critical care, or hospice clinicians, 40% researchers, and 12% bereaved parents. Responses fell into 5 themes: (1) Poor prognosis cancer (e.g. a child with a relapsed or refractory cancer); (2) Specific treatment scenarios (e.g. children who have no further curative treatment options available); (3) Certain populations (e.g. all adolescent and young adult patients); (4) Certain symptoms (e.g. respiratory depression related to brain malignancy); (5) Specific utilization scenarios (patients requiring two or more life-sustaining therapies). Poor prognosis cancer and specific treatment scenarios received the most points (320 points [49%] and 146.5 points [23%], respectively). Conclusions: Interprofessional Nominal Group participants created a framework for identifying children who should be included in EOL quality measures for children with cancer. This differs from similar work in adults in that it does not include all children with cancer or limit to patients with advanced disease. This framework will be a powerful tool for quality improvement, research, and clinical program development and is a critically important step to ensure all children with cancer receive high-quality EOL care.
Non-elective inpatient anti-cancer therapy for solid tumors: To treat or not to treat?
Authors: Shevlin Chloe 
Published: October 2023

234 Background: Administration of anti-cancer therapy to hospitalized patients is associated with greater treatment-related complications and reduced quality of life. We designed and implemented a standardized process to review all non-elective systemic anti-cancer therapy in solid-tumor patients with the goal of reducing aggressive end of life care and improving quality. Methods: A multidisciplinary group of quality and safety, pharmacy, physician, and nursing leadership designed a workflow to standardize the review of all inpatient anti-cancer treatment requests for non-elective solid-tumor (NEST) patients. Our NEST process begins with a formal pharmacy and nursing review, which can flag a case for further physician review. The pharmacist reviews for adequate hematologic counts, hepatic function, creatinine clearance as well as any active infections requiring IV antibiotics. Then the nursing review assesses treatment plan parameters, patient’s performance status, recent vital signs, and other clinical concerns. If either review flags one or more criteria, the case then goes to physician review. The NEST escalation process includes two levels of physician review – a single reviewer and a committee. If the review determines that there are more potential benefits than risks associated with administering anti-cancer treatment, the treatment can be approved for inpatient administration. However, if the formal review estimates significantly greater risk than potential benefit, the treatment will not be approved for inpatient administration. Results: A total of 58 requests for inpatient anti-cancer therapy occurred between initial implementation (10/31/2022) through 3/31/2023. 82.8% (48/58) were reviewed by both pharmacy and nursing and 45.8% of those were approved without need to escalate. The remaining requests had baseline patient characteristics that triggered physician review - with 13 reviewed by a single physician and 3 requiring committee review. Of the cases requiring further review, 5 did not receive their requested therapy (either denied or the family decided to not pursue treatment). 36.2% (21/58) of NEST patients died within 60 days of process initiation, 22.4% (13/58) died within 30 days, and 13.8% (8/58) died within 10 days. These outcomes were more common in individuals where NEST was denied or inpatient treatment was not pursued (77.8% died within 60 days, 44.4% died within 10 days; note 2 patients discharged to hospice with no death date on record). Conclusions: We designed a formal review process for anti-cancer therapy to be administered in the inpatient setting to solid tumor patients. This multi-disciplinary review led to 15.5% of requests not being administered to patients. Ongoing continuous improvement work focuses on further developing review criteria, exploring options for hard stops prior to treatment administration and increasing earlier goals of care discussions.
Where do patients die when there is no hospice? Real-world data.
Authors: Kalapanida Despoina , Tsimpidakis Antonis , Labropoulos Stefanos V. , Rigakos Georgios , Vernadou Anastasia , Chatziyiasemi Lina , Myrodia Dimitra-Melia , Razis Evangelia 
Published: October 2023

235 Background: The role of real-world data has been shown to be of vital importance in cancer clinical research in recent years. Furthermore, palliative and end of life care is rarely studied outside the real world setting. Lastly, Greece lacks any significant palliative care or services and the law does not recognize advance directives. Methods: We conducted a retrospective review of real world data derived from the medical files of the deceased patients of our group, in order to assess where patients in Greece die given the lack of hospice facilities. We routinely collect the cause and place of death for all patients as well as the source of the information of the patient's passing prospectively. We then retrospectively collected the date of diagnosis and cancer type. Results: Between 04/01/2019 and 01/30/2022, we collected information regarding the cause and place of death of patients that had been under clinical care in our oncology department. During this time period, 454 patient deaths occurred, of which 54.67% were male and 45.33% female. The median age of death was 63.85 years and the most frequent cause of death was disease progression (76,21%), with only 1,98% of our patients having lost their lives due to toxicity of anticancer treatment. Importantly, the majority of our patients were hospitalized at the time of death in contrast to 23.79% that passed away at home. Data regarding cancer type and overall survival since diagnosis are being processed. Conclusions: Because of the lack of specialized facilities providing end of life care in Greece, most of our patient choose or are forced to spend the last days of their life in general tertiary care hospitals, a situation which might be indicative of both the socio-economic characteristics of our country and the lack of awareness of the necessity of this healthcare infrastructure. Further analysis is pending regarding associated parameters.
Impact of early palliative care on healthcare utilization in patients with advanced lung cancer in the final year of life.
Authors: Knox Heater Natalie Knox , Tong Wendy , Meraz Jocelyn , Prieskorn Jessica , Szmuilowicz Eytan 
Published: October 2023

239 Background: The benefits of early palliative care (PC) in advanced lung cancer are well established, including both increased quality of life and decreased hospital costs at end-of-life. We performed a quantitative and preliminary qualitative analysis on end-of-life healthcare utilization of patients with advanced lung cancer in their final year of life to explore the impact of early vs. late PC. Methods: We retrospectively reviewed claims and clinical data of 54 patients with advanced lung cancer who died between 2021 and 2022 under Northwestern Medicine’s Accountable Care Organization. We classified patients as having received PC if a diagnosis code (Z51.5) appeared in claims data or if the patient’s treatment team included a PC specialist. We identified patients as having received “early” PC if their first PC visit was 90 or more days before death. Statistical analysis was performed with Fisher exact tests. Results: Forty-three (80%) patients had a PC code on claims data, while 38 (70%) had a PC team member identified within the electronic medical record. Patients receiving PC were less likely to visit the emergency department in their last 6 months of life (71% vs. 94%, p = 0.03) and more likely to utilize hospice (53% vs. 44%, p = 0.27) compared to patients without PC. Patients receiving early vs. late PC were more likely to have initiated PC as an outpatient (67% vs. 31%, p = 0.02), more likely to utilize hospice (57% vs. 44%, p = 0.21), more likely to have shorter intensive care unit stays in their last month of life (average of 10 vs. 25 days), and significantly less likely to undergo systemic treatment in their last 30 days of life (24% vs. 56%, p = 0.02) or die in the hospital (29% vs. 56%, p = 0.04). From a preliminary qualitative review, patients receiving early PC may have engaged in increased communication about clinical prognosis and goals of care, while their PC teams provided more detailed documentation of conversations about end-of-life wishes and advanced directives. Conclusions: Our data demonstrate a difference in end-of-life healthcare utilization between patients who received early vs. late PC. Limitations of this study include its small sample size and the nature of retrospective cohort studies. Qualitative evaluation is ongoing to investigate the impact of early oncologist-driven goals of care discussions on end-of-life healthcare utilization as well as moderators of early palliative care’s positive impact.
Integrated supportive oncology program and outcomes for cancer patients at the end of life.
Authors: Rebman Jamie , Montague Rachel , Gill David Michael , Thota Ramya 
Published: October 2023

240 Background: Patients with advanced cancer are often exposed to acute medical care that does not improve quality of life or restore health. Further, the cost of care during the terminal phase defined as the last 30 days of life is substantially higher with the vast majority related to acute care services. We established an integrated outpatient supportive oncology service to improve quality of life for patients with advanced cancer. The embedded program provides same day access, longitudinal symptom management, and advanced care planning services. Here, we looked at our institutional outcomes of those patients managed by the integrated supportive oncology program. Methods: A retrospective cohort analysis was performed on patients with metastatic cancer treated at Intermountain Medical Center who died between January 1, 2022 and December 31, 2022. The study population included patients who were seen in the integrated supportive oncology clinic. Hospitalizations, length of stay, and deaths in the hospital during the last 30 days of life were recorded. We used Medicare and commercial insurance claims data to calculate the cost of these end-of-life hospitalizations. Results: Of 164 patients with cancer who died in 2022, 111 (67%) received longitudinal care from the supportive oncology clinic. Hospitalization rate in the last 30 days of life was lower in the study population compared to the control cohort (26% vs 50%) as were in-hospital deaths (7% vs 19%). The median cost of an end-of-life hospitalization was $20,648. Conclusions: An integrated supportive oncology service decreases the rates of end of life hospitalizations and in-hospital deaths for patients with advanced cancer. This is associated with a cost savings.
Long-acting opioids as a trigger for palliative care consultation in pancreatic cancer.
Authors: Thakur Richa , King Daniel , Martins-Welch Diana 
Published: October 2023

252 Background: Pancreatic cancer is associated with significant symptom burden, a poor prognosis, and a poor quality of life. Early involvement of palliative care alongside standard disease modifying treatment in metastatic pancreatic cancer has been associated with improved quality of life and improved symptom burden. Receipt of opioids has been shown to improve overall survival in patients with pancreatic cancer, while escalating opioid usage has been associated with higher risk of death. Given this dichotomy in prognosis, the utilization of a long-acting opioid for cancer-related pain should warrant a palliative care consultation. Methods: This is a retrospective study conducted under an IRB-approved protocol of patients who were diagnosed with pancreatic cancer between January 1, 2021 and May 30, 2023, and who had been prescribed a long-acting opioid for cancer-related pain at our institution. Data collection including patient demographics, opioid doses, hospice utilization, date of death, and aggressive interventions at end-of-life were collected via chart review. Descriptive statistics were calculated using means and medians. Statistical methods included percentage calculations of baseline characteristics. Time from initiation of long-acting opioid to death was measured. Results: Of 51 patients surveyed, 50 met eligibility criteria for our study. The median age was 66 years (Range 42-90). Stage at diagnosis included 6 resectable, 6 borderline resectable, 12 locally advanced, and 26 metastatic. Ten were able to undergo a surgical resection. 28% of patients died within 90 days of starting a long-acting opioid. 36% died within 180 days of starting a long-acting opioid. Access to palliative care services was associated with increased utilization of medical cannabis (P=0.00001) and documentation of MOLST (Medical Orders for Life Sustaining Treatment) forms (p=0.049). Access to palliative care consultation (p=0.0007) as well as access to medical cannabis (p=0.00001) was more likely at academic main site as opposed to satellite hospitals. Conclusions: The initiation of long-acting opioids in patients with advanced pancreatic cancer should be considered as a trigger for palliative care involvement as it portends a poorer prognosis. Furthermore, even at a single institution, there were disparities in access to specialty palliative care resources. Further research needs to be conducted to optimize timing of palliative care referrals in a resource limited environment.
Grief in the practice of oncology: Prevalence and impact.
Authors: Morgan Sarah , Berger Benjamin T , McGue Shannon R , Barlow Sara A , Pieper Carl F , Oswalt Cameron , Sutton Linda , Labriola Matthew , Galanos Anthony N. 
Published: October 2023

253 Background: Oncology providers regularly face death and serious illness while shepherding patients through the cancer journey. International research shows that oncologists frequently experience grief and that grief is linked to compassion fatigue. Providing care for patients with terminal cancer has been linked to burnout, but the relationship between grief and burnout has not been explored. We sought to describe the prevalence of grief in oncology providers in the US and its link to burnout. Methods: We surveyed 255 Duke oncology providers, including in the Duke Cancer Network. Our survey included demographics, two questions about burnout, and an adaptation of the Traumatic Grief Inventory. Results: We received 128 responses, with 50% response rate. Our sample included 26% attendings, 12% fellows, and 62% advanced practice providers, with 78% of providers from the academic setting and 22% from the community. Of 123 participants who completed the grief inventory, 92 (94%) endorsed feelings of grief in the past year. Approximately half of participants endorsed burnout, and they attributed an average of 30.6% of their burnout to grief. Oncologists with personal grief, in academic settings, and <10 years in practice had higher grief scores trending toward statistical significance. Using logistic regression, we found that burden of grief predicted burnout in providers. For each increase in one point on the grief scale there was a 15% increase in odds of experiencing burnout (95% CI 7% - 22%). Conclusions: The prevalence of grief among US oncologists has not been studied. We found that the experience of professional grief is widespread among oncology providers, with 94% answering at least “sometimes” to any item on an adapted grief inventory. Moreover, we found grief to be an important predictor of burnout, suggesting a key opportunity for intervention in support of oncology providers. [Table: see text]
Frequency of malnutrition and anorexia-cachexia syndrome in patients with advanced cancer evaluated in an outpatient supportive care clinic.
Authors: Dev Rony , Bramati Patricia , Delgado Guay Marvin Omar , Azhar Ahsan , Tang Michael J , Tennison Jegy , Becerra Josue , Hui David , Bruera Eduardo 
Published: October 2023

257 Background: Patients with cancer are at risk for malnutrition and the development of anorexia-cachexia syndrome, which is often under-treated. The objective of our study was to determine the frequency of these conditions in advanced cancer patients who were evaluated in an outpatient Supportive Care Clinic (SCC). Methods: Advanced cancer patients seen in SCC were prospectively enrolled to complete a cross-sectional one-time survey. We collected patient demographics, weight history and height, cancer history, the Functional Assessment of Anorexia Therapy – Anorexia/Cachexia Subscale (FAACT-A/CS) questionnaire, Edmonton Symptom Assessment Scale (ESAS), the Patient Generated Subjective Global Assessment – short form (PG-SGA SF), and a Body Image Scale (BIS) questionnaire. Malnutrition was indicated by a PG-SGA cut-off of ≥ 5, and loss of appetite, anorexia, was defined as either ESAS ≥ 3 or FAACT-ACS ≤ 37. Results: Of 165 cancer patients that were approached, 100 (61%) completed the prospective survey. The average (SD) age was 61.6 years old (11.5). The majority of patients were female gender (52%), Caucasian (75%), were married (80%), and the most common cancers were gastrointestinal (22%) and genitourinary (21%). At the time of the survey, 14% of patients were noted to have a BMI < 20, 60% of patients reported anorexia (ESAS ≥ 3), 53% patients screened positive for the FAACT-A/CS (≤ 37), 69% were malnourished (PGSGA ≥ 5), and 55% had body image dissatisfaction (BIS ≥ 4). Documented weight loss of >10% in the medical records was recorded in 59% of patients with an average (SD) of -12.8% (15.3). Patient self-reported weight loss of > 5% over 6 months and > 10% over a lifetime was noted in 56% and 62% of the patients, respectively. Conclusions: Advanced cancer patients seen in an outpatient SCC are at high risk of malnutrition and roughly 60% experience complications of anorexia-cachexia syndrome. Routine screening for malnutrition and weight loss should be incorporated into all Supportive Care encounters, and nutritional counseling and support should be offered to the majority of cancer patients.
Palliative care usage in large cell lung carcinoma: An analysis of the National Cancer Database.
Authors: Han Emily , Wu Xinxin , Keirns Darby , Silberstein Peter T. 
Published: October 2023

266 Background: The treatment approach for large cell lung carcinoma (LCLC) typically involves a multimodal treatment strategy, including chemotherapy, radiation therapies, and immunotherapy, to target both the primary tumor and any metastatic lesions. Palliative care (PC) optimizes the treatment of individuals with LCLC by relieving suffering improving quality of life for patients and their loved ones. When implemented early, PC can lengthen survival in patients with advanced non-small cell lung cancer (NSCLC) like LCLC. The association between PC utilization and race, ethnicity, insurance status, education level, income level, rural/urban geography, and facility type in the face of a LCLC diagnosis has not yet been investigated in isolation from other types of NSCLC. We will analyze these factors in this study to highlight key discrepancies in the implementation of PC when treating LCLC. Methods: A retrospective study was conducted using data collected from adults diagnosed with all subtypes of LCLC between 2004 and 2020 in the National Cancer Database to evaluate trends in PC utilization. Demographic characteristics were studied with regards to the use of PC. Multivariate with binary logistic regression was implemented to analyze the following variables: age, sex, Hispanic status, race, Charlson-Deyo comorbidity score (CDCS), education level quartile, income status quartile, facility region, geographic residence status, and primary insurance status. Exclusion criteria included missing values. Results: Among the 25362 patients diagnosed with LCLC, about 12.8% received PC (n = 3727). Patients who were more likely to receive PC had a CDCS of ≥3 (p = 0.017, CI = 1.04-1.47). Additionally, PC usage was more likely in rural (p = 0.003, CI = 1.05-1.27) and urban (p = 0.013, CI = 1.06-1.62) settings compared to metro settings. Patients who were less likely to utilize PC were Black (p = 0.018, CI = 0.77-0.98) and male (p < 0.001, CI = 0.82-0.95). Facility locations in the South (Atlantic) and West (Mountain and Pacific) regions were less likely to provide PC services. Patients paying primarily with Medicaid were the most likely to undergo PC compared to their counterparts lacking insurance or having different insurance (private, Medicare, other government). There was no statistically significant difference in PC usage among different education levels and income brackets. Conclusions: We identified patterns in PC utilization among individuals with LCLC. Variables correlated with PC usage include CDCS, race, facility location, and primary payor at diagnosis. Given that LCLC is aggressive, PC can complement curative treatments to provide comprehensive cancer care. We hope this study will serve as a foundation for reducing health disparities in the treatment of LCLC, thus advancing health equity.