Concurrent Care Research Articles

Early integration of palliative care in haemato-oncology: latest developments.

This review aimed to explore recent progress made in the past five years towards early access to, and integration of palliative care services within the haemato-oncology context to address the unique needs of patients with Haematological malignancies (HMs). We included 14 articles in our review. We identified three themes, namely (i) disparities in the timing of referrals remain, (ii) specialist palliative care and impact on quality of life and (iii) perceptions on early integration. Patients with HM, receive less palliative care services, regardless of their higher symptom burden compared to patients with solid tumours. Structured approaches and models of early integration have shown substantial benefits, including improved pain and symptom management, shorter hospital stays and better end of life planning. Perceptions on existing barriers include the curative treatment focus, haematologists' personal perceptions on timing of palliative care and lack of palliative care training. For early integration to happen, it is crucial to address training gaps, improve communication skills, and foster interdisciplinary collaboration. Standardised organisational pathways can facilitate early and concurrent palliative care integration. System-level flexibility and supportive policies are essential to ensure that patients with HM receive comprehensive and high-quality care.

Functional Outcome of Intertrochanteric Fractures of the Femur Treated With Standard Surgical Modalities.

Among the most prevalent injuries among the elderly with trivial trauma are trochanteric fractures. Osteoporosis and female sex are additional risk factors. The patient's age, the fracture, their overall health, the amount of time between the fracture and treatment, the effectiveness of the treatment, any concurrent medical care, and the stability of the fixation all affect how well the patient responds to treatment. For its fixation, various implants are used. The main aim of this study is to assess the functional outcome in intertrochanteric fractures using the Harris Hip Scoring in intertrochanteric fractures. Patients presenting with intertrochanteric femur fracture were evaluated. Written consent was taken from the patient. Radiographic data were collected. Complications and varus collapse evaluated. Functional outcome was assessed with the Harris Hip Scoring system. The proportion of excellent Harris Hip Evaluation (HHE) scores was the highest in proximal femur nail(PFNA2) at six months follow-up examination, which was 11 (57.19%) more than any method. In the incidence of varus deformity, the proportion was maximum in the case of the dynamic hip screw (DHS) with three patients (33.33%), followed by PFN in 11 patients (28.95%), and the least for PFNA2 in three patients (15.79%). The mean operative time was lower in the PFN A2 group, and the HHE score values were higher than those of PFN and DHS. This study concludes that these implants have a comparable radiological and functional outcome for unstable intertrochanteric fracture except for less surgical time and blood loss in PFN A2.

Safe and supportive prescribing in transgender and non-binary patients with cancer.

Global prevalence rates for transgender individuals vary with estimates ranging from 0.3% to 1%, translating to a potential global population of 24.3 million to 81 million. It is estimated that one in two people will develop cancer in their lifetime. Gender-affirming hormone therapy (GAHT) is a common medical intervention for transgender and non-binary individuals. GAHT requires careful consideration for concurrent medical care due to potential drug interactions and physiological changes. A multi-disciplinary team with expertise in transgender health, oncology and pharmacy met to develop a document summarizing current knowledge on the topic for practical use. The team included trans and non-binary authors who shaped the document's language and focus. The document gives a status update on the current understanding of GAHT and how this may intersect with the safe prescribing of systemic anti-cancer therapies (SACT). The document underwent multiple review stages including internal review, review by the British Oncology Pharmacy Association (BOPA) EDI Subcommittee and, finally, BOPA Executive Committee review and final approval. Key recommendations of this document include the use of inclusive and effective communication, vigilant monitoring of kidney function and cardiovascular health, and considerations for hormone receptor-positive cancers. The document also recognizes the multidisciplinary nature of transgender healthcare and where this relates to social prescribing.

Concurrent Care and Use of Advanced Cardiac Therapies for Hospitalized Veterans With Heart Failure

ContextConcurrent care allows patients to receive hospice while continuing disease-directed therapies. This treatment model is available in the Veterans Administration (VA) medical system, but its use in Veterans with heart failure (HF) is unexplored. ObjectiveTo compare use of advanced HF therapies 30 days posthospitalization in Veterans on hospice versus not on hospice following admission for HF exacerbation. MethodsWe evaluated Veterans admitted for HF exacerbation to VA hospitals between Jan 2011 and June 2019 who received advanced HF therapies, hospice services, or both postdischarge. Concurrent care was defined as receiving both hospice services and advanced HF therapies. Demographics, comorbidities, and prior healthcare utilization were compared. Secondary outcomes included burdensome transitions and mortality. ResultsAmong 317,967 HF Veterans, 18,350 (5.8%) chose hospice posthospitalization. Only 58 hospice-enrolled Veterans (0.3%) received advanced HF therapies (i.e. concurrent care) within 30 days postdischarge. Of 299,617 Veterans not on hospice, 6,083 (2.0%) received advanced HF therapies (0.3% vs. 2.0%; P < 0.001). Veterans receiving concurrent care had higher six-month mortality than those receiving advanced HF therapies alone (77.6% vs. 14.9%, SMD 1.61). Hazard of burdensome transitions was similar (adjusted HR 1.44, 95% CI 0.95–2.17). ConclusionVeterans with HF receiving concurrent care were few and experienced higher mortality. Rate of burdensome transitions was similar between Veterans receiving concurrent care and those not on hospice. Further research may explore why Veterans infrequently utilize concurrent care at the end of life.

Comparison of concurrent care and traditional hospice at a regional VA.

e24065 Background: While hospice care offers many patients services promoting comfort and quality of life, the traditional hospice model described in Medicare policy presents numerous barriers to utilization. Notably, since hospice pays for all therapies related to a terminal illness, patients are often forced to make a difficult choice to stop disease-directed therapies in order to enroll in hospice. Poor provider understanding of hospice also contributes to the common scenario in which hospice is offered too late to make a meaningful impact for patients and their families. These issues were prominent in the VA population in 2006, when only 5% of eligible Veterans received hospice services. Consequently, the VA Comprehensive End-of-Life Care Initiative in 2009 created the concurrent care hospice model in where Veterans no longer had to stop all disease-directed therapies to enroll. Initial national VA data in lung cancer suggested that concurrent care may be better than traditional hospice by decreasing aggressive treatments, ICU hospitalizations, and medical costs. Our regional VA developed a Hospice Flag system that tagged patients in the electronic medical record who had either a concurrent or traditional hospice enrollment to better inform health care providers. This project investigates how the concurrent care hospice model may help achieve an important Veteran-centered outcome, which is to die in the home setting and improve access to hospice care. Methods: We retrospectively reviewed all Veterans with a hospice flag from October 2017 to July 2021 and cancer as the primary hospice diagnosis. Our primary aim was to establish correlation between hospice type and Veterans’ ultimate location of death with the percentage at home versus institution (e.g. care center, hospital, or hospice house). A secondary measure was median length-of-stay (LOS) in hospice. Results: 317 total Veterans were enrolled in concurrent care hospice (96) and traditional hospice (221) from Oct 2017 to July 2021. 72% of Veterans in concurrent care (69/96) died at home compared to only 57% in traditional hospice (125/221) with the remainder dying in an institution; this result was statistically significant by Chi-square analysis (p = 0.01). Median LOS in hospice was 62 days for concurrent care and 26 days for traditional hospice. Conclusions: This project demonstrates that concurrent care hospice is significantly associated with Veterans being able to die in their own home. Concurrent care was also correlated with longer median LOS in hospice, suggesting greater duration of support services provided to patients and families.

Continuous glucose monitoring and rates of hyperglycemia during chemotherapy for early-stage breast cancer.

e24134 Background: Diabetes (DM) and hyperglycemia (HG) during chemotherapy increase the risk of treatment-related toxicities. The prevalence of HG and daily patterns of HG over the course of chemotherapy in patients with early-stage breast cancer (ESBC) are currently unknown. Methods: We conducted a prospective single-arm pilot study of continuous glucose monitoring in patients with ESBC receiving chemotherapy from 12/2020 – 2/2022. Eligibility criteria included: diagnosis of Stage I-III BC, age ≥18, and planned chemotherapy with concurrent corticosteroid supportive care use. Patients were excluded if they were receiving other systemic corticosteroids or insulin. Patients wore FreeStyle Libre Pro continuous glucose monitoring sensors from the time of chemotherapy initiation (± 7 days) through completion. The sensors detected interstitial glucose levels every 15 minutes and were reapplied by the study team every 2-3 weeks. Primary endpoints were: (1) prevalence of HG, defined as number of patients with ≥1 glucose reading ≥140 mg/dL and (2) among those who developed HG, the proportion of time spent hyperglycemic, defined as number of readings ≥140 mg/dL divided by total number of readings. Key secondary endpoints included prevalence of prediabetes (pre-DM) and diabetes (DM) at baseline and changes in A1c from baseline to weeks 12 and 24. The analysis was stratified by baseline A1c (euglycemia [A1c &lt; 5.7%], pre-DM [A1c 5.7%-6.4%], or DM [A1c ≥6.5% and clinical diagnosis of DM prior to study enrollment]). Results: Among 20 evaluable patients, the median age at baseline was 59 (range 34-78) and median body mass index (BMI) was 29.5 kg/m2 (range 19.5-41.6). The most common chemotherapy regimens included docetaxel/cyclophosphamide (25%), weekly paclitaxel ± trastuzumab (20%), paclitaxel followed by doxorubicin/cyclophosphamide (15%), docetaxel/carboplatin/trastuzumab/pertuzumab (15%), and cyclophosphamide/methotrexate/fluorouracil (15%). All 20 patients developed HG. Of 124,165 total readings, 17% were ≥140 mg/dL and mean glucose was 112.7 mg/dL. At baseline, n = 10 were euglycemic, n = 7 had pre-DM, and n = 3 had DM. By cohort, the proportion of time spent hyperglycemic was 3.9% (euglycemia group), 10% (pre-DM group), and 73.3% (DM group) (p &lt; .0001). Mean glucose values were 95.5 mg/dL (euglycemia group), 104.5 mg/dL (pre-DM group), and 183.0 mg/dL (DM group) (p &lt; .0001). Change in mean A1c from baseline to weeks 12 and 24 varied significantly across groups. Conclusions: Among patients receiving chemotherapy for ESBC, we found evidence of HG in all patients, and the proportion of time spent hyperglycemic during chemotherapy varied significantly by baseline A1c. Further interventions should evaluate the benefits of improved glucose control among patients with baseline A1c &gt; 5.7%. Clinical trial information: NCT04473378 .

An Age Group Comparison of Concurrent Hospice Care: A Cost-Effectiveness Analysis.

This study aimed to examine the cost-effectiveness of concurrent hospice care compared with standard care among pediatric patients of different age groups. Using a national Medicaid database of 18 152 pediatric patients enrolled in hospice care between 2011 and 2013, this study calculated and analyzed incremental cost-effectiveness ratios (ICERs) for concurrent care versus standard hospice care for children of 4 age categories: <1 year, 1 to 5 years, 6 to 14 years, and 15 to 20 years. The results indicated that the total Medicaid cost of hospice care was $3229 per patient per month (PPPM; SD, $8709) for those younger than 1 year, $4793 PPPM (SD, $8178) for those aged 1 to 5 years, $5411 PPPM (SD, $7456) for those aged 6 to 14 years, and $5625 PPPM (SD, $11459) for those aged 15 to 20 years. Incremental cost-effectiveness ratio values across all age groups showed that children enrolled in concurrent care had fewer live discharges but at a higher Medicaid cost of care as compared with those enrolled in standard hospice care. Concurrent hospice care was the most cost-effective in the age groups of <1 year and 1 to 5 years, with ICERs equal to $45 (95% confidence interval [CI], $23-$66) and $49 (95% CI, $8-$76), respectively. For the other older age groups, benefits of enrollment in concurrent care came at a much higher cost: in the age group of 6 to 14 years, ICER was equal to $217 (95% CI, $129-$217), and in the age group of 15 to 20 years, it was $107 (95% CI, $82-$183). Concurrent hospice is an effective way to reduce live discharges but has a higher total Medicaid cost than standard hospice care.

A Novel Machine Learning Algorithm for Creating Risk-Adjusted Payment Formulas

Models predicting health care spending and other outcomes from administrative records are widely used to manage and pay for health care, despite well-documented deficiencies. New methods are needed that can incorporate more than 70 000 diagnoses without creating undesirable coding incentives. To develop a machine learning (ML) algorithm, building on Diagnostic Item (DXI) categories and Diagnostic Cost Group (DCG) methods, that automates development of clinically credible and transparent predictive models for policymakers and clinicians. DXIs were organized into disease hierarchies and assigned an Appropriateness to Include (ATI) score to reflect vagueness and gameability concerns. A novel automated DCG algorithm iteratively assigned DXIs in 1 or more disease hierarchies to DCGs, identifying sets of DXIs with the largest regression coefficient as dominant; presence of a previously identified dominating DXI removed lower-ranked ones before the next iteration. The Merative MarketScan Commercial Claims and Encounters Database for commercial health insurance enrollees 64 years and younger was used. Data from January 2016 through December 2018 were randomly split 90% to 10% for model development and validation, respectively. Deidentified claims and enrollment data were delivered by Merative the following November in each calendar year and analyzed from November 2020 to January 2024. Concurrent top-coded total health care cost. Model performance was assessed using validation sample weighted least-squares regression, mean absolute errors, and mean errors for rare and common diagnoses. This study included 35 245 586 commercial health insurance enrollees 64 years and younger (65 901 460 person-years) and relied on 19 clinicians who provided reviews in the base model. The algorithm implemented 218 clinician-specified hierarchies compared with the US Department of Health and Human Services (HHS) hierarchical condition category (HCC) model's 64 hierarchies. The base model that dropped vague and gameable DXIs reduced the number of parameters by 80% (1624 of 3150), achieved an R2 of 0.535, and kept mean predicted spending within 12% ($3843 of $31 313) of actual spending for the 3% of people with rare diseases. In contrast, the HHS HCC model had an R2 of 0.428 and underpaid this group by 33% ($10 354 of $31 313). In this study, by automating DXI clustering within clinically specified hierarchies, this algorithm built clinically interpretable risk models in large datasets while addressing diagnostic vagueness and gameability concerns.

Children with cancer at the end of life in a middle-income country: integrated pediatric palliative care improves outcomes

BackgroundIn 2020, the Global Cancer Observatory reported 280,000 cases of childhood cancer worldwide, with a higher burden of disease and mortality rates in low- and middle-income countries. In 2022, the National Institute of Health reported 1708 new cases of childhood cancer in Colombia and an overall survival rate of approximately 55%. The aim of this study is to compare outcomes in children with cancer in the hospital setting during the last 72 h of life who received concurrent Pediatric Palliative Care (PPC) versus oncology care alone.MethodsAn observational descriptive study was conducted between January 2013 and June 2022 in a center for pediatric patients with oncological diagnoses. In 2017, the PPC team was created. Patients between 28 days and 17 years of age who were hospitalized at least 72 h before death were included. A retrospective review of the medical records of patients in the last 72 h of life was performed. Two cohorts were established: oncology-alone group received exclusive management by oncology, and oncology and PPC received concurrent oncology and PPC management since the diagnosis.ResultsWe evaluated 257 medical records of deceased pediatric patients with cancer diagnoses. For the first cohort (2013–2017), 136 patients were included; for the second cohort (2018 and 2022), 121 patients were evaluated. The most frequent diagnosis was leukemia [47.1% (n = 121)]. No significant difference was found in either group between dyspnea, pain, and seizures. Dyspnea was the most frequent symptom in both groups. Agitation and anxiety were reported more frequently in children from the oncology-alone group (22.1% and 13.2%, respectively). The oncology and PPC group received more psychology and social work consultation (94.2% and 70.2% vs. 84.6 and 54.4% in the oncology alone group) and had a higher percentage of advance care planning (79.3% vs. 62.5% in the oncology alone group).ConclusionsThis retrospective study highlights that PPC at the end of life (EoL) offers a holistic approach to the physical and psychosocial symptoms experienced by children with cancer; these patients received more comfort through symptom management and less aggressive treatment at the EoL. The availability of a PPC team may contribute to improvements in the quality of end-of-life care.Trial registrationretrospectively registered.

An audit of the maternal medicine clinic: Cancer and pregnancy.

To explore the incidence and complexity of women presenting for maternity care who require concurrent cancer care, and to report the birth outcomes of these women. A retrospective audit of women attending a 'high risk' maternal medicine clinic at an Australian tertiary maternity hospital between 1 October 2021 and 30 April 2023 was conducted. The inclusion criteria were a diagnosis of cancer and a concurrent pregnancy, or a diagnosis of cancer prior to the current pregnancy. Clinic lists and coding data were screened via the electronic medical record to identify potential subjects. Data were collected from the individual maternity and neonatal records. Forty of 705 (5.7%) women attending the maternal medicine clinic met the inclusion criteria, of which ten had a new diagnosis of cancer in pregnancy and 30 presented for maternity care after a previous diagnosis of cancer. Cancer therapy during pregnancy included surgery and chemotherapy. Most pregnancies (92.5%) resulted in term deliveries (≥37 weeks gestation). Four neonates were preterm, and one was small-for-gestational-age. Caesarean section delivery and post-partum haemorrhage were more common than expected, but the rate of other adverse pregnancy outcomes was consistent with the background population. Over half of neonates required neonatal intensive care unit / special care nursery admission but the indications for admission were common, self-limiting conditions, and the length of stay was short (mean <5.0 days). Approximately 6% of women attending the maternal medicine clinic had a current or previous diagnosis of cancer. Most pregnancies resulted in term deliveries and neonatal outcomes were excellent.

The Current Status of Palliative Care, Hospice, and End-of-Life Health Care Utilization in Patients With Malignant Ureteral Obstruction.

Malignant ureteral obstruction is associated with a poor prognosis, with a median survival of 3 to 7 months. These patients are ideal candidates for concurrent palliative care services, consistent with American Society of Clinical Oncology guidelines. We aimed to characterize palliative care, hospice, and end-of-life health care utilization in patients with malignant ureteral obstruction. Patients ≥ 18 years old at our institution and diagnosed with malignant ureteral obstruction between May 2014 and August 2020 were retrospectively identified and pertinent data extracted. Palliative care, hospice, and end-of-life health care utilization was described, and factors associated with each were assessed with logistic regression models. Overall survival was assessed with Cox proportional hazard regression models. One hundred fifteen patients qualified for analysis; 39.1% (45/115) utilized palliative care and spent a median of 12.5 days (IQR 3-52 days) on nonhospice palliative care. On adjusted analysis Black ethnicity (aOR 3.44, 95% CI: 1.08-10.94) was associated with palliative care utilization. Of the patients, 53.9% (62/115) utilized hospice. The median time from hospice initiation to death was 12 days (IQR 5-23 days). On adjusted analysis, prior extirpative surgery (aOR 3.63, 95% CI 1.01-13.05) and palliative care utilization (aOR 4.38, 95% CI 1.70-11.31) were associated with hospice utilization. Median survival following diagnosis was 141 days (IQR 37.5-442.5). Of the patients, 43.0% (37/86) had high end-of-life health care utilization. On multivariable analysis, only hospice (aOR 0.03, 95% CI 0.01-0.14) was associated with less end-of-life health care utilization. Palliative care is underutilized in malignant ureteral obstruction. Hospice, but not palliative care utilization, was associated with decreased end-of-life health care utilization.

Concurrent Hospice and Dialysis Care: Considerations for Implementation.

Hospice positively impacts care at the end of life for patients and their families. However, compared to the general Medicare population, patients on dialysis are half as likely to receive hospice. Concurrent hospice and dialysis care offers an opportunity to improve care for people living with end-stage kidney disease (ESKD). We sought to (1) develop a conceptual model of the Program and (2) identify key components, resources, and considerations for further implementation. We conducted a template analysis of qualitative interviews and convened a community advisory panel (CAP) to get feedback on current concurrent care design and considerations for dissemination and implementation. Thirty-nine patients with late-stage chronic kidney disease (CKD), family caregivers, bereaved family caregivers, hospice clinicians, nephrology clinicians, administrators, and policy experts participated in interviews. A purposive subset of 19 interviewees composed the CAP. Qualitative feedback on concurrent care design refinements, implementation, and resources. Participants identified four themes that define an effective model of concurrent hospice and dialysis: it requires (1) timely goals-of-care conversations and (2) an interdisciplinary approach; (3) clear guidelines ensure smooth transitions for patients and families; and (4) hospice payment policy must support concurrent care. CAP participants provided feedback on the phases of an effective model of concurrent hospice and dialysis, and resources, including written and interactive educational materials, communication tools, workflow processes, and order sets. We developed a conceptual model for concurrent hospice and dialysis care and a corresponding resource list. In addition to policy changes, clinical implementation and educational resources can facilitate scalable and equitable dissemination of concurrent care. Concurrent hospice and dialysis care must be systematically evaluated via a hybrid implementation-effectiveness trial that includes the resources outlined herein, based on our conceptual model of concurrent care delivery.

The integration of palliative care with oncology: the path ahead.

The delivery of comprehensive cancer care within a progressively intricate healthcare environment requires oncology providers to become well-versed in the integration of palliative care (PC). Moreover, as healthcare professionals are urged to prioritize the individual preferences of patients and their families who confront life-limiting illnesses, it has become evident that oncology patients and their families have identified their psychosocial care needs as multifaceted and distinct, calling for specialized attention from care providers. Nevertheless, this is a skill that can be acquired through learning and practice. The landscape of PC is rapidly changing, with paradigm shifting studies highlighting the importance of early concurrent palliative and oncology inpatient and outpatient care for those with new advanced cancer diagnosis. Early concurrent care can notably improve quality of life (QoL), symptom control, patient and caregiver satisfaction, reduce costs and even improve survival. There is no longer a question of if PC should be offered, but instead when referral should be completed, what is the optimal model for service delivery and what barriers are present to achieve concurrent care. Conceptual models have been identified for optimal integrated palliative and oncology care delivery. In order to provide the best integrated care however, multiple obstacles need to be overcome. This narrative review discusses the importance of early integrated oncology and PC for patients with advanced cancer diagnosis, as well as the barriers to the integration of these specialties and potential models for delivery.

Concurrent Hospice Healthcare Utilization in the Hematology/Oncology Veteran's Affairs Patient Population.

Objectives: Concurrent care is a unique care delivery system that allows patients to receive disease modifying treatments and other supportive interventions while also receiving the traditional benefits of hospice care. The objectives of our observational study were to examine health care utilization, use of cancer-directed therapies and palliative interventions, and location of death in patients enrolled in concurrent care. Methods: 72 hematology-oncology patients at the Hines Veteran's Affairs Medical Center (VAMC) who enrolled in concurrent care from 12/2018-4/2021 were reviewed. Data were summarized with descriptive statistics including medians and percentages. Results: A minority of patients received cytotoxic chemotherapy (27.8%), immunotherapy (20.8%), palliative radiation (20.9%), blood products (11.1%), or invasive pain procedures (4.2%). Patients also used fewer cancer-directed treatments as they approached end of life (24.4% within 30 days of death compared to 13.3% within 14 days of death). Most patients died at home (62.9%) or in inpatient hospice (12.9%) as opposed to the hospital (2.9%). Conclusions: A minority of concurrent care patients received cancer-directed therapies or additional types of health care interventions despite the option to do so. Cancer-directed treatment utilization also decreased as patients approached end of life. Patients enrolled in concurrent care were able to appreciate its benefits for longer, as the average length of stay on concurrent care was nearly 3months.

An Interpretative Phenomenological Analysis of the Lived Experience of Concurrent Caring

Concurrent carers are individuals approved as both foster carers and adopters for children in care. These carers have a child placed with them while reunification with the child’s birth parents is assessed. If reunification proves impossible, the carers can then adopt the child. Little is known about the impact of the concurrent process on the individuals who chose to adopt through this route. Interpretative Phenomenological Analysis was used to explore the lived experiences of ten individuals with experiences of adopting through the concurrent care process in Northern Ireland. Three superordinate themes emerged. These are discussed alongside implications for research and practice.

Instilling Care

This paper explores the concept of care as a socialisation goal for school-age children among contemporary Chinese parents. Data was generated from interviews with parents from rural and urban families in Nanjing, China in 2011– 2012. Parents’ spontaneous remarks on care revealed how today’s Chinese parents highlighted childcare as parental responsibilities, cultivated children’s self-care skills, and promoted children’s other-caring qualities. In so doing, parents attempted to motivate concurrent and future elder care, improve children’s social competence, and inspire altruistic other-care in their children. Although Chinese parents’ imagination of care is largely centralised within the family due to sociocultural contexts such as the culture of intensive parenthood, China’s care deficiency in a neoliberal economy, and the One-Child Policy, Chinese parents also aspired instilling other-caring qualities in their children.

Pregnancy reduces concurrent pup care behaviour in meerkats, generating differences between dominant and subordinate females.

In some mammals, and particularly in cooperative breeding ones, successive bouts of reproduction can overlap so that a female is often pregnant while still nurturing dependent young from her previous litter. Such an overlap requires females to divide their energetic budget between two reproductive activities, and pregnancy costs would consequently be expected to reduce investment in concurrent offspring care. However, explicit evidence for such reductions is scarce, and the potential effects they may have on work division in cooperative breeders have not been explored. Using 25 years of data on reproduction and cooperative behaviour in wild Kalahari meerkats, supplemented with field experiments, we investigated whether pregnancy reduces contributions to cooperative pup care behaviours, including babysitting, provisioning and raised guarding. We also explored whether pregnancy, which is more frequent in dominants than subordinates, could account for the reduced contributions of dominants to the cooperative pup care behaviours. We found that pregnancy, particularly at late stages of gestation, reduces contributions to cooperative pup care; that these reductions are eliminated when the food available to pregnant females is experimentally supplemented; and that pregnancy effects accounted for differences between dominants and subordinates in two of the three cooperative behaviours examined (pup provisioning and raised guarding but not babysitting). By linking pregnancy costs with reductions in concurrent pup care, our findings illuminate a trade-off between investment in successive, overlapping bouts of reproduction. They also suggest that some of the differences in cooperative behaviour between dominant and subordinate females in cooperative breeding mammals can be a direct consequence of differences in their breeding frequency.

Concurrent hospice healthcare utilization in the hematology/oncology patient population at veterans affairs.

12125 Background: The benefits of early hospice enrollment include improved quality of life and overall survival (Kumar, 2017). Yet, most oncology patients continue to receive aggressive treatments including chemotherapy, radiation therapy, and hospitalizations until close to death (Ersek, 2017). Veterans have the unique opportunity to receive concurrent hospice which allows patients enrolled in hospice to receive disease modifying treatments and other interventions not typically provided under the traditional Medicare hospice benefit. Methods: A single institution retrospective review of 72 hematology and oncology patients who enrolled in the concurrent care program at the Hines VA between 12/28/2018-4/3/2021 was conducted. Patients were eligible for the concurrent care program if they (1) had a life-limiting illness with a prognosis of less than six months (2) were willing to enroll in hospice (3) had an oncologist willing to administer cancer-directed therapy. Data were summarized with descriptive statistics including medians and percentages. Results: Patients in the concurrent care hospice program were predominantly White (69.4%) and older than 70 years of age (63.9%). Most patients were diagnosed with primary gastrointestinal (29.2%), thoracic (22.2%), or genitourinary (19.4%) malignancies. While enrolled in concurrent care hospice, 15.3% of patients visited the emergency department and 45.8% had at least one hospitalization. Few patients received cytotoxic chemotherapy (27.8%), immunotherapy (20.8%), palliative radiation (20.8%), or pain procedures (4.2%) while enrolled in concurrent care hospice. Of the 19 patients who received chemotherapy, only one patient received treatment within 7 days prior to death. The minority of patients (11.1%) received a blood product and of those patients that did, 8.3% required one to three transfusions and 2.8% required three or more transfusions. Most (91.7%) patients died while in concurrent care hospice; 21.2% died within 30 days of enrollment and 56.1% died within 31 to 180 days of enrollment. Patients were more likely to die at home (63.6%) or in inpatient hospice (13.6%) as opposed to the hospital (3%). Conclusions: Enrollment in concurrent hospice care prevents patients from having to choose between comfort care and cancer-directed treatments, which is often a barrier to early hospice enrollment (Salz, 2009). At Hines VA, most patients receiving concurrent hospice care rarely or never utilized cancer directed treatments, pain procedures, blood products, or emergency room visits/hospitalizations despite having access to these resources. Furthermore, the majority of patients died with hospice-style care at home or in inpatient hospice rather than in the hospital. This observational study demonstrates that when offered the choice to pursue cancer-directed treatments, most patients opt instead to focus on comfort care at end of life.

Intervention for Intraoperative Teaching in Anesthesiology Using Weekly Keyword Program: Development and Usability Study

Learning in the operating room (OR) for residents in anesthesiology is difficult but essential for successful resident education. Numerous approaches have been attempted in the past to varying degrees of success, with efficacy often judged afterward using surveys distributed to participants. The OR presents a particularly complex set of challenges for academic faculty due to the pressures required by concurrent patient care, production pressures, and a noisy environment. Often, educational reviews in ORs are personnel specific, and instruction may or may not take place in this setting, as it is left to the discretion of the parties without regular direction. This study aims to determine if a structured intraoperative keyword training program could be used to implement a curriculum to improve teaching in the OR and to facilitate impactful discussion between residents and faculty. A structured curriculum was chosen to allow for the standardization of the educational material to be studied and reviewed by faculty and trainees. Given the reality that educational reviews in the OR tend to be personnel specific and are often focused on the clinical cases of the day, this initiative sought to increase both the time and efficiency of learning interactions between learners and teachers in the stressful environment of the OR. The American Board of Anesthesiology keywords from the Open Anesthesia website were used to construct a weekly intraoperative didactic curriculum, which was distributed by email to all residents and faculty. A weekly worksheet from this curriculum included 5 keywords with associated questions for discussion. The residents and faculty were instructed to complete these questions on a weekly basis. After 2 years, an electronic survey was distributed to the residents to evaluate the efficacy of the keyword program. A total of 19 teaching descriptors were polled for participants prior to and following the use of the intraoperative keyword program to assess the efficacy of the structured curriculum. The survey results showed no improvement in intraoperative teaching based on respondent perception, despite a slight improvement in teaching time, though this was statistically insignificant. The respondents reported some favorable aspects of the program, including the use of a set curriculum, suggesting that greater structure may be beneficial to facilitate more effective intraoperative teaching in anesthesiology. Although learning is difficult in the OR for residents, the use of a formalized didactic curriculum, centered on daily keywords, does not appear to be a useful solution for residents and faculty. Further efforts are required to improve intraoperative teaching, which is well known to be a difficult endeavor for both teachers and trainees. A structured curriculum may be used to augment other educational modalities to improve the overall intraoperative teaching for anesthesia residents.

Predictors of dropout from treatment among patients using specialized addiction treatment centers

ObjectivesThis study investigated the use of outpatient care, and sociodemographic and clinical characteristics of patients with substance-related disorders (SRD) to predict treatment dropout from specialized addiction treatment centers. The study also explored risks of adverse outcomes, frequent emergency department (ED) use (3+ visits/year), and death, associated with treatment dropout within the subsequent 12 months. MethodsThe study examined a cohort of 16,179 patients who completed their last treatment episode for SRD between 2012–13 and 2014–15 (financial years: April 1 to March 31) in 14 specialized addiction treatment centers using Quebec (Canada) health administrative databases. We used multivariable logistic regressions to measure risk of treatment dropout (1996–96 to 2014–15), while we used survival analysis controlling for sex and age to assess the odds of frequent ED use and death in 2015–16. ResultsOf the 55 % of patients reporting dropout from SRD treatment over the 3-year period, 17 % were frequent ED users, and 1 % died in the subsequent 12 months. Patients residing in the most socially deprived areas, having polysubstance-related disorders or personality disorders, and having previously dropped out from specialized addiction treatment centers had increased odds of current treatment dropout. Older patients, those with a history of homelessness, past SRD treatment, or more concurrent outpatient care outside specialized addiction treatment centers had decreased odds of treatment dropout. Patients who dropped out were subsequently at higher risk of frequent ED use and death. ConclusionsThis study highlighted that patients with more severe problems and previous dropout may need more sustained and adequate help to prevent subsequent treatment dropout. Specialized addiction treatment centers may consider enhancing their follow-up care of patients over a longer duration and better integrating their treatment with other outpatient care resources to meet the multiple needs of the more vulnerable patients using their services.