Opportunities For Palliative Care Research Articles

Technologies for monitoring patients with Alzheimer’s disease: A systematic mapping study and taxonomy

Alzheimer’s disease (AD) is an incurable disease and a type of dementia. About 55 million people around the world have AD. However, technologies have been used to assist in the healthcare of AD, supporting physicians in the palliative care of patients. This article presents a systematic mapping study (SMS) to identify articles that use technologies to monitor patients with AD in order to show an overview of the literature, identifying gaps and research opportunities in this field. The scientific contribution of this work is to identify monitoring technologies related to AD and highlight current trends on the subject. The paper uses the term technologies as hardware infrastructure and devices or systems without considering software technologies. In addition, this article proposes a taxonomy for the domain of technologies applied to AD patients. The SMS study was conducted in six databases, including articles from 1997 to 2021. An initial search resulted in 7,781 articles. After applying filter criteria, throwing automatic selection on databases, and manual assortment, 171 articles were selected. Subsequently, a second search was performed to reduce the list of articles and filter by the specific search objective of articles focused on technologies for monitoring with tracking, resulting in 74 works. The main results obtained are: (1) a relevant number of articles (43.42%) reported solutions used in sensor-based devices; (2) several works (33.33%) have the interaction focus on Position/Distance/Proximity/Location sensor type; (3) another group of articles has a secondary focus on Emergency help (18.97%). The results indicated the need for technologies to help caregivers monitor patients, in addition to evidence of research opportunities in palliative care and support for the daily activities of AD patients.

An Online Pediatric Palliative Care Education and Mentoring (Project ECHO) in Nepal: A Program Implementation Case Study and Assessment of Changes in Healthcare Providers' Knowledge, Confidence, and Attitudes.

The goal of this implementation study was to describe the implementation and evaluation of the impact of an online pediatric palliative care training program in Nepal, using the Project ECHO model. The study used mixed methods, including a program case study describing the online learning program and before-and-after surveys of program participants, assessing learning through changes in knowledge, comfort, and attitudes. An end-of-program survey was used to evaluate participants' overall experiences with the learning program and use of the learning resources. A literature review, stakeholder surveys, and expert input informed the design of the intervention. The course used the Project ECHO model of online education, with modifications based on the leadership team's previous ECHO experiences and local stakeholder input. The intervention occurred over 9 months, with 22 online teaching sessions. Each session consisted of a didactic lecture, case presentation, and interactive discussion with expert clinical teachers. Fifty-five clinicians in Nepal participated, including physicians (47%), nurses (44%), and psychotherapists (5%). Clinicians reported improvements in knowledge, skills, and attitudes after program participation. Program acceptability scores were high, with 93% of participants reporting that the course provided effective learning. Project ECHO can be successfully implemented to deliver continuing professional development in Nepal. Delivering palliative care education online using the Project ECHO model, leads to improved knowledge, skills, and attitudes for clinicians. Project ECHO suggests an innovative solution which can provide training and support to clinicians in settings where educational opportunities in palliative care are limited.

Workforce Plan: A Missed Opportunity for Palliative Care?

Workforce Plan: A Missed Opportunity for Palliative Care?

High Rate of Unpaid Caregiving, Pain, and Depression Among Older Seriously Ill Patients Undergoing Elective Surgery Is an Opportunity for Palliative Care

INTRODUCTION: Serious illness is defined as a life-limiting condition negatively impacting daily function, quality of life, or excessively straining caregivers. Over 1 million older seriously ill adults undergo major operation annually, and understanding preoperative caregiving needs and symptom burden could inform intervention to improve outcomes. We hypothesize that before elective surgical admission, older seriously ill surgical patients have high unpaid caregiving hours and high prevalence of pain and depression. METHODS: Using Health and Retirement Study data (2008 to 2018) linked to Medicare claims, we identified patients older than 66 years of age who met an established definition of serious illness for administrative data and underwent major elective surgery using Agency for Healthcare Research and Quality criteria. Descriptive analyses were performed for baseline patient characteristics, as well as number of preoperative unpaid caregiving hours (dichotomized by hours/week: low, <14; high, >14), pain (dichotomized as none/mild or moderate/severe), and depression (dichotomized as no, Center for Epidemiologic Studies Depression Scale [CES-D] < 3, or yes, CES-D >3). RESULTS: Of 1,404 patients, 55.3% were women and 81.2% White. Mean age was 77.9 years (SD 6.8), and 84.9% had more than 2 comorbidities. The most common procedure was total knee replacement (8.6%). Before admission, approximately 30% of patients had unpaid caregivers, and of these, 45.8% received more than 14 caregiving hours/week. Preadmission pain and depression was 43.8% and 33.7%, respectively. CONCLUSION: Before elective surgery, older adults with serious illness have high numbers of unpaid caregiving hours and high prevalence of pain and depression. These findings highlight opportunities for targeted palliative care intervention during the surgical episode.

Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration.

ContextApproximately 40%-60% of deaths in the pediatric intensive care unit (PICU) are in the context of de-escalation of life-sustaining treatments (LSTs), including compassionate extubation, withdrawal of vasopressors, or other LSTs. Suffering at the end of life (EOL) is often undertreated and underrecognized. Pain and poor quality of life are common concerns amongst parents and providers at a child’s EOL. Integration of palliative care (PC) may decrease suffering and improve symptom management in many clinical situations; however, few studies have described medical management and symptom burden in children with cancer in the pediatric intensive care unit (PICU) undergoing de-escalation of LSTs.MethodsA retrospective chart review was completed for deceased pediatric oncology patients who experienced compassionate extubation and/or withdrawal of vasopressor support at EOL in the PICU. Demographics, EOL characteristics, and medication use for symptom management were abstracted. Descriptive analyses were applied.ResultsCharts of 43 patients treated over a 10-year period were reviewed. Most patients (69.8%) were white males who had undergone hematopoietic stem cell transplantation and experienced compassionate extubation (67.4%) and/or withdrawal of vasopressor support (44.2%). The majority (88.3%) had a physician order for scope of treatment (POST – DNaR) in place an average of 13.9 days before death. PC was consulted for all but one patient; however, in 18.6% of cases, consultations occurred on the day of death. During EOL, many patients received medications to treat or prevent respiratory distress, pain, and agitation/anxiety. Sedative medications were utilized, specifically propofol (14%), dexmedetomidine (12%), or both (44%), often with opioids and benzodiazepines.ConclusionsPediatric oncology patients undergoing de-escalation of LSTs experience symptoms of pain, anxiety, and respiratory distress during EOL. Dexmedetomidine and propofol may help prevent and/or relieve suffering during compassionate de-escalation of LSTs. Further efforts to optimize institutional policies, education, and collaborations between pediatric intensivists and PC teams are needed.

Prevalence of One-Year Mortality after Implantable Cardioverter Defibrillator Placement: An Opportunity for Palliative Care?

Background: Current guidelines recommend against placement of implantable cardioverter defibrillators in patients with a life expectancy less than one year. These patients may benefit from early palliative care services; however, identifying this population is challenging. Objective: Determine whether a validated prognostic tool, based on patient factors and health care utilization from electronic medical records, accurately predicts one-year mortality at the time of implantable cardioverter defibrillator placement. Design: We used the United States (U.S.) Veterans Administration's "Care Assessment Needs" one-Year Mortality Score to identify patients at high risk of mortality (score ≥95) before their procedure. Data were extracted from the Corporate Data Warehouse. Logistic regression was used to assess the odds of mortality at different score levels. Setting/Subjects: Patients undergoing a new implantable cardioverter defibrillator procedure between October 1, 2015 and September 30, 2017 in the U.S. Veterans Administration. Results: Of 3194 patients with a new implantable cardioverter defibrillator placed, 657 (21.8%) had a score ≥95. The mortality rate among these patients was 151/657 (22.9%) compared with 281/3194 (8.8%) for all patients undergoing a new implantable cardioverter defibrillator procedure. Patients with a score ≥95 had 14.0 (95% confidence interval 8.0-24.4) higher odds of death within one year of the procedure compared with those with a score ≤60. Conclusions: The "Care Assessment Needs" Score is a valid predictor of one-year mortality following implantable cardioverter defibrillator procedures. Integrating its use into the management of Veterans Administration (VA) patients considering implantable cardioverter defibrillators may improve shared decision making and engagement with palliative care.

Palliative Care Clinical Trials: Building Capability and Capacity.

Clinical trials are a key component of expanding the evidence base in palliative care. A key strategic objective of the Victorian Comprehensive Cancer Centre (VCCC), a multisite cancer center alliance, was to increase palliative care clinical trial expertise. The palliative care services within the VCCC alliance presented substantial trial development opportunities with large number of patients and established relationships, but few trial-active centers. Objectives: To establish a multi-site "Building Capability in Palliative Care Clinical Trials" program as a service development, and to assess the strategies, activities, and the outcomes resulting from this program. Methods: A series of strategies and activities were developed linked to the key program objectives of increasing the number of clinical sites and skilled clinicians conducting clinical trials, increasing the number of trials available and patients participating, broadening research opportunities in palliative care, and establishing the program sustainability. Results: In the two years of implementation, the program resulted in the establishment and conduct of several Phase 4 postmarketing pharmacovigilance studies, nine Phase 2 and 3 trials across five palliative care services, and a Phase 1 clinical trial. During the program, 150 patients were recruited to clinical trials, and 258 prospective pharmacovigilance monitoring cases were recorded. Five investigator-initiated trials were developed by clinical trial fellows and achieved competitive (n = 3) or commercial (n = 2) funding. Clinicians reported that undertaking clinical trials had increased attention to the evidence base of care provision, and increased service research activity more broadly. Long-term sustainability remains a challenge, particularly in the context of the COVID-19 pandemic. Conclusions: Clinical trials in palliative care services are feasible, acceptable, and result in increased attention to the evidence base of care. The strategies detailing the framework, activities, and outcomes have been collated to facilitate implementation of clinical trials in other sites and with other trial-naive disciplinary groups.

Stakeholder engagement in research on quality of life and palliative care for brain tumors: a qualitative analysis of #BTSM and #HPM tweet chats.

BackgroundResearch is needed to inform palliative care models that address the full spectrum of quality of life (QoL) needs for brain tumor patients and care partners. Stakeholder engagement in research can inform research priorities; engagement via social media can complement stakeholder panels. The purpose of this paper is to describe the use of Twitter to complement in-person stakeholder engagement, and report emergent themes from qualitative analysis of tweet chats on QoL needs and palliative care opportunities for brain tumor patients.MethodsThe Brain Cancer Quality of Life Collaborative engaged brain tumor (#BTSM) and palliative medicine (#HPM) stakeholder communities via Twitter using tweet chats. The #BTSM chat focused on defining and communicating about QoL among brain tumor patients. The #HPM chat discussed communication about palliative care for those facing neurological conditions. Qualitative content analysis was used to identify tweet chat themes.ResultsAnalysis showed QoL for brain tumor patients and care partners includes psychosocial, physical, and cognitive concerns. Distressing concerns included behavioral changes, grief over loss of identity, changes in relationships, depression, and anxiety. Patients appreciated when providers discussed QoL early in treatment, and emphasized the need for care partner support. Communication about QoL and palliative care rely on relationships to meet evolving patient needs.ConclusionsIn addition to providing neurological and symptom management, specialized palliative care for brain tumor patients may address unmet patient and care partner psychosocial and informational needs. Stakeholder engagement using Twitter proved useful for informing research priorities and understanding stakeholder perspectives on QoL and palliative care.

Opportunities for Palliative Care in Patients with Burn Injury—A Systematic Review (GP718)

•Identify, compare and discuss shared fundamental components of quality palliative care and quality burn care.•Describe process of designing and executing a systematic review of palliative care interventions for burn patients and analyze results.•Assess implications of our results for further research opportunities at the intersection of palliative medicine and burn care. Patients with significant burn injuries likely have palliative care needs. We performed a systematic review of existing evidence concerning the palliative care needs of burn patients. Through November 26, 2018, we systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using search terms representing burn injuries and the eight domains of quality palliative care as outlined by the National Consensus Project for Quality Palliative Care. Eligible articles were required to involve burn injured patients who were treated with an intervention targeting at least one of the eight domains of quality palliative care. For each article meeting criteria, two members of the team independently extracted data. Results from the identified studies were presented in a tabular summary and summarized in a qualitative synthesis. Meta analysis was not possible due to varied content and data. Our searches yielded 7,532 unique records which led to 238 manuscripts for full review and 88 studies which met inclusion criteria. Seventy-five studies addressed the domain “Physical Aspects of Care” and merit a separate systematic review; 13 studies were included in our final review. Four of the 7 domains—rocesses of care, psychologic symptoms, social aspects, and end-of-life—were addressed by studies, but three domains—spiritual, cultural, or ethics—were unaddressed. Included studies highlight potential benefits in patient quality-of-life from peri-discharge self-care education programs, peer support and group therapy. End-of-life decision making protocols initiated in patients with severe injuries were associated with increased utilization of comfort-focused treatments. Most existing palliative care-related research in burn patients addresses interventions for physical symptoms with minimal literature concerning other domains. Future research opportunities include: intervention generation and testing for under-researched domains and standardizing language and outcomes across palliative care interventions.

Opportunities for Palliative Care in Patients with Burn Injury—A Systematic Review (FR407C)

Opportunities for Palliative Care in Patients with Burn Injury—A Systematic Review (FR407C)

Health Insurance 101: Opportunities for Palliative Care (FR471)

Health Insurance 101: Opportunities for Palliative Care (FR471)

Opportunities for Palliative Care in Patients With Burn Injury—A Systematic Review

ContextPatients with significant burn injuries likely have palliative care needs. ObjectivesWe performed a systematic review of existing evidence concerning the palliative care needs of burn patients. MethodsThrough November 26, 2018, we systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using terms representing burn injuries and the eight domains of quality palliative care as outlined by the National Consensus Project for Quality Palliative Care. Eligible articles involved burn-injured patients treated with an intervention targeting at least one of the eight domains. ResultsOur searches yielded 7532 unique records, which led to 238 articles for full review and 88 studies that met inclusion criteria. Seventy-five studies addressed the domain physical aspects of care and merit a separate systematic review; 13 studies were included in our final review. Four of the seven domains—processes of care, psychologic symptoms, social aspects, and end of life—were addressed by studies but three domains—spiritual, cultural, or ethics—were unaddressed. Included studies highlight potential benefits from peridischarge self-care education programs, peer support, and group therapy in improving quality of life. In patients with severe injuries, end-of-life decision-making protocols were associated with increased utilization of comfort-focused treatments. ConclusionMost existing palliative care-related research in burn patients addresses interventions for physical symptoms with minimal literature concerning other domains. Opportunities exist for further research of palliative care in burn populations with emphasis on addressing interventions for all domains and better standardizing the language and outcomes for the palliative care interventions.

Emergency abdominal surgery in patients presenting from skilled nursing facilities: Opportunities for palliative care

BackgroundResidents of skilled nursing facilities (SNF) with acute abdomen present with more comorbidities and frailty than community-dwelling (CD) counterparts. Outcomes in this population are poorly described. MethodsWe hypothesized that SNF patients have higher mortality and morbidity than CD patients. This retrospective review of the NSQIP database from 2011 to 2015 compared outcomes of SNF and CD patients presenting with bowel obstruction, ischemia and perforation. Primary outcomes were in-hospital and 30-day mortality and failure-to-rescue (FTR). Results18,326 patients met inclusion criteria. 904 (5%) presented from SNF. In-hospital (26% vs 10%) and 30-day mortality (33% vs 26%) was higher in SNF patients (p < 0.001). The FTR rate was 34% for SNF patients and 20% for CD patients (p < 0.001). ConclusionsPresentation from SNF is an independent predictor of mortality and FTR. Presentation from SNF is a potential trigger for early, concurrent palliative care to assist surgeons, patients, and families in decision making and goal-concordant treatment.

Palliative Care Opportunities Among Adults With Congenital Heart Disease—A Systematic Review

ContextLittle is known about advance care planning (ACP) and palliative care needs among adults with congenital heart disease (ACHD). ObjectivesThe objective of this study was to identify and synthesize studies concerning palliative care among ACHD patients. MethodsWe searched five electronic databases (PubMed, Embase, SCOPUS, Web of Science, and CINAHL) using the keywords palliative care and congenital heart disease. Inclusion criteria were adults (age > 18 years) with congenital heart disease and publications in English through March 3, 2019. ResultsOur search yielded 2872 studies, and after removal of duplicates, we screened 2319 abstracts and identified seven for inclusion. Study findings were grouped into three domains: ACP, symptomatology, and end-of-life care. Among the five cross-sectional studies, only 1%–28% of ACHD patients recalled participating in ACP discussions with their doctors but 69%–78% reported a strong interest and desire to participate in ACP. In one study, 46% (n = 67) of patients had elevated anxiety symptoms (Hospital Anxiety and Depression Scale [HADS-A] ≥ 8) and 11% (n = 15) had elevated depressive symptoms (HADS-A ≥ 8). ACHD patients who had a documented goals of care conversation before cardiac decompensation had a lower incidence of resuscitation and aggressive treatments at end of life (12% [n = 3] vs. 100% [n = 12], P < 0.001). ConclusionWhile few ACHD patients complete advance directives, our findings support that many ACHD patients recognize the value of initiating end-of-life and goals of care conversations early on in the course of illness. Future studies investigating communication and implementation strategies of ACP as well as the symptom experience of patients with ACHD are needed.

Translational and basic science opportunities in palliative care and radiation oncology.

Radiation therapy is commonly used in the metastatic setting to palliate pain, neurological deficits, bleeding and other complications of metastatic disease, allowing patients to live longer and have better quality of life. Despite the effective use of radiation and other palliative treatment modalities, many patients continue to experience poorly controlled pain and other serious sequelae of their disease, underscoring the need for additional research in this area. In this review we highlight recent developments impacting the fields of palliative care and radiation oncology and describe opportunities for research and innovation including studies of tumor microenvironment, identification of effective biomarkers of tumor response and combinatorial treatments with new systemic agents. It is our hope that progress in these fields will improve the lives of patients living with advanced malignancies.

Patient-Reported Outcomes for Cancer Patients Receiving Checkpoint Inhibitors: Opportunities for Palliative Care—A Systematic Review

ContextImmune checkpoint inhibitors (ICIs) are increasingly used to treat a variety of cancers, but comparatively little is known about patient-reported outcomes (PROs) and health-related quality of life (HRQoL) among patients receiving these novel therapies. ObjectivesWe performed a systematic review to examine PROs and HRQoL among cancer patients receiving ICIs as compared to other anticancer therapies. MethodsWe systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using search terms representing ICIs, PROs, and HRQoL on August 10, 2018. Eligible articles were required to involve cancer patients treated with ICIs and to report PROs and/or HRQoL data. ResultsWe screened 1453 references and included 15 publications representing 15 randomized controlled trials in our analysis. Studies included several cancer types (melanoma, lung cancer, genitourinary cancer, and head/neck cancer), used four different ICIs (nivolumab, pembrolizumab, atezolizumab, and ipilimumab), and compared ICIs to a wide range of therapies (chemotherapy, targeted therapies, other immunotherapy strategies, and placebo). Studies used a total of seven different PROs to measure HRQOL, most commonly the European Organisation for the Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) (n = 12, 80%). PRO data were reported in a variety of formats and at a variety of time points throughout treatment, which made direct comparison challenging. Some trials (n = 11, 73%) reported PROs on specific symptoms. In general, patients receiving ICIs had similar-to-improved HRQoL and experiences when compared to other therapies. ConclusionDespite the broad clinical trials experience of ICI therapies across cancer types, relatively few randomized studies reported PROs and patient HRQoL data. Available data suggest that ICIs are well tolerated in terms of HRQoL compared to other anticancer therapies although the conclusions are limited by the heterogeneity of trial designs and outcomes. Currently used instruments may fail to capture important symptomatology unique to ICIs, underscoring a need for PROs designed specifically for ICIs.

Introduction to a New Special Series for the Journal of Pain and Symptom Management—Science in Action: Evidence and Opportunities for Palliative Care Across Diverse Populations and Care Settings

Practices to optimize palliative care delivery and new opportunities in which to integrate palliative care vary across populations and care settings. Systematic reviews are an efficient and methodologically rigorous approach to summarize existing research to identify both evidence-based best practices and new areas for future research and clinical practice. This is the introduction to a special series of articles in which members of the American Academy of Hospice and Palliative Medicine Research Committee report the results of circumscribed systematic reviews, which in a specific population or care setting seek to 1) summarize existing evidence for optimal palliative care practices or 2) identify opportunities where better palliative care delivery could improve patient and/or family outcomes.

An Opportunity for Palliative Care: Symptom Burden in Patients with Amyloidosis (S872)

1.Evaluate symptom burden of patients undergoing treatment for amyloidosis.2.Justify the need for palliative specialists to be a part of standard of care for patients with amyloid.3.Propose a model for palliative care to be integrated with standard of care for patients with amyloidosis. Although significant symptom burden has been described in patients with amyloidosis, few studies have used a validated tool to assess symptom burden or severity. Amyloidosis has many similarities to cancer; prognosis is poor, multiple organs may be involved, and treatment toxicities are common. To evaluate baseline symptom severity using the Edmonton Symptom Assessment System (ESAS), and the change in total symptom burden between outpatient hematology-oncology clinic visits in patients with amyloidosis. Retrospective chart review of 48 consecutive patients with amyloidosis presenting to a cancer center outpatient clinic. ESAS and Total Symptom Distress Scores (TSDS) representing the combined physical, emotional, and well-being intensities were reported at each visit. Individual ESAS scores ≥4 were considered moderate to severe intensity. The minimal clinically important difference (MCID) was calculated for TSDS between first and second visits. Based on past research cutoffs used were ≥+3/90 for improvement and ≤-4/90 for deterioration. Patients being co-managed with at least one appointment with palliative care (PC) during the study period, were noted. Baseline ESAS scores were collected on 48 patients with 31 also receiving a second. At baseline 34 (71%) had at least one or more moderate-severe symptoms. Fatigue in 23 (48 %) and insomnia 42% were most common. The MCID for TSDS showed 35% of patients improved while 35% showed deterioration. Only 6 (13%) of patients received palliative care. Many patients with amyloidosis experience high symptom burden, and although the majority report moderate/ severe fatigue, and insomnia, few are co-managed by PC. About one third had improved symptom burden at their second visit.

Patients with End-Stage Renal Disease and Acute Surgical Abdomen: Opportunities for Palliative Care.

Background: End-stage renal disease (ESRD) is a life-limiting condition that is often complicated by acute abdominal emergency. Palliative care (PC) has been shown to improve the quality of life in patients with serious illness and yet is underutilized. We hypothesize that ESRD patients with abdominal emergency have high unmet PC needs. Objective: To characterize the outcomes of ESRD patients with acute surgical abdomen, define PC utilization patterns, and identify areas of unmet PC needs. Design: Retrospective study querying the National Inpatient Sample database (2009-2013). Setting and Subjects: Subjects were identified using ICD-9 codes for those aged ≥50 with preexisting diagnosis of ESRD with an acute abdominal emergency diagnosis of gastrointestinal perforation, obstruction, or ischemia. Measurements: Outcomes included PC rate, in-hospital mortality, discharge disposition, and intensity of care. Multivariable logistic regression analysis was used to identify predictors of PC. Results: A total of 9363 patients met the inclusion criteria; 24% underwent surgery, 16% died in hospital, and 43% were discharged to dependent living. Among in-hospital deaths, 23% received PC. Only 4% of survivors with dependent discharge received PC. Surgical mortality was 26%. PC was less utilized in surgical patients than nonsurgical patients. PC was associated with shorter hospital stay. Predictors of PC included increasing age, severity of underlying illness, white race, teaching hospitals, and the Western region. Conclusions: Patients with ESRD admitted for acute abdominal emergency have high risk for mortality and functional dependence. Despite this, few receive PC and have a high utilization of nonbeneficial life support at the end of life.

The National Palliative Care Research Center: Ten Years of Promoting and Developing Research in Palliative Care.

The evidence base to support high-quality clinical care and number of scientists available to develop this evidence base are inadequate. To describe the first 10 years of the National Palliative Care Research Center's (NPCRC) programs and their outcomes. Established in 2005, NPCRC was created in direct response to the recommendations of the Institute of Medicine. Specifically, NPCRC was created to expand the palliative care evidence-based needed for both health policy and clinical practice by supporting research scientists, stimulating research and innovation, and creating a community of researchers focused on the needs of persons with serious illness and their families. Subsequent grant funding following NPCRC investment (web searches of NIH Research Portfolio Online Reporting Tools [RePORT], Veterans Administration and Patient Centered Outcomes Research Institute [PCORI] grant databases, grantee on-line surveys, and grantee annual reports) promotions (grantee on-line surveys and annual reports), publications (PubMed searches), and NPCRC participant satisfaction (grantee questionnaires). As of July 2017, NPCRC has funded 47 junior investigators representing over 10 disciplines. These investigators have leveraged NPCRC's $7.8 million investment into 52 federal grants totaling $74.8 million dollars and 69 foundation grants totaling $16 million. Thirty-five grants ($5.8 million) have been awarded to experienced investigators, resulting in additional grant funding of $104.5 million dollars ($78.5 million federal, $26 million nonfederal). Satisfaction with NPCRC's program has been uniformly high and policy efforts have resulted in enhanced federal funding opportunities in palliative care research. NPCRC's focus on people and infrastructure in conjunction with a top-down bottom-up strategy has been critical in improving the palliative care evidence base.