Palliative Research Articles

Impact on ambulatory palliative appointment lead times by standardizing scheduling protocols based on cognitive computing models.

62 Background: Although palliative care is available across the United States, access continues to remain variable. In Texas, only 52% of hospital systems have palliative services. As a result, optimizing existing systems is critical to providing timely services to this vulnerable population. The Supportive Care Services Clinic at University Health in San Antonio, TX provides ambulatory palliative services to patients including physical and psychosocial symptom management and care coordination. For the period April 1, 2023 to June 30, 2023 average lead times for new palliative patient visits (NPPV) and hospital consult discharge visits (HCDV) was 53 days and 39 days respectively. The aim of this project was to decrease the lead times for NPPV and HCDV through standardization of scheduling criteria. We hypothesized that by applying a scheduling protocol utilizing cognitive computing models (CCM) calculating readmission risk scores to prioritize referrals, we could reduce appointment lead times. Methods: During the implementation phase, we developed referral triage criteria to prioritize patients on a scheduling wait list, including patients who were at higher risk of hospitalization or rapid decline based on CCM readmission risk scores calculated within the electronic medical record. Patients were assigned to next available in template. If a cancelation occurred, patients were pulled forward and vacancy was filled based on priority score. Results: For the initial post-implementation period between September 1, 2023 and November 30, 2023 NPPV average lead time was 47 days which was a reduction of 11% from baseline. The average lead time for HCDV was 33 days which was a reduction of 15% from baseline. In a second follow-up period from February 1, 2024 to April 30, 2024, the average lead time of NPPV was 22 days, a 58% decrease from baseline. The average lead time for HCSV was 24 days which was a significant reduction (p-value = 0.011) of 38% from the pre-implementation baseline. Conclusions: Utilization of CCM risk scores to triage NPPV and HCDV significantly reduced the lead times and resulted in more timely services for critical patients. We also noted increased template utilization. Future projects aim to study the effects of scheduling protocols on template utilization, cancellation rates, no-show rates, readmission rates and other health care utilization. Palliative appointment lead times. April-June 2023 Sept-Nov 2023 Feb-Apr 2024 Total Pt Seen 292 364 534 Avg Lead Time (d) 41 38 29 New Patient New Patient New Patient Completed 66 82 74 Avg Lead Time (d) 53 47 22 Hospital Discharge Hospital Discharge Hospital Discharge Completed 27 28 25 Avg Lead Time (d) 39 33 24

Substance Use Disorder, Opioid Use Disorder, and Symptom Management in Palliative Care: A Rapid Review of Evidence.

Substance Use Disorder, Opioid Use Disorder, and Symptom Management in Palliative Care: A Rapid Review of Evidence.

Development and implementation of an equitable and efficient navigation program to address supportive care needs in patients with cancer.

58 Background: Despite evidence backing the use of navigation along the cancer care trajectory, existing programs struggle to deliver services efficiently and equitably. To bridge this gap, we developed and implemented a patient-centric, data-driven navigation program that leverages a risk-stratification approach to prioritize and address unmet needs. Methods: Our program was developed with key principles to address inefficiencies in existing navigation systems. First, we embedded the program within our institution’s Epic environment, using data-driven risk calculators, dashboards, flowsheets, and templates to support the navigation curriculum. Second, the program structure aligned with the patient’s journey from initial consult through treatment, focusing on early identification of unmet needs, centralized resourcing, and remote symptom monitoring for high-risk patients. Third, we unified the workflows of navigators, intake personnel, triage nurses, and providers, fostering system-wide collaboration. Results: The program has been successfully implemented in patients with new consults in gastrointestinal, breast, and hematologic oncology. To date, 2,080 patients have had an initial assessment leading to a Navigation Assessment Score (NAS) that predicts longitudinal burden of unmet needs and directs subsequent resourcing. 226 referrals have been generated to: cancer rehabilitation (76), nutrition (60), psychosocial oncology (48), tobacco cessation (39), and palliative care (3). Remote symptom monitoring was piloted in 34 gastrointestinal oncology patients meeting the calculated highest decile risk for unplanned acute care event use. Proportions of patients with a NAS score (N=2,080): 69.3% White, 17.7% Black, 3% Latinx, 1.8% Asian, 0.9% American Indian; referrals (N=226): 61.2% White, 23.0% Black, 4.9% Latinx, 1.1% Asian, 0.5% American Indian; remote symptom monitoring (N=34): 79.4% White, 11.8% Black, 5.9% American Indian. Except for Latinx patients, these distributions align with the patient population in gastrointestinal, breast, and hematologic oncology (N=4,267; 68.0% White, 22.5% Black, 6.4% Latinx, 1.9% Asian, 0.9% American Indian). Conclusions: Development and implementation of our program is feasible, and the approach has potential to mitigate disparities in cancer service delivery and outcomes. Ongoing efforts include exploring accessibility among Latinx patients and developing the business case for sustainability and scaling.

Palliative Care and Hospice Utilization in US Veterans Treated with Conservative Management vs. Dialysis

Palliative Care and Hospice Utilization in US Veterans Treated with Conservative Management vs. Dialysis

Effect of an oncology care management program on ED visits in a rural Medicaid population.

175 Background: Optum’s Cancer Support Program (CSP) provides care management to members with cancer diagnoses facing healthcare barriers. CSP nurses educate members on symptom management, palliative care and advance care planning, address psychosocial needs and close gaps in care. Improving health equity and outcomes is a program priority. In 2023, Optum analyzed outpatient claims for 24,221 Medicaid members with cancer and found that rural members visit emergency departments (ED) 31% more than urban members. As part of a CSP quality and outcomes assessment, we aimed to understand CSP’s impact on ED utilization within a high-risk rural Medicaid population. Methods: Beginning 1/1/23, Medicaid members in rural zip codes with an active cancer diagnosis were stratified as high- or low-risk based on diagnosis and clinical factors. High-risk members were invited to participate in CSP and receive individualized telephonic care management. 2023 outpatient medical claims were evaluated, and rural ED visit rates were compared for high-risk CSP participants and non-participants for approximately 4 months (average CSP engagement) after CSP enrollment or identification (non-participants). Population demographics were tested via a Mood's median test; ED visits per thousand members per year (PTMPY)—engaged, non-engaged, and difference in means—was tested via a 10,000-iteration bootstrap. Results: The study population included 421 members stratified as high-risk. Of those, 38% (161) enrolled in CSP. Reasons for non-enrollment included inability to reach the member (61%) and member refused (39%). There were no statistically significant differences between the groups’ demographic composition (all variables had p ≥ 0.05). Under a 10,000-iteration bootstrap, there were 2,696 ED visits PTMPY, 80% CI [2,258, 3,150] in the participant group and 3,427 ED visits PTMPY, 80% CI [2,904, 3,974] in the non-participant group. The difference in means between the groups was 730 ED visits PTMPY, 80% CI [52, 1,421]. Conclusions: Rural Medicaid members enrolled in CSP experienced lower ED visit rates, suggesting that care management may be effective at reducing ED utilization within rural populations that lack access to wraparound oncology services. Limitations of this study include small sample size and potential enrollment bias. Further analysis is underway to increase the study sample size and identify other factors that may be impacted by care management, thereby improving healthcare equity.

INTEREST OF REGULAR ASSAYS OF AQUEOUS HUMOR INTERLEUKIN-10 LEVELS IN MONITORING OF VITREORETINAL LYMPHOMA.

To investigate the variation of interleukin-10 (IL-10) levels in the aqueous humor (AH) of patients with vitreoretinal lymphoma (VRL) throughout therapy and follow-up and analyze the relation of these variations with VRL clinical course and relapse. This study retrospectively included consecutive patients diagnosed with VRL in a single center. AH IL-10 samples and patient clinical course were evaluated. The response to treatment was evaluated according to the criteria set by the International Primary Central Nervous System Lymphoma Collaborative Group. A total of 59 eyes of 34 patients were included. Interleukin-10 levels decreased significantly at first AH sample after therapy induction (median [IQR] 3.0 [2.8-3.6] months) among patients in complete clinical remission (P < 0.001). Among patients in complete clinical remission with residual detectable IL-10 in AH after therapy induction (85.3% systemic chemotherapy, 11.8% intravitreal methotrexate, 2.9% palliative care), 87.5% experienced ocular relapse within 5 years. The detection of IL-10 in AH at the first visit after induction for complete clinical remission obtained a sensitivity of 77.8% (95% CI 0.45-0.96) and a specificity of 96.4% (95% CI 0.82-0.99) to predict ocular relapse. For relapsing eyes (N = 26), IL-10 significantly increased between the last IL-10 measurement and the time of the first ocular relapse (P < 0.001). In 76.0% of cases, an increase in IL-10 was detected earlier than clinical relapse with a mean (SD) of 4.0 (2.4) months. The present study suggested the usefulness of IL-10 in the prognosis of VRL. This study showed a relation between IL-10 in AH and tumoral activity, and for the first time with disease relapse.

Improving goal-concordant care via a uniquely collaborative and multi-site PFAC model.

265 Background: Studies reveal a mismatch between the goals of care (GOC) of cancer patients and actual care received. The 10 members of the Alliance of Dedicated Cancer Centers (ADCC) convened the Improving Goal Concordant Care (IGCC) initiative to address system gaps. IGCC was led by palliative care and oncology experts, with guidance from patient and family advisors. Uniquely, the advisors were identified from patient family advisory councils (PFAC) at each center, forming a collaborative Advisory Group (AG) with the lived experience of each center and the knowledge of advocating for the patient/family voice locally. Methods: PFAC members were recruited from each site to serve on the AG. The 19 member AG met quarterly, with minutes shared with the IGCC oversight group, the Implementation Workgroup (IWG). In September 2023, all AG members were surveyed about perceptions of PFAC engagement and local impact of IGCC. In May 2024, 20 IWG members were surveyed about implementation successes and barriers, including items related to PFAC engagement. Results: AG evaluation and recommendations altered IGCC planned core implementation and evaluation actions meaningfully; for example in 1) selection of structured fields in electronic health record (EHR) and universally accessible GOC documentation and in 2) centering patients in the GOC measure set, including incorporating “Heard &amp; Understood” survey into IGCC evaluation. Other AG guidance around direct patient engagement readiness for GOC conversations and implementing patient GOC surveys was left to individual sites to consider with variable adoption. AG Survey: 63% response rate. 80% noted that the GOC program was discussed with their local PFAC and 92% experienced changed routine patient care after GOC implementation. IWG Survey: 100% response rate. 68% agreed that their center sought guidance from their PFAC during GOC implementation and that leadership presented to their PFAC about their GOC implementation. 26% indicated reporting data to their PFAC; of those that did, 80% agreed that this positively impacted their GOC implementation. Conclusions: While PFACs are occasionally included in quality interventions, this model centered the patient/family voice by supporting a PFAC stakeholder feedback loop working collaboratively and locally to support implementation and evaluation of IGCC objectives. While not all AG recommendations were formally integrated into IGCC, all were considered and many adopted at individual centers. Despite ongoing IGCC-level involvement, center-specific engagement of PFACs varied. Future efforts can track this during process evaluation as local PFAC engagement was highly valued. Consensus building for national best practice implementation and evaluation by recruiting local experts including PFAC members into national collaborative efforts is a successful model for local change.

The role of primary care practitioners in cancer control in South Africa: a systems-based case study

Aim Cancer care has largely been the domain of oncology specialists. With increased awareness of the importance of primary care in the context of universal health coverage, there has been a shift to explore the role of primary care in comprehensive cancer management. This includes health promotion, screening, diagnosing, referral to oncology services, and longitudinal care that includes co-ordination of care, survivorship, and palliative care. This paper focuses on the role of primary care practitioners in health promotion, early detection and care co-ordination. Nurses and doctors who work in primary care are included as primary care practitioners. Methods Using a patient vignette narrative tool, the triad of patient empowerment in the form of enhanced health literacy, clinical competence, and system effectiveness, are discussed as the basis for early cancer detection. A complex intervention to improve primary-level cancer care and the implications thereof for the important role of care co-ordination undertaken by primary care practitioners, is also presented. Findings For effective patient assessment, primary care practitioners must be trained in screening and diagnostic techniques as part of their clinical competencies as generalists. These competencies include risk identification, counselling skills, expert clinical examination, interpretation of basic x-rays, minor surgical skills, interpreting blood tests, and point-of-care ultrasound. Against a backdrop of ongoing budget constraints, consumables and equipment needed for diagnosis should be readily available and referral pathways for patients and specimens should be clearly defined and resourced. Conclusions Primary care practitioners in community-based facilities are well-placed to engage with the psychosociocultural dimensions of care. The SA health system places primary care at the point of closest contact with communities. Efficient care pathways are needed by primary care practitioners to adopt the role of care co-ordinator when patients with suspected or confirmed cancer enter these pathways. When considered alongside the overburdened primary care patient-load and the ever-increasing mix of co-morbidities, the complexity of primary care is appreciated. Understanding the complexities of primary care in the context of cancer control is an important component of a holistic cancer control programme.

Transfusion in Anemic Patients with Acute Coronary Syndromes: A Population-Based Cohort Study

BackgroundThere is controversy surrounding the effectiveness of red blood cell (RBC) transfusion for treating anemia in patients hospitalized for acute coronary syndromes (ACS), particularly as hemoglobin levels (Hb) approach and drop below the range of moderate anemia. MethodsThis population-based cohort study followed all adults hospitalized for ACS who experienced an in-hospital nadir Hb between 6.0-8.9g/dL between April 1, 2012 to March 31, 2021 in Ontario, Canada. Patients were excluded if they underwent coronary artery bypass graft surgery or had history of dementia, palliative care, or long-term care. Transfused patients were compared to non-transfused patients. The primary outcome was a composite of all-cause death and hospitalization for myocardial infarction (MI) within 30-days of hospital discharge. Overlap propensity score weighting was used to account for confounding and to emphasize the comparison in patients for whom there is clinical equipoise. ResultsThis study included 7,922 patients, of whom 3,498 were transfused and 4,424 were not transfused. In the propensity weighted cohort, the mean nadir Hb for each group was 7.75g/dL. The 30-day cumulative incidence rate for the primary outcome after application of propensity score weights was 28.6% in the transfusion group and 33.3% in the no-transfusion group (hazard ratio [HR]: 0.83, 95% confidence interval [CI] 0.75-0.91), which persisted at 1-year after hospital discharge and across sensitivity analyses. ConclusionsIn patients hospitalized for ACS who experience nadir Hb levels between 6.0-8.9g/dL, RBC transfusion was associated with a reduction in the composite event of all-cause death and hospitalization for MI within 30-days after hospital discharge.

Racial disparities in end-of-life care among patients with neuroendocrine tumors.

60 Background: Due to the rising incidence of neuroendocrine tumors (NETs), the prevalence of NETs now surpasses many other malignancies. Due to a slower course of disease and lack of awareness among care teams, end-of-life (EOL) care is typically underutilized in patients with NETs. Owing to a heavy symptom burden (related to disease burden and/or functionality), patients with NETs often struggle due to lack of palliative care and eventually EOL care support. Prior studies have revealed that Black patients with advanced cancer are more likely to receive aggressive care and suffer a significant decline in quality of life at EOL. However, similar data investigating racial differences in EOL among patients with NETs are lacking. Methods: The National Inpatient Sample (NIS) was queried between years 2016-2020 to identify all hospitalizations (regardless of site of origin) with NETs utilizing the appropriate ICD-10 codes (neuroendocrine carcinomas were excluded). Hospitalizations of White and Black patients with documented inpatient mortality events were then extracted. Demographic and clinical data were analyzed using independent sample t-test, Chi-square test, and binary logistic regression (adjusted for age, gender, and Charlson comorbidity index or CCI). NIS discharge weights were applied to calculate national estimates. Statistical analyses were performed with SPSS 28.0. A p-value of &lt;0.05 was considered statistically significant. Results: A total of 6,265 hospitalizations with NETs were included, of which 5,125 (81.8%) and 1,140 (18.2%) had White and Black patients respectively. Black patients were younger, more likely to be females, and less likely to have a do not resuscitate (DNR) code status. There was no significant difference in CCI between the groups. Palliative care consultation was less likely to be performed among Black patients (adjusted OR=0.70, p&lt;.001). Black patients also had longer mean length of stay in the hospital (10.25 vs 8.42 days, p&lt;.001). Black patients were also more likely to receive aggressive care in the form of mechanical ventilation at EOL (Table). Conclusions: This is the largest analysis demonstrating significant racial disparities in EOL care among patients with NETs. Black patients had longer inpatient stay, were less likely to receive inpatient palliative care consultation, have a DNR order and more likely to receive aggressive care at EOL. These findings may have implications for informing healthcare decision making for EOL care among Black patients with NETs. WhiteN=5125 BlackN=1140 aOR (95% CI) p-value Age (years) 67.67 ± 11.89 65.14 ± 11.29 - &lt;.001 Females 46.1% 50.9% - .004 CCI 11.0 ± 3.22 10.9 ± 3.42 - .538 Mean length of stay 8.42 ± 10.03 10.25 ± 15.75 - &lt;.001 Palliative 62.6% 54.5% 0.70 (.61-.80) &lt;.001 DNR 64.9% 60.1% 0.80 (.70-.92) .002 Blood transfusion 13.2% 15.4% 1.18 (.98-1.41) .052 Mechanical ventilation 28.8% 38.6% 1.55 (1.35-1.77) &lt;.001 Vasopressor 9% 9.6% 1.07 (.86-1.33) .47

Everyday Ethics or Deference to Expertise: Experiences of Pediatric Palliative Care Teams with Ethics Consultancy.

Background: Little is known about the extent to which pediatric palliative care (PPC) clinicians are engaged in ethics consults or how they perceive interactions with ethics consultants. Objective: Describe the extent to which PPC team members serve in pediatric health care ethics (PHCE) consultancy roles and to describe their experiences interacting with pediatric ethic consultant services. Design: Online survey distributed to members of the American Academy of Pediatrics and American Academy of Hospice and Palliative Care pediatric and ethics section and special interest groups in the United States. Results: Eighty-six responses were obtained (response rate 45%) from PPC teams in 70 different children's hospitals located in 34 states. Almost all (97%) reported a functional ethics consult service such that PPC is not expected to meet the ethics need of the institution. A person involved on the PPC team also performed ethics consults in half (49%) of the settings, predominantly the PPC physician. Most respondents who perceive PPC teams engage in ethics-relevant work as part of their everyday PPC work. Formal ethics training was lacking among PPC members involved in ethics consults with few ethics degrees (15%), certifications (6%), or fellowships (2%). Discord (67%), conflict (49%), limitations to treatment (48%), and distress (41%) were cited as the most frequent reasons for which PPC teams consult ethics. PPC respondents identified role clarity, coordinated engagement, timely presence, and open communication as strong PHCE consultant practices. Conclusions: PPC team members performing ethics consults may benefit from additional ethics education and training. Further research is warranted to delineate scope of ethics consultancy relevant to PPC and role clarity.

The human side of cancer care in Japan: barriers and challenges

Abstract Among the core concepts of psycho-oncology, “addressing the human aspects of cancer” is one of the most important. In particular, the enhancement of physicians' empathic communication is welcomed in Japan. In 2006, the enactment of the Cancer Control Act in Japan promoted psychosocial and palliative care to anyone. Thus, the designated cancer hospitals adopted a palliative care team, including a psycho-oncologist, as well as a communication skills training program practicing empathic communication. The Cancer Registry data have suggested regional disparities in suicides among patients with cancer in Japan, suggesting fragile regions of psycho-oncology. How can we deliver empathic communication to patients across the country, and how far will technological innovation, including AI, produce innovative support? Although constant efforts are needed to move closer to solutions, the human side of cancer must not be changed; however, clinical practice must continue to change over time.

Health and Related Indicators, 2023

Aim This paper presents a comprehensive repository of data detailing the current status of the South African health system and the health status of its population. The focus is on national and provincial levels, encompassing sociodemographic indicators, determinants of health, health status indicators, and health service indicators. Methods Data were primarily sourced from national routine data systems, supplemented by major surveys and global reports. In line with the theme of the South African Health Review 2023, special emphasis was placed on indicators related to the burden of cancers in South Africa, access to cancer-related services, and, to some extent, outcomes. Results The findings indicate significant gaps in the availability of relevant and quality indicators, particularly concerning cancer, echoing challenges seen with other non-communicable diseases. While some data exist, they are often fragmented, outdated, or incomplete, limiting their utility in guiding effective policy-making and intervention strategies. Conclusions The limited availability of robust cancer-related data highlights the challenges in accurately assessing the burden of the disease and the effectiveness of current interventions. This scarcity of data impedes the ability to monitor progress and make informed decisions regarding cancer prevention, treatment, and palliative care.

COMPLIMENTARY ROLE OF COMPREHENSIVE PALLIATIVE CARE TREATMENT TO INTRATHECAL THERAPY: CASE REPORT

Intrathecal therapy with implanted devices is often reported in some recommendations.for the management of difficult cancer pain However, data is often biased by optimistic view and poor assessment.We report a case of patient in which a comprehensive and complex palliative care treatment was effective in managing a patient who was implanted a subcutaneous port for intrathecal analgesiaThis patient had many characteristics of a difficult pain, really defined as refractory due to various negative prognostic pain factors, such as neuropathic pain and psychological distress..A comprehensive pain management with a balanced approach including both interventional therapy and palliative care simultaneously, allowed to achieve optimal pain control. Terms such as intractable or refractory pain, have been ambiguously used in literature to select patients as candidates for implated pumps. A meaningful evaluation and a comprehensive treatment should be mandatory when using intrathecal anlgesia in patients with very difficult pain conditions.

Cardio-Oncology and Heart Failure: A Scientific Statement from the Heart Failure Society of America.

Heart failure and cancer remain two of the leading causes of morbidity and mortality and the two disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnosis and cancer survivors. Risk stratification, monitoring, and management of cardiotoxicity are presented across Stages A through D heart failure, with focused discussion on heart failure preserved ejection fraction and special populations such as survivors of childhood and young adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary team approach and critical collaboration between heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Nursing Practices for Dyspnea Management in Patients with Cancer Based on Monthly and Weekly Prognoses: A Multi-Site Cross-Sectional Study of Palliative Care Nurses in Japan.

Dyspnea in patients with terminal cancer worsens near death, necessitating effective nonpharmacological management. Despite guideline recommendations, detailed studies on nonpharmacological nursing practices are scarce. This study aimed to elucidate nursing practices for dyspnea in patients with cancer based on monthly and weekly prognoses. A multi-site cross-sectional study was conducted among nurses in 389 palliative care units in Japan. The study surveyed the frequency of direct care practices for dyspnea management (nurse-led intervention, multidisciplinary intervention, psychoeducational programs, breathing techniques, walking therapy, inspiratory muscle training, respiratory rehabilitation, yoga, acupressure, fan therapy, guided imagery, abdominal massage, aromatherapy, and a reduction in room temperature and humidity) in patients with cancer with monthly and weekly prognoses. Of the 389 invited units, 162 participated. From these, 2448 registered nurses were invited and 539 (22.3%) responded. Almost similar nursing practices were provided regardless of patient prognosis. Nurse-led intervention was the most frequently practiced, followed by room temperature and humidity reduction, multidisciplinary intervention, and fan therapy. Yoga, respiratory rehabilitation, and acupressure were rarely practiced. Nursing practices for dyspnea are similar, irrespective of prognosis. Nurse-led interventions, reducing room temperature and humidity, multidisciplinary intervention, and fan therapy are frequently used for dyspnea in patients with cancer. Future studies should evaluate the effectiveness of these nursing practices.

Perspectives and lived experiences of survivors and caregivers of COVID-19 patients in a teaching hospital in a tribal district of Chhattisgarh, India

ABSTRACT Background: The rural–urban healthcare disparity in India was exacerbated during the COVID-19 pandemic, with the second wave hitting rural areas particularly hard due to weak infrastructure. A study in Chhattisgarh aims to explore the experiences of severely ill COVID-19 survivors and caregivers to inform patient-centric care delivery in primary settings. Methods: In this qualitative study, we conducted in-depth interviews with seven patients and seven caregivers during home visits or telephonically to understand lived experiences of receiving care for COVID-19 in an ICU in the public health system. Socioecological model was used to guide the qualitative inquiry. Results: COVID-19 patients faced stigma due to their diagnosis. The survivors felt lonely due to isolation, uncertainty about their illness, and fear of death. Poor mental health during ICU stay affected their physical health. Patients with caregivers felt supported despite visitor restrictions. Transparent communication with health providers reduced distress. Conclusion: The study in Chhattisgarh, India, highlights ICU survivors’ and caregivers’ experiences, revealing fear and loneliness among patients. Effective communication and caregiver presence improve outcomes, emphasizing holistic support. There’s an urgent need for palliative care integration, caregiver inclusion, and comprehensive post-discharge follow-up by primary-level practitioners in rural settings. Lack of state-level palliative care policy emphasizes the need for comprehensive initiatives to enhance healthcare outcomes.

Clinician engagement strategies to increase palliative care access in a multi-site community oncology practice.

196 Background: Despite nearly 20 years since PC was recognized as a medical subspecialty, and ACS, ASCO and NCCN’s recommendations for early involvement, many oncologists continue to categorize PC synonymously with hospice and therefore refer to palliative medicine specialists very late in the disease trajectory, if at all. Each year, more oncology and PC researchers study and report the life changing impact of early PC for patients living with stage III and IV “advanced cancer” (AC). While mandating PC would have its challenges, creating workflows to encourage providers to change their behavior and attitude regarding PC, while empowering other clinical team members to directly refer, should result in patients and families receiving earlier PC services. Methods: The study included a pre-intervention period (9/1/2023 - 12/31/2023), and an intervention period (1/1/2024 - 4/30/2024). Pre-intervention referral data was collected from OncoEMR, OneAnalytics and Social Work reports. PC referrals were requested for both oncology and hematology patients, regardless of diagnosis date or stage. During the intervention period, 6 strategies were designed to increase PC referrals and were deployed equally in all 8 oncology/hematology offices. Strategies included 1) weekly MD/APP huddles with one of the goals to discuss the palliative care needs of all patients, 2) self-directed referrals from nursing, 3) self-directed referrals from social work, 4) APP referrals for advance care planning, 5) proactive chart reviews by PC APNs and direct PC referral suggestions to MD/APPs for AC patients, and 6) hardwiring timely scheduling of PC referrals. The primary end point is the percent of unique cancer (UC) patients who had a PC referral; the secondary end point is the percent of referred AC patients with early PC referral as defined by referral within 8 weeks of diagnosis. Results: During the pre-intervention period, of the 8,551 UC patients, 154 (1.8%) received PC referrals as compared to 227 (2.8%) of the 8,055 UC patients during the intervention period, yielding a 56% increase in the intervention period. In the pre-intervention period, 24 (14%) of the 177 newly diagnosed AC patients received early PC referrals compared to 32 (21%) of the 153 newly diagnosed AC patients in the intervention period, giving rise to a 50% increase. Conclusions: Strategies to increase PC referrals in a community oncology practice increased overall referrals as well as earlier referrals in newly diagnosed AC patients. As the interventions mature, the total number of PC referrals and a shift toward earlier referrals will likely be seen. Future goals will include assessing patient and family comfort with their treatment plan with PC versus without PC, as well as assessing providers' perceived value of PC over time. With attitude and behavior change, practice culture change is anticipated amid PC becoming the standard of care for all AC patients.

Current state content analysis of patient-reported outcome measures and clinical needs assessment tools utilized throughout the cancer care continuum at an academic medical center.

238 Background: The Cancer Survivorship Care Quality Framework (CSCQ-F) is an evidence-based framework that outlines domains and indicators pertinent to the provision of quality cancer survivorship care. Many indicators from the CSCQ-F can be assessed by clinical interview or patient-reported outcome measures (PROMs) to gauge whether patients are receiving quality survivorship care. We conducted a current-state analysis of the PROMs and needs assessment tools (NATs) utilized throughout our academic medical center and assessed the extent to which constructs covered on our assessments align with relevant domains and indicators from the CSCQ-F. Methods: Healthcare leaders identified assessments currently available for use throughout oncology clinics at our institution. We included assessments directly completed by patients (i.e., PROMs) and assessments completed by clinicians based on patient feedback gathered through clinical interview or oncology nurse navigation (i.e., NATs). We excluded assessments not currently in use. We coded each assessment item by construct (e.g., depression, neuropathy, substance use, referral) and time of administration (e.g., new patient visits, treatment change, unknown). Then, we mapped items/constructs to the CSCQ-F domains. Afterward, we compared items/constructs mapped to the CSCQ-F domains with CSCQ-F indicators to identify gaps in assessment. Results: We identified two PROMs (Lucet and The Edmonton Symptom Assessment Scale (ESAS)) and two NATs (Epic Wheel and an internally developed cancer navigation assessment). Constructs covered by these assessments aligned with all domains of the CSCQ-F, except for “Patient/Caregiver Experience.” Gaps in assessment based on the CSCQ-F depend on which assessments patients receive. All new patients are administered Lucet (an electronic distress screening tool) and referred for cancer navigation assessment. However, ESAS is administered through Palliative Care, and it is unclear whether and when all providers administer Epic Wheel (a social determinants of health NAT). The CSCQ-F indicates reassessment of symptoms and/or conditions should occur at defined intervals throughout the cancer continuum, but there is no clear reassessment protocol at our institution. Conclusions: To our knowledge, this is the first content-analysis of PROMs and NATs mapped to the CSCQ-F. Our results signify a need to (1) address gaps in assessment, (2) determine a protocol for symptom reassessment, and (3) standardize enterprise-wide administration procedures for PROMs and NATs throughout the cancer continuum. Future work should also identify who is responsible for following up on patients’ identified concerns and determine whether adequate resources are available to address patients’ symptoms and needs.

Care trajectories and transitions at the end of life: a population-based cohort study.

End-of-life periods are often characterised by suboptimal healthcare use (HCU) patterns in persons aged 65years and older, with negative effects on health and quality of life. Understanding care trajectories (CTs) and transitions in this period can highlight potential areas of improvement, a subject yet only little studied. To propose a typology of CTs, including care transitions, for older individuals in the 2 years preceding death. Retrospective cohort study. We used multidimensional state sequence analysis and data from the Care Trajectories-Enriched Data (TorSaDE) cohort, a linkage between a Canadian health survey and Quebec health administrative data. In total, 2080 decedents were categorised into five CT groups. Group 1 demonstrated low HCU until the last few months, whilst group 2 showed low HCU over the first year, followed by a steady increase. A gradual increase over the 2 years was observed for groups 3 and 4, though more pronounced towards the end for group 3. A persistent high HCU was observed for group 5. Groups 2 and 4 had higher proportions of cancer diagnoses and palliative care, as opposed to comorbidities and dementia for groups 3 and 5. Overall, 68.4% of individuals died in a hospital, whilst 27% received palliative care there. Care transitions increased rapidly towards the end, most notably in the last 2 weeks. This study provides an understanding of the variability of CTs in the last two years of life, including place of death, a critical step towards quality improvement.