Rate Of Palliative Care Consultation Research Articles

Investigation of Medical Student and Resident Physician Palliative Care Consulting Practices.

Palliative care (PC) underutilization stems from provider conflicts and the belief that PC involvement may confuse patients. We hypothesized medical students, less exposed to these barriers and misconceptions, would be more likely to consult PC than residents/fellows. A survey of 88 medical students, residents, and fellows was conducted, querying the appropriateness of PC utilization in clinical scenarios. Students were more likely to consult PC than trainees when PC was not indicated (47.2% vs 22.9%, P = .02). In the two cases where PC was indicated, there was no difference in PC utilization among students and trainees (92.5% vs 91.4%, P = .86; 90.6% vs 100%, P = .06). When stratifying participants into medical and surgical specialties, or career interests regarding students, there was no difference in rates of PC consultation. This suggests medical education advancements are producing physicians adept at identifying patients needing PC and willing to integrate a PC service into patient care.

Trends in End-of-Life Care and Satisfaction Among Veterans Undergoing Surgery.

To examine trends in end-of-life care services and satisfaction among Veterans undergoing any inpatient surgery. The Veterans Health Administration has undergone system-wide transformations to improve end-of-life care yet the impacts on end-of-life care services use and family satisfaction are unknown. We performed a retrospective, cross-sectional analysis of Veterans who died within 90 days of undergoing inpatient surgery between 01/2010 and 12/2019. Using the Veterans Affairs (VA) Bereaved Family Survey (BFS), we calculated the rates of palliative care and hospice use and examined satisfaction with end-of-life care. After risk and reliability adjustment for each VA hospital, we then performed multivariable linear regression model to identify factors associated with the greatest change. Our cohort consisted of 155,250 patients with a mean age of 73.6 years (standard deviation 11.6). Over the study period, rates of palliative care consultation and hospice use increased more than two-fold (28.1% to 61.1% and 18.9% to 46.9%, respectively) while the rate of BFS excellent overall care score increased from 56.1% to 64.7%. There was wide variation between hospitals in the absolute change in rates of palliative care consultation, hospice use and BFS excellent overall care scores. Rural location and ACGME accreditation were hospital-level factors associated with the greatest changes. Among Veterans undergoing inpatient surgery, improvements in satisfaction with end-of-life care paralleled increases in end-of-life care service use. Future work is needed to identify actionable hospital-level characteristics that may reduce heterogeneity between VA hospitals and facilitate targeted interventions to improve end-of-life care.

Impact of Antithrombotic Medications and Reversal Strategies on the Surgical Management and Outcomes of Traumatic Acute Subdural Hematoma

Careful hematologic management is required in surgical patients with traumatic acute subdural hematoma (aSDH) taking antithrombotic medications. We sought to compare outcomes between patients with aSDH taking antithrombotic medications at admission who received antithrombotic reversal with patients with aSDH not taking antithrombotics. Retrospective review identified patients with traumatic aSDH requiring surgical evacuation. The cohort was divided based on antithrombotic use and whether pharmacologic reversal agents or platelet transfusions were administered. A 3-way comparison of outcomes was performed between patients taking anticoagulants who received pharmacologic reversal, patients taking antiplatelets who received platelet transfusion, and patients not taking antithrombotics. Multivariable regressions, adjusted for injury severity, further investigated associations with outcomes. Of 138 patients who met inclusion criteria, 13.0% (n= 18) reported taking anticoagulants, 16.7% (n= 23) reported taking antiplatelets, and 3.6% (n= 5) reported taking both. Patients taking antiplatelets who received platelet transfusion had longer intraoperative times (P= 0.040) and higher rates of palliative care consultations (P= 0.046) compared with patients taking anticoagulants who received pharmacologic reversal and patients not taking antithrombotics. Across groups, no significant differences were found in frequency of in-hospital intracranial hemorrhage and venous thromboembolism, length of hospital stay, rate of inpatient mortality, or follow-up health status. In multivariable analysis, intraoperative time remained longest for the antiplatelets with platelet transfusion group. Other outcomes were not associated with patient group. Among surgical patients with traumatic aSDH, those taking antiplatelet medications who receive platelet transfusions experience longer intraoperative procedure times and higher rates of palliative care consultation. Comparable outcomes were observed between patients receiving antithrombotic reversal and patients not taking antithrombotics.

Nationwide utilization of palliative care in patients admitted for GI malignancies.

e24114 Background: Gastrointestinal (GI) cancers account for a large proportion of cancer-related deaths and are often associated with significant impairment in quality of life, even at earlier stages. Although guidelines recommend early palliative care (PC) involvement in all patients with advanced cancer, and select patients at earlier stages, implementation of these practices has been highly variable. Methods: Using the National Inpatient Sample (NIS) database, we selected all adult patients admitted with a primary diagnosis of any GI malignancy from 2016 to 2020. We compared demographic characteristics as well as differences in in-hospital mortality, total hospital charges, and length of stay for patients who received a palliative care consultation during the admission and those who did not, with a goal of elucidating biases and informing future quality improvement efforts. Multivariate logistic regression analysis was conducted to adjust for confounders. Results: There were 1,123,075 admissions with a primary diagnosis of a GI malignancy from 2016 to 2020, which represented 0.8% of total adult admissions.10.5% of admissions included a PC consultation. Rate of PC consultation varied based on the site of primary malignancy (see table). Patients for whom PC was consulted were older (69.3 vs. 66.2 years, p < 0.01), less likely to be white (62.7% vs. 67.1%, p < 0.01), and more likely to have Medicare (60.4 vs. 55.5, p < 0.01). These patients were 12.8 times more likely to die during admission (mortality 24.2% vs. 1.9%, p < 0.01), had longer lengths of stay (8.5 vs. 6.9 days, p < 0.01) and lower total charges (84,400.2 vs. 96,637.6 USD, p < 0.01). Conclusions: Early PC involvement in cancer care has been associated with improvement in quality of life and decreases in costs and readmissions. Rates of PC involvement in our cohort were overall low. Different rates of consultations for different races signal possible provider bias. The significantly higher mortality in patients who received a PC consult reflects the still current practice of involving PC only at the end of life. Quality improvement efforts should focus on eliminating biases and implementing strategies to maximize early palliative care utilization among patients with locally advanced or metastatic GI malignancies. [Table: see text]

Palliative and Supportive Care Consultation for Patients With Malignant Gastrointestinal Obstruction is Associated With Broad Interdisciplinary Management.

The aim of this study was to assess rates of palliative care (PC) involvement in the care of patients with malignant gastrointestinal obstruction (GIO) and its influence on interdisciplinary team involvement. Malignant GIO is an advanced oncologic diagnosis with associated poor prognosis. Data regarding PC and interdisciplinary team involvement in these patients is lacking. We identified consecutive surgical consultations for GIO in cancer patients at a single institution from August 2017 to July 2019. Clinical characteristics were collected. Rates of PC consultation, ACP discussion, code status change to do not resuscitate, and interdisciplinary service consultation were evaluated. We identified 200 patients with consultations for GIO, of whom 114 (57%) had malignant GIO and were included in our study. Of these patients, 95 (83%) had stage IV disease; 68 (60%) had peritoneal metastasis, and 70 (61%) had other intra-abdominal recurrence or metastasis. PC consultation was obtained in 69 patients (61%). PC consultation was associated with higher rates of ACP discussion (64% vs 29%; P < 0.001), code status change to do not resuscitate (30% vs 2%; P < 0.001), nonsurgical procedure (46% vs 11%; P < 0.001), discharge to hospice (30% vs 7%; P < 0.001), and involvement of spiritual care (48% vs 22%; P = 0.01), social work (77% vs 42%, P < 0.001), psychology/psychiatry (42% vs 4%, P < 0.001), nutrition (86% vs 62%, P = 0.006), physical therapy (54% vs 31%, P = 0.02), and occupational therapy (42% vs 16%, P = 0.004). PC consultation benefits patients with malignant GIO by facilitating comprehensive interdisciplinary care, ACP discussions, and transition to hospice care, where appropriate. Diagnosis of malignant GIO should be a trigger for PC consultation or, in facilities with limited PC resources, consideration of deliberately broad interdisciplinary consultation.

Impact of Referring Team Characteristics on Inpatient Palliative Care Consultation Rate at a Comprehensive Cancer Center.

Background: No prior study addresses the impact of admitting team characteristics on inpatient palliative care (PC) consultation rate in cancer patients. Understanding consultation rate differences among admitting service types may reveal PC access disparities for patients who would benefit from consultation. Aim: To determine the impact of admitting service characteristics (teaching vs. nonteaching and surgical vs. medical) on inpatient PC consultation rates. Methods: A six-month cross-sectional study was performed at an academic comprehensive cancer center. Inpatient PC consultations and follow-up visits were compared to total admissions by admitting service category. Results: Five thousand six hundred ninety-seven admissions resulted in 710 new PC consultations and 2494 follow-up visits. Patients admitted to medical services had highest odds of PC consultation, while data for teaching services were mixed. There was no difference in follow-up visits. Conclusions: Significant differences between medical and surgical service PC consultation rates may indicate specialty PC access disparities solely based on their admitting service.

An Internal Review of Rates of Palliative Medicine Referral for Patients With Advanced Pancreatic Cancer.

BackgroundThe American Society of Clinical Oncology recommends that patients with advanced cancer receive palliative care services in concurrence with active treatment. While the benefits of palliative care are clear, integration of palliative care can be challenging. We aim to review rates of palliative care consultation in patients with advanced pancreatic cancer at our institution, intending to improve these rates.MethodsWe retrospectively reviewed the electronic records of all patients with pancreatic cancer treated at Allegheny General Hospital diagnosed between 2009-2020. Summary statistics are presented as percentages for categorical data and median with interquartile range for quantitative data.ResultsOf the 171 patients reviewed, 121 completed all treatment and evaluation within our health network (Pittsburgh, United States). The median age was 63 years (IQR 40-91 years); 55 patients (45%) were male; the majority were white (107 patients, 88%). At the time of diagnosis, 28% of our patients had stage IV disease (34 patients), and 19.8% of patients who developed stage IV disease had palliative care referrals.ConclusionsPalliative care is an integral part of usual care for advanced pancreatic cancer. Our analysis showed that palliative care is underutilized in our hospital. We aim to improve palliative care integration in our patients’ care by adding a hard stop to electronic medical records to remind physicians to offer palliative care to our patients with pancreatic cancer and to arrange lecture series to emphasize the importance of palliative care in this setting.

End-of-Life Care for Older Adults with Aggressive Non-Hodgkin Lymphoma

Background: Aggressive non-Hodgkin lymphoma (NHL) commonly affects older adults and is often treated with intensive therapies. Receipt of intensive therapies and absence of a clear transition between the curative and palliative phases of treatment yield prognostic uncertainty and risk for poor end-of-life (EOL) outcomes. However, data regarding the EOL outcomes of this population are lacking.Methods: We conducted a retrospective analysis of adults >65 years with aggressive NHL treated with systemic therapy at Massachusetts General Hospital from 4/2000-7/2020 who subsequently died. We abstracted patient and clinical characteristics and EOL outcomes from the electronic health record (EHR), including patients' place of death, cause of death, palliative care and hospice utilization, and hospice length of stay using the EHR and the Social Security Death Index. We also determined whether patients were hospitalized (yes versus no), received systemic therapy (yes versus no), or were admitted to the ICU (yes versus no) within 30 days of death. Using multivariable logistic regression, we examined factors associated with hospitalization within 30 days of death and hospice utilization.Results: Among 91 patients (median age = 75 years; 37.4% female), the most common lymphoma diagnosis was de novo DLBCL/grade 3B follicular lymphoma (64/91, 70.3%), and the majority (64/91, 70.3%) had advanced stage disease. Overall, 70.3% (64/91) were hospitalized, 34.1% (31/91) received systemic therapy, and 23.3% (21/90) had an intensive care unit admission within 30 days of death. The rates of palliative care consultation and hospice utilization were 47.7% (42/88) and 39.8% (35/88), respectively. A minority (21/88, 23.9%,) received palliative care more than 30 days before death. Of those receiving palliative care consultations, the majority (33/42, 78.6%) occurred exclusively in the inpatient setting, and most (32/42, 76.2%) were seen either as a one-time consultation or followed during a single inpatient hospitalization. Symptom management (24/42, 57.1%) was the most common reason for palliative care consultation, followed by both symptom management and goals of care (11/42, 26.2%) and goals of care (4/42, 9.5%). Only 39.8% (35/88) received hospice services, with 80.7% (71/88) having a hospice length of stay ≤ 7 days. Among hospice enrollees, the median length of stay on hospice was 7 days (range: 0-117). Among all patients, 51.6% (47/91) died in hospital, rehab, or nursing home, 23.1% (21/91) died at home, 11.0% (10/91) died in inpatient hospice or a hospice house, and 14.3% (13/91) had an unknown or other place of death. The most common cause of death was cancer progression (44/91, 48.4%,) followed by infection or cancer treatment complication (20/91, 22.0%). In multivariable analysis, elevated LDH was associated with risk of hospitalization within 30 days of death (OR 3.61, p=0.014). Palliative care consultation (OR 4.45, p=0.005) and hypoalbuminemia (OR 0.29, p=0.026) were associated with likelihood of hospice utilization.Conclusions: Older adults with aggressive NHL often experience high health care utilization and infrequently utilize hospice care at the EOL. Our findings underscore the need for interventions to optimize the quality of EOL care for this population, and provide important data to guide informed decision-making and help inform future interventions aimed at improving the EOL care of this unique geriatric oncology population. DisclosuresNo relevant conflicts of interest to declare.

End-of-Life Care for Older Adults with Aggressive Non-Hodgkin Lymphoma.

Background: Aggressive non-Hodgkin lymphoma (NHL) commonly affects older adults and is often treated with intensive therapies. Receipt of intensive therapies and absence of a clear transition between the curative and palliative phases of treatment yield prognostic uncertainty and risk for poor end-of-life (EOL) outcomes. However, data regarding the EOL outcomes of this population are lacking. Methods: We conducted a retrospective analysis of adults ≥65 years with aggressive NHL treated with systemic therapy at Massachusetts General Hospital from April 2000 to July 2020 who subsequently died. We abstracted patient and clinical characteristics and EOL outcomes from the medical record. Using multivariable logistic regression, we examined factors associated with hospitalization within 30 days of death and hospice utilization. Results: Among 91 patients (median age = 75 years; 37.4% female), 70.3% (64/91) were hospitalized, 34.1% (31/91) received systemic therapy, and 23.3% (21/90) had an intensive care unit admission within 30 days of death. The rates of palliative care consultation and hospice utilization were 47.7% (42/88) and 39.8% (35/88), respectively. More than half of patients (51.6%, 47/91) died in a hospital or health care facility. In multivariable analysis, elevated lactic acid dehydrogenase was associated with risk of hospitalization within 30 days of death (odds ratio [OR] 3.61, p = 0.014). Palliative care consultation (OR 4.45, p = 0.005) was associated with a greater likelihood of hospice utilization, whereas hypoalbuminemia (OR 0.29, p = 0.026) was associated with a lower likelihood of hospice utilization. Conclusions: Older adults with aggressive NHL often experience high health care utilization and infrequently utilize hospice care at the EOL. Our findings underscore the need for interventions to optimize the quality of EOL care for this population.

Trends and guideline-related changes in provision of palliative care in older women with gynecologic malignancies

Objectives: To determine if the rate of palliative care consultation (PCC) in older women with gynecologic malignancies increased after the publication of the American Society of Clinical Oncology guidelines in 2012. Additionally, to identify factors associated with utilization of palliative care. Methods: We included women ≥ 66 years with stage III-IV, ovarian, uterine, cervix or vulvar cancer diagnosed in 2011 and 2013 in the linked Surveillance Epidemiology, End Results (SEER)- Medicare database. Patient demographic, cancer, and treatment characteristics were extracted. We evaluated PCC within 365 days of diagnosis (PCC365) and within 56 days of diagnosis (PCC56). We used a multivariable Cox proportional hazard model to compare PCC in 2011 versus 2013. We identified factors associated with PCC in women diagnosed with cancer in 2013 using a univariate and multivariable logistic regression. Results: We identified 2,643 women diagnosed with advanced gynecologic malignancies. 56% of patients had ovarian cancer, 34% uterine cancer, 8% cervical cancer and 3% vulvar cancer. In 2011, 12% of women had a PCC365 versus 14% in 2013. Taking into account multiple factors, women diagnosed in 2013 were more likely to have a PCC365 than women diagnosed in 2011 (adjusted HR 1.36, 95% CI 1.09, 1.71). Women diagnosed with an advanced gynecologic malignancy in 2013 who were Black versus White (adjusted HR 1.72, 95% CI 1.06, 2.78), had a Charlson comorbidity index of 3 versus 0 (adjusted HR 1.81, 95% CI 1.17, 2.80) or stage IV verus stage III cancer (adjusted HR 1.79, 95% CI 1.26, 2.54) were more likely to receive PCC365. Women who received initial cancer treatment with surgery were less likely to receive PCC365 (adjusted HR 0.52, 95% CI 0.35, 0.78). Conclusions: The rate of palliative care in women with advanced gynecologic malignancies increased slightly, although significantly, between 2011 and 2013 but the absolute rate remains low despite changes in recommendations. New innovations are needed to increase concurrent palliative care with standard oncology treatment for woman with advanced gynecologic malignancies.

An internal review of rates of palliative medicine referral for patients with advanced pancreatic cancer.

e16245 Background: Patients diagnosed with advanced pancreatic cancer face many challenges in addition to symptom burden including psychological stressors and often the need for supportive care at home. In recent years, both clinical trials and retrospective reviews have confirmed the benefits of early integration of palliative care services such as improved quality of life and reduced symptom intensity. The American College of Clinical Oncology recommends patients with advanced cancer receive directed palliative care services early after diagnosis and in concurrence with active treatment. While the benefit of palliative care services is clear, the best way to integrate palliative services has not been determined. Our project aims to review the rates of palliative care consultation in patients with advanced pancreatic cancer intending to improve patient outcomes. Methods: We retrospectively reviewed the electronic medical records of all patients diagnosed with pancreatic cancer at Allegheny General Hospital diagnosed between 2009-2020. Summary statistics are presented as percentages for categorical data and median with interquartile range for quantitative data. Results: Of the 171 patients reviewed, 121 competed all treatment and evaluation within our health network. Median age was 63 years (IQR 40-91 years); 55 patients (45%) were male. The majority were white (88%). At the time of diagnosis, 28% of our patients had stage IV disease and 19.8% of patients with stage IV disease had documented palliative care referrals. Eight patients had pain documented at diagnosis, six patients underwent celiac plexus neurolysis, 31 underwent palliative radiation and 43 patients had documented opiate use. Of the 6 patients who underwent celiac plexus neurolysis, only 4 documented pain at 6-month follow-up. Of the 31 patients who underwent palliative radiation, 6 documented pain at 6-month follow-up. Conclusions: Palliative care is an integral part of usual care for pancreatic cancer. Our analysis showed that palliative care is underutilized in our hospital with only 19.8% of patients having documented palliative care visits. While patients may refuse palliative care consult, other contributing factors are likely the lack of access or lack of early involvement of palliative care team members. Integration of palliative care has been proven repeatedly to improve quality of life in patients diagnosed with advanced pancreatic cancer. We aim to improve palliative care integration in out patients’ care by adding a hard stop to electronic medical records to remind physicians to offer palliaitive care to the patients, in addition to arranging medical grand rounds and various lectures to increase awareness of the importance of palliative care in this setting.

Racial and Ethnic Disparities in Management and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction.

BackgroundThe role of race and ethnicity in the outcomes of cardiac arrest (CA) complicating acute myocardial infarction (AMI) is incompletely understood.Methods and ResultsThis was a retrospective cohort study of adult admissions with AMI‐CA from the National Inpatient Sample (2012–2017). Self‐reported race/ethnicity was classified as White, Black, and others (Hispanic, Asian or Pacific Islander, Native American, Other). Outcomes of interest included in‐hospital mortality, coronary angiography, percutaneous coronary intervention, palliative care consultation, do‐not‐resuscitate status use, hospitalization costs, hospital length of stay, and discharge disposition. Of the 3.5 million admissions with AMI, CA was noted in 182 750 (5.2%), with White, Black, and other races/ethnicities constituting 74.8%, 10.7%, and 14.5%, respectively. Black patients admitted with AMI‐CA were more likely to be female, with more comorbidities, higher rates of non–ST‐segment–elevation myocardial infarction, and higher neurological and renal failure. Admissions of patients of Black and other races/ethnicities underwent coronary angiography (61.9% versus 70.2% versus 73.1%) and percutaneous coronary intervention (44.6% versus 53.0% versus 58.1%) less frequently compared to patients of white race (p<0.001). Admissions of patients with AMI‐CA had significantly higher unadjusted mortality (47.4% and 47.4%) as compared with White patients admitted (40.9%). In adjusted analyses, Black race was associated with lower in‐hospital mortality (odds ratio [OR], 0.95; 95% CI, 0.91–0.99; P=0.007) whereas other races had higher in‐hospital mortality (OR, 1.11; 95% CI, 1.08–1.15; P<0.001) compared with White race. Admissions of Black patients with AMI‐CA had longer length of hospital stay, higher rates of palliative care consultation, less frequent do‐not‐resuscitate status use, and fewer discharges to home (all P<0.001).ConclusionsRacial and ethnic minorities received less frequent guideline‐directed procedures and had higher in‐hospital mortality and worse outcomes in AMI‐CA.

Palliative care in cardiac intensive care units (CICUs): Insights from the Critical Care Cardiology Trials Network (CCCTN) registry

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf Critical Care Cardiology Trials Network (CCCTN) registry Introduction Palliative care is a practice focused on providing relief of symptoms of illness, while optimizing the quality of life for patients and families. We aimed to quantify palliative care (PC) practices and end-of-life decision-making in critically ill cardiac patients in contemporary CICUs. Methods The CCCTN Registry is a network of tertiary care CICUs in the United States and Canada. Between 2017 and 2020, up to 26 centers contributed an annual 2-month snapshot of all consecutive admissions to the CICU. We captured code status, rates of palliative care consultation, and decisions for comfort measures only (CMO) before all deaths in the CICU. Results Of 8231 admissions, 10% ended with death in the CICU and 2.6% were discharges to hospice. Of deceased patients, 68% were CMO before death. The median age of CMO patients was 70y (25th-75th: 59-78) vs. 67 (56-77) among deaths without CMO. In the CMO group, only 13% were DNR/DNI at admission, and the remainder were full code. Respiratory insufficiency and non-cardiogenic shock were the CICU indications most frequently associated with CMO. The median time from CICU admission to CMO decision was 3.4 days (25th-75th: 1.2-7.7) and was ≥7 days in 27% (Figure). Time from CMO decision to death was &amp;lt;24h in 88%, with a median of 3.8h (25th-75th 1.0-10.3). Before a CMO decision, 73% received mechanical ventilation and 25% mechanical circulatory support. Of total deaths, 34% of intubated patients were palliatively extubated. Formal PC services were engaged in only 28% of deaths. Conclusions In contemporary CICUs, CMO preceded death in 2/3 of cases. The high use of advanced ICU therapies, lengthy times to a CMO decision, and the very short time from CMO to death, highlight a potential opportunity for greater PC consultation, as well as training programs to build skills in PC for practitioners in the CICU. Abstract Figure

Inpatient palliative care utilization for patients with brain metastases.

Given the high symptom burden and complex clinical decision making associated with a diagnosis of brain metastases (BM), specialty palliative care (PC) can meaningfully improve patient quality of life. However, no prior study has formally evaluated patient-specific factors associated with PC consultation among BM patients. We examined the rates of PC consults in a cohort of 1303 patients with BM admitted to three tertiary medical centers from October 2015 to December 2018. Patient demographics, surgical status, 30-day readmission, and death data were collected via retrospective chart review. PC utilization was assessed by identifying encounters for which an inpatient consult to PC was placed. Statistical analyses were performed to compare characteristics and outcomes between patients who did and did not receive PC consults. We analyzed 1303 patients admitted to the hospital with BM. The average overall rate of inpatient PC consultation was 19.6%. Rates of PC utilization differed significantly by patient race (17.5% in White/Caucasian vs 26.0% in Black/African American patients, P = .0014). Patients who received surgery during their admission had significantly lower rates of PC consultation (3.9% vs 22.4%, P < .0001). Patients who either died during their admission or were discharged to hospice had significantly higher rates of PC than those who were discharged home or to rehabilitation (P < .0001). In our dataset, PC consultation rates varied by patient demographic, surgical status, discharging service, and practice setting. Further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.

Abstract 127: Racial Disparities in Management and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction

Introduction: Racial disparities in outcomes of acute myocardial infarction (AMI) and cardiac arrest (CA) exist. This study assessed the racial differences in the management and outcomes of CA complicating AMI to better inform clinical care. Hypothesis: We hypothesized that racial minorities would have worse outcomes with AMI-CA as compared to white patients. Methods: During 2012-2017, AMI admissions with a concomitant diagnosis of CA were identified from the National Inpatient Sample. Race was classified as white, black and others (Hispanic, Asian or Pacific Islander, Native American, Others). The primary outcome was racial disparities in in-hospital mortality. Secondary outcomes included racial disparities in invasive procedures and hospitalization characteristics. Results: We identified 3,504,225 admissions for AMI in the study period, of which 182,750 (5.2%) were complicated by CA. 74.8% were white, 10.7% were black and 14.5% belonged to other races. Black and other race AMI-CA admissions received less frequent early coronary angiography (41.4% vs 50.2% vs 52.8%), coronary angiography (61.9% vs 70.2% vs. 73.1% %), PCI (44.6% vs 53.0% vs 58.1%), CABG and mechanical circulatory support compared to white and other races. The mean time to coronary angiography was highest among blacks (3.4 ± 4.2 days) and lowest among whites (3.0 ± 3.7 days). Black and other races had significantly higher unadjusted mortality, however in a multivariable logistic regression analysis with white race as referent, black race was associated with lower in-hospital mortality (OR 0.95 [95% CI 0.91-0.99]; p =0.007) whereas other races had higher in-hospital mortality (OR 1.11 [95% CI 1.08-1.15]; p &lt;0.001) compared to white race. AMI-CA admissions of black race had longer length of hospital stay, higher rates of palliative care consultation, less frequent DNR status use, and fewer discharges to home. Admissions of other races had higher use of DNR status and higher hospitalization costs compared to whites and blacks. Conclusions: Significant racial disparities exist in in-hospital mortality among AMI admissions complicated with CA. Further quantitative and qualitative research into the equitable care of racial minorities with AMI-CA is needed to address this disparity.

Patterns of palliative care consultation among patients with brain metastasis: an opportunity for radiation oncologists to facilitate earlier referral

Early palliative care (PC) physician involvement alongside standard oncologic care has been recommended by the American Society of Clinical Oncology (ASCO) guidelines for all advanced cancer patients, although adherence to these guidelines is variable. Radiation oncologists (ROs) could help facilitate early PC referral for patients treated with palliative radiation, particularly those with brain metastasis (BRM), and the aim of this study was to evaluate the circumstances of PC referral at our institution to better understand the multidisciplinary approaches to facilitate it. Patients diagnosed with BRM from non-small cell lung cancer (NSCLC) from 2012 to 2018 whose primary RO and MO were at our institution were reviewed. Overall survival and time to PC consultation from the first oncologic visit following BRM diagnosis was determined using the KaplanMeier method. Mann-Whitney U and Chi-Squared assessed for predictive factors for shorter time to PC consultation. For these factors, the overall survival, rate of PC consultation, and PC setting was used to determine utilization of early PC. Among 103 eligible patients, only 48% underwent a PC consultation in their lifetime, with the initial evaluation being as an outpatient for 37%, and within 1 month of death for 35%. Median survival from BRM diagnosis was 9.0 months. The median time from oncologic appointment to PC referral was 2.8 months, and from initial PC consultation to death was 1.6 months. Only more recent BRM diagnosis (2016-2018 vs. 2012-2015) was associated with shorter time to PC consultation (1.0 vs. 5.6 months, P=0.013), increased PC consult rate (60% vs. 42%, P=0.105), and increased outpatient PC consultation (56% vs. 26%, P=0.037). The majority of patients did not undergo early PC consultation, though utilization has improved over time. As ROs are commonly involved in BRM management, they may be in a position to proactively support early PC consultations in this patient population.

Patterns of inpatient palliative care consultation for patients with brain and spine metastases.

e24117 Background: Patients diagnosed with brain and/or spine metastases (BSM) face high symptom burden and complex clinical decision-making. Through expertise in pain and symptom management, facilitation of end-of-life planning, and caregiver support, specialty Palliative Care (PC) can provide a crucial component of the care for these patients. No prior study has formally evaluated the rates of inpatient PC referral in BSM patients, nor the patient-specific factors that may affect consultation rates within this context. Methods: Analysis was performed of the rates of PC consults in a cohort of BSM inpatients admitted to three tertiary medical centers: one major academic center and two smaller affiliate centers. Patients were identified using a combination of ICD-9 and -10 codes and surgical provider lists to aggregate brain and spine metastases patient cohorts at each institution. Patient demographics, surgical status, and readmission data were collected. PC utilization was assessed by flagging encounters within which an inpatient consult to PC was placed. Results: 2608 total discharges were analyzed, with 2397 brain metastasis and 301 spine metastasis discharges. Average rate of inpatient PC consultation over the 3.5 year study period was 13.6% for brain metastasis patients and 11.0% for spine metastases patients. Rates of PC utilization differed significantly by patient race (11.6% in white vs. 17.0% in non-white patients, p = 0.02). Patients who received surgery had significantly lower rates of PC consultation in both brain (3.5% vs 15.6%, p &lt; 0.001) and spine (5.5% vs 14.1% p &lt; 0.001) cohorts. The large academic center had the lowest utilization as compared to two smaller affiliate centers, with 6.4% of brain and 7.6% of spine metastasis patients receiving PC consults. For both cohorts, Neurology was the discharging service with the highest rates of PC utilization, consulting PC for 37.7% of brain and 42.9% of spine metastasis patients respectively. Over time, PC utilization increased for brain, but not spine, metastasis patients. Conclusions: Despite their high symptom burden and low overall survival, BSM patients have low rates of inpatient PC consultation. Utilization appears to vary by patient demographics and surgical status, as well as discharging service and practice setting. These single-institution patterns may ultimately provide a microcosm for national patterns and trends at similar institutions, and further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.

Patterns of Palliative Care Consultation Among Patients with Brain Metastasis: An Opportunity for Radiation Oncologists to Facilitate Earlier Referral

Background Early palliative care (PC) physician involvement alongside standard oncologic care has been recommended by the American Society of Clinical Oncology (ASCO) guidelines for all advanced cancer patients, although adherence to these guidelines is variable. Radiation oncologists (ROs) could help facilitate early PC referral for patients treated with palliative radiation, particularly those with brain metastasis (BRM), and the aim of this study was to evaluate the circumstances of PC referral at our institution to better understand the multidisciplinary approaches to facilitate it. Methods Patients diagnosed with BRM from non-small cell lung cancer (NSCLC) from 2012 to 2018 whose primary RO and MO were at our institution were reviewed. Overall survival and time to PC consultation from the first oncologic visit following BRM diagnosis was determined using the KaplanMeier method. Mann-Whitney U and Chi-Squared assessed for predictive factors for shorter time to PC consultation. For these factors, the overall survival, rate of PC consultation, and PC setting was used to determine utilization of early PC. Results Among 103 eligible patients, only 48% underwent a PC consultation in their lifetime, with the initial evaluation being as an outpatient for 37%, and within 1 month of death for 35%. Median survival from BRM diagnosis was 9.0 months. The median time from oncologic appointment to PC referral was 2.8 months, and from initial PC consultation to death was 1.6 months. Only more recent BRM diagnosis (2016-2018 vs. 2012-2015) was associated with shorter time to PC consultation (1.0 vs. 5.6 months, P=0.013), increased PC consult rate (60% vs. 42%, P=0.105), and increased outpatient PC consultation (56% vs. 26%, P=0.037). Conclusions The majority of patients did not undergo early PC consultation, though utilization has improved over time. As ROs are commonly involved in BRM management, they may be in a position to proactively support early PC consultations in this patient population.

The Discrepancy Between Palliative and Oncology Providers in Palliative Referrals (QI704)

1.Justify the need for palliative care consultation to outpatient oncologists by meeting with them on a regular basis in order to increase the rate of referrals.2.Identify other patient-centered outcomes as a result of proactive palliative care consultation, including rate of completion of advance directives, rate of state-authorized portable orders (SAPO) completion, and rates of in-hospital and community deaths. According to NCCN and ASCO guidelines, there is evidence that early palliative care consultation in patients with advanced cancer led to significant improvement in quality of life, mood and longer survival as compared to patients receiving standard care. To improve the rate of palliative care consultation by 20% in patients with advanced cancer over a 15 month period at Buffalo Veterans Affairs Medical Center (VAMC). Buffalo VAMC is an academic center affiliated with the University at Buffalo. We provide both outpatient palliative and oncology services. In 2017, we decided to seek proactive palliative care consultations (PPCC) with advanced cancer patients; defined as stage 4 lung cancer, any pancreatic cancer, or any cancer with more than 1 emergency, hospital or ICU admissions. Based on our root analysis our intervention was a meeting between palliative and oncology services once a week since 01/01/2017 to 3/30/2018 at the VA and reviewing the oncology cases on weekly basis with average 80-100 patients per week. From 163 patients requested to be seen by palliative team, oncologists approved 63 proactive palliative consults with denial rate of 60%. PPCC resulted in an increase of referrals by 33% over a 15 month period. Of those patients seen by outpatient palliative care, 92% died in a community setting (hospice or home) while those identified but denied PPCC died in the community setting only 50% of the time. Interestingly, patients whose PPCC were denied but were later seen by the palliative care team during a hospital admission died in the community 91% of the time. In addition, advanced directives and SAPO increased by 30% and 65% respectively. Seeking proactive palliative care consultation in patients with advanced cancer led to an increased outpatient referral rate with a simultaneous decrease in in-hospital mortality.

Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses.

Efforts to improve end-of-life care have focused primarily on patients with cancer. High-quality end-of-life care is also critical for patients with other illnesses. To compare patterns of end-of-life care and family-rated quality of care for patients dying with different serious illnesses. A retrospective cross-sectional study was conducted in all 146 inpatient facilities within the Veteran Affairs health system among patients who died in inpatient facilities between October 1, 2009, and September 30, 2012, with clinical diagnoses categorized as end-stage renal disease (ESRD), cancer, cardiopulmonary failure (congestive heart failure or chronic obstructive pulmonary disease), dementia, frailty, or other conditions. Data analysis was conducted from April 1, 2014, to February 10, 2016. Palliative care consultations, do-not-resuscitate orders, death in inpatient hospices, death in the intensive care unit, and family-reported quality of end-of-life care. Among 57 753 decedents, approximately half of the patients with ESRD, cardiopulmonary failure, or frailty received palliative care consultations (adjusted proportions, 50.4%, 46.7%, and 43.7%, respectively) vs 73.5% of patients with cancer and 61.4% of patients with dementia (P < .001). Approximately one-third of patients with ESRD, cardiopulmonary failure, or frailty (adjusted proportions, 32.3%, 34.1%, and 35.2%, respectively) died in the intensive care unit, more than double the rates among patients with cancer and those with dementia (13.4% and 8.9%, respectively) (P < .001). Rates of excellent quality of end-of-life care reported by 34 005 decedents' families were similar for patients with cancer and those with dementia (adjusted proportions, 59.2% and 59.3%; P = .61), but lower for patients with ESRD, cardiopulmonary failure, or frailty (54.8%, 54.8%, and 53.7%, respectively; all P ≤ .02 vs patients with cancer). This quality advantage was mediated by palliative care consultation, setting of death, and a code status of do-not-resuscitate; adjustment for these variables rendered the association between diagnosis and overall end-of-life care quality nonsignificant. Family-reported quality of end-of-life care was significantly better for patients with cancer and those with dementia than for patients with ESRD, cardiopulmonary failure, or frailty, largely owing to higher rates of palliative care consultation and do-not-resuscitate orders and fewer deaths in the intensive care unit among patients with cancer and those with dementia. Increasing access to palliative care and goals of care discussions that address code status and preferred setting of death, particularly for patients with end-organ failure and frailty, may improve the overall quality of end-of-life care for Americans dying of these illnesses.