bluuebunny/crossref_metadata_2025_split huggingface dataset:
The impact of hospice on end-of-life expenditures and total cost of care in episodic value-based care models at a community oncology network.
Authors: Sharma Gunjan , Deepak Divya , Neeb Jessica , Garey Jody S. , Thomas Hope Ives , Mills Lydia , Payne-De Bock Judi , Wilfong Lalan S. , Indurlal Puneeth 
Published: October 2023

228 Background: The Institute of Medicine highlighted that multiple care transitions and fragmented care delivery at the end-of-life (EOL) is a burden to patients and caregivers. Hospice care has been shown to deliver high-quality, coordinated, and comprehensive EOL care while reducing unneeded healthcare interventions and improving EOL patient experience (preference of place of death, type of EOL care). The impact of timely hospice care on Total Cost of Care (TCOC) in episodic value-based care (VBC) models and patient experience at the EOL is largely unknown. The Oncology Care Model (OCM) was a 6-year long Medicare VBC program that encouraged care transformation at Oncology practices to drive better quality of care and patient experience, while decreasing TCOC. We studied the impact of timely hospice enrollment on TCOC, EOL expenditures, and patient experience. Methods: We obtained episode level data for patients who died in an episode (decedents) during the 6-years of the OCM (July 2016 to June 2022), for 15 practices in The US Oncology Network (The Network) participating in the OCM, along with several expenditure, clinical and episodic characteristics. We evaluated utilization and experience outcomes for episodes with and without hospice. Results: Of the 26,074 decedents during the 6-year period of the OCM, 55% were enrolled in hospice for 3 or more days (Hsp), and 45% were not enrolled or enrolled in hospice for less than 3 days (NoHsp). Mean TCOC for Hsp episodes ($41,297, n = 14,240) was significantly lower (Mann Whitney U test, p-value < 0.0001, significance level = 0.01) than NoHsp ($47,601, n = 11,834) episodes. TCOC comparison by expense cohort results are provided in Table 1. Median duration of hospice for Hsp episodes was 9 days. Mean ICU and inpatient spend in last 30 days of life in NoHsp group was more than 2 times the spend in Hsp group. 44% of patients in NoHsp group died in a hospital or an ICU setting, whereas 97% of patients in Hsp group died at home or in a hospice setting. Conclusions: Patients enrolled in hospice for 3 or more days had lower EOL care expenditures, fewer acute care interventions, and died at home or in hospice. Timely and proactive enrollment in hospice and coordinated EOL care can improve patient experience, but also reduce EOL costs for the healthcare system and patients. CMMI Disclaimer: The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.[Table: see text]
Outcomes of patients placed on comfort care at a large, urban, quaternary care medical center.
Authors: Tucker Matthew , Hovern Dayna , Liantonio John , Collins Elizabeth , Binder Adam F 
Published: October 2023

229 Background: End-of-life care in the typical hospital setting has several drawbacks including lack of interdisciplinary hospice teams, less comfortable environments, and lack of provider experience. In addition, patients at the end of their life are often severely symptomatic and imminently dying and thus have barriers to appropriate disposition. Few studies have explored the outcomes of patients placed on comfort care with respect to hospice disposition. The objective of this study was to perform a retrospective analysis of patients who transitioned to comfort care at Thomas Jefferson University Hospital (TJUH) to better understand the ultimate disposition of patients placed on comfort care. Methods: We conducted a retrospective study of patients placed on the comfort care order set between July 1st, 2021, until June 30th, 2022. A report of all patients placed on our institutions “comfort care order set” was run using Qlik analytics and data platform. Each individual patient chart was then analyzed to collect multiple clinical variables, including diagnoses, palliative care involvement, time on comfort care, hospital length of stay (in total and after comfort care order set placed), healthcare utilization prior to hospitalization, and IV medications used for symptom management. Participants were limited to those 18 years or older. IRB approval was obtained as per institutional guidelines. Results: 541 patients were included in the analysis. 424 (78.37%) patients died while still admitted to the hospital. This amounts to 1.5 patients a day requiring comfort care support. 60% of patients on comfort care were in the intensive care unit (ICU). The ICU population spent on average 11.04 (+/- 24) hours on comfort care. 19% of these patients were on comfort care for longer than 12 hours. Subspecialty and hospital medicine patients were on comfort care for 3.3 (+/- 3.3) days and 5 (+/- 9.5) days respectively. Within oncology patients, the average time was 3 (+/- 2.4) days. 94% of the patients placed on comfort care in the ICU died in the hospital as compared to 53% of subspecialty and 59% of hospital medicine patients. 40% of non-ICU patients were discharged with hospice services. The average length of stay for the study population was 12.5 (+/- 13.0) days. Conclusions: The majority of patients placed on comfort care died during their hospitalization demonstrating a real need for comprehensive end of life care and immediate hospice services for our patient population. For those discharged with hospice services, they spent an excessive amount of time in the hospital waiting for services to be arranged. Establishing a hospital based inpatient hospice unit has the potential to improve the patient and family experience, provide better end of life care, and reduce length of stay. Previous studies have also demonstrated decreased costs. Ongoing work is underway at our institution to provide optimal end of life care for this patient population.
Impacts of an outpatient palliative care team on the end-of-life care at a cancer center in Brazil.
Authors: Gomes Sarah Ananda , Silva Danielle , Bergerot Cristiane Decat , Sorice Flavia , Barreto Arantes Alexandra , Passarini Thais , Alvarenga Petrocchi Julia , de Paula Marcela , Melo Andreia Cristina De , Jácome Alexandre A. , Ferrari Bruno Lemos 
Published: October 2023

231 Background: It has been demonstrated. that early palliative care improves the quality of life of cancer patients by reducing overtreatment at the end-of-life (EoL) and improving symptomatic control. However, there is a lack of research on the impact of palliative care on the EoL outcomes in developing countries. EoL cancer care varies widely and very few centers evaluate it systematically. Studies suggest that people often prefer dying at home, however, data also shows that most deaths in Latin America occur at hospitals. Methods: This study aimed to analyze the impact of cancer patients’ follow-up by an outpatient palliative care team (OPCT) on the EoL outcomes at a private Multicentric Cancer Center in Brazil. Data were retrospectively retrieved from electronic medical records of patients who were treated at a Brazilian Cancer Center and who died between January 2022 and December 2022. Adults with any type of cancer were considered eligible. The participants were divided into two groups: the OPCT group was followed up by a palliative care multidisciplinary team who regularly evaluated cancer patients during their treatments in an outpatient setting and the No-OPCT group followed up by oncologists with multidisciplinary teams as demanded. Univariate comparisons and multivariate analysis adjusted to the multivariate logistic regression model were performed and p<0.05 was deemed as statistically significant. Results: A total of 1980 patients were included in the study: OPCT (N=640) and No-OPCT (N=1340). Most of the patients in both groups were older than 65 years (61% vs 66%). The groups were well balanced concerning gender (women: 54% vs 46%), and TNM stage (stage IV: 87% vs 89%). Gastrointestinal and breast cancers were the most prevalent in both groups. The rate of home death was 20.2% in the OPCT group, compared to 10.6% in the No-OPCT group, meaning a 2 times greater chance of dying at home when the OPCT was provided (p<0.001). In multivariate analysis, follow-up by the OPCT was the strongest independent predictor of home death. Age, gender, and TNM stage did not influence the place of death. Conclusions: The current study suggests that an active palliative care program in an outpatient care institution, through early conversations about goals of care, prognostic awareness, and EoL preferences may potentially improve the EoL outcomes for patients with cancer, while also reinforcing the need of early referral for a palliative care team. Future studies and ongoing prospective studies in Brazil are needed to validate these findings and also to evaluate the impact of other variables, such as health support systems for home deaths.
Exploring factors and trends in place of death by cancer: A population-based study in Brazil.
Authors: Gomes Sarah Ananda , Da Silva Jesse Lopes , Moura Lívia Machado , de Albuquerque Lucas Zanetti , de Oliveira Livia Costa , Thuler Luiz Claudio Santos , de Melo Andréia Cristina 
Published: October 2023

237 Background: Place of death serves as an indicator of the quality of end-of-life care. This study seeks to elucidate the place of deaths by cancer in Brazil, also identifying factors contributing to regional disparities in end-of-life settings. Methods: Using data obtained from the National Mortality Information System, this study extracted sociodemographic characteristics and the location of cancer deaths in Brazil from 2012 to 2021. The place of death was classified into hospital death, home death, and other settings (not shown). Results: A total of 2.165.643 deaths by cancer were included. Almost half of the cases were from Southeast (47.4%), while 22.0% were from Northeast, 19.0% from South and the minority from Central-west (6.5%) and North (5.0%) regions; remarkably, 73.3% of deaths occurred out of capitals. A downward trend was observed from 2012 to 2021 with a Relative Percent Difference (RPD) of -4,0. The frequency of deaths occurring at home in the Northeast region (26.6%) was found to be higher than the reference region, the Southeast (10.6%), RPD -22.2. Furthermore, Indigenous individuals showed a higher frequency of death at home (25.4%) compared to White ethnicity (14.2%), RPD -18.4. A clear inverse relation between in-hospital deaths and aging can be noted, as more at-home deaths are observed in the elderly (17.8%) compared to the young group (4.1%). Conclusions: Most cancer deaths in Brazil occur in hospitals. Death at home is related to pronounced regional differences, being higher in the North and Northeast, and may be related to advanced age, race and educational level.[Table: see text]
Economic burden in patients (pt) with CLL/SLL (CLL) who received ≥ 2 prior lines of therapy (LOT), including a Bruton tyrosine kinase inhibitor (BTKi): A SEER-Medicare analysis.
Authors: Awan Farrukh Tauseef , Yande Soham , Esterberg Lizzi , Nagar Saurabh P. , Goyal Ravi K. , Priyadarshini Masoom 
Published: October 2023

24 Background: In third-line or later (3L+) CLL, there is no standard of care after failure of oral-targeted treatments (tx) (eg, BTKi, B-cell lymphoma 2 inhibitor [BCL2i]). There is limited real-world evidence on tx received and economic burden among pts with advanced CLL. Therefore, this study assessed tx patterns, health care resource utilization (HCRU), and costs in 3L+ Medicare-enrolled pts with CLL who received prior BTKi. Methods: A retrospective study was conducted using SEER data from 2010 to 2017 linked to Medicare claims data through 12/31/2019. Eligible pts had a CLL diagnosis, were ≥ 66 y of age at diagnosis, received ≥ 2 prior LOTs, including a BTKi, and initiated a subsequent LOT. Index date was defined as start of 3L+ tx after discontinuation of prior LOT containing a BTKi. Pts were continuously enrolled in Medicare parts A, B, and D ≥ 6 mo before and ≥ 1 mo after index date. Baseline pt characteristics, HCRU, and associated health care costs in the postindex period were summarized descriptively. HCRU and costs (adjusted to 2019 US dollars) were reported as mean CLL-related and all-cause per pt per month (PPPM). Results: Among 98 eligible pts with post-BTKi 3L+ CLL, mean age was 78 y; 54.1% were male. Pts had a median of 2 prior LOTs with median postindex follow-up of 12 mo. Mean Charlson Comorbidity Index score was 2.8. The top 3 index LOT txs received were chemotherapy with anti-CD20 monoclonal antibodies (mAb [19.4%]), anti-CD20 mAb monotherapy (19.4%), and BCL2i monotherapy (14.3%). In the postindex period, 90.8% of pts had ≥ 1 office visit; 63.3% had ≥ 1 inpatient admission with a mean length of stay of 7.6 d. All-cause mean PPPM HCRU was 2.3 office visits, 1.8 hospital outpatient visits, 0.02 skilled nursing facility (SNF) visits, 1.6 ancillary care visits, 0.2 emergency room (ER) visits, and 0.2 inpatient admissions. Total all-cause mean (standard deviation [SD]) PPPM cost was $12,679 ($15,123). The main drivers of total all-cause PPPM cost were inpatient admissions ($4891) followed by drugs ($4379), hospital outpatient ($2338), office visits ($412), ancillary care ($412), SNF ($140), and ER ($26). CLL-related HCRU and costs are shown in the Table. CLL-related PPPM costs accounted for 83% of total all-cause costs with a mean (SD) of $10,501 ($14,052). Conclusions: Our study demonstrated that Medicare-enrolled pts with 3L+ CLL who received prior BTKi experienced high economic burden (mean monthly cost of $12,679). Inpatient admissions and drugs were the largest cost drivers. Considering the survival in this population (median OS of 33.1 mo; Awan et al. Blood 2022), the lifetime economic burden to Medicare could be significant. [Table: see text]
Effect of removing an oncologist-directed behavioral nudge on sustaining rates of serious illness conversations: An interrupted time series analysis.
Authors: O'Keefe Ryan M , Wileyto E. Paul , Gabriel Peter Edward , Blumenthal Daniel , Tejada Sharon , Beidas Rinad S , Schnoll Robert , Bekelman Justin E. , Parikh Ravi Bharat , Takvorian Samuel U 
Published: October 2023

242 Background: Behavorial economic nudges are increasingly used in oncology settings to encourage evidence-based practices, such as serious illness conversations (SIC). Prior work demonstrated the effectiveness of an oncologist-directed nudge identifying patients at high risk of 180-day mortality, which led to a 3-fold increase in SIC documentation. It is unknown whether such nudges must continue indefinitely to sustain effective behavior change, or whether clinician behavior change would persist in their absence. The objective of this analysis was to examine the effect of removing an oncologist-directed nudge on overall SIC rates. Methods: From 2019 to 2022, clinicians within our institution received a nudge consisting of weekly performance feedback on SIC completion and opt-out text messages identifying patients at high-risk of 180-day mortality based on a validated machine-learning algorithm. In March 2022, at the conclusion of clinical trial NCT04867850, this program ended. For this analysis, the population included adult patients seen by a medical oncologist at one of 11 practices between Sept 2021 and Sept 2022. Patient encounters with an SIC documented in the previous year were excluded, as well as those occurring during a washout period (March-April 2022). SICs were attributed to an encounter if documented within 30 days. The primary outcome was the number of SICs documented per 1000 patient encounters. We used linear probability models and an interrupted time series analysis at the patient-encounter level to analyze the association between nudge cessation and SIC rates. All analyses were unadjusted. Results: 111,459 encounters were included in the final analysis (56.9% prior to nudge cessation). Demographic data showed mean age 64.16 (SD 13.29), 57.02% female, 75.25% non-Hispanic white, 61.88% Medicare. There were 1,517 unique encounters with an SIC documented within 30 days (1.36%), with 1,030 pre-cessation (1.62%) and 487 post-cessation (1.01%). Rates of SICs were 15.3 per 1000 encounters in February 2022 (pre-cessation) vs. 9.7 in May 2022 (post-cessation), representing a 37% decline (Table). Unadjusted interrupted time series analyses showed a significant decrease in documented SICs per 1000 encounters (odds ratio 0.64, 95% CI 0.57 - 0.71). Conclusions: Removal of a clinician nudge was associated with a significant decline in SIC rates, suggesting a lack of sustained clinician behavior change without an ongoing behavioral nudge. Because nudges may be required indefinitely to promote evidence-based practices such as SICs, their design should be minimally intrusive and easily adaptable to evolving care standards. Adjusted analyses, marginal effects analysis, and time-to-event analyses are in progress.[Table: see text]
Simultaneous care clinic: A mono-institutional experience at an ESMO designated center for palliative care.
Authors: Stragliotto Silvia , Gallio Ivan , Cambi Caroline , Lo Mauro Leda , Moretto Valentina , Lorusso Marina , Scelzi Elvira , Ahcene-Djaballah Selma , Roma Anna , Frezzini Simona , Nardi Mariateresa , Feltrin Alessandra , Pasalic Mirsad , Salmaso Flavia , Gottardi Michele , Saieva Anna Maria , Formaglio Fabio , Zagonel Vittorina , Lonardi Sara 
Published: October 2023

254 Background: Early palliative care has been shown to improve patient (pts) and caregiver satisfaction, symptom control, quality of end-of-life care, cost and in some cases survival in pts with advanced cancer. In accordance with ASCO, ESMO and AIOM guidelines a Simultaneous Care Clinic (SCC) was set up at Veneto Institute of Oncology (IOV) since 2014. In the Castelfranco Branch of the IOV, SCC started in January 2022. Methods: Data from all consecutive outpatient patients seen in SCC were retrieved from a prospectively maintained database.Data collected included cancer type, status of disease, performance status (PS), ongoing oncological treatment, nutritional evaluation, social evaluation, psychological evaluation, activation of home territorial and/or palliative care services,use of other health services after a first visit and place of death. At the first visit pts were evaluated with validated tools for symptom identification, Edmonton Symptom Assessment (ESAS), distress thermometer, Malnutrition Universal Screening Toll (MUST). Results: From January to December 2022seventy-four pts were evaluated by a multidisciplinary team and re-evaluated 2 months later in terms of improvement or stabilization of symptoms, appropriateness of intervention and outcome. All patients had a metastatic disease and were in active oncological treatment. The median age was 73 y and the most prevalent disease type was gastrointestinal cancers (48%). The median time from first SCC visit to death was 3.8 months; 32 pts are still alive. At the first visit symptom management measures were adopted. The median score for the distress thermometer was 5 with higher prevalence of physical problem. A higher prevalence on 7-10 ESAS score (26% of the pts) was found for pain, fatigue and lack of appetite. At the second visit, an improvement was observed: the median score for the distress thermometer was 4 and ESAS score was 7-10 in 18% of the pts. At first SCC visit, patients deemed in need of home care services were 17 (23%) and for these a formal request for Home Care services activation was sent to the Local Health Territorial Unit (Distretto ULSS). Conclusions: The SCC multidisciplinary assessment represents an organizational model effective in granting a global management of needs with the aim of improving the therapeutic path for patients and their caregivers.
Palliative prognostic index in end-of-life cancer care: A comparative study of different cut-off scores.
Authors: Elfaituri Muhammed Khaled , Khaled Ala , Faraj Hazem , Msherghi Ahmed 
Published: October 2023

258 Background: Accurate prognostication of survival in terminally ill cancer patients, particularly those with a life expectancy of less than three weeks, is critical to palliative care. It facilitates tailored care and enhances communication with patients and their families. The Palliative Prognostic Index (PPI) is a commonly used approach. However, a comprehensive examination of PPI's utility and predictive accuracy remains largely unexplored, particularly at different cut-off scores, compared to other prognostic tests. This study aims to determine and compare the predictive utility of PPI (at cut-off scores >4, >5, and >6) in estimating survival of less than three weeks in terminally ill cancer patients. Methods: A systematic search of MEDLINE, Embase, and Cochrane databases was conducted until November 2022, focusing on studies evaluating the predictive utility of PPI and other prognostic tests for cancer patients with a survival prognosis of less than three weeks. Statistical analyses were carried out using R software (version 4.0.3) and the mada package, enabling the aggregation of sensitivity, specificity, false-positive rate estimates, diagnostic odds ratio, and both positive and negative Likelihood Ratios (LRs). All outcomes are reported with a 95% Confidence Interval (CI) and I2 statistic to measure heterogeneity among the studies. Results: The meta-analysis included 16 studies with 9,839 patients. At a PPI cut-off score >4, the pooled sensitivity was 83.3% (95% CI: 79.6-86.5%, I2=78.1%), specificity was 58.5% (95% CI: 52.4-64.4%, I2=83.6%), false-positive rate was 41.5% (95% CI: 35.6-47.6%), diagnostic odds ratio was 7.04 (95% CI: 4.95-9.98), positive LR was 2.01 (95% CI: 1.73-2.34), and negative LR was 0.29 (95% CI: 0.23-0.36). At a PPI cut-off score >5, the pooled sensitivity decreased to 65.9% (95% CI: 54-76%, I2=96.2%), but specificity increased to 70.2% (95% CI: 57-80.7%, I2=97.3%), false-positive rate was 29.8% (95% CI: 19.3-43%), diagnostic odds ratio was 4.54 (95% CI: 2.13-9.71), positive LR was 2.21 (95% CI: 1.43-3.42), and negative LR was 0.49 (95% CI: 0.34-0.70). At a PPI cut-off score >6, the pooled sensitivity was 68.6% (95% CI: 58.4-77.2%, I2=95%), specificity increased further to 79% (95% CI: 72.1-84.6%, I2=95.1%), false-positive rate was 21% (95% CI: 15.4-27.9%), diagnostic odds ratio was 8.24 (95% CI: 4.61-14.71), positive LR was 3.27 (95% CI: 2.36-4.55), and negative LR was 0.39 (95% CI: 0.29-0.54). Conclusions: This study evaluated the predictive utility of varying Palliative Prognostic Index (PPI) cut-off scores for short-term survival in terminally ill cancer patients, suggesting a higher cut-off score (>6) optimizes specificity and reduces false positives. Our findings offer practical insights for healthcare providers in tailoring PPI score selection and underscore the need for further research in diverse settings and populations.