Community Care Program Research Articles

Utilization of Palliative Care in Diffuse Large B Cell Lymphoma Patients Is Linked to Insurance Type and Household Income

Background There is increasing evidence supporting the use of palliative care in the management of both solid and hematologic malignancies. As an integral part of oncologic care, palliative care has been reported to improve survival in diverse malignancies. Our study aimed to describe trends in the utilization of palliative care in diffuse large B cell lymphoma (DLBCL) patients. Methods Patient-level data of patients with DLBCL reported between 2004 to 2019 was extracted from the National Cancer Data Base (NCDB). After excluding 1173 patients with unknown palliative care status, we included 264,549 patients in our analyses. Chi-square tests were used to assess the characteristics of palliative care recipients and non-recipients. Multivariate logistic regression was used to identify the variables which influenced the likelihood of receiving palliative care. Age (<45, 45-59,60-74, 75+), sex (male and female), race (Hispanics, Whites, Blacks, Asian), Charlson-Deyo comorbidity score, insurance status (uninsured, private insurance, Medicare, Medicaid, other government), median household income (<$40227, $40227-$50353, $50,354-$63332, >$63333), educational status (as specified by the database), facility type (community, academic, comprehensive and integrated cancer centers), and year of diagnosis (2004-2007, 2008-2011, 2012-2015, 2016-2019) were variables included in our study. Statistical analyses were performed using SPSS. Results Of 264,549 DLBCL patients, 3.2% (n=8460) utilized palliative care. The utilization of palliative care increased significantly from 2004-2007 to 2016-2019 (2.6% vs 3.71%, p < 0.001). A greater proportion of patients older than 75 years old received palliative care than those younger than 45 years old (5.09% vs 1.66% p<0.001). Patients of Hispanic origin were less likely to receive palliative care compared to Whites (OR 0.74, 95% CI 0.65-0.83). No statistically significant difference in palliative care utilization was found between Whites and other non-Hispanic groups. Privately insured patients had the lowest palliative care utilization amongst all insurance groups and these patients were less likely to receive palliative care compared to uninsured patients (OR 0.70, 95% CI 0.59-0.83). The odds of receiving palliative care were higher at integrated cancer centers than at community care programs (OR 1.17, 95% CI 1.05-1.32). DLBCL patients from households with a median income of >$63,333 were less likely to receive palliative care than those from low-income (<$40,227) households (OR 0.77, 95% CI 0.70-0.85). Conclusions We made several observations in this most up-to-date and largest study on the utilization of palliative care in DLBCL patients. While there is a rise in the use of palliative care in DLBCL in recent years, the overall use of palliative care in these patients remains low. There was a higher utilization of palliative care in patients treated in integrated cancer centers. However, we found an unexpectedly low utilization of palliative care among privately insured patients and in those with higher incomes. A plausible explanation for this finding might be that palliative care measures are not covered by private insurance. It is also possible that affluential patients, and/or those with private insurance, are more likely to pursue novel treatments. Alternatively, these patients might be more likely to be offered further chemotherapy by their oncologists rather than palliative care. These postulates should be further studied and could serve as a guide for health care policy. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Community experiences and aspirations of young Syrian newcomers in a neighborhood in Amsterdam, the Netherlands

ABSTRACT In the Netherlands, several housing projects have housed local young adults and refugees together, attracting media and academic attention. Along with praise for complementing the integration process of newcomers, criticism has also been leveled that such projects are often located far from residential areas. Meanwhile, the SET project located in a residential area in Amsterdam attempt to extend the active participation of locals in facilitating the integration of newcomers. This qualitative study investigated the community experiences of Syrian newcomers, the elements which stimulate or hinder newcomers’ participation in community activities and care programs in their everyday lives.

How Did Veterans' Reliance on Veterans Health Administration Outpatient Care Change After Expansion of the Veterans Community Care Program?

The Veterans Community Care Program (VCCP) aims to address access constraints in the Veterans Health Administration (VA) by reimbursing care from non-VA community providers. Little existing research explores how veterans' choice of VA versus VCCP providers has evolved as a significant VCCP expansion in 2014 as part of the Veterans Access, Choice, and Accountability Act. We examined changes in reliance on VA for primary care (PC), mental health (MH), and specialty care (SC) among VCCP-eligible veterans. We linked VA administrative data with VCCP claims to retrospectively examine utilization during calendar years 2016-2018. 1.78 million veterans enrolled in VA before 2013 and VCCP-eligible in 2016 due to limited VA capacity or travel hardship. We measured reliance as the proportion of total annual outpatient (VA+VCCP) visits occurring in VA for PC, MH, and SC. Of the 26.1 million total outpatient visits identified, 45.6% were for MH, 29.9% for PC, and 24.4% for SC. Over the 3 years, 83.2% of veterans used any VA services, 23.8% used any VCCP services, and 20.0% were dual VA-VCCP users. Modest but statistically significant declines in reliance were observed from 2016-2018 for PC (94.5%-92.2%), and MH (97.8%-96.9%), and a more significant decline was observed for SC (88.5%-79.8%). Veterans who have the option of selecting between VA or VCCP providers continued using VA for most of their outpatient care in the initial years after the 2014 VCCP expansion.

Use and Cost of Low-Value Health Services Delivered or Paid for by the Veterans Health Administration

Within the Veterans Health Administration (VA), the use and cost of low-value services delivered by VA facilities or increasingly by VA Community Care (VACC) programs have not been comprehensively quantified. To quantify veterans' overall use and cost of low-value services, including VA-delivered care and VA-purchased community care. This cross-sectional study assessed a national population of VA-enrolled veterans. Data on enrollment, sociodemographic characteristics, comorbidities, and health care services delivered by VA facilities or paid for by the VA through VACC programs were compiled for fiscal year 2018 from the VA Corporate Data Warehouse. Data analysis was conducted from April 2020 to January 2022. VA administrative data were applied using an established low-value service metric to quantify the use of 29 potentially low-value tests and procedures delivered in VA facilities and by VACC programs across 6 domains: cancer screening, diagnostic and preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and other procedures. Sensitive and specific criteria were used to determine the low-value service counts per 100 veterans overall, by domain, and by individual service; count and percentage of each low-value service delivered by each setting; and estimated cost of each service. Among 5.2 million enrolled veterans, the mean (SD) age was 62.5 (16.0) years, 91.7% were male, 68.0% were non-Hispanic White, and 32.3% received any service through VACC. By specific criteria, 19.6 low-value services per 100 veterans were delivered in VA facilities or by VACC programs, involving 13.6% of veterans at a total cost of $205.8 million. Overall, the most frequently delivered low-value service was prostate-specific antigen testing for men aged 75 years or older (5.9 per 100 veterans); this was also the service with the greatest proportion delivered by VA facilities (98.9%). The costliest low-value services were spinal injections for low back pain ($43.9 million; 21.4% of low-value care spending) and percutaneous coronary intervention for stable coronary disease ($36.8 million; 17.9% of spending). This cross-sectional study found that among veterans enrolled in the VA, more than 1 in 10 have received a low-value service from VA facilities or VACC programs, with approximately $200 million in associated costs. Such information on the use and costs of low-value services are essential to guide the VA's efforts to reduce delivery and spending on such care.

THIRD-YEAR HEALTH PROFESSIONS STUDENTS’ INTERPROFESSIONAL EDUCATION IN THE COMMUNITY SETTING: WHAT DID THEY EXPERIENCE?

Background: Learning by experiencing a real situation is believed to be more powerful than using simulation. This hypothesis is also applied to interprofessional learning for students in health professions education. Learning to collaborate and practice students' knowledge of health care in a community became the purpose of the community and family health care (CFHC) program in the Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada.Aim: To describe the third-year students’ experiences of learning interprofessional collaboration in a community setting based on their activity report.Case Discussion: The CFHC team created a particular design for third-year students, focused on community health problems rather than family health problems. The groups conducted focus group discussions to explore health issues and to decide together with the community the main problem that would be given intervention. The groups documented the entire process through a written report, video, and an article about their intervention outcome.Conclusion: The reports showed that students were able to demonstrate interprofessional practice in solving health problems in the community. They learned to work as an interprofessional team while experiencing it. Thus, conducting community-based IPE for undergraduate students is necessary to develop interprofessional collaboration competencies.

An approach to identify people with mental illness that can be expected to benefit from integrated community care in Germany

IntroductionAlthough integrated community care programs specifically tailored to patients with severe mental illness (SMI) are available, recent studies show that these programs are not always provided to the population which would benefit the most from it.ObjectivesAims of this study were the selection of clinical and psychosocial characteristics and the development of a screening algorithm indicating the need for integrated community care services in people with mental disorders.MethodsData of an observational longitudinal study including N=511 participants has been used to examine the hypothesized determinants. At baseline, self-reported empowerment has been assessed via the EPAS and psychosocial impairment and perceived needs have been rated by research workers via the HoNOS and the CAN, respectively. Use of integrated community care services was defined as at least four appointments with service providers over six months and has been recorded via the CSSRI twelve to 18 months after baseline. Mixed-effects regression analyses have been performed to test the predictive value of the hypothesized determinants and marginal predictions were used to define cut-offs for the assessment tool.ResultsEPAS, HoNOS and CAN scores each proved to be significant predictors for using integrated community care services. Cut-off scores for each predictor are presented, forming practical assessment guidelines for future studies.ConclusionsA screening tool and an algorithm for the identification of mentally ill patients who can be expected to benefit from integrated community mental health care programs is available for the German health care system.DisclosureNo significant relationships.

A comparison of patient-reported mental health outcomes for the Department of Veterans Affairs' regional telehealth and Community Care Programs.

ObjectivesTo compare patient‐reported outcomes for veterans with limited access to Department of Veterans Affairs (VA) mental health services referred to the Veterans Community Care Program (VCCP) or regional telehealth Clinical Resource Hubs‐Mental Health (CRH‐MH).Data SourcesThis national evaluation used secondary data from the VA Corporate Data Warehouse, chart review, and primary data collected by baseline survey between October 8, 2019 and May 27, 2020 and a 4‐month follow‐up survey.Study DesignA quasi‐experimental longitudinal study design was used to sample 545 veterans with VCCP or CRH‐MH referrals for new treatment episodes. Patient‐reported outcomes included symptom severity, perceived access, utilization, and patient‐centeredness.Data CollectionDuring the baseline and follow‐up surveys, all veterans were administered the Patient Health Questionnaire‐8 (PHQ‐8) to assess depression severity, and veterans with a provisional diagnosis of posttraumatic stress disorder (PTSD) were also administered the PTSD Checklist for DSM‐5 (PCL‐5) to assess PTSD symptom severity. The 4‐month follow‐up survey also asked about perceived access using the Perceived Access Inventory, the number of encounters, and patient‐centeredness of care using the Patient‐Centered Care portion of the Veterans Satisfaction Survey.Principal FindingsResults indicated that compared to VCCP consults, veterans with CRH‐MH consults reported 0.65 (CI95 = 0.51–0.83, p < 0.01) times the number of barriers to care, but a non‐significant lower number of encounters (−0.792, CI95 −2.221, 0.636, p = 0.28). There was no significant (p = 0.24) difference in satisfaction with patient‐centeredness, with both groups “agreeing” on average to positively worded questions. Veterans in both groups experienced little improvement in depression or PTSD symptom severity, and there were no clinically meaningful differences between groups.ConclusionsOverall findings indicate that the CRH‐MH and VCCP generate similar patient‐reported outcomes. Future research should compare the quality and cost of care delivered by the VCCP and CRH‐MH programs.

Implementation of a pharmacist-led transitional pharmaceutical care programme: Process evaluation of Medication Actions to Reduce hospital admissions through a collaboration between Community and Hospital pharmacists (MARCH).

What is known and objectiveThe recently conducted Medication Actions to Reduce hospital admissions through a collaboration between Community and Hospital pharmacists (MARCH) transitional care programme, which aimed to test the effectiveness of a transitional care programme on the occurrence of ADEs post‐discharge, did not show a significant effect. To clarify whether this non‐significant effect was due to poor implementation or due to ineffectiveness of the intervention as such, a process evaluation was conducted. The aim of the study was to gain more insight into the implementation fidelity of MARCH.MethodsA mixed methods design and the modified Conceptual Framework for Implementation Fidelity was used. For evaluation, the implementation fidelity and moderating factors of four key MARCH intervention components (teach‐back, the pharmaceutical discharge letter, the post‐discharge home‐visit and the transitional medication review) were assessed. Quantitative data were collected during and after the intervention. Qualitative data were collected using semi‐structured interviews with MARCH healthcare professionals (community pharmacists, clinical pharmacists, pharmacy assistants and pharmaceutical consultants) and analysed using thematic analysis.Results and DiscussionNot all key intervention components were implemented as intended. Teach‐back was not always performed. Moreover, 63% of the pharmaceutical discharge letters, 35% of the post‐discharge home‐visits and 44% of the transitional medication reviews were not conducted within their planned time frames. Training sessions, structured manuals and protocols with detailed descriptions facilitated implementation. Intervention complexity, time constraints and the multidisciplinary coordination were identified as barriers for the implementation.What is new and ConclusionOverall, the implementation fidelity was considered to be moderate. Not all key intervention components were carried out as planned. Therefore, the non‐significant results of the MARCH programme on ADEs may at least partly be explained by poor implementation of the programme. To successfully implement transitional care programmes, healthcare professionals require full integration of these programmes in the standard work‐flow including IT improvements as well as compensation for the time investment.

Literature Review on the Establishment of a Community Care System: For some Vulnerable Groups in Busan

Objectives: This study presented a community care model for the vulnerable(elderly people with dementia, mobility difficulties, and severe diseases). Methods: Comparison with existing community care programs operated at home and abroad and literature review were used. Results: It is necessary to establish a community care model that complements manpower shortage and effectiveness. Conclusions: For the successful operation of community care, support for community-based integrated care services must be carried out as a project according to the strategic stage that must be promoted after active interest from local governments and related human infrastructure. In addition, the interest of local governments is the most important for the promotion of community care programs, and specific consultations should be prioritized on what is needed for project promotion.

Health Care for Our Nation's Veterans: A Policy Paper From the American College of Physicians.

The Veterans Health Administration (VHA) is the United States' largest integrated health care delivery system, serving over 9 million enrollees at nearly 1300 health care facilities. In addition to providing health care to the nation's military veterans, the VHA has a research and development program, trains thousands of medical residents and other health care professionals, and conducts emergency preparedness and response activities. The VHA has been celebrated for delivering high-quality care to veterans, early adoption of electronic medical records, and high patient satisfaction. However, the system faces challenges, including implementation of an expanded community care program, modernization of its electronic medical records system, and providing care to a population with complex needs. The position paper offers policy recommendations on VHA funding, the community care program, medical and health care professions training, and research and development.

Effects of Community-Care Program on Activities of Daily Living, Fall Efficacy, and Depression of Elderly Community-Dwelling People

Effects of Community-Care Program on Activities of Daily Living, Fall Efficacy, and Depression of Elderly Community-Dwelling People

Effectiveness Of A Physician Referred Exercise Is Medicine Program With At-risk Community Members

Lack of adequate daily physical activity contributes to the burden of chronic disease on our health system and reduces quality of life. A clinic to community care program focusing on exercise, nutrition education and behavior change coaching may aid in the prevention and management of chronic disease. PURPOSE: To investigate the outcomes of a physician referred exercise, nutrition and behavior change intervention in preventing and managing chronic disease. METHODS: Eleven subjects (3 males, 8 females, age 56 ± 6.5) volunteered for the 12 week program. To be included subjects did not meet ACSM guidelines for physical activity and presented with symptoms of hypertension, hyperlipidemia, obesity, and type 2 diabetes. All subjects completed a fitness assessment, received 6 virtual lifestyle coaching sessions, personalized exercise prescriptions and 3 virtual training sessions. Participants completed weekly logs tracking exercise minutes, mood, resting heart rate, blood pressure and weight. Body composition was estimated using an InBody analysis at weeks 1 and 12. Self-efficacy surveys (SES) were administered at weeks 1 and 12. The Psychological General Well-being Index (PGWBI) was administered at weeks 1, 6 and 12. A paired samples t-test was used to analyze the pre and post program data for BMI, exercise minutes, percent body fat, mood, PGWBI and SES. Resting heart rate and blood pressure were not analyzed due to a lack of reporting by the subjects. RESULTS: BMI significantly decreased (36.8 ± 10.5 vs 36.5 ± 10.6, p < .05), exercise minutes significantly increased (46 ± 56 vs 232 ± 88, p < .05) and mood significantly increased (3.2 ± 0.76 vs 4.2 ± .64, p < .05) after 12 weeks. No differences were found for percent body fat, scores on the PGWBI and SES surveys (p > .05). CONCLUSION: This pilot program had positive outcomes for a small first cohort. Increases in physical activity level over 12 weeks is promising since this program was adapted to a virtual format due to the pandemic. Although not significant, an upward trend in scores was seen on the PGWBI and SES surveys, more subjects are needed to detect significant differences. With continued program recruitment, more data will be analyzed to determine the effectiveness of a clinic to community care program for the prevention and management of chronic disease.

Interprofessional collaboration in home-based community care programs: A leadership imperative

Community Paramedic (CP) services are relatively new in home-based community care, and as these programs expand, there are additional opportunities for leadership in interprofessional and cross-sectoral collaboration. Understanding the unique contributions of each health care provider can ensure that a patient-centered approach remains forefront. This qualitative study included 33 participants representing nurses, physicians and CPs involved in home-based community care. Interviews explored attitudes, barriers and enablers to collaboration, role optimization and integration of paramedics into home-based community care and were analyzed with interpretive descriptive methods. Participants recognized the benefits of CP services and positive attitudes motivated them to engage in collaboration to support patient-centered care. Participants stated they require support and leadership to strengthen interprofessional collaboration and care coordination. Strategies such as the removal of silos, forging new networks of collaboration, interprofessional education, and changes in professional regulation for paramedics can support new roles and opportunities for nurses, paramedics and physicians in home-based community care.

Interorganizational Care Coordination of Rural Veterans by Veterans Affairs and Community Care Programs: A Systematic Review.

In the unique context of rural Veterans' health care needs, expansion of US Department of Veterans Affairs and Community Care programs under the MISSION Act, and the uncertainties of coronavirus disease 2019 (COVID-19), it is critical to understand what may support effective interorganizational care coordination for increased access to high-quality care. We conducted a systematic review to examine the interorganizational care coordination initiatives that Veterans Affairs (VA) and community partners have pursued in caring for rural Veterans, including challenges and opportunities, organizational domains shaping care coordination, and among these, initiatives that improve or impede health care outcomes. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search 2 electronic databases (PubMed and Embase) for peer-reviewed articles published between January 2009 and May 2020. Building on prior research, we conducted a systematic review. Sixteen articles met our criteria. Each captured a unique health care focus while examining common challenges. Four organizational domains emerged: policy and administration, culture, mechanisms, and relational practices. Exemplars highlight how initiatives improve or impede rural health care delivery. This is the first systematic review, to our knowledge, examining interorganizational care coordination of rural Veterans by VA and Community Care programs. Results provide exemplars of interorganizational care coordination domains and program effectiveness. It suggests that partners' efforts to align their coordination domains can improve health care, with rurality serving as a critical contextual factor. Findings are important for policies, practices, and research of VA and Community Care partners committed to improving access and health care for rural Veterans.

Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care.

Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care.

Factors facilitating positive outcomes in community-based end-of-life care: A cross-sectional qualitative study of patients and family caregivers

Background: Delivery of community-based end-of-life care for patients and family members has been recognized as an important public health care approach. Despite differences in different healthcare settings and the significance of a person-centered approach, little research has investigated facilitators of community-based end-of-life care from the perspective of service recipients. In particular, there has been limited exploration of strategies to ensure positive outcomes at an operational level. Aim: To explore factors facilitating positive end-of-life care provision in community-based settings and how these are achieved in practice, from the perspectives of patients and family caregivers. Design: A qualitative cross-sectional descriptive study was undertaken through semi-structured interviews with patients and family caregivers subjected to thematic analysis. Setting/participants: Ten patients and 16 family caregivers were recruited from an end-of-life community care program provided by four non-governmental organizations in Hong Kong. Results: Seven core themes were identified: positive emotions about the relationship, positive appraisals of the relationship, care through inquiring about recipients’ circumstances, instrumentality of care (i.e. information, coaching on care, practical help, psychological support, multiple activities), comprehensiveness of care (i.e. diversity, post-death care, family-level wellbeing), structure of care (i.e. timely follow-up, well-developed system), and qualities of workers. Conclusions: Improvement in service quality might be achieved through alternating the perceptions or emotional reactions of care recipients toward care providers and increased use of sensitive inquiry. Comprehensive care and positive outcomes might be facilitated by addressing the dualities of care by providing diverse choices in pre-death and post-death care.

Dietary interventions with dietitian involvement in adults with chronic kidney disease: A systematic review

A comprehensive evidence base is needed to support recommendations for the dietetic management of adults with chronic kidney disease (CKD). The present study aimed to determine the effect of dietary interventions with dietitian involvement on nutritional status, well-being, kidney risk factors and clinical outcomes in adults with CKD. Cochrane Central Register of Controlled Trials, CINAHL, MEDLINE, PsycINFO and EMBASE.com were searched from January 2000 to November 2019. Intentional weight loss and single nutrient studies were excluded. Risk of bias was assessed using the Cochrane risk-of-bias tool. Effectiveness was summarised using the mean difference between groups for each outcome per study. Twelve controlled trials (1906 participants) were included. High fruit and vegetable intake, as well as a multidisciplinary hospital and community care programme, slowed the decline in glomerular filtration rate in adults with stage 3-4 CKD. Interventions addressing nutrition-related barriers increased protein and energy intake in haemodialysis patients. A Mediterranean diet and a diet with high n-3 polyunsaturated fatty acids improved the lipid profile in kidney transplant recipients. A limited number of studies suggest benefits as a result of dietary interventions that are delivered by dietitians and focus on diet quality. We did not identify any studies that focussed on our primary outcome of nutritional status or studies that examined the timing or frequency of the nutritional assessment. This review emphasises the need for a wider body of high-quality evidence to support recommendations on what and how dietetic interventions are delivered by dietitians for adults with CKD.

Implementing Advance Care Planning in 'The Age of Deferred Death'- the Hong Kong Experience over 4 Years.

ObjectivesTo plan, implement and evaluate a series of initiatives to improve patient centred quality of end of life care through raising public awareness, promoting the concept that all health and social care professionals should be engaged in this practice, and carrying out pilot of community care models.DesignPilot studies of community models of care, training programs for health and social care professionals, public education programmes.SettingSelected hospitals, residential care homes for the elderly, and community centres in Hong Kong.ParticipantsPatients and their families at the end of life stage.MeasurementsCombination of quantitative and qualitative studies according to different components of the initiative.ResultsEffective training for professional staff occurred using training videos, role play, rather than lectures, and when concepts are integrated into daily practice and quality assurance programmes. Members of the public welcomed end of life care discussions and the implementation of advance care planning. The pilot community care program was found to reduce anxiety, depression, physical symptoms, improve communication within the family as well as promoting a feeling of peace among recipients of the service. It also reduced care giver strain and anxiety, as well as hospital visits and duration of stay. Similar findings were also observed among recipients of care in the residential care setting.ConclusionA sustainable model would require uptake by policy makers and chief executives of Social Welfare and Health Bureaus, supported by amendments of relevant legal ordinances, which is in progress after public consultation.

Access to care: a qualitative study exploring the primary care needs and experiences of older people needing assistance with daily living.

Older people who live in the community and need assistance with daily activities are a unique group of patients to treat in the primary care (PC) setting. This study aimed to understand access-related PC needs and experiences of community-living people over 65 years of age receiving home-based assistance through the Home and Community Care (HACC) program in Melbourne, Australia. This descriptive qualitative study used thematic analysis of in-depth interviews with HACC program clients and assessment officers. Access-related needs and experiences were examined using the patient-centred access to care framework. Client (n=11) and assessment officer (n=4) interviews showed that community-living older people receiving home-based assistance from social services are able to find a GP according to their preferences; however, some challenges in access to comprehensive care exist. These challenges relate to regularity of PC attendance, out-of-pocket fees for specialist care and maintaining an enduring patient-GP relationship. GPs can play an important role in improving PC access for vulnerable older people. In particular, GPs can contribute to improving PC attendance and facilitating more affordable access to specialist care by improving systems to recall patients more regularly and developing explicit systems for linking vulnerable patients to affordable specialist services.

Palliative Radiotherapy within the Veterans Health Administration: Barriers to Referral and Timeliness of Treatment

As is the case in the community, most Veterans Health Administration (VHA) hospitals do not have radiation oncology departments on-site and must refer patients requiring palliative radiotherapy (RT) to outside centers. The purpose of this study is to evaluate referral patterns for palliative RT within VHA and to determine how on-site RT impacts referral patterns and timeliness of care. An electronic survey was sent to medical directors at 149 VHA centers. Surveys were filled out by physicians who make referrals for palliative RT at their respective centers– primary care, palliative care, or medical oncology. Questions focused on the frequency of referral for palliative RT, timeliness of RT consults/treatment, and barriers to referral for palliative RT. Chi square analysis was used to determine how responses differed between centers that have on-site RT and centers that refer to outside centers. The survey response rate was 72%. Of 108 responding centers, 33 (31%) have on-site RT and 87 (81%) have on-site medical oncology. At centers without on-site RT, patients are sometimes referred to other VHA centers (20%), but mostly referred to non-VHA centers via contract or the community care program. 95% view palliative RT as an integral treatment for cancer related pain. Chi square analysis revealed that RT consult within one week is more likely at centers with on-site RT (68% vs 31%, p = 0.01). Centers with on-site RT are more likely to deliver RT for spinal cord compression within 24 hours (94% vs 70%, p = 0.01). Centers with on-site RT more frequently consult radiation oncology for tumor related bleeding (p = 0.02) and are more likely to be influenced by radiation oncology presence at tumor board (67% vs 44%, p = 0.001). Those without on-site RT are more likely to want increased involvement by a radiation oncologist for management of metastatic disease (26% vs 64%, p<0.001). Reported barriers to referral for palliative RT include patient ability to travel (81%), patient noncompliance (31%), delays in consult/treatment (31%), difficulty contacting a radiation oncologist (14%), and concern regarding number of treatments (13%). Only 6% of centers with on-site RT report delays in consult/treatment as a barrier, compared to 41% of centers that do not have on-site RT (p<0.0001). All 15 respondents reporting difficulty contacting a radiation oncologist as a barrier do not have on-site RT (See Table 1). The vast majority of respondents consider palliative RT an integral treatment for cancer-related pain. Centers with on-site RT report improved communication with radiation oncologists, as well as more timely consultation and treatment. Methods to improve timeliness of palliative RT for patients at centers without on-site RT should be considered.Abstract 2366: Table 1Differing barriers to referral based on presence of on-site radiation oncologyOn-Site RTNo On-Site RTp-valueDelay in consult/treatment6%41%<0.0001Difficulty contacting a radiation oncologist0%20%0.006 Open table in a new tab