Non-cancer Diagnoses Research Articles

Start of the COVID-19 Pandemic and Palliative Care Unit Utilization: A Retrospective Cohort Study

ContextPeople with noncancer diagnoses have poorer access to palliative care units (PCUs) or hospices compared to those with cancer diagnoses. The COVID-19 pandemic disrupted how specialist palliative care services were delivered and utilized. ObjectiveTo determine the association between the start of the COVID-19 pandemic and PCU/hospice utilization in hospitalized individuals with cancer and noncancer diagnoses with specialist palliative care needs. MethodsRetrospective cohort study using routinely collected data. Percentages of individuals experiencing each disposition from hospital, including discharge to PCU/hospice, were calculated monthly for the total, cancer, and noncancer cohorts and were analyzed descriptively. Hospitalized individuals with specialist palliative care needs at a single academic hospital in Toronto, Canada from January 1, 2017, to September 31, 2022 (pandemic start was defined as April 1, 2020). ResultsThe cohort comprised 4349 individuals (median age=78 years; 52.4% female); 3065 (70.5%) and 1284 (29.5%) had cancer and noncancer diagnoses, respectively. Among individuals with noncancer diagnoses, the most significant absolute changes were a 13.0%-decrease in in-hospital deaths (prepandemic=49.6%; postpandemic=36.6%) and a 11.6%-increase in discharges to PCU/hospice (prepandemic=35.6%; postpandemic=47.3%). Among individuals with cancer, the most significant absolute changes were a 12.8%-increase in discharges home with formal care (prepandemic=2.3%; postpandemic=15.1%) and a 7.0%-decrease in in-hospital deaths (prepandemic=29.1%; postpandemic=22.0%). ConclusionDespite historically poor PCU/hospice access, the COVID-19 pandemic created circumstances that may have enabled unprecedented utilization in individuals with noncancer diagnoses in our cohort.

Cross-sectional study to evaluate patients’ medication management with a new model of care: incorporating a pharmacist into a community specialist palliative care telehealth service

BackgroundPatients receiving palliative care are often on complex medication regimes to manage their symptoms and comorbidities and at high risk of medication-related problems. The aim of this cross-sectional study was to evaluate the involvement of a pharmacist to an existing community specialist palliative care telehealth service on patients’ medication management.MethodThe specialist palliative care pharmacist attended two palliative care telehealth sessions per week over a six-month period (October 2020 to March 2021). Attendance was allocated based on funding received. Data collected from the medication management reviews included prevalence of polypharmacy, number of inappropriate medication according to the Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy criteria (STOPP/FRAIL) and recommendations on deprescribing, symptom control and medication management.ResultsIn total 95 patients participated in the pharmaceutical telehealth service with a mean age of 75.2 years (SD 10.67). Whilst 81 (85.3%) patients had a cancer diagnosis, 14 (14.7%) had a non-cancer diagnosis. At referral, 84 (88.4%, SD 4.57) patients were taking ≥ 5 medications with 51 (53.7%, SD 5.03) taking ≥ 10 medications. According to STOPP/FRAIL criteria, 142 potentially inappropriate medications were taken by 54 (56.8%) patients, with a mean of 2.6 (SD 1.16) inappropriate medications per person. Overall, 142 recommendations were accepted from the pharmaceutical medication management review including 49 (34.5%) related to deprescribing, 20 (14.0%) to medication-related problems, 35 (24.7%) to symptom management and 38 (26.8%) to medication administration.ConclusionThis study provided evidence regarding the value of including a pharmacist in palliative care telehealth services. Input from the pharmacist resulted in improved symptom management of community palliative care patients and their overall medication management.

Nonspecific Signs and/or Symptoms of Cancer: A Retrospective, Observational Analysis from a Secondary Care, US Community Oncology Dataset.

To help determine the unmet need for improved diagnostic tools to evaluate patients with nonspecific signs and/or symptoms (NSSS) and suspicion of cancer, we examined patient characteristics, diagnostic journey, and cancer incidence of patients with NSSS within The US Oncology Network (The Network), a secondary care community oncology setting. This retrospective, observational cohort study included patients aged ≥40 years with ≥1 NSSS in their problem list at their first visit within The Network (the index date) between 1 January 2016 and 31 December 2020. Patients were followed longitudinally with electronic health record data for initial cancer diagnosis, new noncancer diagnosis, death, end of study observation period, or 12 months, whichever occurred first. Of 103,984 patients eligible for inclusion, 96,722 presented with only 1 NSSS at index date; 6537/103,984 (6.3%) were diagnosed with 1 primary cancer within 12 months after the index date; 3825/6537 (58.5%) with hematologic malignancy, and 2712/6537 (41.5%) with solid tumor. Among patients diagnosed with cancer (n = 6774), the median time to cancer diagnosis after their first visit within The Network was 5.13 weeks. This study provides a real-world perspective on cancer incidence in patients with NSSS referred to a secondary care setting and highlights the unmet need for improved diagnostic tools to improve cancer outcomes.

Comparing the characteristics and outcomes of hospitalizations between cancer and non-cancer survivors.

12138 Background: Cancer prevalence is rising, with a corresponding increase in hospitalizations across the cancer continuum. However, little is known about how in-hospital patterns of care and outcomes of cancer survivors compare with non-cancer survivors as administrative data may not capture in-hospital details (e.g., investigations and medications) required for characterization. Understanding differences in how cancer and non-cancer inpatients are managed and their outcomes can help optimize their acute care delivery. Methods: In a multicenter registry of all patients (pts) admitted to medical wards across 26 hospitals (Ontario, Canada) from 2015-2022, we deterministically linked population-level administrative data, including ambulatory oncology data for cancer survivors, with each hospital’s electronic information (pharmacy, orders, notes, laboratory, imaging) at the patient level. Multivariable regression models compared resource use and outcomes between cancer and non-cancer pts for the top 5 discharge diagnoses among non-cancer pts. Results: Of 1,221,067 hospitalizations belonging to 666,569 pts, 30% of medical ward hospitalizations were for pts with a cancer history, with median admission date 4 years post-diagnosis; most common cancer sites were genitourinary (21%), gastrointestinal (20%), breast (12%), lung (10%). Most common discharge diagnoses among cancer pts were heart failure (HF) (5%), palliative care (5%), urinary tract infection (UTI) (2%), pneumonia (2%) renal failure (2%); while for non-cancer pts were HF (5%), myocardial infarction (3%), coronary artery disease (3%), COPD (2%) and UTI (2%). Compared to non-cancer pts, cancer pts were older (72 vs 66), had greater length of stay (LOS; 10 vs 8.7 days), in-hospital mortality (11% vs 6%) and 30 day re-admission rates (16% vs 11%) and were more likely to receive CTs (21% vs 15%), MRIs (9% vs 8%) and interventional procedures (6% vs 4%) (p < 0.001, all comparisons). When evaluating the top 5 discharge diagnoses among non-cancer patients, cancer survivors had higher LOS (aOR=1.06 95% [1.05-1.07] p<0.001), in-hospital mortality (aOR=1.20 [1.14-1.26] p<0.001), and 30 day re-admission rates (aOR=1.24 [1.14-1.35] p<0.001) and were more likely to receive CTs (aOR=1.25 [1.21-1.30] p<0.001), MRIs (aOR=1.36 [1.25-1.48] p<0.001) and interventional procedures (aOR=1.36 [1.25-1.47] p<0.001). Subgroup analyses focusing on cancer survivors admitted 3 and 5 years out from their diagnosis showed resource use and outcomes were closer to non-cancer patients. Conclusions: Cancer survivors represent a unique population on medical wards and have higher resource use, mortality and LOS compared to non-cancer patients, even for the same non-cancer diagnoses. Specialized models of care for hospitalized cancer survivors may be warranted, in particular for those admitted closer to their diagnosis date.

Exploring the State of Cancer Imaging Research in Africa

IntroductionThe growing cancer burden in Africa demands urgent action. Medical imaging is crucial for cancer diagnosis and management and is an essential enabler of precision medicine. To understand the readiness for quantitative imaging analysis to support cancer management in Africa, we analyzed the utilization patterns of imaging modalities for cancer research across the continent. MethodsWe retrieved articles by systematically searching PubMed, using a combination of search terms {“Neoplasm”} AND {“Radiology” or “Diagnostic imaging” or “Radiography” or “Interventional Radiology” or “Radiotherapy” or “Radiation Oncology”} AND {Africa∗ or 54 African countries}. Articles describing cancer diagnosis or management in humans with the utilization of imaging were included. Exclusion criteria were review articles, non-English articles, publications before 2000, noncancer diagnoses, and studies conducted outside Africa. ResultsThe analysis of diagnostic imaging in Africa revealed a diverse utilization pattern across different cancer types and regions. The literature search identified 107 publications on cancer imaging in Africa. The studies were carried out in 19 African countries on 12 different cancer types with 6 imaging modalities identified. Most cancer imaging research studies used multiple imaging modalities. Ultrasound was the most used distinct imaging modality and MRI was the least frequently used. Most research studies originated from Nigeria, South Africa, and Egypt. ConclusionWe demonstrate substantial variability in the presence of imaging modalities, widespread utilization of ultrasonography, and limited availability of advanced imaging modalities for cancer research.

Investigating harms of testing for ovarian cancer - psychological outcomes and cancer conversion rates in women with symptoms of ovarian cancer: A cohort study embedded in the multicentre ROCkeTS prospective diagnostic study.

To investigate psychological correlates in women referred with suspected ovarian cancer via the fast-track pathway, explore how anxiety and distress levels change at 12 months post-testing, and report cancer conversion rates by age and referral pathway. Single-arm prospective cohort study. Multicentre. Secondary care including outpatient clinics and emergency admissions. A cohort of 2596 newly presenting symptomatic women with a raised CA125 level, abnormal imaging or both. Women completed anxiety and distress questionnaires at recruitment and at 12 months for those who had not undergone surgery or a biopsy within 3 months of recruitment. Anxiety and distress levels measured using a six-item short form of the State-Trait Anxiety Inventory (STAI-6) and the Impact of Event Scale - Revised (IES-r) questionnaire. Ovarian cancer (OC) conversion rates by age, menopausal status and referral pathway. Overall, 1355/2596 (52.1%) and 1781/2596 (68.6%) experienced moderate-to-severe distress and anxiety, respectively, at recruitment. Younger age and emergency presentations had higher distress levels. The clinical category for anxiety and distress remained unchanged/worsened in 76% of respondents at 12 months, despite a non-cancer diagnosis. The OC rates by age were 1.6% (95% CI 0.5%-5.9%) for age <40 years and 10.9% (95% CI 8.7%-13.6%) for age ≥40 years. In women referred through fast-track pathways, 3.3% (95% CI 1.9%-5.7%) of pre- and 18.5% (95% CI 16.1%-21.0%) of postmenopausal women were diagnosed with OC. Women undergoing diagnostic testing display severe anxiety and distress. Younger women are especially vulnerable and should be targeted for support. Women under the age of 40 years have low conversion rates and we advocate reducing testing in this group to reduce the harms of testing.

Racial Differences in Hospice Care Outcomes in Patients With Advanced Heart Failure: Systematic Review and Meta-analysis

There remains a paucity of investigational data about disparities in hospice services in people with non-cancer diagnoses, specifically in heart failure (HF). Black patients with advanced HF have been disproportionally affected by health care services inequities but their outcomes after hospice enrollment are not well studied. We aimed to describe race-specific outcomes in patients with advanced HF who were enrolled in hospice services. We obtained the data from PubMed, Scopus, and Embase for all investigations published until January 11, 2023. All studies that reported race-specific outcomes after hospice enrollment in patients with advanced HF were included. Of the 1,151 articles identified, 5 studies (n = 24,899) were considered for analysis involving a sample size ranging from 179 to 11,754 patients. Black patients had an increased risk of readmission (odds ratio 1.55, 95% confidence interval [CI] 1.34 to 1.79, I2 0%) and discharge (odds ratio 1.75, 95% CI 1.53 to 1.99, I2 0%) compared with White patients. Moreover, Black patients have a nonsignificant lower risk of mortality compared with White patients (relative risk 0.67, 95% CI 0.43 to 1.05, I2 90%). In conclusion, this study showed that Black patients with advanced HF receiving hospice care have a higher risk of readmission and discharge compared with White patients.

Promising Impact of Telenovela Intervention for Caregivers of Hospice Patients: A Pilot Study.

Hospice family caregivers (HFCGs) support the needs of their loved ones but are at risk of developing distress and anxiety. NOVELA is a four-chapter telenovela-style educational video to support topics related to hospice caregiving. Telehealth visits are scheduled in 4 weekly sessions consisting of a chapter and subsequent discussion with an interventionist. This feasibility pilot study tested NOVELA's effect to change HFCGs' outcomes, session and outcome measure completion (defined a priori as >70%). This is a single-group pretest-posttest study of HFCGs of care recipients with PPS score >20% from 3 hospices in the U.S. Mid-Atlantic region. At baseline and at final posttest, participants completed a web-based survey assessing 3 outcomes: anxiety, self-efficacy, and satisfaction with intervention. Descriptive, t-test, and chi-square statistics were computed. Participants in our study (N = 59) were mainly collage educated, White, female, adult children of home-bound people with a non-cancer diagnosis. Outcomes changed in the expected direction (P > .05) with higher self-efficacy (Cohen's d = -.08 [95% CI -.4 to .2) and lower anxiety (Cohen's d = .2 [95% CI -.1 to .5]) scores from final to baseline, 86% of HFCGs were satisfied or very satisfied with NOVELA, session (33/59) and outcome measure (43/59) completion averaged 68%. Encouraging trends in NOVELA's estimation of effect suggests that NOVELA may buffer stressful aspects of hospice caregiving. However, further refinement of NOVELA is needed. Supporting HFCGs through supportive educational interventions may reduce distress and anxiety with broad implications for quality improvement.

A refined ICD-10 diagnoses-based approach for retrospective analysis of potential palliative care need and coverage in claims data of deceased.

ICD-10-based approaches often provide the basis for retrospective estimation of potential palliative care need. Applying the ICD-10-based Murtagh et al. classification from 2014 (Murtagh classification), developed using mortality data, to administrative claims data leads to inconsistencies in estimating palliative care need. The aim of the study was to refine the classification for palliative care need estimation in deceased individuals with cancer and non-cancer diagnosis. A retrospective population-based study comparing Murtagh classification to a new ICD-10-based classification (revised by expert opinion) was conducted using outpatient and inpatient claims data, including billing codes for palliative care. Palliative care need was estimated for diagnoses groups and was contrasted with palliative care utilization rates in the last year of life. Our dataset included records of 417,405 individuals who deceased in 2016-2019. Out of individuals deceased in 2019 (n = 117,436), 81.4% had at least one diagnosis from the new classification, while 97.0% had at least one diagnosis from the Murtagh classification. Classification revision thus identified fewer individuals as potentially in need of palliative care. Among individuals with cancer, 70.7% (vs. 55.7% via Murtagh classification) received palliative care. In non-cancer subgroups, the utilization rate was considerably lower, with a maximum of 36.7% (vs. 33.7% via Murtagh classification) in 2019. Similar results were observed for the other years. Compared to the ICD10-based Murtagh classification, the revised ICD-10-based classification enables more realistic estimations if the cause of death is unavailable and reveals higher rates of palliative care coverage and differences especially in cancer versus non-cancer diseases. German Clinical Trials Register (DRKS00024133).

Cancer Predisposition Genetic Testing Among Children with Hematologic Malignancies

Introduction: There is growing recognition of germline cancer predisposition syndromes (CPS) that increase risk of hematologic malignancies including leukemias, lymphomas, bone marrow failure syndromes and myeloproliferative diseases. Somatic (tumor) testing can identify potential germline variants based on multiple factors including variant allele fraction, sequence characteristics, and other findings; however, subsequent germline testing is required to characterize the lesion. Paired tumor and germline testing (T/N testing) is more accurate to diagnose CPS and may mitigate loss to follow-up, reduce time to CPS diagnosis, and possibly alleviate unnecessary anxiety due to suspected but ultimately disproved germline conditions. Previously, our center performed tumor-only diagnostic testing for patients with newly diagnosed hematologic malignancies. In 2020 we transitioned to paired T/N testing for all new hematologic malignancy diagnoses with patient/caregiver consent. Here we report the frequency of CPS diagnoses suggested by tumor-only testing and subsequently confirmed with germline testing, as well as CPS diagnoses identified from the outset by T/N testing. Methods: Data was automatically abstracted from the Children's Hospital of Philadelphia (CHOP) Diagnostic Genomics Database (FileMaker and Nexus) for 1057 pediatric, adolescent, and young adult patients who underwent testing with the CHOP Comprehensive Hematologic Malignancy panel between 2016 and 2023. This panel interrogates 117 genes for single nucleotide variants, insertions, deletions, and copy number variants. Of those tested, 932 patients underwent tumor-only testing, and 125 patients underwent paired T/N testing. Characteristics of patients with possible pre-established genetic syndromes (e.g. Trisomy 21) were cross-checked via manual chart review. Results: Schematic representation of patient testing is summarized in Figure 1. Among 932 patients who underwent tumor-only testing, 98 were identified to have potential or previously established germline pathogenic variants. Of these, 9 had known genetic syndromes and 8 had non-cancer related genetic diagnoses (e.g. Usher syndrome). Of the 81 patients with a suspected CPS, 26 were referred from an outside hospital with unavailable follow-up data. Among suspected germline patients from our center (n=55), 34 (62%) did not undergo confirmatory testing. Of the 21 (38%) who underwent confirmatory testing, 2 (10%) were diagnosed with a CPS. For patients with T/N testing, 16 of 125 (7%) were identified to have germline conditions; 8 were pre-established diagnoses and 4 were non-cancer related genetic diagnoses. Thus, 4 (3%) of patients with T/N testing were newly diagnosed with a CPS. New CPS diagnoses included: ETV6 thrombocytopenia and leukemia predisposition syndrome, CBL syndrome, GATA2 MDS/AML predisposition syndrome, Noonan syndrome, and CEBPA AML predisposition syndrome. Conclusion: At our center, 62% of patients with suspected germline conditions on tumor-only testing had no follow up testing documented in the available medical record. These data suggest that paired T/N testing at the time of hematologic malignancy diagnosis assists in mitigating loss-to-follow up for patients with possible CPS. Additionally, T/N testing may streamline result interpretation, reduce time to diagnosis, aid in treatment decisions, and guide cascade testing for potentially affected family members. When possible, genetic testing decisions and results should be discussed with a trained genetic counselor. Over time, increasing utilization of paired T/N testing may also enhance understanding of CPS-associated genes that increase risk of hematologic malignancies.

Increasing Trend and Effects of Pediatric Palliative Care on Children With Noncancer Diagnoses.

Pediatric palliative care (PPC), especially among noncancer pediatric patients, faces challenges including late referral, limited patient care, and insufficient data for Asian patients. This retrospective cohort study used the integrative hospital medical database between 2014 and 2018 to analyze the clinical characteristics, diagnoses, and end-of-life care for patients aged less than 20 who had died in our children's hospital, a tertiary referral medical center implementing PPC shared-care. In our cohort of 323 children, 240 (74.3%) were noncancer patients who a younger median age at death (5 vs. 122 months, P < 0.001), lower rate of PPC involvement (16.7 vs. 66%, P < 0.001), and fewer survival days after PPC consult compared to cancer patients (3 vs. 11, P=0.01). Patients not receiving PPC had more ventilator support (OR 9.9, P < 0.001), and less morphine use on their final day of life (OR 0.1, P < 0.001). Also, patients not receiving PPC had more cardiopulmonary resuscitation on the last day of life (OR 15.3, P < 0.001) and died in the ICU (OR 8.8, P < 0.001). There was an increasing trend of noncancer patients receiving PPC between 2014 and 2018 (P < 0.001). High disparities exist between children receiving PPC in cancer versus noncancer patients. The concept of PPC is gradually becoming accepted in noncancer children and is associated with more pain-relief medication and less suffering during end-of-life care.

Differences in trends in discharge location in a cohort of hospitalized patients with cancer and non-cancer diagnoses receiving specialist palliative care: A retrospective cohort study

Background: Patients with and without cancer are frequently hospitalized, and have specialist palliative care needs. In-hospital mortality can serve as a quality indicator of acute care. Trends in acute care outcomes have not previously been evaluated in patients with confirmed specialist palliative care needs or between diagnostic groups. Aim: To compare trends in discharge location between hospitalized patients with and without cancer who received specialist palliative care. Design: Retrospective cohort study. Association between diagnosis (cancer, non-cancer) and in-hospital mortality was assessed using multivariable logistic regression, controlling for demographic, clinical, and admission-specific information. Setting/participants: Patients who received specialist palliative care at an academic tertiary hospital in Toronto, Canada from 2013 to 2019. Results: The cohort comprised 6846 patients, 5024 with and 1822 without cancer. A higher proportion of patients without cancer had a Palliative Performance Scale score <30%, anticipated prognosis of <1 month, and were referred for end-of-life care (all p < 0.001). The adjusted odds of dying in hospital was 1.24-times higher among patients without cancer (95% CI: 1.05–1.46; p = 0.011). Though the proportion of patients without cancer who died in hospital decreased by 8.4% from 2013 to 2019, this proportion (41.2%) remained substantially higher compared to patients with cancer (14.0%) in 2019. Conclusions: Hospitalized patients without cancer were referred to specialist palliative care at a lower functional status, a poorer anticipated prognosis, and more likely for end-of-life care; and were more likely to die in hospital. Future studies are required to determine whether a proportion of hospital deaths in patients without cancer represent goal-discordant end-of-life care.

Reality of Family Caregiving for Hispanics With Alzheimer's Disease and Related Dementias: A Qualitative Analysis.

Background: Underserved Hispanic patients often experience unmet palliative care (PC) needs, particularly those with noncancer diagnoses such as Alzheimer's disease and related dementias. Most caregivers for Hispanic patients are family relatives who are less likely to use health care and community resources and experience high caregiver burden. We adapted a culturally tailored patient navigator (PN) intervention to provide support and improve PC outcomes for Hispanics with Alzheimer's disease and related dementias and their family caregivers (FCGs). Objectives: To explore Hispanic FCGs' experiences and perceptions of caregiving for a loved one, and how our PN intervention impacted their needs. Design: Qualitative descriptive. Setting/Subjects: FCG participants (n = 10) from our randomized control trial's intervention group were recruited from academic and safety net hospitals and community-based clinics across urban and rural Colorado in the United States. Measurements: Data obtained from individual, semistructured, 30-minute telephone interviews were recorded, transcribed, translated, and analyzed using NVivo and qualitative thematic analyses. Results: Four major themes emerged: Methods of Support, Cultural Expectations and Varying Family Contributions, Lack of Self-Care, and Awareness. Subthemes highlighted differing definitions of "contributing," role resentment, and interpersonal issues. Varying familial expectations underscore FCG strain when the burden of caregiving is not shared. Participants used various coping strategies as necessary support and gained awareness through education, guidance, and referrals to resources. Conclusions: PNs helped FCGs and patients beyond the intervention's scope. Providing support and awareness to FCGs, and incorporating cultural beliefs, may improve PC access to disparate populations and guide future interventions. Clinical Trial Registration Number NCT03181750.

Systematic Review of Models of Effective Community Specialist Palliative Care Services for Evidence of Improved Patient-Related Outcomes, Equity, Integration, and Health Service Utilization.

Background: The benefits of palliative care programs are well documented. However, the effectiveness of specialist palliative care services is not well established. The previous lack of consensus on criteria for defining and characterizing models of care has restrained direct comparison between these models and limited the evidence base to inform policy makers. A rapid review for studies published up to 2012 was unable to find an effective model. Aim: To identify effective models of community specialist palliative care services. Design: A mixed-method synthesis design reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Prospero: CRD42020151840. Data sources: Medline, PubMed, EMBASE, CINAHL and the Cochrane Database of Systematic Reviews were searched in September 2019 for primary research and review articles from 2012 to 2019. Supplementary search was conducted on Google in 2020 for policy documents to identify additional relevant studies. Results: The search yielded 2255 articles; 36 articles satisfied the eligibility criteria and 6 additional articles were identified from other sources. Eight systematic reviews and 34 primary studies were identified: observational studies (n = 24), randomized controlled trials (n = 5), and qualitative studies (n = 5). Community specialist palliative care was found to improve symptom burden/quality of life and to reduce secondary service utilization across cancer and noncancer diagnoses. Much of this evidence relates to face-to-face care in home-based settings with both round-the-clock and episodic care. There were few studies addressing pediatric populations or minority groups. Findings from qualitative studies revealed that care coordination, provision of practical help, after-hours support, and medical crisis management were some of the factors contributing to patients' and caregivers' positive experience. Conclusion: Strong evidence exists for community specialist palliative care to improve quality of life and reducing secondary service utilization. Future research should focus on equity outcomes and the interface between generalist and specialist care.

A Retrospective Medical Record Review of Adults with Non-Cancer Diagnoses Prescribed Medicinal Cannabis

Research describing patients using medicinal cannabis and its effectiveness is lacking. We aimed to describe adults with non-cancer diagnoses who are prescribed medicinal cannabis via a retrospective medical record review and assess its effectiveness and safety. From 157 Australian records, most were female (63.7%; mean age 63.0 years). Most patients had neurological (58.0%) or musculoskeletal (24.8%) conditions. Medicinal cannabis was perceived beneficial by 53.5% of patients. Mixed-effects modelling and post hoc multiple comparisons analysis showed significant changes overtime for pain, bowel problems, fatigue, difficulty sleeping, mood, quality of life (all p < 0.0001), breathing problems (p = 0.0035), and appetite (p = 0.0465) Symptom Assessment Scale scores. For the conditions, neuropathic pain/peripheral neuropathy had the highest rate of perceived benefit (66.6%), followed by Parkinson's disease (60.9%), multiple sclerosis (60.0%), migraine (43.8%), chronic pain syndrome (42.1%), and spondylosis (40.0%). For the indications, medicinal cannabis had the greatest perceived effect on sleep (80.0%), followed by pain (51.5%), and muscle spasm (50%). Oral oil preparations of balanced delta-9-tetrahydrocannabinol/cannabidiol (average post-titration dose of 16.9 mg and 34.8 mg per day, respectively) were mainly prescribed. Somnolence was the most frequently reported side effect (21%). This study supports medicinal cannabis' potential to safely treat non-cancer chronic conditions and indications.

Experiences and Challenges of a New Palliative Care Service in the United Arab Emirates

Introduction Palliative care as a medical subspecialty in the United Arab Emirates (UAE) is very much in its formative stage of development. There are a small number of healthcare facilities that provide a specialist palliative care service, the most recent of which is the Palliative and Supportive Care Service at Burjeel Medical City (BMC), a private hospital in Abu Dhabi. Aim This retrospective review of all the referrals to our palliative and supportive care service within the first 9-months of operation is a direct reflection of the challenges we currently face in the day-to-day delivery of palliative care in the UAE. Result Of a total of 360 referrals received during the study period, under 50% were for local, Emirati patients with international expatriates making up the rest. Most of the referrals received were for symptom control (including pain) and end-of-life care (EoLC), with 85% of the patients having a diagnosis of cancer. One third of the referrals received were for EoLC, with 90% of the patients who received EoLC on a hospital ward having a valid do not attempt resuscitation (DNAR) status in place. For the patients who received EoLC, all but one patient received EoLC in the hospital setting. Conclusion Our experiences are consistent with the challenges that other colleagues in the Middle East and North Africa (MENA) region face in providing palliative care. The majority of referrals to the palliative and supportive care service were for patients with a diagnosis of cancer with only 15% reflecting a non-cancer diagnosis. Of the 150 decedents cared for during this study period, more than 75% had a valid DNAR status in effect suggesting a growing awareness and acceptance of a less medicalized EoLC period.

Medical Assistance in Dying in Oncology Patients: A Canadian Academic Hospital’s Experience

Medical assistance in dying (MAID) was legislatively enacted in Canada in June 2016. Most studies of patients who received MAID grouped patients with cancer and non-cancer diagnoses. Our goal was to analyze the characteristics of oncology patients who received MAID in a Canadian tertiary care hospital. We conducted a retrospective review of all patients with cancer who received MAID between June 2016 and July 2020 at London Health Sciences Centre (LHSC). We describe patients' demographics, oncologic characteristics, symptoms, treatments, and palliative care involvement. Ninety-two oncology patients received MAID. The median age was 72. The leading cancer diagnoses among these patients were lung, colorectal, and pancreatic. At the time of MAID request, 68% of patients had metastatic disease. Most patients (90%) had ECOG performance status of 3 or 4 before receiving MAID. Ninety-nine percent of patients had distressing symptoms at time of MAID request, most commonly pain. One-third of patients with metastatic or recurrent cancer received early palliative care. The median time interval between the first MAID assessment and receipt of MAID was 7 days. Most oncology patients who received MAID at LHSC had poor performance status and almost all had distressing symptoms. The median time interval between first MAID assessment and receipt of MAID was shorter than expected. Only one-third of patients with metastatic or recurrent cancer received early palliative care. Improving access to early palliative care is a priority in patients with advanced cancer. We received research approval from Western University's Research Ethics Board (REB) with project ID number 115367, and from Lawson's Research Database Application (ReDA) with study ID number 9579.

A systematic review defining non-beneficial and inappropriate end-of-life treatment in patients with non-cancer diagnoses: theoretical development for multi-stakeholder intervention design in acute care settings

BackgroundNon-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life.AimTo define and understand determinants of non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life.DesignSystematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles.Data sourcesCochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science.ResultsSixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences.Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to ‘Motivation to Address Conflict & Seek Agreement’ helped to lessen uncertainty around decision-making. Establishing agreement was reliant on ‘Valuing Clear Communication and Sharing of Information’. Reaching consensus was dependent on ‘Choices around Timing & Documenting of end-of-life Decisions’.ConclusionA framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool.Trial registrationPROSPERO Protocol CRD42021214137.

Telephone triage for 2-week-wait cancer clinics: a viable alternative to face-to-face clinics?

Head and neck cancer services have had to adapt to reduce the risk of exposure to patients and staff during the pandemic. Telephone consultations as a first point contact have been adopted in some centres. It is important that this does not lead to delays in diagnosis. Our hospital adopted a telephone triage service and we aim to describe the implications of this structure. Data were collected from all new patients referred to the head and neck 2-week-wait (2ww) pathway from June to September of 2019 and 2020. Days between first clinic appointment and cancer or noncancer diagnosis were calculated. Statistical tests were performed between years. A total of 215 patients in 2019, and 165 in 2020 were included; 23 (6.8%) cancer diagnoses were identified across 2019 and 2020 groups. The cancer group had a mean time from first consultation to date of diagnosis of 16.33 days in 2019 and 12.81 days in 2020. There was no significant difference in days until diagnosis between 2019 and 2020 (p=0.05). In the noncancer group there was no significant difference in days until noncancer diagnosis (p=0.05). In 2020 26.1% (n=43) patients did not need to be seen face-to-face (f2f) under the 2ww pathway after telephone triage. No difference in diagnosis timing was observed between cancer and noncancer patents in 2019 and 2020. Telephone clinics reduce the total number of f2f appointments required. Reduction in the number of f2f appointments may have other benefits in saving time and environmental costs.

Improving identification of symptomatic cancer at primary care clinics: A predictive modeling analysis in Botswana.

In resource-limited settings, augmenting primary care provider (PCP)-based referrals with data-derived algorithms could direct scarce resources towards those patients most likely to have a cancer diagnosis and benefit from early treatment. Using data from Botswana, we compared accuracy of predictions of probable cancer using different approaches for identifying symptomatic cancer at primary clinics. We followed cancer suspects until they entered specialized care for cancer treatment (following pathologically confirmed diagnosis), exited from the study following noncancer diagnosis, or died. Routine symptom and demographic data included baseline cancer probability assessed by the primary care provider (low, intermediate, high), age, sex, performance status, baseline cancer probability by study physician, predominant symptom (lump, bleeding, pain or other) and HIV status. Logistic regression with 10-fold cross-validation was used to evaluate classification by different sets of predictors: (1) PCPs, (2) Algorithm-only, (3) External specialist physician review and (4) Primary clinician augmented by algorithm. Classification accuracy was assessed using c-statistics, sensitivity and specificity. Six hundred and twenty-three adult cancer suspects with complete data were retained, of whom 166 (27%) were diagnosed with cancer. Models using PCP augmented by algorithm (c-statistic: 77.2%, 95% CI: 73.4%, 81.0%) and external study physician assessment (77.6%, 95% CI: 73.6%, 81.7%) performed better than algorithm-only (74.9%, 95% CI: 71.0%, 78.9%) and PCP initial assessment (62.8%, 95% CI: 57.9%, 67.7%) in correctly classifying suspected cancer patients. Sensitivity and specificity statistics from models combining PCP classifications and routine data were comparable to physicians, suggesting that incorporating data-driven algorithms into referral systems could improve efficiency.