Supportive Care Clinic Research Articles

Early palliative care interventions in patients with hematologic malignancies prior to hematopoietic cell transplantation.

e21634 Background: Early palliative care (EPC) interventions have been endorsed by multiple medical societies, mostly for solid tumors but not for hematological malignancies. Patients undergoing hematopoietic stem cell transplantation (HSCT) suffer significant physical and emotional distress affecting negatively their quality of life (QOL). They also receive more aggressive end-of-life interventions than other cancer patients. Few studies have shown the impact of EPC in the pre-transplant phase on post transplant morbidity and mortality. Methods: 53 patients undergoing HSCT were evaluated on the supportive care clinic for symptom and needs assessment using the Edmonton symptom assessment scale (ESAS) to evaluate symptom burden prior to transplant. Consecutive palliative care visits were offered to patients. We also evaluated whether the supportive care clinic (SCC) visits made a difference on hospitalization rate and mortality comparing this group with 108 patient who did not undergo evaluation. Kaplan-Meier method and log-rank test were used in the survival analysis and Fisher’s exact test was used in the data analysis for categorical variables. Results: The most common symptoms reported by patients included: fatigue (4.4), sleep problems (3.7), pain (2.8), anxiety (2.8), well-being (2.7), and drowsiness (2.3). 26% (14) of the patients were followed in the SCC at 3 months. The most common symptoms at that time included fatigue (5.1), pain (4), drowsiness (3.6), sleep problems (3.1), well-being (2.9), and appetite (2.4). Overall mortality for the whole group was 24%. 28% for the palliative care group and 21% for the control group. Odds Ratio for mortality at 3 and 6 months were not significantly different between groups. Differences in hospital admissions were also not statistically significant. Conclusions: EPC in HSCT patients is feasible and may help with symptom detection and control. No effect on mortality or hospital admission rates was found on this study on patients referred for EPC interventions. Prospective studies are needed to clearly define the role of EPC in HSCT patients.

Advanced cancer patients' self-reported perception of timeliness of their referral to outpatient supportive/palliative care and their survival data.

10121 Background: Palliative Care referral is often thought to be delayed as judged by health professionals and caregivers. However, no studies have ever examined patients’ perception of timeliness of referral. The primary objective of this study was to determine patients’ perception of the timeliness of their own referral to an outpatient palliative care clinic. We also examined the association between perceived timeliness and actual timing of referral. Methods: In this prospective survey, patients with advanced cancer were asked to rate their perceived timeliness of referral using a 5-point Likert scale ranging from much too early to much too late within 7-35 days after their first consultation visit at Supportive Care Center. They were also asked when they felt referral to Supportive Care should occur along 4 points in their disease trajectory. Actual timing of referral was assessed based on survival from the timing of completion of the survey. Results: 200 advanced cancer patients were surveyed. Median age was 64, 111 (55%) were female, and 35 (18%), 32 (16%) and 26 (13%) had gastrointestinal, lung and breast cancer, respectively. The median overall survival was 8.5 months. 144 (72%) patients perceived their referral was “just in time,” 42 (21%) felt it was “late/much too late,” and 14 (7%) felt it was much “too early/early.” 76/193 (39%) felt the referral should occur at the time of diagnosis of cancer, 32 (17%) when they start first-line chemotherapy, 46 (24%) at diagnosis of recurrent disease, 14 (7%) when there are no further treatment options, and 4 (2%) reported never. We found no significant difference in survival among patients who reported their referral was early, just in time, and late (median 9.8 vs. 8.3 vs. 9.0 months, P=0.43). Conclusions: Patients with advanced cancer were referred to our outpatient Supportive Care clinic a median of 8.5 months before death. A vast majority of patients perceived the timing of referral was appropriate, and many agreed that referral should occur early in the disease trajectory. The lack of association between perceived timeliness of referral and survival may be related to the ceiling effect and the small number of patients who felt their referral was late.

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

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

Improving quality of care for end-stage respiratory disease: Changes in attitude, changes in service.

The illness trajectory for many patients with severe respiratory disease is characterized by steady decline. Yet most healthcare resources are poured into managing acute exacerbations that are only temporarily effective. Further, ‘bad deaths’ can result from inappropriate medical interventions at times of crisis. In this article, we describe a range of changes in attitudes, behaviour and service provision that together focus on improving quality of care for respiratory patients with frequent crises. These changes include prognostic conversations, developing and implementing anticipatory care plans both in hospital and in the outpatient settings, and establishing a supportive care clinic devoted to complex disease and optimizing palliative care. The underpinning philosophy is that common sense and compassion should motivate broader and more flexible care much more than adherence to the ‘curative–restorative’ guidelines-based model.

Urine drug screen findings among ambulatory oncology patients in a supportive care clinic.

Professional organizations provide no guidelines regarding assessment and management of opioid abuse risk in cancer. Universal precautions (UP) developed for non-cancer pain, include assessments for aberrant behavior, screening questionnaires, and urine drug screens (UDS). The role of UDS for identifying opioid abuse risk in cancer is uncertain. Our aim is to characterize inappropriate UDS, and identify a potential role for UDS in therapeutic decision-making. An observational retrospective chart review of 232 consecutive supportive care clinic patients were seen during the study. Twenty-eight of the two hundred thirty-two did not meet inclusion criteria. One hundred fifty of the two hundred four had active cancer, while 54 had no evidence of active disease. Clinicians ordered UDS based on their clinical judgment of patients' substance misuse risk. Edmonton symptom assessment scores, history of substance abuse, alcohol use, tobacco use, aberrant behavior, and morphine equivalent daily dose (MEDD) were obtained. Pain scores and MEDD were higher (p=0.021; p<0.001) in the UDS group vs non-UDS. Forty percent of the patients (n=82/204) had at least one UDS and 70% (60/82) had an inappropriate result. Thirty-nine percent (32) were inappropriately negative, showing no prescribed opioids. Forty-nine of the eighty-two were positive for non-prescribed opioids, benzodiazepine, or illicit substance. Eleven of the forty-nine had only cannabis metabolites in their urine. There were no significant differences between appropriate and inappropriate UDS groups regarding pain scores, MEDD or referral to psychology, psychiatry, or substance abuse specialists. UDS on the 82 oncology patients at high risk for substance misuse were frequently positive (46%) for non-prescribed opioids, benzodiazepines or potent illicit drugs such as heroin or cocaine, and 39% had inappropriately negative UDS, raising concerns for diversion.

One Thing Leads to Another: Untangling the Relationship Between Depression and Pain in Outpatients with Serious Illness (S730)

•Describe the issue and prevalence of co-occurring pain and depression in an outpatient palliative care clinic•Describe the relationship between depression severity and pain intensity Depression and pain are commonly experienced by patients with serious illness, such as cancer and heart disease. Depression and pain co-occur in patients 30-50% of the time resulting in the exacerbation of each symptom, warranting equal attention to develop an effective treatment plan. The objective of this study was to determine the relationship between depression severity & pain intensity (least, worst, average, pain now) among patients with chronic illnesses. We conducted a secondary analysis of the UAB Supportive Care and Survivorship Clinic dataset of outpatients with serious illnesses treated from 2012-2016. Depression, scaled 0-27, was measured by the PHQ-9, and pain, scaled 0-10, was measured by the Brief Pain Inventory. The sample (n=120) was mean age 51.27 years, 58.3% female, 24.2% black/African-American, 74.2% white/Caucasian and 52.5% married. The diagnoses of the outpatients were 72.5% cancer, 13.3% heart diseases, and 14.2% other diagnoses. We found positive correlations between mean depression total scores (12.43±6.21) and “least” (mean=4.07±2.86, r=.347, p=.001), “worst” (mean=7.48±2.45, r=.285, p=.012), & “pain now” (mean=4.89±3.27, r=.312, p=.002) pain scores. One-way ANOVA and post hoc tests demonstrated that the “least” (p=.009) and “pain now” (p=.027) pain scores were significantly higher in the patients with severe depression than those with mild depression. These results suggest that outpatients with severe depression report higher “least” and “pain now” pain scores than those with mild depression. These findings are consistent with other literature describing a close relationship between pain and depression but adds specificity regarding the relationship of depression severity and pain intensity.

Oncology supportive care clinics as a novel model to integrate oncology and palliative care.

154 Background: The integration of oncology with palliative care (PC) has been endorsed by the American Society of Clinical Oncology. Starting in 2012, Kaiser Permanente Northern California (KPNC) began introducing Oncology Supportive Care Clinics (OSCCs) to better provide integrated oncology and PC services. We evaluated the impact of OSCCs on outpatient PC referrals among patients diagnosed with advanced cancers. Methods: We included all adult patients diagnosed with incidental stage IV cancer from 2010-2014 from 19 medical centers within KPNC. We excluded 2 medical centers for inconsistent PC referral tracking. Patients were required to have continuous KPNC coverage during the study period and were followed for a minimum of 12 months after diagnosis or until death. Outcomes included the rate of PC referral following diagnosis and time elapsed from diagnosis to referral. Because the introduction of OSCCs was staggered by medical center, we used a difference-in-differences model to compare the outcomes in medical centers with and without OSCC, before and after OSCC establishment. Results: OSCCs are currently operational at 11 medical centers. A total of 1,7640 patients were included. At centers with OSCCs, the referral rate after OSCC increased from 16.5% to 30.9% (p &lt; 0.01); compared to no change at centers without OSCCs (12.5% before vs. 11.7% after, p = 0.35). There was a decrease in the median time from diagnosis to PC referral at all medical centers, from 163 days (IQR 33-541) to 75 (IQR 20-255) days, p &lt; 0.01, regardless of OSCC presence. Conclusions: The KPNC OSCC model has been successful at increasing PC referrals in patients with stage IV cancers, highlighting the important role healthcare delivery systems have in driving practice change. More research is ongoing to examine patient-centered outcomes associated with receiving OSCC services.

Frequency, predictors, and outcomes of urine drug test among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic.

94 Background: Data on the utilization and outcomes of urine drug tests (UDT) among advanced cancer patients is limited. The main objective of this study was to determine the factors associated with UDT ordering and results in advanced cancer outpatients. Methods: A retrospective chart review of 1058 patients seen from March 2014 to November 2015 at an outpatient supportive care clinic was conducted. Sixty-one patients on chronic opioid therapy who underwent UDT were identified. A control group of 120 patients who did not undergo UDT was selected for comparison of information on demographic and clinical characteristics. Results: 61/1058 patients (6%) underwent UDT. 33/61 patients (54%) had abnormal results. Multivariate analysis found that the odds ratio for UDT ordering was 3.9 in CAGE positive patients (p = 0.002), 4.41 in patients less than 45years (p &lt; 0.001), 5.58 in patients with moderate to severe pain (ESAS pain score ≥ 4) (p &lt; 0.001), 0.27 in patients with advanced cancer stage, (p = 0.008), and 0.25 in patients with moderate to severe fatigue (p = 0.001). Among 52 abnormal UDT results in 33 patients, the most common opioid findings were: prescribed opioids absent in urine (14/52, 27%) and un-prescribed opioids in urine (13/52, 25%). Conclusions: UDT was used infrequently among advanced cancer patients receiving outpatient chronic opioid therapy. Younger age, CAGE positivity, early cancer stage or NED status, higher pain intensity, and lower fatigue were significant predictors of UDT ordering. More than 50% of UDTs were abnormal. More research is necessary to better characterize aberrant opioid use in advanced cancer patients.

Use of the Edmonton Symptom Assessment Scale in patients with advanced cancer referred to an embedded palliative care clinician.

96 Background: Physical and emotional symptoms are highly prevalent in patients with advanced cancers and contribute to overall distress level and decreased self-reported quality of life. Oncology organizations and accrediting bodies now routinely recommend universal distress screening among patients with advanced cancers. Palliative and supportive care clinicians play an important role in implementing symptom and distress screening in cancer centers. Methods: As part of an embedded palliative care nurse practitioner (PC-NP) intervention within a large ambulatory oncology clinic, patients with advanced breast, GU, GI and lung cancer were screened for physical and emotional symptoms using the Edmonton Symptom Assessment Scale (ESAS) and treated appropriately including referral to psychology-based supportive care clinic for moderate to severe anxiety and depression or clinician-identified need. We used pre-test post-test methods to see if symptoms improved after enrollment in an embedded palliative oncology program. Results: Sixty-eight patients were screened at initial visit and 41 had follow-up screening during the first 13 months of the program with a part-time PC-NP. Only the 41 patients who had both an initial and a follow-up visit were included in the analysis. Patients were assessed using the ESAS at initial visit and at a follow-up visit an average of 5.9 weeks later (RANGE 1.0-30.6), and significant reductions were found in self-reported pain (4.0 v. 3.0), shortness of breath (3.0 v. 2.1), lack of appetite (2.8 v. 2.1), and overall well-being (4.7 v 3.8) (p &lt; 0.05). Emotional symptoms (anxiety and depression) also decreased but were not statistically significant. Aggregate scores (emotional symptoms plus physical symptoms plus well-being) demonstrated a 6 point reduction in severity (26.2 baseline to 20.3 at follow-up, p = 0.17). Conclusions: These findings are suggestive of improvement in cancer-related symptoms and distress after enrollment in an embedded palliative oncology program. More rigorous study designs are needed to better understand the impact of the intervention on symptom management.

Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic.

Data are limited on the use and outcomes of urine drug tests (UDTs) among patients with advanced cancer. The main objective of this study was to determine the factors associated with UDT ordering and results in outpatients with advanced cancer. A retrospective chart review was conducted of 1058 patients who attended an outpatient supportive care clinic from March 2014 to November 2015. Sixty-one patients who were receiving chronic opioid therapy and underwent UDTs were identified. A control group of 120 patients who did not undergo UDTs was selected for comparison. Sixty-one of 1058 patients (6%) underwent UDTs, and 33 of 61 patients (54%) had abnormal results. Multivariate analysis indicated that the odds ratio for UDT ordering was 3.9 in patients who had positive Cut Down, Annoyed, Guilty, and Eye Opener (CAGE) questionnaire results (P = .002), 4.41 in patients aged < 45 years (P < .001), 5.58 in patients who had moderate-to-severe pain (Edmonton Symptom Assessment Scale pain scores ≥4; P < .001), 0.27 in patients with advanced-stage cancer, (P = .008), and 0.25 in patients who had moderate-to-severe fatigue (P = .001). Among 52 abnormal UDT results in 33 patients, the most common opioid findings were prescribed opioids absent in urine (14 of 52 tests; 27%) and unprescribed opioids in urine (13 of 52 tests; 25%). UDTs were used infrequently among outpatients with advanced cancer who were receiving chronic opioid therapy. Younger age, positive CAGE questionnaire results, early stage cancer or no evidence of disease status, higher pain intensity, and lower fatigue scores were significant predictors of UDT ordering. More than 50% of UDT results were abnormal. More research is necessary to better characterize aberrant opioid use in patients with advanced cancer. Cancer 2016;122:3732-9. © 2016 American Cancer Society.

Characteristics of patients with advanced lung cancer referred to a rapid-access supportive care clinic.

There is a limited number of pragmatic studies to evaluate the criteria for referral to outpatient palliative care. The aim of our study was to compare the characteristics, symptoms, and survival of patients with advanced non-small-cell lung cancer (NSCLC) referred (RF) versus not referred (NRF) to a novel embedded same-day rapid-access supportive care clinic (RASCC) and to compare the subgroups among referred patients. We reviewed the medical records of all patients who received treatment at the thoracic oncology clinic for advanced non-small-cell lung cancer between August 1, 2012, and June 30, 2013, who were referred to the RASCC and those who were not referred. An oncology-estimated prognosis of ≤6 months and/or severe symptom distress was employed as criteria for referral to the RASCC. Of 410 eligible patients, 155 (37.8%) were referred to the RASCC. RF patients had significantly higher patient-reported scores for pain, fatigue, lack of appetite, and symptom distress, as well as worse performance status and shorter survival than NRF patients. Among the RF patients, those who were referred early (≤3 months) had significantly worse symptom distress and shorter overall survival than patients who were referred later on. The patients treated by thoracic oncologists who referred a smaller proportion of their patients to the RASCC had significantly worse anxiety, well-being, spiritual pain, and symptom distress than patients treated by those who referred a larger proportion of their patients to the RASCC. We found that patients who were referred to the RASCC had higher reported symptom distress and worse survival ratings. Further studies are needed to evaluate the optimal criteria for timely integration of palliative care and oncology care.

An Interdisciplinary Outpatient Palliative Care Model for Cancer Patients: Successful and Reproducible (TH307)

•Identify key attributes that an integrated interdisciplinary care team model brings to the palliative care clinic, the delivery of care and patient outcomes.•Identify key components of a successful outpatient palliative care model that integrates interdisciplinary palliative care with oncology in a cancer center.•Identify benefits and opportunities to influence institutional leaders, initiate, maintain, and advance outpatient palliative care programs, while recognizing some of the challenges and pitfalls of initiating, sustaining, and expanding an outpatient program within academic institutions and in the community cancer center. Only 59% of NCI centers have outpatient palliative care clinics. Clinics are crucial for the integration of palliative care into oncology and improve outcomes, including caregiver satisfaction, symptoms, and survival. ASCO’s recommendation for comprehensive cancer care by 2020 includes “dissemination of effective models of cancer care that incorporate palliative care.” They recognize MD Anderson Cancer Center (MDACC) as an innovative model for integration of palliative care into oncology. We will describe the MDACC model and exponential growth of the outpatient program, including improved clinical outcomes supported by published research. We will discuss the necessary ingredients for a successful program, including the importance of changing an institutional culture; how an interdisciplinary team brings an additive role to palliative care; the use of routine screenings for symptom distress and chemical coping; the use of family conferences and split visits (parallel meetings with patient and accompanying family for counseling); and unique methods of follow-up such as phone care programs and same-day consults. And, in spite of some institution-specific characteristics unique to MDACC, the clinical model, including an interdisciplinary palliative care team and a simultaneous cancer care approach, is reproducible. To demonstrate this, we will describe the Virginia Commonwealth University palliative care program that implemented core features of the MDACC model into their supportive care clinic, producing an eight-fold increase in patient contacts and clinic availability. We will conclude with discussing the opportunities and benefits for adapting this model into cancer centers to advance delivery of care, as well as the challenges and pitfalls encountered. Ultimately, the information delivered will provide concrete experiences for both academic institutions as well as community cancer centers to apply effective strategies to implement a dynamic interdisciplinary model of palliative care.

Frequency, types of interventions and changes in symptoms after consultation with Rapid Access Supportive Care Clinic (RASCC).

153 Background: ASCO recommends an integration of palliative care to oncology care so as to improve outcomes. Recognizing the importance our center created a pilot RASCC. The aim of the study was to determine the most frequent interventions by RASCC and symptom change at first follow-up visit. Methods: In this retrospective study all patients seen as a part of RASCC clinic (August 2012- June 2013) were reviewed. Pts with stage 4 NSCLC with oncologist estimated survival of ≤ 6 months were eligible. Delivery of standardized palliative care was ensured using Palliative Care Checklist and weekly meetings. Care followed a standardized management plan. Results: 156 patients were evaluable. The median age was 63, 56% were male, 74% were white. SDS scores improved at follow-up (Table 1). The most common interventions were counseling (including advance cancer planning), medication changes. At the initial consultation, all patients received counseling n = 176 (pts received counseling by more than one IDT member); among the medications, dose initiation and increase of analgesics/opioids n = 122, laxatives n = 123, antiemetics 66, appetite stimulants 18, corticosteroids 10, antidepressants 9, methylphenidate 8, gabapentin 8, neuroleptics 5, sedatives 0. Among analgesics, dose initiation/increased morphine, n = 53, hydrocodone 24, oxycodone 18, hydromorphone12, methadone and fentanyl 6, codeine 1, NSAIDS3. Conclusions: RASCC was associated significant improvement of symptoms and SDS scores at 1st follow-up and the most common interventions were counseling, medication changes related to pain. Further studies are needed. [Table: see text]

Characteristics of patients referred to embedded rapid access supportive care clinic.

141 Background: ASCO recommends Palliative care and Oncology integration to improve quality care outcomes. There is limited data on the patient (pt) characteristics (PC) for those who access integrated care. Our center created a pilot rapid access supportive care clinic (RASCC) to facilitate same-day consultation. The aim of this study was to determine the PC of pts referred (R) and not referred (NR) to RASCC. We also examined the PC of those who referred early[ER] (within 12 weeks of diagnosis or registration) vs those who have referred late [LR]. Methods: We reviewed pt medical records of all pts R and NR during the pilot period (Aug 01, 2012 to June 30, 2013). To be eligible all pts had advanced Stage IV non-small cell lung cancer with oncologist estimated overall survival (OS) of ≤ 6 months. Results: Of a total of 419 eligible pts seen at the thoracic oncology clinic, 157 (37%) pts were referred to RASCC. R group had a higher symptom distress scores, SDS (Table 1), weight loss, worse PS and OS compared to NR. There was no difference in PC between ER and LR except in the ESAS symptoms and SDS scores were higher in ER than LR, 40(29.5,52) vs 31.5(22.25,40.125), P &lt; .001. Conclusions: R pts had higher symptom burden and worse OS. Similarly ER had a higher SDS than LR suggesting referrals to RASCC were primarily based on symptom burden. [Table: see text]

CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life.

Survival, symptom burden, and quality of life (QOL) are uncertain for elderly patients with advanced CKD managed without dialysis. We examined these outcomes in patients managed with renal supportive care without dialysis (RSC-NFD) and those planned for or commencing dialysis. In this prospective observational study, symptoms were measured using the Memorial Symptom Assessment Scale and the Palliative care Outcomes Scale - Symptoms (renal) inventory and QOL was measured using the Short Form-36 survey. This study comprised 273 predialysis patients who had usual nephrology care and 122 nondialysis pathway patients who also attended a renal supportive care clinic adding the skills of a palliative medicine team. A further 72 patients commenced dialysis during this period without attending either clinic. Nondialysis patients were older than the predialysis group (82 versus 67 years; P<0.001) but had similar eGFR at the first clinic visit (16 ml/min per 1.73 m(2); P=0.92). Of the predialysis patients, 92 (34%) commenced dialysis. Compared with the RSC-NFD group, the death rate was lower in the predialysis group who did not require dialysis (hazard ratio, 0.23; 95% confidence interval, 0.12 to 0.41] and in those requiring dialysis (0.30; 0.13 to 0.67) but not in dialysis patients who had not attended the predialysis clinic (0.60; 0.35 to 1.03). Median survival in RSC-NFD patients was 16 (interquartile range, 9, 37) months and 32% survived >12 months after eGFR fell below 10 ml/min per 1.73 m(2). For the whole group, age, serum albumin, and eGFR <15 ml/min per 1.73 m(2) were associated with poorer survival. Of the nondialysis patients, 57% had stable or improved symptoms over 12 months and 58% had stable or improved QOL. Elderly patients who choose not to have dialysis as part of shared decision making survive a median of 16 months and about one-third survive 12 months past a time when dialysis might have otherwise been indicated. Utilizing the skills of palliative medicine helps provide reasonable symptom control and QOL without dialysis.

The symptoms of patients with CKD stage 5 managed without dialysis

BackgroundThere is an increasing number of patients with stage 5 chronic kidney disease (CKD) being managed conservatively without dialysis. A critical aspect of their care is symptom management. To date there is only a small body of literature examining the prevalence and severity of the symptoms they experience.AimsTo describe symptom prevalence, severity and total symptom burden on patients with stage 5 CKD being managed conservatively.MethodsSymptom data were collected from all the patients with stage 5 CKD being managed conservatively at their first presentation to a renal supportive care clinic. Symptoms were assessed using the patient-completed palliative care outcome scale-symptoms (POS-S) (renal) instrument, a validated symptom inventory tool for patients with CKD.ResultsSymptoms were evaluated in 42 patients. Their mean age was 83 years (SD: ±8.17) and the mean estimated glomerular filtration rate (eGFR) was 10.6 mL/min/1.73 m2 (SD: ±2.23). Symptoms reported by more than one-third of patients were lack of energy, 88% (CI: 78–98); difficulty with mobility, 76% (CI: 63–89); pruritus, 69% (CI: 55–83); lack of appetite, 62% (CI: 47–77); shortness of breath, 60% (CI: 45–75); drowsiness, 57% (CI: 42–72); sleep disturbance, 57% (CI: 42–72); feeling depressed, 52% (CI: 37–67); pain, 45% (CI: 30–60); constipation, 43% (CI: 28–58); feeling anxious, 43% (CI: 28–58); and skin changes, 38% (CI: 23–53). The mean number of symptoms reported on POS-S (renal) per patient was 8.1 (SD: ±3.99) of a maximum 17. Those symptoms which were most likely to be reported as ‘moderate’ to ‘overwhelming’ were fatigue (66%), difficulty with mobility (64%), pruritus (45%), disturbed sleep (45%), anorexia (43%), drowsiness (38%), depression (38%), and dyspnoea (36%). The three most prevalent symptoms were also the most severe. There was no statistical correlation between the severity of disease as measured by eGFR, haemoglobin (Hb), and prevalence or severity of symptoms. Although 92% of the studied group had a ‘very high co-morbidity’ index according to the modified Charlson co-morbidity index, there was no statistical correlation between the eGFR and the burden of co-morbidities nor between the burden of co-morbidities and the number or severity of reported symptoms.ConclusionPatients with end-stage kidney disease managed conservatively are burdened with multiple symptoms. Many of those symptoms are moderate to overwhelming in severity and not easily predicted on the basis of the eGFR. The responsibility for the management of these symptoms rests on all disciplines who care for this cohort of patients throughout the course of their illness.

The routine use of the Edmonton classification system for cancer pain in an outpatient supportive care center.

180 Background: There is no standardized and universally accepted pain classification system for the assessment and management of cancer pain in both clinical practice and in research studies. The Edmonton Classification System for Cancer Pain (ECS-CP) is an assessment tool that has demonstrated value in assessing pain characteristics and response. The purpose of the study was to determine the relationship between the negative ECS-CP features and some pain related variables like pain intensity and opioid use. Also, we explored whether the number of negative ECS-CP features was associated with higher pain intensity. Methods: Electronic charts of 100 patients at the outpatient supportive care clinic in a comprehensive cancer center were reviewed for patient characteristics, initial ECS-CP assessment, the morphine equivalent daily dose (MEDD), opioid rotation, the Edmonton Symptom Assessment Score (ESAS), Memorial Delirium Assessment Scale (MDAS), performance status, and the use of adjuvant analgesics. Results: Ninety one out of the 100 charts were therefore eligible for analysis. The median age was 58.4 years. The most common primary cancer site was gastrointestinal cancer (22.1%). The median pain intensity was 6 and the median MEDD was 45mg. Incident pain was the most common ECS-CP feature (60%) and cognitive dysfunction was the least frequent feature (2%). Neuropathic pain was associated with higher median pain intensity (7 vs. 5, p=0.007) and median MEDD requirement (83 vs. 30, p=0.013). Psychological distress was associated with higher median pain intensity (7 vs. 5, p=0.042). Incident pain was also associated with a trend for higher pain intensity (6 vs 5, p= 0.06). A higher number of negative ECS-CP features was associated with higher pain intensity (p=0.01). Conclusions: The ECS-CP was successfully completed in the majority of patients, demonstrating its utility in routine clinical practice. Neuropathic pain and psychological distress were associated with higher pain intensity. Also, neuropathic pain was associated with higher MEDD. A higher sum of negative ECS-CP features was associated with higher pain intensity. Further studies will be needed to explore this observation.

The routine use of the Edmonton Classification System for Cancer Pain in an outpatient supportive care center.

There is no standardized and universally accepted pain classification system for the assessment and management of cancer pain in both clinical practice and research studies. The Edmonton Classification System for Cancer Pain (ECS-CP) is an assessment tool that has demonstrated value in assessing pain characteristics and response. The purpose of our study was to determine the relationship between negative ECS-CP features and some pain-related variables like pain intensity and opioid use. We also explored whether the number of negative ECS-CP features was associated with higher pain intensity. The electronic charts of 100 patients at an outpatient supportive care clinic in a comprehensive cancer center were reviewed for variables like patient characteristics, initial ECS-CP assessment, morphine equivalent daily dose (MEDD), opioid rotation, Edmonton Symptom Assessment Score (ESAS), and use of adjuvant analgesics. Some 91 of the 100 charts were eligible for analysis. The most common primary cancer type was gastrointestinal (22.1%). The median pain intensity was 6, and the median MEDD was 45 mg. Neuropathic pain was associated with higher median pain intensity (7 vs. 5, p = 0.007) and median MEDD requirement (83 vs. 30, p = 0.013). Psychological distress was associated with higher median pain intensity (7 vs. 5, p = 0.042). Incident pain was also associated with a trend toward higher pain intensity (6 vs. 5, p = 0.06). A higher number of negative ECS-CP features was associated with higher pain intensity (p = 0.01). The ECS-CP was successfully completed in the majority of patients, demonstrating its utility in routine clinical practice. Neuropathic pain and psychological distress were associated with higher pain intensity. Also, neuropathic pain was associated with a higher MEDD. A higher sum of negative ECS-CP features was associated with higher pain intensity. Further studies will be needed to verify and explore these observations.

HEART FAILURE SUPPORTIVE CARE CLINIC: DOES IT IMPROVE QUALITY OF LIFE?

OBJECTIVE: Intravenous administration of loop diuretics is a cornerstone of therapy for acute decompensated heart failure (ADHF). Best practices to achieve safe, efficient fluid loss are dependent on appropriate monitoring and then adequate responses including diuretic dose adjustment and electrolyte correction. Our objective was to evaluate real-world practices for furosemide administration during the first 48 hours of admission for ADHF at our academic institution and to identify areas for quality improvement. We assessed the adequacy of weight monitoring, the relationship to drug administration, and practices to monitor and replace potassium. METHODS: Retrospective single center electronic chart review was conducted of hospitalized ADHF patients treated with intravenous furosemide from the time of admission. Patients who died or were discharged within 48 hours of starting furosemide were excluded. Demographics, length of stay and clinical data from the first 48 hours of admission were collected. RESULTS: We identified 402 unique episodes of care for ADHF between February 2010 and November 2012. Twenty-seven percent of patients had a baseline weight recorded within 12 hours of admission. The median time to first recorded weight after admission was 19 hours. The median total number of weights obtained in the first 48 hours was 1. Fifty-nine percent of patients had less than 2 weights recorded within 48 hours of admission. The mean furosemide dose administered over 48 hours was (163 128 mg). There was no difference in average furosemide dose between patients with and without baseline weight. However, patients who had less than 2 weights received significantly less furosemide (145 120 mg) compared to patients who had 2 or more weights (188 160 mg) (p1⁄40.007) over 48 hours. There was no significant difference in the median length of stay between patients who had less than two weights (8 days) versus those had 2 or more weights over 48 hours (7 days). All patients had a baseline and a repeat potassium measurement within 48 hours. Forty-two percent of patients presented with a baseline potassium <4 mmol/L, and 40% of those patients were administered replacement. CONCLUSION: Sizable proportions of patients were not weighed in a timely fashion, or lacked sufficient documentation to evaluate weight loss after furosemide administration. This appeared related to the total dose of furosemide received early on during admission. Practices for monitoring serum potassium were better, though replacement was less systematic. We identified several targets for quality improvement in the care of ADHF at our center. 281 HEART FAILURE SUPPORTIVE CARE CLINIC: DOES IT IMPROVE QUALITY OF LIFE?

A supportive care clinic for cancer patients embedded within an oncology practice.

Most cancer patients have symptoms from their disease or treatment. Symptoms are not ideally managed in the context of busy clinics, resulting in potentially avoidable emergency department (ED) visits and hospitalizations. Adjunct supportive care clinics (SCCs) may more effectively address patient needs, but they contribute to fractionation of care if different personnel are involved. We describe an SCC embedded within a physician practice in which an employed nurse practitioner delivered most of the care. We measured the disposition of patients from the SCC to the ED, and the effect on ED visits and admissions for symptom management. We conducted a retrospective review of the patients attending the SCC over a period of 11 months. Demographics and disposition outcomes were tracked and compared with pre-intervention controls. In all, 340 visits were recorded from 330 unique patients. Same-day and next-day appointments with a nurse practitioner were arranged for 62% and 25% of patients, respectively. The most common complaints related to pain and gastrointestinal issues. Most of the patients were discharged home. A few needed hospitalization or ED-level care. Admissions for symptom-related care fell by 31%. An estimated 66 ED visits were avoided by patients accessing the SCC. The study was retrospective. It did not include detailed fnancial data. Results may not be generalizable because of the high level of central planning and use of a shared electronic medical record system, which may be lacking in some practices. An embedded supportive care clinic allowed rapid access to experienced oncology care under supervision by the patient's own oncologists. The clinic was associated with less use of the ED and need for hospitalization. New methods of reimbursing medical care will increasingly require oncology practices to improve patient access to symptom-related care to avoid unnecessary admissions. An embedded SCC can accomplish these goals while avoiding further fractionation of care.