Rate Of Palliative Care Consultation Research Articles

An electronic intervention to improve structured cancer stage data capture.

151 Background: Cancer Staging is critical for prognosticating, treatment planning, outcomes analysis, registry reporting and clinical trial eligibility determination. Oncology EHRs have structured staging modules but use by physicians is inconsistent. Typically, stage is entered as unstructured free text in clinical notes and cannot be used for reporting. Instead, institutions depend the tumor registry (TR) which typically lag 6 months behind. Our Cancer Committee determined that real-time capture of structured cancer staging was an imperative. Methods: We created an EPIC best practice advisory (BPA) decision support tool that requires physicians to enter cancer stage if the following criteria are met: 1)unstaged cancer on the problem list 2)EPIC staging module exists for that cancer 3)physician is from a specialty with staging expertise. This BPA was implemented 12/18/14. If physicians chose not to stage they had to enter a reason why. Choices were: 1) cancer diagnosed before 2014, at which the BPA was permanently removed 2) staging studies not yet completed, at which the BPA fired at a future encounter 3) Not a staging provider, at which the BPA no longer fires for that individual provider 4) Cannot stage: document reason, at which the BPA was permanently removed. Results: We used TR data to determine the number of patients who were eligible for staging. In 12 months prior to the intervention, 1480/5222, or 28% of patients who were eligible for staging were staged in the structured staging module. After we launched the intervention, between 12/18/14 and 4/30/15, 1654/1831 or 90% of eligible patients were staged electronically. This is an absolute improvement of > 200% Conclusions: Electronic decision support can dramatically improve rates of structured staging. Such data allows automated reports for clinical trial screening, outcomes analysis, quality comparisons, and reporting. We are now building automated reports for: clinical trial eligibility, Commission on Cancer/ QOPI breast, colon and lung measures, rates of palliative care consultation for advanced disease and outcome measures like disease free interval by stage and overall survival.

Improving Training in Palliative Care for Pediatric Fellows – A Simulation-Based Multi-Institution Trial (TH311B)

•Describe different methods of palliative care education, including simulation-based education and didactic education.•Delineate differences between pediatric fellow self-assessment data and external reviewer data of fellow performance.•Describe how a simulation-based curriculum can lead to changes in palliative care consultation at an institution. Although palliative care (PC) skills can be learned “on the job,” pediatric trainees have few opportunities and often receive no formal PC education. (1) To assess whether simulation-based or didactic education is a more effective method for teaching PC communication. (2) To assess competence over time. (3) To determine if PC consultation rates would increase after simulation-based education. (1) 35 pediatric fellows from cardiology, critical care, oncology and neonatology at two institutions enrolled 17 in the intervention group (IG) and 18 in the control group (CG). IG fellows participated in a 2-day intervention over three months consisting of three simulation scenarios with debriefing and a videotaped PC lecture. CG fellows received written PC education designed to be similar in content and time. Assessments were measured at baseline, post-intervention and at three months; mean differences for each outcome measure were assessed. (2) External reviewers rated IG encounters on nine communication competencies. Changes over time were assessed. (3) PC consultations from the IG institution's four departments were compared in the six months pre- and post-intervention, normalized to inpatient admissions and hospital days. Over three months, IG fellows significantly improved in self-efficacy (p=0.003) and perceived adequacy of medical education (p<0.001), but not knowledge (p=0.20) when compared to CG fellows. External reviewers noted improvement in three competencies (relationship building (p=0.04), opening discussion (p=0.01), gathering information (p=0.01)). There was a 65% increase in PC consultation rate, but no difference when normalized to inpatient admissions or hospital days (OR 1.5, 95% CI 0.9-2.5 for both). IG fellows more strongly agreed that they would use (p=0.04) and recommended (p=0.004).the education. Our simulation-based curriculum is an effective method for teaching PC communication to pediatric fellows compared with a didactic education model.

Palliative care consultation for patients enrolled in cancer clinical trials.

139 Background: Cancer clinical trials often enroll patients with advanced cancer, yet trial participation should not preclude the appropriate use of palliative care (PC) services for these patients. We sought to describe rates and correlates of PC consultation in clinical trial patients and identify factors associated with use of PC. Methods: We prospectively collected data on patient characteristics and rates of PC consultation among all patients enrolled in cancer clinical trials at Massachusetts General Hospital in 2014. We used multiple logistic regression with purposeful selection of covariates to identify factors associated with PC consultation. Results: Of 1,218 clinical trial patients (mean age = 58 years; 643 (53%) female), 781 (64%) were married and 851 (70%) had metastatic disease. All cancer types were represented, but hematologic cancers (21%) were most common. Of those who had tumor genotype testing, 340 (62%) had a somatic mutation. Overall, 177 (15%) received PC consultation. Of those with metastatic disease, 149 (18%) received a PC consult. Metastatic disease, being unmarried, and absence of a somatic tumor mutation correlated with receipt of a PC consult. Conclusions: We found that a minority of cancer clinical trial patients receive PC consultation. Having metastatic disease and being unmarried correlated with receipt of PC consultation, thus highlighting a population likely needing additional supportive care. Presence of a somatic mutation was inversely associated with receiving PC consultation, suggesting that disease biology may impact patients’ supportive care needs or presence of these mutations influences clinician decisions about the need for PC services. These data help identify the factors associated with appropriate use of PC, and add to our understanding about the use of these services in cancer clinical trial patients. [Table: see text]

Palliative care and hospice use among melanoma patients treated with immunotherapy.

116 Background: PD-1/PD-L1 inhibitors (PD-1/PD-L1i) have revolutionized the treatment of patients with metastatic melanoma. However, little is known about the supportive care needs and use of palliative care (PC) services in these patients. We sought to assess rates and correlates of PC consultation and hospice use among melanoma patients treated with PD-1/PD-L1i. Methods: We retrospectively collected data on all patients with melanoma treated with PD-1/PD-L1i at the Massachusetts General Hospital (MGH) from May 2009 to March 2015. We determined rates of PC consultation and hospice use in this sample. We used logistic regression with purposeful selection of covariates to identify correlates of PC consultation. Results: Of 122 patients treated at MGH (mean age = 61.2 years), most were married (n = 91, 75%) and college educated (n = 66, 54%). Overall, 83 patients (68%) experienced autoimmune toxicities, 22 (18%) had liver metastases, 87 (71%) had cancer progression and 44 (36%) died during our study period. We found that 36 patients (30%) received PC consultation during their treatment course; 9 (25%) of these occurred over 6 months prior to the patients’ death, and 11 (31%) in their last month of life. Among the patients who died, 36 (82%) received hospice services, and 11 (31%) enrolled in hospice during their last week of life. In our regression model, younger age, having cancer progression and presence of liver metastases correlated with increased likelihood of receiving PC consultation. Conclusions: Melanoma patients treated with immunotherapy often receive PC and hospice services late in their treatment course. These data underscore the difficulty understanding when to involve hospice and PC for these patients, and highlight the need for further PC research in this patient population. Additionally, younger age, presence of cancer progression and liver metastases were associated with receiving PC consultation, thus suggesting the need for integrated PC services among certain subpopulations of these patients. [Table: see text]

Patterns of palliative care consultation among elderly cancer patients.

e17557 Background: Although the role of palliative care (PC) has expanded over the past several decades, its evolution has not been characterized at the population-based level. Methods: This study defined the patterns of PC delivery using a retrospective cohort of advanced cancer patients within the SEER-Medicare linked database. We identified 83,022 patients with metastatic breast, prostate, lung, and colorectal cancer. We studied trends between 2000-2009 and determined patient-level and regional-level predictors of PC delivery. Results: PC consultation rates increased from 3.0% in 2000 to 12.9% in 2009, with the majority of consultations occurring in the last 4 weeks of life (77%) in the inpatient setting. The rates of PC delivery were highest in the West (7.6%) and lowest in the South (3.2%). The likelihood of PC consultation increased with decreasing numbers of regional acute care hospital beds per capita. PC consultation increased with increasing numbers of regional physicians. PC utilization decreas...

Implementation of clinical triggers for palliative care consultation on a gynecologic oncology inpatient service: A pilot study.

51 Background: Our objectives were to (1) Assess the feasibility of creating clinical triggers for Palliative Care (PC) consultation on a large gynecologic oncology service and (2) Use triggers to increase PC consultation rates among trigger positive patients. Methods: Clinical triggers for PC consultation are listed below. Over a six month period, patients meeting triggers were prospectively identified and PC consultation was requested for those patients. Retrospective chart review was used to identify patients meeting triggers and gather clinical information. PC consultation rates were compared for patients meeting triggers in the 6 months pre and post trigger implementation. Statistical analysis utilized χ2 test, Fisher’s exact test and independent samples t-tests. Results: There was no difference in PC consultation rates among patients meeting triggers between the pre and post-triggers periods (see table). There was also no change in time from admission to PC consult (median time to PC consultation 1.56d vs. 2.24d, p=0.28) and no change in overall PC consultation volume (mean 17.3 new PC consults per 100 admissions/month vs. 18.5, p=0.67). Of the 38 patients in the post-triggers period who were not seen by PC, 50% (n=19) were inaccurately deemed trigger negative during their admission and 13% (n=5) were not screened at all. Conclusions: Creation of clinical triggers for PC consultation was feasible in terms of investment from relevant stakeholders. Trigger implementation was not associated with increased rates of PC consultation for those patients. High baseline rates of PC consultation and screening process issues contributed significantly to the lack of change in PC consultation rates. Use of clinical triggers may still hold promise as a strategy for standardizing PC consultation patterns and capturing subgroups of patients with high needs. Next steps include modifying our clinical triggers and screening process and expanding into the outpatient setting. [Table: see text]

Implementation of clinical triggers for palliative care consultation on a gynecologic oncology inpatient service: A pilot study

51 Background: Our objectives were to (1) Assess the feasibility of creating clinical triggers for Palliative Care (PC) consultation on a large gynecologic oncology service and (2) Use triggers to increase PC consultation rates among trigger positive patients. Methods: Clinical triggers for PC consultation are listed below. Over a six month period, patients meeting triggers were prospectively identified and PC consultation was requested for those patients. Retrospective chart review was used to identify patients meeting triggers and gather clinical information. PC consultation rates were compared for patients meeting triggers in the 6 months pre and post trigger implementation. Statistical analysis utilized χ2 test, Fisher’s exact test and independent samples t-tests. Results: There was no difference in PC consultation rates among patients meeting triggers between the pre and post-triggers periods (see table). There was also no change in time from admission to PC consult (median time to PC consultation 1....

Emergency department-initiated palliative care for advanced cancer patients: protocol for a pilot randomized controlled trial.

BackgroundFor patients with advanced cancer, visits to the emergency department (ED) are common. Such patients present to the ED with a specific profile of palliative care needs, including burdensome symptoms such as pain, dyspnea, or vomiting that cannot be controlled in other settings and a lack of well-defined goals of care. The goals of this study are: i) to test the feasibility of recruiting, enrolling, and randomizing patients with serious illness in the ED; and ii) to evaluate the impact of ED-initiated palliative care on health care utilization, quality of life, and survival.Methods/DesignThis is a protocol for a single center parallel, two-arm randomized controlled trial in ED patients with metastatic solid tumors comparing ED-initiated palliative care referral to a control group receiving usual care. We plan to enroll 125 to 150 ED-advanced cancer patients at Mount Sinai Hospital in New York, USA, who meet the following criteria: i) pass a brief cognitive screen; ii) speak fluent English or Spanish; and iii) have never been seen by palliative care. We will use balanced block randomization in groups of 50 to assign patients to the intervention or control group after completion of a baseline questionnaire. All research staff performing assessment or analysis will be blinded to patient assignment. We will measure the impact of the palliative care intervention on the following outcomes: i) timing and rate of palliative care consultation; ii) quality of life and depression at 12 weeks, measured using the FACT-G and PHQ-9; iii) health care utilization; and iv) length of survival. The primary analysis will be based on intention-to-treat.DiscussionThis pilot randomized controlled trial will test the feasibility of recruiting, enrolling, and randomizing patients with advanced cancer in the ED, and provide a preliminary estimate of the impact of palliative care referral on health care utilization, quality of life, and survival.Trial registrationClinical Trials.gov identifier: NCT01358110 (Entered 5/19/2011).

Providing Palliative Care for American Indians: The University of New Mexico's Experience (516)

1.Develop awareness of the "myths" or stereotypes that may impede the provision of palliative care to American Indians.2.Discuss if Native American patient ethnicity affected the rates of palliative care consultation or outcomes of consultations.3.Identify communication skills and other techniques to provide more "culturally-appropriate" palliative care to American Indian patients and families. The University of New Mexico Hospital admits the highest percentage of American Indian (AI) patients of any hospital in the country (13%). It is the only tertiary care hospital/Level IV trauma center in New Mexico and serves as a safety-net hospital for the entire state. Additionally, it is the the referral center for all Indian Health Service facilities in New Mexico and three surrounding states. Given this background, it is an ideal setting to study the provision of palliative medicine to American Indians. There are common myths and stereotypes that American Indian patients refuse to speak about death or plan for end-of-life care. Obviously these beliefs would prevent AI patients from accessing palliative care services, which are known to improve quality of care. We began an inpatient palliative care consultation service at UNMH in Jan, 2009. During this session, we will present our findings from the >400 consultations we performed in the first year of our clinical service. We found that patient ethnicity (Hispanic, Non-Hispanic Caucasian, American Indian, and "other") did not affect rates of consultation among all admitted patients and admitted patients with high predicted mortality. Primary diagnosis, primary service, age, and predicted mortality were associated with differing rates of consultation. Outcomes of consultation (code status and holding a family meeting) also did not vary by patient ethnicity. This information challenges the myths that American Indians will not participate in discussions about death or end of life care. Our service intentionally used techniques to provide "culturally appropriate" palliative consultations for AI patients. The use of these techniques may have created settings in which it was more comfortable or culturally appropriate to discuss end of life care issues. We will review multiple techniques that may help other clinicians to provide more "culturally-appropriate" consultations for American Indian patients.