Outpatient Supportive Care Center Research Articles

EHR-based process to reduce no-shows at the outpatient supportive care clinic at a tertiary cancer center.

263 Background: No-Shows are pervasive across healthcare systems and are associated with interrupted clinical workflows, increased cost, healthcare utilization, and increased morbidity, and mortality. In palliative care, patients who miss their appointments are more likely to have uncontrolled symptoms, frequent Emergency Room visits, and unplanned hospitalization. There is an ongoing need to reduce no-shows to improve patient outcomes. Methods: The aim of this quality improvement (QI) project, launched in September 2022 at the outpatient supportive care center (SCC) at the University of Texas MD Anderson Cancer Center, was to reduce overall no-shows by process improvement in the targeted areas. We developed a process map and Ishikawa diagram to outline workflow and reasons for no-shows. Based on the results of a previous study from our center, 8% of no-shows were due to hospitalization. We used the Plan Do Study Act (PDSA) tool. We developed an electronic query for the Electronic Health Record (EHR) to identify hospitalized patients with an upcoming appointment at SCC in the next 10 days. We redesigned the clinical workflow to generate a daily list of such appointments which were canceled and replaced by patients on the waitlist. We assessed overall no-show rate and rate specific to hospitalizations for our center monthly for eight months. This QI project was approved by the Quality Improvement Assurance Board at the University of Texas MD Anderson Cancer Center. Results: Overall no-show rate was 12% before intervention (BI) and decreased to 8% after intervention (AI), measured at 8 months. No-show rate due to hospitalizations decreased from 9% BI to 2% AI. Telehealth visits had a lower rate of no-shows (5.9%) than in person visits (10.4%). No-show rates did not differ based on days of the week (median 7.4%, SD 0.3%), and the type of visit - consult vs. follow-up (8% vs. 7%). Conclusions: Clinical workflow redesign using EHR at our SCC decreased no-shows due to hospitalization, thereby reducing overall no-show rate by 33% of the original. However, most no-shows are due to reasons other than hospital stays, and more research is needed to identify these patient and system level factors.

A Comparison of Caregiver Burden of Patients with Advanced Cancer in Different Palliative Cancer Care Settings.

Background: Informal caregivers may experience a significant burden while caring for cancer patients. Little is known about how caregiver burden varies across different palliative cancer care settings and the factors influencing it. Objectives: We compared the severity of caregiver subjective stress burden (emotional impact) among caregivers of patients seen in the outpatient supportive care center (SCC) with those being cared for in the acute palliative care unit (PCU). Secondary aims were to compare other caregiver burden dimensions, quality of life, and any association of caregiver subjective stress burden to various patient and caregiver factors. Setting and Design: Eligible patients and their informal caregivers in the SCC or PCU at a comprehensive cancer center in the USA were approached and enrolled. The Montgomery-Borgatta Caregiver Burden Scale and the Short-form 36 were used to measure burden and quality of life. Multivariate general linear regression was employed to evaluate the effect of covariates on subjective stress burden. Results: Ninety-eight dyads in the SCC and 74 dyads in the PCU were enrolled. PCU caregivers reported worse subjective stress burden (p = 0.0029) and mental health (p = 0.0299). Multivariate analysis showed correlations between subjective stress burden and caregivers' objective burden (p = 0.0136), subjective demand burden (p ≤ 0.0001), mental health (p = 0.0074), duration of caregiving (p = 0.0680), education (p = 0.0192) and with patients' anxiety (p = 0.0003) and current/recent cancer treatment (p = 0.0579). Conclusion: PCU caregivers demonstrated worse emotional burden and mental health than those in the SCC. More research is needed to tailor interventions for various caregiver burden dimensions. NCI Clinical Trial Registration Number ID: NCI-2019-01197.

Genetic Factors Associated With Pain Severity, Daily Opioid Dose Requirement, and Pain Response Among Advanced Cancer Patients Receiving Supportive Care

BackgroundCurrent understanding of genetic factors associated with pain severity, and improvement of pain with opioids in advanced cancer patients (AC) is inadequate for delivery of personalized pain therapy (PPT). Therefore, the aim of this study was to determine the genetic factors associated with pain severity, daily opioid dose, and pain response in AC patients receiving supportive care. MethodsIn this prospective study, AC patients were eligible if they had cancer pain ≥4/10 on Edmonton Symptom Assessment Scale (ESAS) - Pain Item and needed opioid rotation for pain control by specialist at the outpatient supportive care center. Association of genetic factors with pain phenotype was assessed using logistic regression models and SKATO (Gene-block) analysis. ResultsAbout 174/178 (98%) patient samples were analyzed. After adjustment for demographic and clinical variables, pain severity was negatively associated with intron variant alleles in OPRM1 rs9322446, P = 0.02; rs2270459, P = 0.038; rs62052210, P = 0.038. Opioid daily dose was positively associated NFKBIA rs2233419, P = 0.008; rs2233417, P = 0.007; rs3138054, P = 0.008; rs1050851, P = 0.015; ORPM1 rs9479759, P = 0.046; rs2003185, P = 0.047; rs636433, P = 0.044; COMT (rs9306234, P = 0.014; rs165728, P = 0.014; rs2020917, P = 0.036; rs165728, P = 0.034); ARRB2 (rs1045280, P = 0.045); and pain response to opioids was negatively associated OPRM1 rs1319339, P = 0.024; rs34427887, P = 0.048; and COMT rs4646316, P = 0.03; rs35478083, P = 0.028, respectively. SKATO analysis showed association between pain severity and CXCL8 (P = 0.0056), and STAT6 (P = 0.0297) genes respectively, and pain response with IL-6 (P = 0.00499). ConclusionsThis study identified that SNPs of OPRM1, COMT, NFKBIA, CXCL8, IL-6, STAT6, and ARRB2 genes were associated with pain severity, opioid daily dose, and pain response in AC receiving supportive care. Additional studies are needed to validate our findings for PPT.

Edmonton Symptom Assessment Scale Time Duration of Self-Completion Versus Assisted Completion in Patients with Advanced Cancer: A Randomized Comparison.

To compare the time duration of self-completion (SC) of the Edmonton Symptom Assessment Scale (ESAS) by patients with advanced cancer (ACPs) versus assisted completion (AC) with a health care professional. In this randomized comparison of ACPs seen in initial consultation at the outpatient Supportive Care Center at MD Anderson, ACPs who have never completed the ESAS at MD Anderson were allocated (1:1) to either SC of the ESAS form versus AC by a nurse. Time of completion was measured by the nurse using a stopwatch. Patients completed the Rapid Estimate of Adult Literacy in Medicine (REALM) test prior to administration of the ESAS. In the SC group, the nurse reviewed the responses to verify that the reported ESAS scores were correct. A total of 126 ACPs were enrolled (69 patients to AC and 57 to SC). Seventy-one patients were female, median age was 60 years, and median REALM score was 65. Median (interquartile range) time (in seconds) of SC was significantly less than AC (73 [42.9-89.1] vs. 109 [79.5-136.7], p < .0001). With nurse review time included, median time of SC increased to 117 seconds, which was not significantly different from AC (p = .28). Lower literacy (REALM) score and shortness of breath were significantly associated with increased completion time (p = .007). Regular use of ESAS will have minimal impact on clinical time, as it can be completed in about 1 minute and provides a concise yet comprehensive and multidimensional perspective of symptoms that affect quality of life of patients with cancer. Because the Edmonton Symptom Assessment Scale can be completed in less than 2 minutes, hopefully the routine use of this simple yet comprehensive and multidimensional symptom assessment tool will be used at all medical visits in all patients with cancer so that the timely management of symptoms affecting patients' lives and treatment courses can occur, further enhancing personalized cancer care.

Cancer Patients' Perceived Difficulties Filling Opioid Prescriptions After Receiving Outpatient Supportive Care

ContextLimited access to opioids for patients with cancer has been reported as a potential unintended consequence of recent regulations restricting opioid use and prescribing practices. To our knowledge, there are a limited number of peer-reviewed studies that evaluate the perceived difficulties of the patients with cancer when filling their opioid prescription. To understand these difficulties, we surveyed patients receiving opioids in our outpatient supportive care center (SCC). ObjectivesThe primary objective of this study was to evaluate cancer patients' perceptions of overall difficulties when filling their opioid prescription. Secondary objectives included determining associations between patient characteristics and difficulty and comparing difficulty between filling opioid and nonopioid prescriptions. MethodsPatients with cancer receiving opioids that had been seen two times or more at our SCC were asked to complete a survey. The information collected included patient demographics, clinical characteristics, and patients' experiences filling their opioid prescription. ResultsThe patients' median age was 60 years; 54% were female and 69% were white. Forty-four patients (32%) reported that they have experienced difficulty filling their opioid prescription. More than 25% of those 44 patients perceived difficulty from interactions with the pharmacy and/or pharmacist. Forty-six patients (33%) reported more difficulty filling their opioid prescriptions than filling their nonopioid prescriptions. ConclusionThis study provides evidence that patients with cancer visiting our SCC perceived difficulties obtaining their opioid prescriptions. The results suggest that negative interactions with the pharmacy and/or pharmacist contribute to their perceived difficulty. Additional research is needed to further characterize the contributors of the difficulties patients with cancer face in filling their opioid prescriptions.

Enhancing palliative care patient access to psychological counseling through outreach telehealth services.

Palliative care encompasses an interdisciplinary team, including mental health care professionals, to address psychological distress of cancer patients. To present the implementation of an outreach counseling program via videoconferencing or telephone to patients receiving care in an outpatient palliative care clinic and to compare patients using this service to those who only received psychological counseling in our outpatient clinic. We conducted a retrospective chart review of cancer patients seen for psychology counseling services in an outpatient supportive care center between June 2015 and March 2017. We reviewed 2072 unique patients (52% of the total patients seen at the outpatient Supportive Care Center), who had 4567 total counseling encounters across outreach and outpatient settings. A total of 452 (22%) patients participated in a combination of outpatient and outreach counseling services. Patients who participated in outreach services had significantly more encounters (311 [69%] had two to five sessions) compared with those who had outpatient services only (1137 [70%] had one session only) (P < .001). Outreach patients also had shorter times between the initial and follow-up encounters (median 14 days) compared with those who had outpatient services only (median 30 days) (P < .0001). Outreach telehealth counseling services was found to enhance palliative care patient access to psychological counseling. These services represent an additional modality for providing continuous psychological care.

Impact of Physician Attire on Palliative Care Patients’ Perception of Physician Compassion and Professionalism: A Randomized Clinical Trial (RCT) (S804)

1.List different elements of communications skills.2.Discuss how attire can be a form of non-verbal communication. Environment is an important component of communication skills. Physicians’ communication style including attire may influence patient perceptions. Previous studies mostly based on pictures of providers in different attires provide conflicting evidence. This RCT aimed to explore the effects of a physician’s attire on patients’ perceptions. Hypothesis was that patients will perceive the physician with formal attire as more compassionate & professional than the physician wearing casual attire. 105 English speaking adult patients presenting as follow-ups to out-patient supportive care center, were randomized to watch 2 standardized, 3-minute video vignettes, with similar script, depicting a routine clinic encounter. In one video, physician was wearing formal attire with tie and buttoned up white coat, while in the other, physician was in casual attire without a tie or white coat. Actors and patients were all blinded to the purpose of the study. Investigators were blinded to the videos watched by the patients. After viewing each video, patients completed validated questionnaires rating their perception of physician compassion (0 = best, 50 = worst), professionalism (5 = poor, 25 = very good) & overall preference for the physician. No significant differences seen between formal and casual attire for compassion [median (interquartile range), 25 (10, 31) vs 20 (8, 27); P=0.31] and professionalism [17 (13, 21) vs 18 (14, 22); P=0.42]. 30% (32) patients preferred formal, 31% (33) preferred casual attire and 38% (40) had no preference. Subgroup analysis did not show statistically significant differences among age, sex, marital status & education level for compassion, professionalism & physician preference. Doctor’s attire did not have an impact on patients’ perceptions of physicians’ level of compassion & professionalism and did not influence their preferences for their doctor or their trust and confidence in the doctor’s ability to provide care. More RCTs are needed to better understand the impact of different forms of attire on patient perceptions & preferences.

Physician attire and palliative care patients’ perception of physician compassion and professionalism: A randomized controlled trial (RCT).

39 Background: Environment is important component of communication skills. Physicians’ communication style including attire may influence patient perceptions. Previous studies mostly based on pictures of providers in different attires provide conflicting evidence. This RCT aimed to explore the effects of physician attire on patients’ perceptions of compassion, professionalism and physician preference. Hypothesis was that patients will perceive the doctor in formal attire as more compassionate than the doctor wearing casual attire. Methods: 105 English speaking adult follow-ups at outpatient supportive care center, were randomized to watch 2 standardized, 3-minute video vignettes, with similar script, depicting a routine clinic encounter. In one video, physician was wearing formal attire with tie and buttoned up white coat, while in the other, physician was in casual attire without a tie or white coat. Actors and patients were all blinded to purpose of the study. Investigators were blinded to the videos watched by patients. After viewing each video, patients completed validated questionnaires rating their perception of physician compassion (0 = best, 50 = worst) and professionalism (5 = poor, 25 = very good). Patients were also asked to rate their preference for the physician. Results: There were no significant differences between formal and casual attire for compassion [median (IQR), 25 (10, 31) vs 20 (8, 27); P = 0.31] and professionalism, [17 (13, 21) vs 18 (14, 22); P = 0.42]. 32 (30%) patients preferred formal, 33 (31%) preferred casual attire and 40 (38 %) patients had no preference. Subgroup analysis did not show significant differences among age, sex, marital status and education level for compassion, professionalism and physician preference. Conclusions: Doctor’s attire did not have an effect on patients’ perception of physicians’ level of compassion and professionalism. Dress code also did not influence the patients’ preference for their doctor or their trust and confidence in the doctor’s ability to provide care. There is need for more RCTs in area of communication skills specifically to better understand the impact of different attires on patient perceptions. Clinical trial information: NCT03168763.

Timing of Referral and Characteristics of Uninsured, Medicaid, and Insured Patients Referred to the Outpatient Supportive Care Center at a Comprehensive Cancer Center

ContextLow-income patients face barriers to palliative care access, which might negatively influence symptom management and advanced care planning. ObjectiveOur aim was to compare time of referral and characteristics (level of symptom distress) among uninsured (indigent), low-insured (Medicaid), and insured patients presenting to our supportive care center (SCC). MethodsWe conducted a retrospective review of randomly selected 100 indigent, 100 Medicaid, and 300 insured outpatients referred during the same five-year period. We reviewed demographic and clinical characteristics including date of diagnosis of advanced cancer and of first visit to SCC, symptom assessment (Edmonton Symptom Assessment System), type and dose of opioid medication, number of total outpatient visits, and date of last contact with palliative care team. ResultsAmong 482 evaluable patients, indigent, Medicaid, and insured patients, respectively, had mean (SD) ages of 48 (11), 50 (12), and 63 (13) years (P < 0.001); Edmonton Symptom Assessment System pain scores at first visit of 6.7 (2.5), 5.6 (3.2), and 4.9 (3.2) (P < 0.001); nonwhite race in 60%, 49%, and 25% of cases (P < 0.001); unmarried status in 68%, 64%, and 33% of cases (P < 0.001), while 63%, 87%, and 54% of patients (P < 0.001) were on opioids with median number of encounters per month of 0.6, 0.8, and 0.5 (P = 0.001). Median survival (95% CI) from first visit to last contact was 4.6 (2.8–6.2), 5.4 (3.5–7), and 5.6 (4.7–7.3) months (P = 0.036). ConclusionPatients with limited or no insurance had significantly higher pain and were more frequently on opioids, younger, nonwhite, and not married. They required higher number of SCC follow-up visits. Insurance status did not affect timing of SCC referral or follow-ups at our cancer center.

The Effect of Message Content and Clinical Outcome on Patients' Perception of Physician Compassion: A Randomized Controlled Trial.

In a previous randomized crossover study, patients perceived a physician delivering a more optimistic message (MO) as more compassionate and professional. However, the impact of the clinical outcome of the patient on patient's perception of physician's level of compassion and professionalism has not been previously studied. Our aim was to determine if the reported clinical outcome modified the patient's perception of physician compassion, professionalism, impression, and preference for physician. One hundred twenty-eight advanced cancer patients in an outpatient Supportive Care Center were randomized to complete validated questionnaires about patients' perception of physician's level of compassion, professionalism, impression, and preference of physician for themselves and their family after watching scripted videos depicting a physician delivering an MO versus a less optimistic (LO) message followed by a clinical vignette depicting a worse outcome. Median age was 61 years and 55% were female. There was no difference in compassion score after the vignette in the MO and LO groups. However, there were significantly worse overall impression and professionalism scores in both the MO and LO groups after the vignette. In the MO group, preference for the physician for themselves and their family significantly decreased after the vignette. Seeing a worse clinical outcome did not change the patients' appraisal of an inappropriately optimistic physician. However, it reduced the overall impression of both physicians that conveyed an MO or an LO message and it also resulted in less likelihood of choosing the MO physician for themselves and their family. The study found that a patient's perception of a physician's compassion did not change after reading a vignette describing a negative clinical outcome, regardless of whether the physician had given a more or a less optimistic message to the patient. However, the results suggested that patients perceived worse professionalism and overall physician impression scores for both more and less optimistic physicians and lower likelihood to choose the more optimistic physician for themselves and their family.

Enhancing palliative care patient access to outpatient and outreach counseling services.

184 Background: MD Anderson’s interdisciplinary out-patient clinic, palliative care team includes mental health professionals who provide psychological care, including 3 full time Master’s level counselors. Counseling sessions are offered during the patient’s clinic appointments. To increase opportunity and access for additional counseling, patients are offered follow-up counseling through an outreach program which includes videoconferencing or telephone sessions. The data presented represents almost 2 years of our Master’s level clinicians’ practices. Methods: Retrospective chart review of 2041 consecutive patients (3606 total contacts) seen for psychology counseling services in the Supportive Care Center between 6/2015 and 3/2017. Results: Counselors saw 2041 consecutive patients (52% of the patients seen at the out-patient Supportive Care Center). Most patients only had 1 session in clinic (63%); almost 1/3 received 2-5 sessions (33.9%). Median time for the follow-up visit was 30.5 days. Approximately 25% (N = 511) were offered outreach services; 79% (N = 405) of those offered received these services. Median number of outreach sessions received was 1 (57%); 2-5 (38%); 6-9 (4%) and 10+ (1%). Sessions lasted 10-15 minutes (58%); 20-35 minutes (31%); and 40+ minutes (11%). Patient preferred mode of outreach included telephone (93%), Facetime (5.0%), and videoconferencing (2%). In total, 798 outreach sessions were provided representing 18% of total counseling sessions offered. Conclusions: The out-patient palliative care service is able to offer psychological assessment and counseling to more than half of the patients they serviced due to the addition of 3 Master’s level counselors embedded in the clinic. Follow-up counseling for these patients can be challenged for those residing in rural areas, with limited resources and/or transportation problems, and with physical limitations that make travel difficult. Our outreach program has successfully enhanced access to services to patients who otherwise may have had limited to no follow-up psychosocial care.

Effects of examination room computer on cancer patients perception of physician's compassion, communication skills, and professionalism: A randomized clinical trial.

26 Background: The use of electronic health records (EHR) continues to rise in various clinical settings. The full effects of EHR use on physician-patient interactions remain unclear. This study aims to compare patient perception of physician’s compassion, communication skills, and professionalism between a traditional face to face clinic visit with a visit where an examination room computer is used by the physician to access and document patient information. Methods: RCT was conducted at an outpatient supportive care center. 120 English speaking adults with advanced cancer were recruited. Patients were randomized to watch 2 standardized, 3-minute video vignettes depicting a routine physician-patient clinical encounter. Both videos had identical script. In one video, physician communicated face to face while in the other video physician used the examination room computer during conversation. Both actors and patients were blinded to the purpose of the study. Investigators were blinded to the sequence of videos watched by the patients. After viewing each video, patients completed validated questionnaires rating their perception of physician’s compassion (0 = best, 50 = worst), communication skills (0 = poor, 70 = excellent) and professionalism (0 = poor, 20 = very good). Patients were also asked to rate their overall physician preference. Results: After watching the first video, the face to face clinical encounter resulted in better compassion scores (median [interquartile range], 9[0-18] vs 20[6-28]; P = .0003), communication skills 65[54-70] vs 54[41-63]; P = .0001) and professionalism 19[5-20] vs 14[11-17]; P = .013). After crossover analysis, we found a significant period ( P = .004) and sequence ( P = .005) effect favoring the second video on compassion scores. After watching the second video, 86 (72%) of the patients preferred face to face communication. Conclusions: Patientsperceived physicians who communicated face to face without the use of computer as more compassionate, professional and with better communication skills. Moreover they preferred face to face physician to be their provider. Clinical trial information: NCT02957565.

The effect of message content and clinical outcome on patients' perceptions of physician compassion: A randomized controlled trial.

27 Background: In a previous randomized cross-over study, patients perceived a physician delivering a more optimistic message as more compassionate and professional. However, the impact of the clinical outcome of patient on patients’ perception of physician’s level of compassion and professionalism has not been previously studied. Our aim was to determine if the reported clinical outcome modified the patient’s perception of physician compassion, professionalism, impression, and preference for physician. Methods: 128 advanced cancer patients in an outpatient Supportive Care Center were randomized to complete validated questionnaires about patients’ perception of physician’s level of compassion, professionalism, impression and preference of physician for themselves and their family after watching scripted videos depicting a physician delivering a more optimistic (MO) vs. a less optimistic (LO) message followed by a clinical vignette depicting a worse outcome. Results: Median age was 61 years and 55% were female. There was no difference in compassion score after the vignette for both the MO and LO groups respectively [mean difference (SD): 1.7(8.74) p = 0.4684 vs. 0.89(10.24) p = 0.1225] but there were worse overall impression [mean difference (SD): MO -0.79(1.62) p &lt; 0.0001 vs. LO -1.17(1.91) p &lt; 0.0001] and professionalism scores [MO -0.88(2.25) p = 0.0022 vs. LO -0.76(2.22) p = 0.0094]. In the MO group, preference for the physician for themselves [mean difference (SD) -0.29(0.77) p = 0.0049] and their family [mean difference (SD) -0.29(0.71) p = 0.0009] decreased after the vignette. Conclusions: Seeing a worse clinical outcome did not change the patients’ appraisal of an inappropriately optimistic physician. However, it reduced the overall impression of both physicians that conveyed a more or a less optimistic message and it also resulted in less likelihood of choosing the more optimistic physician for themselves and their family. Clinical trial information: NCT02498899.

Frequency and factors predictive of aberrant drug behavior in patients presenting to outpatient supportive care center at a comprehensive cancer center.

10118 Background: Opioid misuse is a growing crisis in cancer patients. Cancer patients at risk of aberrant drug behaviors (ADB) are frequently underdiagnosed in routine cancer care. The aim of this study was to determine the frequency and factors associated with ADB using the “Screener and Opioid Assessment for Patients tool” (SOAPP-14) in cancer patients seen at the outpatient supportive care center. We also examined the screening performance of Cut Down, Annoyed, Guilty, and Eye Opener (CAGE-AID) as compared to The SOAPP-14 as a gold standard. Methods: In this retrospective study, 1108 consecutive patients referred to supportive care clinic were reviewed. Patients were eligible if they were ≥18 yrs, have a diagnosis of cancer, and were on opioids for pain for atleast a week. Patients’ demographics, the Edmonton Symptom Assessment Scale (ESAS), SOAPP-14, and CAGE-AID scores were analyzed. ADB+ was defined as SOAPP-14 score ≥7. Descriptive statistics, spearman correlation coefficient, multivariate, and ROC analysis were performed. Results: 703/1108 consults were eligible. A total of 153/703 (22%) were ADB +ve. SOAPP-14 scores were positively correlated with CAGE-AID r = .38, p &lt; 0.001; male gender r = 0.11, p = 0.003; ESAS pain r = 0.11, p = 0.005; ESAS depression r = 0.22, p &lt; 0.001; ESAS anxiety r = 0.22, p &lt; 0.001, and ESAS financial distress r = 0.23, p &lt; 0.001. Multivariate analysis indicated that the odds ratio for ADB +ve was 6.18 in patients with CAGE-AID+ (p &lt; 0.001), 1.8 for male gender (p = 0.007), 1.1/pt. for ESAS anxiety (p = 0.044), and 1.1/pt. for ESAS financial distress (p = 0.007). A CAGE-AID score of 1/4 has a sensitivity of 47%, specificity of 89% positive predictive value 63.6% and negative predictive value 69.2%. Conclusions: Our study suggests that 22% of cancer patients on opioids presenting to supportive care center are at risk of aberrant drug behavior (ADB). Male patients with anxiety, financial distress, and prior alcoholism/illicit drug use are significant predictors of ADB’s. A cut off score of ≥1 out 4 on CAGE-AID questionnaire allows better screening of ADB in outpatient advanced cancer patients. Further research to effectively manage these patients is needed.

Testing the feasibility of using the Edmonton Symptom Assessment System (ESAS) to assess caregiver symptom burden.

Caregiver symptom assessment is not part of regular clinical cancer care. The ESAS (Edmonton Symptom Assessment System) is a multidimensional tool regularly used to measure symptom burden in patients but not caregivers. The objectives of the present study were to determine the feasibility of the ESAS in caregiver completion (defined as ≥ 9 of 12 items) and determine its concurrent validity with the Zarit Burden Interview-12 (ZBI-12). We conducted a prospective study on 90 patient-primary caregiver dyads seen in an outpatient supportive care center in a cancer center. The 12 item ESAS-FS (financial-spiritual) was completed by the dyads along with other clinical and psychosocial measures. The caregiver ESAS was found to be feasible (90/90 caregivers, 100% completed ≥ 9/12 items) and useful (66/90 caregivers, 73%) by caregivers to report their symptom burden. Some 68 of 90 (76%) caregivers had symptom distress scores ≥ 4 on at least one symptom. A significant association was found between the ESAS scores of caregivers and patients for fatigue (0.03), depression (<0.01), anxiety (<0.01), sleep (0.05), well-being (<0.01), financial distress (<0.01), spiritual pain (<0.01), and total ESAS score (<0.01). Concurrent validity with the ZBI-12 was not achieved (r = 0.53, p = 0.74). A significant correlation was found between caregiver ESAS scores and time spent feeding, housekeeping, total combined caregiver activities, and total ZBI-12 scores. The caregiver ESAS is a feasible tool and was found useful by our caregivers. Further research is needed to modify the ESAS based on caregivers' recommendations, and further psychometric studies need to be conducted.

P135 Snapshot of an Outpatient Supportive Care Center at a Comprehensive Cancer Center

P135 Snapshot of an Outpatient Supportive Care Center at a Comprehensive Cancer Center

Association between tobacco use, pain expression, and maladaptive coping among patients with advanced cancer.

65 Background: Cancer patients who smoke have been reported to have higher pain expression and increased risk for opioid abuse. The purpose of our study is to evaluate the association between tobacco use, symptom expression, and maladaptive coping in advanced cancer patients. Methods: We prospectively enrolled advanced cancer patients evaluated in an outpatient Supportive Care Center and collected data on patient demographics, cancer diagnosis, morphine equivalent daily dose (MEDD), cigarette smoking status using Behavioral Risk Factor Surveillance System, symptom expression as measured by Edmonton Symptom Assessment Scale, Cut down/Annoyed/Guilty/Eye opener (CAGE alcoholism questionnaire), short form Screener and Opioid Assessment for Patients with Pain (SOAP-SF) survey, and Brief COPE Questionnaire. Results: Among399 patients, 195 (49%) were never smokers, 158 (40%) former smokers, and 46 (11%) current smokers. The most common malignancies were gastrointestinal (21.1%) and breast (19.5%). Never smokers were more likely to be female (p = 0.005). Current smokers expressed significantly higher pain scores at consultation than former or never smokers [median 7 vs. 6 vs. 5, respectively (p = 0.015)], increased MEDD (median 90 vs. 60 vs. 50, p = 0.002), and more likely to screen CAGE positive (33% vs. 24% vs. 8.7%, p &lt; 0.0001). Compared with former and never smokers, current smokers were significantly more likely to cope with substance use (p = 0.02), denial (p = 0.007), and self-blame (&lt; 0.0001), while both current and former smokers significantly more likely to use venting (p = 0.04). In addition, current smokers compared with former and never smokers were significantly more likely screen positive (≥ 4) on the SOAP-SF survey (74% vs. 13% vs. 9.3%, p = &lt; 0.0001) and clinicians rated patients to be at higher risk for maladaptive coping (6.5% vs 2.5% vs. 1.5%, p = 0.003). Conclusions: In advanced cancer, current and former smokers were significantly more likely to have higher pain expression, CAGE positivity, and increased MEDD at consultation. In addition, a history of current or past tobacco use in advanced cancer patients was associated with increased risk of maladaptive coping.

Snapshot of an outpatient supportive care center at a comprehensive cancer center.

145 Background: Integration of Palliative Care (PC) in oncology has been found to improve symptom distress, quality of life and survival in patients with advanced cancer. Early integration is most appropriate in the outpatient (OP) setting. However, most PC services in the U.S. do not have an OP component. Our study aims to provide a snapshot of the type of patients that are referred to this novel setting for the delivery of early PC. Methods: We reviewed a day in the SCC to illustrate the structure and process involved in the delivery of outpatient PC. We highlighted 9 patients seen that day to show the variety of patients, scope of services, and the unique roles that PC interdisciplinary team members perform. Results: 41 patients were seen that day in the SCC: 10 scheduled consults, 22 scheduled follow-ups, 9 (22%) same-day unscheduled patients: 4 follow-ups, 1 consult and 4 nurse triages. There were also 31 telephone encounters. Most patients seen were for routine follow-up and symptom assessment. However, 10 presented with worsening symptoms with one needing hospital admission. 21 patients required additional counseling: 2 for hospice transitioning, 12 for psychosocial distress, 7 for opioid education. PC was delivered predominantly by physicians and nurses with collaboration with our pharmacist, counselors, and case manager. Conclusions: Traditionally, PC has been delivered predominantly to patients with advanced disease and to aid in transition to end of life. In recent years, OP centers have dramatically changed the nature of PC work as in our snapshot. In addition to patients regarded as traditional PC patients, such as those transitioning to end of life, there are now patients who come in soon after arrival to a cancer center requiring specialized care to address a variety of symptom and educational needs, thus requiring adaptation of structure and processes to allow access for frequent follow ups and counseling and flexibility for walk-in visits. Our findings suggest that SCC needs to practice in a very different way which requires certain skills and assessment tools that are not conventionally present in traditional oncology clinic setting. More research is needed to identify the type of patients that would benefit most from a PC referral.

Characteristics of patients with unscheduled versus scheduled visits to outpatient supportive care center (SCC) at a comprehensive cancer center.

144 Background: There is limited literature regarding outpatient palliative care, and even more limited literature describing factors associated with unscheduled visits. Our aim was to identify clinical characteristics of patients who walk-in (present unscheduled) to the outpatient SCC with the hypothesize that the patients who present for unscheduled visits have more severe symptom distress as compared to those patients who present for scheduled appointments. Methods: We compared 183 patients with unscheduled consults (CO) vs a random sample of 361 patients with scheduled CO and 159 patients with unscheduled follow-up (FU) visits vs a random sample of 318 patients with scheduled FU visits. Results: Among 544 total CO visits, unscheduled visits had worse median Edmonton Symptom Assessment Scale (ESAS) symptoms (on a scale from 0 to 10): pain (6.5 vs 4.7, p &lt; .0001), fatigue (p = .002), nausea (p = .017), depression (p = .003), anxiety (p = 0.02), sleep (p = .0002), and overall feeling of well-being (p = 0.0009). There was no statistical difference in shortness of breath, financial distress, nor spiritual pain. Daily opioid dose (MEDD in mg) was significantly higher in unscheduled CO visits (119.7 vs 62.9, p = .0004). Among 344 total FU visits, unscheduled visits had worse median ESAS symptoms: pain (5.7 vs 4.2, p = .0001), fatigue (p = .0006), depression (p = .019), anxiety (p = .014) and higher MEDD (111.3 vs 73.6, p = .0009). There was no difference in type of insurance coverage and better ECOG (p = .015) in unscheduled vs scheduled CO visits. Unscheduled CO visits were more likely to be from outside the Houston area (161/361, 45% vs. 40/133, 30%, p &lt; 0.0001). Conclusions: Patients who are either referred as unscheduled CO visits or who present as unscheduled FU visits have higher levels of physical and psychosocial distress and higher opioid dose. Outpatient palliative care centers need to provide opportunity for walk-in referrals for timely management of these issues.

Referral patterns and characteristics of uninsured versus insured patients referred to the outpatient supportive care center (SCC) at a comprehensive cancer center.

116 Background: Multiple barriers exist in providing quality palliative care to low-income patients with cancer. Such disparities may negatively influence effective management of symptoms including pain. Our objective was to compare referral patterns and characteristics (level of symptom distress) of uninsured vs insured patients. Methods: We reviewed randomly selected charts of 100 Indigent (IND) and 100 Medicaid (MC) patients and compared them with a random sample of 300 patients with insurance (INS) referred during the same time period (1/2010 to 12/2014) to our SCC. Data was collected for date of registration at the cancer center, diagnosis of Advanced Cancer (ACD), first visit to the SCC (PC1), symptom assessment (Edmonton Symptom Assessment Scale-ESAS) at PC1. We excluded self-pay patients. Results: Results for IND, MC and INS (n = 481) respectively are as follows: Mean (SD) Age in yrs. was 50 (12), 48 (11) and 63 (13); p &lt; 0.001. Percentage of non-white was 44%, 51% and 19.5%; p &lt; 0.001. Percentage of unmarried patients was 64%, 68% and 33%; p &lt; 0.001. Mean (SD) ESAS score at PC1 for pain was 5.6 (3.2), 6.7 (2.5), 4.9 (3.2); p &lt; 0.001. Percentage of patients on opioids upon referral was 86%, 62%, and 54%; p &lt; 0.001. Mean (SD) for referral time in months from ACD to PC1 was 8.7 (SD 10.4), 12.3 (SD 18.1) and 12 (SD 19.9) p = 0.31; for no. of encounters with SC per month were 0.46 (0.45), 0.41 (0.46) and 0.3 (0.55); p = 0.01; for survival in months (PC1 to last contact) was 6.4 (5.8), 5.6 (6.4) &amp; 6 (7.22) p = 0.77. Conclusions: Uninsured patients had significantly higher levels of pain, were more frequently on opioids, younger, non-white and not married. They also required a larger number of SCC encounters. Insurance status did not impact timing of SCC referral or SCC follow ups at our cancer center.