Aggressive Care Research Articles

Association of early completion of portable medical orders with inpatient costs at end-of-life for patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS).

6645 Background: Patients with hematologic malignancies receive more aggressive care at end-of-life (EOL) compared to patients with solid tumors. Costs of care in patients with hematologic malignancies at EOL are high, particularly in the inpatient setting. We previously found that early completion of portable medical orders [termed medical orders for life sustaining treatment (MOLST) in New York state] is associated with less intense care at EOL for patients with AML and MDS. Thus, we hypothesized that early MOLST completion would also be associated with lower inpatient costs at EOL among patients with AML and MDS. Methods: We previously conducted a retrospective study of 358 adults patients with AML or MDS treated at Wilmot Cancer Institute and its affiliated sites who died between January 1, 2014, and December 31, 2019. Of these, 271 patients were eligible for cost analysis. Cost of inpatient care received at the University of Rochester Medical Center (URMC) within the last 30 days of life was obtained from our Finance Decision Support Department. Patients were excluded if inpatient costs at EOL were unavailable. Results: Mean age of patients was 69 years (N=271, range 20-95); 84% (n=227) of patients were hospitalized within 30 days of death. One-third (34%, n=93) of patients completed a MOLST early (>30 days prior to death) whereas 66% (n=178) either did not complete a MOLST or completed a MOLST late (less than or equal to 30 days prior to death). Mean and median inpatient cost of care for all patients at EOL was $39,284 and $19,703, respectively. The rate of hospitalization was lower for patients who completed a MOLST early vs late/never (73.1% vs 90.5%, respectively; p=0.0003), although there was no difference in the number of inpatient visits between the two groups (median=1 visit in both groups; p=0.23). In addition, median cost of inpatient care was lower for patients who completed a MOLST early vs late/never ($10,673 vs $23,177, respectively; p<0.0001). After adjusting for age, sex, and diagnosis, there was a trend toward lower EOL costs in patients completing a MOLST early (p=0.07). Conclusions: In patients with AML or MDS, early MOLST completion may be associated with lower inpatient costs at EOL. Viewing MOLST completion as a surrogate for a goals-of-care discussion, it follows that interventions aimed to increase the frequency of early goals-of-care discussions, advanced care planning, and MOLST completion are likely to improve quality of care and decrease costs at EOL in these patient populations.

Don't Throw the Baby Out With the Bathwater: Meta-Analysis of Advance Care Planning and End-of-life Cancer Care.

There is ongoing discourse about the impact of advance care planning (ACP) on end-of-life (EOL) care. No meta-analysis exists to clarify ACP's impact on patients with cancer. To investigate the association between, and moderators of, ACP and aggressive vs. comfort-focused EOL care outcomes among patients with cancer. Five databases were searched for peer-reviewed observational/experimental ACP-specific studies that were published between 1990-2022 that focused on samples of patients with cancer. Odds ratios were pooled to estimate overall effects using inverse variance weighting. Of 8,673 articles, 21 met criteria, representing 33,541 participants and 68 effect sizes (54 aggressive, 14 comfort-focused). ACP was associated with significantly lower odds of chemotherapy, intensive care, hospital admissions, hospice use fewer than seven days, hospital death, and aggressive care composite measures. ACP was associated with 1.51 times greater odds of do-not-resuscitate orders. Other outcomes-cardiopulmonary resuscitation, emergency department admissions, mechanical ventilation, and hospice use-were not impacted. Tests of moderation revealed that the communication components of ACP produced greater reductions in the odds of hospital admissions compared to other components of ACP (e.g., documents); and, observational studies, not experimental, produced greater odds of hospice use. This meta-analysis demonstrated mixed evidence of the association between ACP and EOL cancer care, where tests of moderation suggested that the communication components of ACP carry more weight in influencing outcomes. Further disease-specific efforts to clarify models and components of ACP that work and matter to patients and caregivers will advance the field.

Surgical repair of ruptured omphalocele in a high genetic merit neonatal Holstein bull calf

AbstractA neonatal Holstein bull calf presented emergently for abdominal evisceration. Calving was unassisted. Ninety minutes postpartum, farm staff noted the defect and brought the patient to the hospital. On presentation, the calf was recumbent, dull, and in hypovolemic shock with uncompensated hyperlactatemic metabolic acidosis. Multiple organs were identified through a 4–5 cm defect in the caudoventral midline. Differentials included a ruptured omphalocele, gastroschisis, trauma and schistosomus reflexus. This presentation was consistent with a ruptured omphalocele. Following triage and haemodynamic stabilisation, the eviscerated abdominal contents were lavaged, surgically replaced and an umbilical resection with partial cystectomy performed to remove a patent urachus. Postoperatively, the patient was hospitalised with aggressive nursing care. Pharmacotherapy included prophylactic antibiotics, gastroprotectants and anti‐inflammatory medication. The calf developed mild postoperative pneumonia, but was discharged after 6 days. This report details management of omphalocele evisceration in a calf and the pathology of congenital midline anomalies in neonatal ruminants.

Immunotherapy in glioblastoma treatment: Current state and future prospects

Glioblastoma remains as the most common and aggressive malignant brain tumor, standing with a poor prognosis and treatment prospective. Despite the aggressive standard care, such as surgical resection and chemoradiation, median survival rates are low. In this regard, immunotherapeutic strategies aim to become more attractive for glioblastoma, considering its recent advances and approaches. In this review, we provide an overview of the current status and progress in immunotherapy for glioblastoma, going through the fundamental knowledge on immune targeting to promising strategies, such as Chimeric antigen receptor T-Cell therapy, immune checkpoint inhibitors, cytokine-based treatment, oncolytic virus and vaccine-based techniques. At last, it is discussed innovative methods to overcome diverse challenges, and future perspectives in this area.

Associations Between Psycho-Social-Spiritual Interventions, Fewer Aggressive End-of-Life Measures, and Increased Time After Final Oncologic Treatment.

Little is known about the impact of spiritual caregivers, psychologists, and social workers on desired end-of-life (EoL) medical outcomes, such as reduced use of aggressive care in the final 2 weeks of life, having more time between the last active oncological treatment and death, and increased hospice use. We conducted a prospective study of 180 patients with cancer and their families, their interactions with social work, psychology, and spiritual care, and the above three treatment outcomes. We found that having one or more spiritual care visits (adjusted odds ratio (AOR) = 2.02; P = .04), having more quality visits with the psychologist (P = .01), and speaking with someone about one's inner resources (AOR = 2.25; P = .03) all correlated with reduced EoL aggressive care. The key interventions correlating with increased time after final treatment were more visits with the spiritual caregiver or the social worker (AOR = 1.30; P < .001), and speaking about the medical treatment (AOR = 1.54; P < .001) and about interpersonal relationships (AOR = 2.28; P < .001). A subjectively good-quality connection with the spiritual caregiver correlated with increased hospice use (AOR = 10.00; P = .01). Patients with cancer who availed themselves of the spiritual care, psychology, and social work services, each profession in distinct ways, had significantly different outcomes in their EoL medical treatment, including undergoing fewer futile aggressive measures, having more time after their last active treatment, and using hospice services more. These outcomes directly bear on improved quality of life and reduced costs.

MP16-15 DISPARITIES IN INPATIENT CARE AND OUTCOMES FOR OLDER ADULTS WITH INFECTED STONES

You have accessJournal of UrologyCME1 Apr 2023MP16-15 DISPARITIES IN INPATIENT CARE AND OUTCOMES FOR OLDER ADULTS WITH INFECTED STONES Alexandria Spellman, Tetsu Ohnuma, Sonali Advani, Vijay Krishnamoorthy, Karthik Raghunathan, Kenneth Schmader, Michael Lipkin, Jodi Antonelli, and Charles D. Scales Alexandria SpellmanAlexandria Spellman More articles by this author , Tetsu OhnumaTetsu Ohnuma More articles by this author , Sonali AdvaniSonali Advani More articles by this author , Vijay KrishnamoorthyVijay Krishnamoorthy More articles by this author , Karthik RaghunathanKarthik Raghunathan More articles by this author , Kenneth SchmaderKenneth Schmader More articles by this author , Michael LipkinMichael Lipkin More articles by this author , Jodi AntonelliJodi Antonelli More articles by this author , and Charles D. ScalesCharles D. Scales More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003236.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: An obstructing urinary tract stone complicated by infection (septic stone) requires urgent intervention with both antibiotics and urinary tract decompression. Delayed treatment can lead to significant morbidity and sometimes mortality. Current published claims analyses reflect data up to 2011. Given a rapidly aging population and advances in critical care, we sought to examine characteristics and outcomes of patients with sepsis secondary to obstructing stones in a contemporary cohort, with a focus on outcomes in older adults. METHODS: We conducted a retrospective cohort study using data from the nationwide Premier Healthcare claims database (2016-2020) to identify hospital inpatients aged 18-95 treated for septic urolithiasis, using ICD-10 diagnostic codes consistent with sepsis with urinary stones. Baseline sociodemographic factors were described and stratified into 2 age groups: adults 65 years and older defined as “older adults”, and adults aged <65 years defined as the “younger cohort”. Outcomes such as length of stay, mortality, and discharge disposition were also compared in the 2 groups. RESULTS: The study cohort included 27,976 patients, of which 15,304 (54.7%) were older adults (Table 1). The average age of older adults was 76.0 (SD ±11.6) years, compared with 49.8 (SD ±7.3) years in younger cohort (p<0.001). Among older adults, 46.4% were male, versus 35.9% in the younger cohort; overall the cohort was predominantly non-Hispanic white (76.6%). Older adults were less likely to be cared for in teaching hospitals (p<0.001), and more likely to be cared for in smaller hospitals (<500 beds, p<0.001). Despite receiving more aggressive care (invasive mechanical ventilation, vasopressor use) and incurring higher costs (p<0.001), older adults experienced substantially higher mortality (RR 2.35, 95% confidence interval 2.1-2.7, p<0.001). In addition, older adults were significantly more likely to be discharged to a skilled nursing facility (31.8%) than younger adults (13.4%). CONCLUSIONS: Older adults hospitalized with septic stones have significantly worse outcomes, receive more aggressive care, and incur higher healthcare costs. Additional investigation is needed to identify patient, clinician, and facility-level drivers of these outcomes, so as to create pathways to reduce disparities and optimize outcomes for older adults. Source of Funding: Duke University © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e208 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexandria Spellman More articles by this author Tetsu Ohnuma More articles by this author Sonali Advani More articles by this author Vijay Krishnamoorthy More articles by this author Karthik Raghunathan More articles by this author Kenneth Schmader More articles by this author Michael Lipkin More articles by this author Jodi Antonelli More articles by this author Charles D. Scales More articles by this author Expand All Advertisement PDF downloadLoading ...

Hyperfractionated Cyclophosphamide and Dexamethasone Alone or in Combination with Daratumumab and/or Carfilzomib for the Treatment of Relapsed or Refractory Multiple Myeloma: A Single-Center Retrospective Analysis.

Hyperfractionated cyclophosphamide and dexamethasone (HyperCd) alone, or with carfilzomib(K) and/or daratumumab(D), represents a potential treatment option when rapid disease control is needed for patients with aggressive presentations of relapsed/refractory multiple myeloma (RRMM). This is a single-center, retrospective analysis of adult patients with RRMM who received HyperCd with or without K and/or D between May 1, 2016 and August 1, 2019 at the University of Texas MD Anderson Cancer Center. We here report treatment response and safety outcomes. Data from 97 patients, 12 with plasma cell leukemia (PCL), were reviewed in this analysis. Patients had had a median of 5 prior lines of therapy and received a median of 1 consecutive cycle of hyperCd-based therapy. The overall response rate (ORR) of all patients was 71.8% (HyperCd 75%, HyperCdK 64.3%, D-HyperCd 73.3%, and D-HyperCdK 76.9%). Median progression-free survival and overall survival among all patients was 4.3 months (HyperCd 3.1 months, HyperCdK 4.5 months, D-HyperCd 3.3 months, and D-HyperCdK 6 months) and 9.0 months (HyperCd 7.4 months, HyperCdK 9.0 months, D-HyperCd 7.5 months, and D-HyperCdK 15.2 months), respectively. Grade 3/4 hematologic toxicities were common, thrombocytopenia being the most frequent at 76%. Notably, 29-41% of patients per treatment group had existing grade 3/4 cytopenias at initiation of hyperCd-based therapy. HyperCd-based regimens provided rapid disease control among MM patients, even when heavily pre-treated and with few remaining treatment options. Grade 3/4 hematologic toxicities were frequent, but manageable with aggressive supportive care.

Management of Patients With Kennedy Terminal Ulcer: Challenges and Best Practices

Whether receiving acute, long-term, or home care, patients at the end of life may experience skin failure due to hemodynamic changes and insufficient perfusion of skin tissue. Skin failure begins as superficial ulcers that can quickly become full-thickness lesions, which are referred to as Kennedy terminal ulcers. Skin lesions commonly occur in the final 6 weeks of life and can occur even in the presence of a comprehensive care plan. The pathogenesis of Kennedy terminal ulcers is often misunderstood and these ulcers are commonly misdiagnosed as pressure injuries. This confusion may lead to aggressive care with subpar clinical outcomes that cause further psychological and emotional distress to patients and family members. Patients at the end of life must be provided care focused on their comfort rather than wound healing. To provide the highest quality of care to patients, four end-of-life strategies should be used, including: taking account of the preferences of patients and families, protecting the skin, describing the wound, and preserving a high quality of care. The terms, pathophysiological and clinical manifestations, and nursing treatments related to skin failure at the end of life described in the literature are introduced in this paper. Furthermore, monitoring indicators of nursing quality are provided.

Not All Leiomyosarcomas Are the Same: How to Best Classify LMS.

Leiomyosarcoma arises from smooth muscle and represents one of the most common soft tissue sarcomas. Despite aggressive multimodality care, over half of the patients will ultimately develop metastatic and incurable disease with a median survival of 12-18months. At present, there is no standard system to classify leiomyosarcoma, which itself is a heterogeneous disease. Classification by tumor location is the most simplistic approach and is most frequently utilized in clinical practice. Tumor location impacts diagnosis (recognition pre-operatively versus at the time of surgery) as well as treatment (ability to completely resect with clear margins with minimal morbidity). While tumor location can impact prognosis, for example, extremity tumors would generally be considered as lower risk than inferior vena cava tumors, leiomyosarcoma can exhibit a heterogeneous behavior irrespective of tumor location. Specifically, some patients have rapidly progressing disease despite aggressive chemotherapy, while others display a more indolent course even in the metastatic setting. The pathogenic drivers of the heterogeneity observed in tumor behavior are not well understood. As we learn more about the molecular composition of leiomyosarcoma, various classification groups have been proposed as discussed here. Ultimately, it is unlikely that one variable will be adequate for tumor classification, and a combination of location and molecular composition will be necessary to develop appropriate risk stratification nomograms and treatment strategies.

End-of-Life Care of Acute Myeloid Leukemia Compared with Aggressive lymphoma in Patients Who Are Eligible for Intensive Chemotherapy: An Observational Study in a Japanese Community Hospital.

Patients with hematological malignancies (HMs) are reported to receive more aggressive care at the end of life (EOL) than patients with solid tumors. However, the reasons behind this occurrence are not fully understood. To examine whether the care at EOL for HMs is mainly because of the disease characteristics or hematologists' attitudes and systems of care, we compared the EOL care of patients with acute myeloid leukemia (AML) and diffuse large B cell lymphoma (DLBCL). We retrospectively analyzed the EOL care of patients with AML and DLBCL younger than 80 years who were receiving combination chemotherapy at a city hospital in Japan. Fifty-nine patients with AML and 65 with DLBCL were included. Those with AML received chemotherapy more often within their last 30 days (48% vs. 19%, p < 0.001) and 14 days (37% vs. 1.5%, p < 0.001) of life, and consulted the palliative team less frequently (5.3% vs. 29%, p < 0.001). In the last 3 years, the mortality rate in hematological wards decreased from 74% to 29% in the DLBCL group, but only from 95% to 90% in the AML group. In multivariate analysis, AML (odds ratio [OR] 0.065) and death before 2018 (OR, 0.077) were significant factors associated with reduced referrals to specialized palliative teams. Patients with AML tend to have lesser access to specialized palliative care and fewer options for their place of death than those with DLBCL. Detailed EOL care plans are needed for these patients, considering the characteristics of the disease.

Patient Engagement With Early Stage Advance Care Planning at a Comprehensive Cancer Center.

Establishing care preferences and selecting a prepared medical decision-maker (MDM) are basic components of advance care planning (ACP) and integral to treatment planning. Systematic ACP in the cancer setting is uncommon. We evaluated a systematic social work (SW)-driven process for patient selection of a prepared MDM. We used a pre/post design, centered on SW counseling incorporated into standard-of-care practice. New patients with gynecologic malignancies were eligible if they had an available family caregiver or an established Medical Power of Attorney (MPOA). Questionnaires were completed at baseline and 3 months to ascertain MPOA document (MPOAD) completion status (primary objective) and evaluate factors associated with MPOAD completion (secondary objectives). Three hundred and sixty patient/caregiver dyads consented to participate. One hundred and sixteen (32%) had MPOADs at baseline. Twenty (8%) of the remaining 244 dyads completed MPOADs by 3 months. Two hundred and thirty-six patients completed the values and goals survey at both baseline and follow-up: at follow-up, care preferences were stable in 127 patients (54%), changed toward more aggressive care in 60 (25%), and toward the focus on the quality of life in 49 (21%). Correlation between the patient's values and goals and their caregiver's/MPOA's perception was very weak at baseline, improving to moderate at follow-up. Patients with MPOADs by study completion had statistically significant higher ACP Engagement scores than those without. A systematic SW-driven intervention did not engage new patients with gynecologic cancers to select and prepare MDMs. Change in care preferences was common, with caregivers' knowledge of patients' treatment preferences moderate at best.

Giant benign tumor of the sacrum - A case report

Introduction: A benign sacral tumor is a rare disease, especially with a giant tumor. We will present the clinical examination, imaging diagnosing images, and our experience in this case. Case presentation: We report a 25-year-old female with a massive sacral tumor, which had been developing for ten years. Clinical examination showed a 210 × 150 × 210mm mass originating from S2 into the sacrum with organ displacement. The biopsy confirmed that was a benign tumor. The surgery was performed with the anterior and posterior approach to remove the tumor and preserve sacroiliac joints. After 18 months, her recovery was smooth. However, she still presented irreversible damages to the bladder and rectal sphincter functions. Conclusion: En block resection of the giant benign sacral tumor with the anterior and posterior approaches is only administrated for a massive and complicated mass, which can only be performed in hospitals with advanced operating departments, anesthesiology, and aggressive supportive care.

Incidence of Aggressive End-of-Life Care Among Older Adults With Metastatic Cancer Living in Nursing Homes and Community Settings

Nearly 10% of the 1.5 million persons residing in nursing homes (NHs) have received or will receive a diagnosis of cancer. Although aggressive end-of-life (EOL) care is common among community-dwelling patients with cancer, little is known about such patterns of care among NH residents with cancer. To compare markers of aggressive EOL care between older adults with metastatic cancer who are NH residents and their community-dwelling counterparts. This cohort study used the Surveillance, Epidemiology, and End Results database linked with the Medicare database and the Minimum Data Set (including NH clinical assessment data) for deaths occurring from January 1, 2013, to December 31, 2017, among 146 329 older patients with metastatic breast, colorectal, lung, pancreas, or prostate cancer, with a lookback period in claims data through July 1, 2012. Statistical analysis was conducted between March 2021 and September 2022. Nursing home status. Markers of aggressive EOL care were cancer-directed treatment, intensive care unit admission, more than 1 emergency department visit or more than 1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death. The study population included 146 329 patients 66 years of age or older (mean [SD] age, 78.2 [7.3] years; 51.9% men). Aggressive EOL care was more common among NH residents than community-dwelling residents (63.6% vs 58.3%). Nursing home status was associated with 4% higher odds of receiving aggressive EOL care (adjusted odds ratio [aOR], 1.04 [95% CI, 1.02-1.07]), 6% higher odds of more than 1 hospital admission in the last 30 days of life (aOR, 1.06 [95% CI, 1.02-1.10]), and 61% higher odds of dying in the hospital (aOR, 1.61 [95% CI, 1.57-1.65]). Conversely, NH status was associated with lower odds of receiving cancer-directed treatment (aOR, 0.57 [95% CI, 0.55-0.58]), intensive care unit admission (aOR, 0.82 [95% CI, 0.79-0.84]), or enrollment in hospice in the last 3 days of life (aOR, 0.89 [95% CI, 0.86-0.92]). Despite increased emphasis to reduce aggressive EOL care in the past several decades, such care remains common among older persons with metastatic cancer and is slightly more prevalent among NH residents than their community-dwelling counterparts. Multilevel interventions to decrease aggressive EOL care should target the main factors associated with its prevalence, including hospital admissions in the last 30 days of life and in-hospital death.

Clinicians’ Perception of Spirituality in Oncology Care: A Qualitative Synthesis

Background: By rediscovering the medical field spiritual foundation, clinicians sought to balance their care and realize that spirituality is frequently associated with healthcare, thus one’s spiritual beliefs influence patients' decisions between aggressive care and complementary therapies in oncology care. Aim: This study investigates clinicians’ experiences and perceptions of spirituality in oncology care that clinicians can utilize to improve cancer and spiritual care provision. Methods: A thematic, qualitative synthesis. Results: Four main themes emerged from the synthesis of the 11 included studies that can steer future framework and policies to make clinicians more inept in providing care to address spiritual well-being of the patients and their family from a clinician's point of view of spirituality: “Maintaining Hope and Spiritual Wellness, Clinician’s Sensitivity to Cancer Patients, Provision of Culturally Respectful Spiritual Care, and Education in Providing Spiritual Care”. Conclusion: Cancer patients, cancer survivors, and clinicians’ quality of life is correlated with measures of spirituality and spiritual well-being. Spirituality also fulfill these oncologic patients has been linked to improved emotional and spiritual adjustment. Implications: Clinicians with different proficiencies, novice or expert, develop a strong spiritual belief can also be a strength when it comes to caring for those terminally ill patients, to be able to aid them in their sufferings. Amidst the challenges of spiritual care, these clinicians provide a patient strategy approach that is holistic to the care.

Experimental treatments in clinical trials for diabetic foot ulcers: wound healers in the pipeline

ABSTRACT Introduction Diabetes affects 400 million people globally and patients and causes nephropathy, neuropathy, and vascular disease. Amongst these complications, diabetic foot ulcers remain a substantial problem for patients and clinicians. Aggressive wound care and antibiotics remain important for the healing of these chronic wounds, but even when treated these chronic ulcers can lead to infection and amputations Areas covered This paper reviews the pathophysiology of diabetic foot ulcers and the current management strategies. Then, it discusses novel therapeutics such as topical oxygen therapy as well as autologous patches and macrophage creams. Expert opinion Diabetic foot ulcers are a substantial problem for patients and clinicians. Early identification, aggressive wound care, and normoglycemia remain the standard of care, however when these fail it is important to adapt. Since each patient and wound vary drastically we believe they should be treated as such. For patient with intact perfusion, topical ON101 and sucrose octasulfate creams can help. While patient with peripheral arterial disease should consider topical oxygen therapy as an adjunct. However, as scientists gain a better understanding of the pathophysiology behind DFUs, the hope is that this new wave of therapeutics will emerge.

Association between Consultation by a Comprehensive Integrated Palliative Care Program and Quality of End-of-Life Care in Patients with Advanced Cancer in Edmonton, Canada.

Literature assessing the impact of palliative care (PC) consultation on aggressive care at the end of life (EOL) within a comprehensive integrated PC program is limited. We retrospectively reviewed patients with advanced cancer who received oncological care at a Canadian tertiary center, died between April 2013 and March 2014, and had access to PC consultation in all healthcare settings. Administrative databases were linked, and medical records reviewed. Composite score for aggressive EOL care was calculated, assigning a point for each of the following: ≥2 emergency room visits, ≥2 hospitalizations, hospitalization >14 days, ICU admission, and chemotherapy administration in the last 30 days of life, and hospital death. Multivariable logistic regression was adjusted for age, sex, income, cancer type and PC consultation for ≥1 aggressive EOL care indicator. Of 1414 eligible patients, 1111 (78.6%) received PC consultation. In multivariable analysis, PC consultation was independently associated with lower odds of ≥1 aggressive EOL care indicator (OR 0.49, 95% CI 0.38−0.65, p < 0.001). PC consultation >3 versus ≤3 months before death had a greater effect on lower aggressive EOL care (mean composite score 0.59 versus 0.88, p < 0.001). We add evidence that PC consultation is associated with less aggressive care at the EOL for patients with advanced cancer.

Is aggressive care appropriate for patients with cancer complicated by pneumonia? A retrospective chart review in a tertiary hospital

BackgroundPneumonia in cancer patients is often problematic in order to decide whether to admit and administer antibiotics or pursue a comfort care pathway that may avoid in-hospital death. We aimed to identify factors which are easily assessed at admission in Thailand’s healthcare context that could serve as prognostic factors for in-hospital death.MethodsRegression analysis was utilized to identify the prognostic factors from clinical factors collected at admission. The primary outcome was in-hospital death. Data was collected from the electronic medical records of Chiang Mai University Hospital, Thailand, from 2016 to 2017. Data on adult cancer patients admitted due to pneumonia were reviewed.ResultsIn total, 245 patients were included, and 146 (59.6%) were male. The median age of the patients was 66 years (IQR: 57–75). A total of 72 (29.4%) patients died during admission. From multivariate logistic regression, prognostic factors for in-hospital death included: Palliative Performance Scale (PPS) ≤ 30 (OR: 8.47, 95% CI: 3.47–20.66), Palliative Performance Scale 40–50% (OR: 2.79, 95% CI: 1.34–5.81), percentage of lymphocytes ≤ 8.0% (OR: 2.10, 95% CI: 1.08–4.08), and pulse oximetry ≤ 90% (OR: 2.01, 95% CI: 1.04–3.87).ConclusionThe in-hospital death rate of cancer patients admitted with pneumonia was approximately 30%. The PPS of 10–30%, PPS of 40–50%, percentage of lymphocytes ≤ 8%, and oxygen saturation < 90% could serve as prognostic factors for in-hospital death. Further prospective studies are needed to investigate the usefulness of these factors.

The Association Between Mammography Screening Frequency and Breast Cancer Treatment and Outcomes: A Retrospective Cohort Study.

Guidelines for optimal frequency of screening mammography vary by professional society. Sparse evidence exists on the association between screening frequency and breast cancer treatment options. The main objective was to examine differences in cancer treatment rendered for U.S. women with different numbers of screenings prior to breast cancer diagnosis. Cancer stage at diagnosis and health care cost were assessed in secondary analyses. This IRB-exempt retrospective study used administrative claims data to identify women aged 44 or older with various numbers of mammographic screenings ≥11 months apart, during the four years prior to incident breast cancer diagnosis from January 2010 to December 2018. Outcomes were assessed over the six months following diagnosis. Generalized linear regression models were used to compare women with differing numbers of mammograms, adjusting for patient characteristics. Claims data review identified 25 492 women who met inclusion criteria. There was a stepwise improvement in each of these screening categories such that women with four screenings, compared to women with only one screening, experienced higher rates of lumpectomy (70% vs 55%) and radiation therapy (48% vs 36%), lower rates of mastectomy (27% vs 34%) and chemotherapy (28% vs 36%), less stage 3 or 4 cancer at diagnosis (15% vs 29%), and lower health care costs within six months postdiagnosis (P < 0.001). Results were similar in a subgroup limited to women aged 44 to 49 at diagnosis. Potential benefits of more frequent screening include less aggressive treatment and lower health care costs among women who develop breast cancer.

How to preserve the disnity of cancer patients ?

Results: The sample was composed of 10 patients, male (n=5) and female (n=5). All study participants used at least one hospital service. From the analysis of the discourse, four categories of meaning emerged, namely: less aggressive care, comfort offering, attention to care preferences, and effective communication. The congruence of the categories made possible the inclusion of four dignity domains: physical, emotional, moral and institucional, allowing the creation of the conceptual model contemplating the aspects of global dignity.

Abstract A031: High-intensity end-of-life care among young and middle-aged Hispanic adults with cancer living in Puerto Rico: A population-based study

Abstract Background: High-intensity care with undue suffering at the end of life (EoL) among cancer patients is associated with poor quality of life (QoL). Timely palliative and hospice care along with advance care planning can reduce the use of potentially avoidable aggressive care and enhance the QoL of cancer patients nearing death by providing pain and symptom management. We described the patterns of care at EoL and evaluated the predictors of intensive care among Hispanic cancer patients. Methods: We used data from the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database to examine patients aged 18 to 64 years diagnosed with cancer between 2010 and 2019, with a recorded date of death, who died of cancer between 2017 and 2019, and who were enrolled in Medicaid or private insurance 30 days before death (N=1,637). High-intensity EoL care indicators included the following services in the 30 days before death: ≥2 emergency room (ER) visits, &amp;gt;1 hospitalization, ≥1 intensive care unit (ICU) admission, and ≥1 life-extending procedure. A logistic regression model was used to examine factors associated with high-intensity EoL care. Results: More than half of the patients were 55 to 64 years old (58.7%), 52.9% were female, and 83.1% were enrolled in Medicaid. Most of the patients had solid tumors (91.0%) and 51.1% survived ≤12 months after diagnosis. More than half of the patients had at least one ER visit (54.2%) and nearly three-fourths had at least one hospitalization (73.7%). In addition, 28.2% of patients had ≥2 ER visits, 25.8% had &amp;gt;1 hospitalization, 11.3% were in the ICU, and 13.7% received life-extending procedures. A compound indicator of high-intensity care at EoL showed that 53.0% of patients had at least one of the selected high-intensity indicators, whereas a compound indicator of recommended care at EoL showed that only 29.6% of patients had at least one of the selected recommended care indicators, which included hospice and palliative care and advance care planning. Patients without recommended care at EoL were more likely to receive high-intensity EoL care than patients with recommended care at EoL (adjusted odds ratio 2.53; 95% confidence interval 2.02 – 3.16). High-intensity EoL care was more likely in patients with hematologic cancers than those with solid tumors (P=0.009), patients who survived ≤12 months after diagnosis compared to those who survived &amp;gt;12 months (P&amp;lt;0.001), and patients 18 to 44 years old compared to those 55 to 64 years old (P=0.023). Conclusion: These findings suggest that a higher proportion of Hispanic cancer patients living in Puerto Rico have unmet palliative care needs and potentially lower QoL at EoL. Recommended care can provide prompt pain and symptom management, reduce emotional distress, ensure medical care consistent with individual preferences, and reduce the cost of medical care by eliminating treatments and procedures that may have no or low benefit. Future research evaluating strategies to improve the use of hospice, palliative consultation, and advance care planning is needed. Citation Format: Jessica Velazquez, Barbara Cassese, Guillermo Tortolero-Luna, María R. Ramos-Fernández, Maira A. Castañeda-Avila, Karen J. Ortiz-Ortiz. High-intensity end-of-life care among young and middle-aged Hispanic adults with cancer living in Puerto Rico: A population-based study [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A031.