Impact of advance directive (AD) completion among patients with metastatic cancer treated at an academic medical center.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 114-114
Author(s):  
Nirav S. Kapadia ◽  
Jennifer Snide ◽  
Daniel J Gelb ◽  
Evelyn Schlosser
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Advance Directive ◽  
Medical Center ◽  
Metastatic Cancer ◽  
Quality Care ◽  
Academic Medical Center ◽  
Life Quality ◽  
Cancer Center ◽  
Hospital Death

114 Background: Between February and September 2013, AD documentation for oncology patients across Dartmouth-Hitchcock’s Norris Cotton Cancer Center (NCCC) increased from 36% to 48%. However, it remains unclear whether AD completion itself is associated with other indicators of quality care. Methods: Using the tumor registry and National Death Index patient data, we examined a cohort of deceased NCCC patients diagnosed with metastatic disease between April 1, 2011 and October 31, 2013. To account for unmeasured care provided outside of NCCC, only patients with at least two NCCC visits, one of which occurred within the last six months of life, were included. Individual patient electronic medical record data were then linked to the registry data and multivariable regression was performed to determine the effect of AD completion on end-of-life quality metrics. Results: The cohort consisted of 225 patients, 182 (81%) of whom had an advance directive on file and 43 (19%) who did not. There were no significant differences in the age, gender or cancer diagnosis between the two groups. Patients with an AD had shorter commutes to the medical center (mean 42 vs 58 minutes, p<0.01) and more visits with cancer center providers (median 11.5 vs. 4.0, p=0.03). Palliative Care consulted with 73% of patients with an AD, versus 28% of patients without an AD (p<0.01). Completion of an AD did not decrease the likelihood of hospital death (OR 0.90, 95% CI 0.33-2.49), intensive care unit (ICU) death (OR 0.83, 0.19-3.66), hospital admission in the last 30 days of life (OR 0.94, 0.40-2.21), or ICU admission in the last 30 days of life (OR 1.30, 0.37-4.55). Patients with an AD were twice as likely to receive hospice referrals (OR 2.04, 0.73-5.68) and 70% less likely to visit the emergency department in the last 30 days of life compared with patients without an AD on file (OR 0.28, 0.06-1.40), although these trends were not statistically significant. Conclusions: For patients with metastatic cancer, an advance directive was associated with increased use of palliative care, though not with other measures of quality care. In an attempt to improve the cancer care provided at the end of life, we must expand our strategies beyond the use of an AD.

In-hospital cancer care: Are we missing an opportunity for end of life care?

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 9039-9039
Author(s):  
Gabrielle Betty Rocque ◽  
Anne Elizabeth Barnett ◽  
Lisa Illig ◽  
Howard Harry Bailey ◽  
Toby Christopher Campbell ◽  
...  
Keyword(s):  
Palliative Care ◽  
Overall Survival ◽  
Hospital Admission ◽  
End Of Life ◽  
Poor Prognosis ◽  
Metastatic Cancer ◽  
Academic Medical Center ◽  
Imaging Studies ◽  
Improvement Project ◽  
Palliative Care Consultation

9039 Background: Little data exists on the estimated survival of patients with metastatic cancer after hospitalization. As part of a prospective quality improvement project, we characterized the population of patients admitted to an inpatient oncology service in an academic medical center with emphasis on the disposition at discharge and overall survival. Methods: We collected data over a 4 month period (9/1/10-12/23/10) representing 149 admissions of 119 unique patients. We measured patient characteristics, disease evaluation, procedures, consults, imaging studies performed, disposition, length of stay, and overall survival. These data were compared to a similar study conducted in our center in 2000. Results: Uncontrolled symptoms were the most common reason for admission (pain 28%, dyspnea 9%, nausea 9%). Imaging studies were more common than in 2000 (415 vs. 196 total procedures). Eighty-five percent of patients had progressive disease. Seventy percent of patients were discharged home without additional services such as home health or hospice. The overall median survival was poor in 2000 and in 2010, 100 days and 60 days from discharge, respectively. Despite an overall poor prognosis, palliative care consultation was obtained only 13 times (8% of admissions) and 18% of patients were enrolled in hospice at discharge. Conclusions: An unscheduled hospital admission portends a poor prognosis. Cancer patients in the hospital are nearing the end-of-life with a median life expectancy of approximately 3 months and could be considered hospice-eligible and appropriate for a palliative care consult. We believe that hospital admission represents a missed opportunity to provide palliative care services and end-of-life counseling to this patient population.

Quality matters: Patterns of palliative interventions in metastatic colorectal cancer (mCRC) patients.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 83-83
Author(s):  
Rebecca M. Prince ◽  
Shuyin Liang ◽  
Mantaj Brar ◽  
Stephanie Ramkumar ◽  
Adena Scheer ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Care Service ◽  
Quality Care ◽  
Symptom Relief ◽  
Palliative Care Service ◽  
Palliative Surgery ◽  
Cancer Center ◽  
The Mean ◽  
Mean Time

83 Background: Increasing recognition that high-quality end of life care is essential has resulted in internationally endorsed metrics allowing assessment of interventions at the end of life. Median survival for mCRC patients has improved to more than 24 months resulting in increased opportunity to undergo interventions for symptom relief at the end of life. We explored patterns of palliative interventions (chemotherapy, radiotherapy, surgery, endoscopy, drainage procedures) and outcomes in mCRC patients. Methods: A retrospective review was undertaken of all mCRC patients referred to the palliative care service from 2000 to 2010 at a tertiary cancer center in Toronto, Canada. Descriptive statistics, survival analysis and regression were employed. Results: A total of 542 patients were included of whom 52.8% were male, mean age was 62.8 years and 44.6% had stage 4 disease at diagnosis. Over the course of their disease 93.9% had an intervention at any time after their diagnosis including 27.5% of patients undergoing palliative surgery, 77% of patients had an intervention in the last year of life and 19.1% had an intervention in the last 30 days of life. The percentage of patients receiving interventions within the last 14 days of life were 1.23% for chemotherapy, 4.6% for radiotherapy, 0.5% for surgery, 10.4% for endoscopy and 23% drainage procedures. The mean time between referral to palliative care and death was 7 months (SD 10.4). For patients who received chemotherapy, the mean time between last chemotherapy and death was 9.5 months (SD 14.9). Overall survival for patients who did not receive chemotherapy was 28 months (SD 33) compared with 40 months (SD 32) for those who received chemotherapy. Regression analysis for risks of dying within 30 days of chemotherapy was limited by a low event rate. Increasing age was significantly associated with a lower risk of dying within 30 days of chemotherapy. Conclusions: In their final months of life, palliative mCRC patients undergo a significant number of interventions aiming to improve quality of life. These require considerable multi-disciplinary input with ramifications for quality care, planning for service provision and funding.

scholarly journals Race/Ethnicity as a Predictor for Location of Death in Patients With Acute Neurovascular Events

2017 ◽  
Vol 35 (1) ◽  
pp. 100-103 ◽  
Author(s):  
Say Salomon ◽  
Elizabeth Chuang ◽  
Deepa Bhupali ◽  
Daniel Labovitz
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Low Income ◽  
End Of Life Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Ethnic Disparities ◽  
Life Care ◽  
Location Of Death ◽  
Important Quality

Background: Site of death is an important quality indicator for patients with terminal illness. Racial and ethnic disparities exist in the quality of end-of-life care. This study explores the site of death of patients admitted for and dying of complications of acute neurovascular events in a hospital network in an urban, low-income, predominantly minority community. Methods: This is a retrospective cohort study of patients admitted to 1 of 3 general hospitals that are part of an academic medical center in Bronx, New York, with the diagnosis of acute ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage who died during the index admission or were discharged with hospice services. The main outcome was location of death (palliative care inpatient unit [IPU] at the medical center or hospice services at discharge vs death on any other IPU). Results: A total of 655 patients admitted with acute neurovascular events from January 1, 2009, to March 1, 2015, died or were discharged with hospice services and were included in the analysis. Of those patients, 238 (36.3%) were black, 233 (35.5%) were Hispanic, and 184 (28.1%) were white. A total of 178 (24.4%) died on the palliative care unit or were discharged with hospice services, including 55 black patients (23.1%), 52 (28.3%) white patients, and 53 (22.7%) Hispanic patients. These differences were not statistically significant, even when controlling for confounders. Conclusion: This study did not show a difference in site of death in our institution by race or ethnicity, which is considered an important quality end-of-life care metric.

Effect of palliative care on aggressiveness of end-of-life care in patients with advanced colon cancer.

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 168-168
Author(s):  
Jessica Ann Reifer Hildebrand ◽  
Renuka Bhan
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Advanced Cancer ◽  
Medical Center ◽  
Quality Care ◽  
Cost Savings ◽  
Retrospective Chart Review ◽  
Course Of Illness ◽  
Significant Difference ◽  
Aggressive Care

168 Background: Recent studies have observed that starting Palliative Care (PC) soon after diagnosis for patients with advanced cancer improves quality of life, end of life (EOL) care, and possibly survival. Consequently, it has been recommended that combined standard oncology care and PC should be considered early in the course of illness for patients with advanced cancer. It has been posited that patients enrolled in early PC receive less aggressive care at the EOL and consequently spend fewer healthcare dollars. We sought to compare the aggressiveness of care received by those enrolled in early PC to those enrolled in late PC. Methods: A retrospective chart review of patients diagnosed with stage III or IIII colorectal cancer (CRC) at New Hanover Regional Medical Center between 2009 through 2011 was performed. Patients who were enrolled in PC within 30 days of diagnosis were compared to those enrolled later. Aggressiveness of care given during the last 30 days of life was assessed by: hospitalizations, ED visits, days spent in the ICU, chemotherapy received in the last 14 days of life, and death in the hospital. Results: 186 patients were identified for the study, and 89 met inclusion criteria. We found no significant difference in the aggressiveness of care received by those enrolled in early PC (46.7%) versus later PC (47.8%) (p = 1.00). In fact, almost half of all patients with advanced cancer received some form of aggressive care within the last 30 days of life. While those enrolled in late PC more frequently received chemotherapy, were admitted to the ICU, and died in the hospital, the differences were not statistically significant. Whether or not these differences account for cost savings in the early PC group has yet to be determined. Conclusions: Our study found that patients were just as likely to receive aggressive care at the EOL regardless of whether or not they were enrolled in early PC. This finding was unexpected given the goals and philosophy of PC groups. While early PC has been recommended as a quality care measure, patient and physician factors may limit its effectiveness. For example, patients, while receptive to certain aspects of PC, still desire a cure. Similarly, physicians feel compelled to treat patients aggressively.

Embedded integration of palliative care in an academic outpatient cancer center.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 158-158
Author(s):  
Christian T Sinclair
Keyword(s):  
Palliative Care ◽  
Medical Center ◽  
Descriptive Analysis ◽  
Gynecologic Oncology ◽  
Academic Medical Center ◽  
Cancer Center ◽  
Care Utilization ◽  
Cancer Type ◽  
Multiple Cancer ◽  
Care Clinic

158 Background: Palliative care is no longer reserved for ICUs and inpatient settings, since it can be delivered at any age and any stage regardless of goals of care. Oncologists are beginning to embrace more upstream palliative care but translating that to the long term setting has unique difficulties. Outpatient palliative care is a vital component to quality oncology care, but few examples of successful integration have been demonstrated. Methods: Data was collected from the palliative care clinic at the University of Kansas Medical Center Westwood Cancer Center. Descriptive analysis of the initial and current programs as well as successful outreach and education projects will be discussed. Quantitative analysis of number of initial and follow-up outpatient visits, cancer type, referring service and referring physician are all included. Hospice utilization was also recorded as well as length of time from initial consult to either death, discharge or calendar date June 30, 2015. Results: Since the pilot clinical program of outpatient palliative care in 2012 with two half day clinic sessions focused on BMT patients, the program has expanded to 5 half-day sessions and includes medical oncology, surgical oncology and gynecologic oncology. Referrals to palliative care have grown consistently covering multiple cancer diagnosis and including the entire oncology staff instead of a few champions. Increase in outpatient utilization has also spurred more early and appropriate inpatient palliative care utilization. Staff have moved from crisis-only use of outpatient palliative care to a co-management model. Conclusions: Outpatient palliative care can be successfully integrated into an NCI academic medical center oncology practice. (Note: More detailed data will be presented at the conference on all of the trends mentioned above.)

Enhancing the quality of the patient experience in an academic medical center.

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 149-149
Author(s):  
Gerard Colman ◽  
Emily Hardeman ◽  
Julianna Grisham Moorad
Keyword(s):  
Employee Engagement ◽  
Patient Experience ◽  
Patient Involvement ◽  
Medical Center ◽  
Clinical Care ◽  
Quality Care ◽  
Academic Medical Center ◽  
Steering Committee ◽  
Cancer Center

149 Background: As value-based purchasing evolves, there is a constant focus on efficiency and quality of care delivered during patient interactions before, during, and after each encounter. While perception of quality varies amongst patients, effective communication, patient involvement, and employee engagement have proven to impact patient satisfaction and perceived quality. MD Anderson Cancer Center is re-thinking its practices to provide exceptional quality in clinical care and operations. Methods: MDA has developed a Patient Experience Steering Committee to lay the foundation for the experience strategy and standardization of quality care. The creation of a dedicated patient experience position and the formation of inpatient and ambulatory experience groups have helped to focus initiatives around patient feedback and satisfaction scores. Steps have been taken to enhance patient-focused care: Incentive goals for staff/faculty; Focused communications; Enhanced standards and accountability; Formal rounding; Patient Ambassador pilot; Physician partnerships; New Employee Orientation re-design; Patient involvement; Language of Caring. Results: Ambulatory satisfaction awareness began in July 2011 with an overall score (including custom questions) of 85.6. Focused initiatives began fall 2011, and by March 2013 the score jumped 2.1 points to 87.7. The standard score moved from 88 to 89.6 taking MDA’s C4QI percentile ranking from 6 to 35 over 20 months. Incentive goals focused on information around delays (75.2 to 79.3) and courtesy of staff (93.6 to 94.3). Satisfaction around wait times to see physicians increased from 74.8 to 79.3. Focused efforts revealed increased scores for reaching office staff on the phone and wait time between 1st call and appointment. Conclusions: While a portion of value realized by these initiatives will be evident through reimbursement, VBP rules have led to a much needed structure of standardized operational practices and quality across an academic system. We understand that quality of administrative practices substantially impacts the patient experience, but with over 19,000 employees that treat over 100,000 patients per year, identifying ways to change those practices is not always simple.

Impact of specialist palliative care delivered over three months prior to death on a colorectal cancer patient’s risk of experiencing aggressive end-of-life care.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 6614-6614
Author(s):  
Aynharan Sinnarajah ◽  
Madalene Earp ◽  
Pin Cai ◽  
Andrew Fong ◽  
Kelly Blacklaws ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Palliative Care ◽  
End Of Life ◽  
Quality Care ◽  
Population Level ◽  
Hospital Death ◽  
Specialist Palliative Care ◽  
Short Disease Duration ◽  
Eol Care ◽  
The Impact

6614 Background: More patients are experiencing aggressive end-of-life (EOL) care. This is concerning as aggressive EOL care, on a population level, is associated with poor quality care. Specialist palliative care (PC) has been shown to help relieve EOL symptoms, improve patient quality of life, and reduce aggressive EOL care. This study aimed to estimate the impact of the timing of specialist PC, specifically PC delivered at least 3 months prior to death, on a colorectal cancer (CRC) patient’s risk experiencing aggressive care in the last 30 days of life. Methods: A population-based retrospective cohort study of adult patients who died from CRC in Alberta, Canada from 2011-2015. The Alberta Cancer Registry was used to identify the cohort, which was linked to healthcare resource use data in local, provincial, and national databases. Individuals who died < 30 days from CRC diagnosis were excluded. Patients who accessed any of the provinces specialist PC services were deemed exposed to specialist PC (includes PC consult team, intensive PC unit, palliative home care, hospice). Aggressive EOL care was defined as having experienced at least one of: hospital death, > 1 emergency department visit, > 1 hospital admission, > 14 days of hospitalization, ≥1 intensive care unit admission, ≥1 new chemotherapy program (or any treatment in the last 14 days of life). Logistic regression was used to model factors (specialist PC timing and clinical characteristics) associated with aggressive EOL care. Results: The cohort comprised 2979 patients. Most patients received specialist PC before death (58%); 60% had ≥1 indicator of aggressive EOL care. Relative to patients who received specialist PC > 3 months before death, patients who received specialist PC < 3 months before death were 1.5 times more likely to experience aggressive EOL care (CI: 1.2-1.9). Patients who received no specialist PC were 2.1 times more likely to experience aggressive EOL care (CI: 1.7-2.8). Short disease duration ( < 1 year from diagnosis to death), younger age at death, living in a rural area, and male sex, were also associated with higher odds of experiencing aggressive EOL care. Conclusions: Specialist PC delivered > 3 months before death reduces a CRC patient’s risk of experiencing aggressive EOL care over PC delivered < 3 months before death.

scholarly journals Models of Outpatient Palliative Care Clinics for Patients With Cancer

2019 ◽  
Vol 15 (4) ◽  
pp. 187-193 ◽  
Author(s):  
Esme Finlay ◽  
Kristina Newport ◽  
Shanthi Sivendran ◽  
Laurel Kilpatrick ◽  
Michelle Owens ◽  
...  
Keyword(s):  
Health Care ◽  
Palliative Care ◽  
Advanced Cancer ◽  
Care Delivery ◽  
Medical Center ◽  
Academic Medical Center ◽  
Safety Net ◽  
Cancer Center ◽  
Patients With Cancer ◽  
Safety Net Hospital

PURPOSE: Early integration of outpatient palliative care (OPC) benefits patients with advanced cancer and also the health care systems in which these patients are seen. Successful development and implementation of models of OPC require attention to the needs and values of both the patients being served and the institution providing service. SUMMARY: In the 2016 clinical guideline, ASCO recommended integrating palliative care early in the disease trajectory alongside cancer-directed treatment. Despite strong endorsement and robust evidence of benefit, many patients with cancer lack access to OPC. Here we define different models of care delivery in four successful palliative care clinics in four distinct health care settings: an academic medical center, a safety net hospital, a community health system, and a hospice-staffed clinic embedded in a community cancer center. The description of each clinic includes details on setting, staffing, volume, policies, and processes. CONCLUSION: The development of robust and capable OPC clinics is necessary to meet the growing demand for these services among patients with advanced cancer. This summary of key aspects of functional OPC clinics will enable health care institutions to evaluate their specific needs and develop programs that will be successful within the environment of an individual institution.

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