Retrospective analysis of pharmacist interventions in an ambulatory palliative care practice

Background We have previously reported the development of an outpatient palliative care practice under pharmacist–physician collaboration. The Doris A. Howell Service at the University of California, San Diego Moores Cancer Center includes two pharmacists who participate in a transdisciplinary clinic and provide follow-up care to patients. Objective This study evaluated pharmacist interventions and patient outcomes of a pharmacist-led outpatient palliative care practice. Methods This was a retrospective data analysis conducted at a single, academic, comprehensive cancer center. New (first visit) patient consultations were referred by an oncologist or hematologist to an outpatient palliative care practice. A pharmacist evaluated the patient at the first visit and at follow-up (second, third, and fourth visits). Medication problems identified, medication changes made, and changes in pain scores were assessed. Results Eighty-four new and 135 follow-up patient visits with the pharmacist occurred from March 2011 to March 2012. All new patients ( n = 80) were mostly women ( n = 44), had localized disease ( n = 42), a gastrointestinal cancer type ( n = 21), and were on a long-acting ( n = 61) and short-acting ( n = 70) opioid. A lack of medication efficacy was the most common problem for symptoms of pain, constipation, and nausea/vomiting that was identified by the pharmacist at all visits. A change in pain medication dose and initiation of a new medication for constipation and nausea/vomiting were the most common interventions by the pharmacist. A statistically significant change in pain score was observed for the third visit, but not for the second and fourth visits. Conclusions A pharmacist-led outpatient palliative care practice identified medication problems for management of pain, constipation, and nausea/vomiting. Medication changes involved a change in dose and/or initiating a new medication. Trends were observed in improvement and stabilization of pain over subsequent clinic visits.

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Impact of parenteral opioid shortage on opioid prescriptions among patients seen by the palliative care team of a comprehensive cancer center.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.34_suppl.201 ◽

2018 ◽

Vol 36 (34_suppl) ◽

pp. 201-201

Author(s):

Ali Haider ◽

Yu Qian ◽

Zhanni Lu ◽

Syed Mussadiq Ali Akbar Naqvi ◽

Amy Zhuang ◽

...

Keyword(s):

Palliative Care ◽

Pain Management ◽

Cancer Pain ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Cancer Type ◽

Cancer Pain Management ◽

Before And After ◽

The Impact

201 Background: Recent parenteral opioid shortage (POS) has the potential to impact cancer pain management in hospitalized patients. This study aims to compare changes in the opioid prescriptions by the inpatient palliative care (PC) team before and after the institution first reported the POS. Methods: We reviewed and compared the electronic health records of 386 consecutive eligible consultations seen by the inpatient PC team equally in one month before and after the announcement of POS on February 8, 2018. The eligibility criteria include (1) cancer diagnosis, (2) ≥18 years of age, (3) taking opioid medication at the time of consultation, and (4) having at least two consecutive visits with the PC team. Patient demographics, cancer type, opioid type, route, and dose defined as the morphine equivalent daily dose were assessed. Results: POS was associated with less use of parenteral opioids (patient controlled analgesia, and intravenous breakthrough) and more use of non-parenteral opioids (extended release, transdermal, and oral breakthrough) by the referring oncology teams, and PC team (P≤.001) (Table 1). At first PC follow-up, significantly less proportion of patients achieved better pain control after POS [119/193 (62%) versus 144/193 (75%) (P=.006)] However, at second PC follow-up, the proportion of pain improvement was similar in both cohorts. Conclusions: There is a significant change in opioid routes associated with POS. POS was associated with worse analgesia. More research is needed to better understand the impact of POS on cancer pain management.[Table: see text]

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System-Level Factors Associated With Use of Outpatient Specialty Palliative Care Among Patients With Advanced Cancer

Journal of Oncology Practice ◽

10.1200/jop.18.00234 ◽

2019 ◽

Vol 15 (1) ◽

pp. e10-e19 ◽

Cited By ~ 7

Author(s):

Justin A. Yu ◽

Kristin N. Ray ◽

Seo Young Park ◽

Amanda Barry ◽

Cardinale B. Smith ◽

...

Keyword(s):

Palliative Care ◽

Travel Time ◽

Solid Tumors ◽

Advanced Cancer ◽

System Level ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Cancer Type ◽

Advanced Solid Tumors ◽

Patient Travel

PURPOSE: The proportion of patients with advanced cancer who receive outpatient specialty palliative care (OSPC) is as low as 2.0%. Improved understanding of the system-level factors influencing use of OSPC could inform adaptations to the delivery of palliative care to maximize access. We examined associations between OSPC use among patients with advanced solid tumors and oncology-OSPC clinic colocation and patient travel time to an OSPC clinic. PATIENTS AND METHODS: We conducted a retrospective cohort study of patients with advanced solid tumors receiving oncologic treatment between January 1 and December 31, 2016, within a comprehensive cancer center network with well-established, oncology-specific OSPC clinics. Multivariable logistic regression analysis was used to evaluate the associations of clinic colocation and geographic access with OSPC use. RESULTS: Of 9,485 patients with advanced solid tumors, 478 (5.0%) received OSPC services in 2016. After controlling for age, sex, marital status, cancer type, insurance, treatment intent, and illness severity, patients whose oncologist practices were colocated with OSPC clinics were more likely to use OSPC (odds ratio [OR], 19.2; 95% CI, 14.1 to 26.2). Compared with patients who lived > 90 minutes from an OSPC clinic, patients with travel times of < 30 minutes (OR, 3.2; 95% CI, 2.2 to 4.6) and 31 to 60 minutes (OR, 2.4; 95% CI, 1.6 to 3.6) were also more likely to use OSPC. CONCLUSION: Among patients with advanced solid tumors, colocation of oncology and OSPC clinics and shorter patient travel time were associated with greater odds of using OSPC. Future efforts to increase OSPC use in this population should consider clinic colocation and travel burden.

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External validation of the simple prognostic score in a palliative care clinic at a comprehensive cancer center.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.e19566 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. e19566-e19566

Author(s):

Brinder Vij ◽

Stacy Marie Stabler ◽

Howard T. Thaler ◽

Paul A. Glare

Keyword(s):

Palliative Care ◽

Karnofsky Performance Status ◽

Prognostic Score ◽

External Validation ◽

Comprehensive Cancer Center ◽

Rank Test ◽

Cancer Center ◽

Cancer Type ◽

Care Clinic ◽

Percentage Difference

e19566 Background: Accurate survival predictions are essential for the optimal delivery of palliative care (PC). Clinical predictions of survival are notoriously inaccurate. Tools for making objective survival estimates in ambulatory cancer patients, who have months or years to live, are lacking. The Simple Prognostic Score (SPS) separated Canadian palliative radiotherapy patients into three groups with 12, 6 and 3 months median survivals, respectively. The aim of this study was to test the SPS in an outpatient PC clinic at a U.S. comprehensive cancer center. Methods: Retrospective chart review of 300 consecutive patients referred to one PC clinic at Memorial Sloan-Kettering Cancer Center (MSKCC). Cancer type, metastatic sites and Karnofsky performance status (KPS) score were used to calculate SPS (1 point each for non-breast cancer; non-osseous metastases; KPS score <70%). Outcome was date of death, obtained from the MSKCC institutional data base. Survival analysis was performed. Discrimination (non-overlap between groups) and calibration (percentage difference between estimated and observed survival) were measures of accuracy. Results: 79% (236 of 300) patients had advanced disease. Of them, 90% had cancers other than breast; 76% had metastases in sites other than bone; 27% had a low KPS score. The SPS score was 2 or 3 in 80%. By 10/31/11, 85% had died (median survival 4.9 months). SPS categorized the sample into four prognostic subgroups (see Table), with median survivals of 15, 9, 5 and 2 months respectively (log rank test χ2=38.71, d.f .3, p<0.0001). SPS was not very accurate, with poor discrimination (extensive intergroup overlap) but reasonable calibration (6-15% for the different groups). Conclusions: The SPS is user-friendly and helpful at the group level, but inaccurate at the individual level. Additional variables may narrow the prediction intervals, but will make the tool more complex. [Table: see text]

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Interval between first palliative care consultation and death in patients with advanced cancer

Journal of Clinical Oncology ◽

10.1200/jco.2007.25.18_suppl.9028 ◽

2007 ◽

Vol 25 (18_suppl) ◽

pp. 9028-9028 ◽

Cited By ~ 1

Author(s):

B. El Osta ◽

J. Palmer ◽

T. Paraskevopoulos ◽

B. Pei ◽

L. Roberts ◽

...

Keyword(s):

Palliative Care ◽

Advanced Cancer ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Time Interval ◽

Solid Cancer ◽

Cancer Type ◽

Palliative Care Consultation ◽

Care Consultation ◽

Over Time

9028 Background: Most referrals to acute palliative care (PC) services occur late in the trajectory of the disease, although an earlier intervention can decrease patients’ (pts) symptoms distress. The purpose of this study was to determine the time interval between first palliative care consultation (PC1) and death (D) in pts diagnosed with advanced cancer (aCA) at our comprehensive cancer center and whether such interval has increased over time. Methods: The study group was 2,868 consecutive pts who had their PC1 during a 30-month period. We reviewed the charts for information about demographics, cancer type, date of cancer diagnosis, aCA diagnosis, PC1, and D. aCA was defined as locally recurrent or metastatic. Results: 1,404 pts (49%) were female, 1,791 (62%) were < 65 years old, 2,563 (89%) had solid cancer, and 2,004 (70%) were white. The median PC1-D, aCA- PC1, and aCA-D intervals were 40, 114, and 243 days respectively. The median PC1-D interval (days) was: 47 for pts with solid cancer vs 14 for pts with hematological malignancy (p < 0.0001); 44 for pts < 65 years old vs 36 for pts = 65 years old (p = 0.002); 45 for females vs 37 for males (p = 0.004); 40 for white pts vs 41 for pts from other ethnicities (p = 0.42). The median PC1-D interval in 5 consecutive half-years was 46, 56, 42, 41, and 34 days respectively (p = 0.02). The total number of pts referred for PC1 in this period increased 20%, from 544 to 654. The ratio of PC involvement period in the aCA-D interval (PC1-D/aCA-D) decreased from 0.30 to 0.26 over the 5 half-year periods (p = 0.0004) ( Table ). Conclusions: Patients with solid cancers, younger pts, and females pts were referred earlier to acute PC. Referral timing was not affected by ethnicity. The interval between first palliative care consult and death has decreased over time. Education is needed among referring physicians to increase this interval. Further research on increasing acute PC access and its impact on PC1-D interval is needed. [Table: see text] No significant financial relationships to disclose.

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The project ENABLE II randomized controlled trial to improve palliative care for rural patients with advanced cancer: Baseline findings, methodological challenges, and solutions

Palliative & Supportive Care ◽

10.1017/s1478951509000108 ◽

2009 ◽

Vol 7 (1) ◽

pp. 75-86 ◽

Cited By ~ 103

Author(s):

Marie Bakitas ◽

Kathleen Doyle Lyons ◽

Mark T. Hegel ◽

Stefan Balan ◽

Kathleen N. Barnett ◽

...

Keyword(s):

Palliative Care ◽

Missing Data ◽

Controlled Trial ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Control Group ◽

Randomized Controlled ◽

Methodological Challenges

ABSTRACTObjective:There is a paucity of randomized controlled trials (RCTs) to evaluate models of palliative care. Although interventions vary, all have faced a variety of methodological challenges including adequate recruitment, missing data, and contamination of the control group. We describe the ENABLE II intervention, methods, and sample baseline characteristics to increase intervention and methodological transparency, and to describe our solutions to selected methodological issues.Methods:Half of the participants recruited from our rural U.S. comprehensive cancer center and affiliated clinics were randomly assigned to a phone-based, nurse-led educational, care coordination palliative care intervention model. Intervention services were provided to half of the participants weekly for the first month and then monthly until death, including bereavement follow-up call to the caregiver. The other half of the participants were assigned to care as usual. Symptoms, quality of life, mood, and functional status were assessed every 3 months until death.Results:Baseline data of 279 participants were similar to normative samples. Solutions to methodological challenges of recruitment, missing data, and “usual care” control group contamination are described.Significance of results:It is feasible to overcome many of the methodological challenges to conducting a rigorous palliative care RCT.

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Changes in fatigue, barriers, and predictors towards physical activity in advanced cancer patients over a period of 12 months—a comparative study

Supportive Care in Cancer ◽

10.1007/s00520-021-06020-3 ◽

2021 ◽

Author(s):

J. Frikkel ◽

M. Beckmann ◽

N. De Lazzari ◽

M. Götte ◽

S. Kasper ◽

...

Keyword(s):

Physical Activity ◽

Cancer Patients ◽

Advanced Cancer ◽

Physical Functioning ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Advanced Cancer Patients ◽

Psychological Conditions ◽

Patient Reported

Abstract Purpose Physical activity (PA) is recommended to improve advanced cancer patients’ (ACP) physical functioning, fatigue, and quality of life. Yet, little is known about ACPs’ attitude towards PA and its influence on fatigue and depressiveness over a longer period. This prospective, non-interventional cohort study examined ACPs’ fatigue, depression, motivation, and barriers towards PA before and after 12 months of treatment among ACP Methods Outpatients with incurable cancer receiving treatment at a German Comprehensive Cancer Center reporting moderate/severe weakness/tiredness during self-assessment via MIDOS II were enrolled. Fatigue (FACT-F), depression (PHQ-8), cancer-related parameters, self-assessed PA behavior, motivation for and barriers against PA were evaluated (T0). Follow-up data was acquired after 12 months (T1) using the same questionnaire. Results At follow-up, fatigue (p=0.017) and depressiveness (p=0.015) had increased in clinical relevant extent. Physically active ACP did not show significant progress of FACT-F (p=0.836) or PHQ-8 (p=0.799). Patient-reported barriers towards PA remained stable. Logistic regression analyses identified motivation as a positive predictor for PA at both time points (T0, β=2.152, p=0.017; T1, β =2.264, p=0.009). Clinically relevant depression was a negative predictor for PA at T0 and T1 (T0, β=−3.187, p=0.044; T1, β=−3.521, p=0.041). Conclusion Our findings emphasize the importance of psychological conditions in physical activity behavior of ACP. Since psychological conditions seem to worsen over time, early integration of treatment is necessary. By combining therapy approaches of cognitive behavioral therapy and exercise in interdisciplinary care programs, the two treatment options might reinforce each other and sustainably improve ACPs’ fatigue, physical functioning, and QoL. Trial registration German Register of Clinical Trials, DRKS00012514, registration date: 30.05.2017

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Screening for Palliative Care: Implementation of the NCCN Guideline at a Comprehensive Cancer Center (418-A)

Journal of Pain and Symptom Management ◽

10.1016/j.jpainsymman.2011.12.123 ◽

2012 ◽

Vol 43 (2) ◽

pp. 387-388 ◽

Cited By ~ 1

Author(s):

Paul Glare ◽

Kathy Plakovic ◽

Barbara Egan ◽

David Kelsen

Keyword(s):

Palliative Care ◽

Comprehensive Cancer Center ◽

Cancer Center

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Perceptions of barriers to patient financial hardship screening differ by provider role within gynecologic oncology outpatient care.

Journal of Clinical Oncology ◽

10.1200/jco.2020.39.28_suppl.317 ◽

2021 ◽

Vol 39 (28_suppl) ◽

pp. 317-317

Author(s):

Jhalak Dholakia ◽

Maria Pisu ◽

Warner King Huh ◽

Margaret Irene Liang

Keyword(s):

Nurse Practitioners ◽

Gynecologic Oncology ◽

Financial Hardship ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Patient Centered ◽

Staff Members ◽

Care Plans ◽

Patient Barriers

317 Background: Although approximately half of patients with gynecologic malignancy experience financial hardship (FH) during treatment, best practices to identify and assist patients with FH are lacking. To develop such practices, we assessed oncology provider and staff perspectives about FH screening and provision of assistance. Methods: An anonymous survey was conducted electronically within the Gynecologic Oncology outpatient office at a Comprehensive Cancer Center. Potential barriers to patient FH screening and follow-up were assessed within 2 domains: 1) logistic barriers to incorporating FH screening and follow-up into outpatient workflow and 2) perceived patient barriers to FH screening. Responses were elicited on a 5-point Likert scale from ‘very’ to ‘not at all’ significant and dichotomized into significant and not significant barriers. Results: Of 43 providers approached, 37 responded (86% response rate) of which 14 were physicians (MD)/nurse practitioners (NP) and 23 were other staff members (i.e., clinical and research nurses, social workers, pharmacists, care coordinators, lay navigators, and financial counselors). Altogether, 38% worked in their current position for >5 years (n=14), 11% for 3-5 years (n=4), and 51% for <3 years (n=19). For logistic barriers to implementing FH screening and follow-up, the most frequently reported significant barriers included lack of personnel training (69%) and lack of available staff (62%), training regarding follow-up (72%), and case tracking infrastructure (67%). The most frequent significant perceived patient barriers were lack of knowledge of whom to contact (72%), concerns about impact on treatment if FH needs were identified (72%), and lack of patient readiness to discuss financial needs (62%.) Compared to MD/NP, staff members more often indicated the following as significant barriers: difficulty incorporating FH screening into initial visit workflow (31 % vs. 57%, p=0.03), overstretched personnel (29% vs 73%, p=0.005), and patient concerns about influence on treatment (62% vs 86%, p=0.01). Conclusions: Care team members identified barriers to patient FH screening across logistic and patient-centered domains, although MD/NP less so than other staff possibly reflecting different exposures to patient financial needs during clinical encounters or burden of workflow. Implementation of universal FH screening, dedicated personnel, convenient tracking mechanisms, and multi-disciplinary provider and staff training may improve recognition of patient FH and facilitate its integration into oncology care plans.

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