Palliative care utilization in patients with newly diagnosed, incurable solid tumor malignancies: The experiences of an institution new to palliative care.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 92-92
Author(s):  
Adrian REYES Bersabe ◽  
Joshua Romain ◽  
Wilfred P. Delacruz
Keyword(s):  
Palliative Care ◽  
Solid Tumor ◽  
Metastatic Cancer ◽  
Care Utilization ◽  
Referral Process ◽  
Newly Diagnosed ◽  
Post Intervention ◽  
Absolute Increase ◽  
Early Integration ◽  
Tumor Boards

92 Background: Early palliative care (PC) referral can enhance quality of life (QOL) in patients with metastatic cancer and even improve overall survival in non-small cell lung cancer. Despite compelling data showing benefits of early integration of PC, barriers to care exist. Our institution recently established an outpatient PC service. To improve utilization of this new service we identified clinicians’ attitudes and barriers to PC, and provided education on the PC referral process. The effects of this intervention on PC utilization were assessed. Methods: We conducted a retrospective chart review of outpatient Hematology/Oncology (HO) referrals to identify patients referred for newly diagnosed, solid tumor malignancies with no curative options. Hospice referrals were excluded. We then formally surveyed clinicians participating in multi-disciplinary tumor boards to identify PC referral practices and attitudes/barriers to PC referrals. Education on PC and instruction on PC referral process were provided during this period. Post-intervention review of PC referrals over 4 months was conducted. Results: Prior to our intervention, of the 53 new consultations reviewed meeting study criteria only three (5.7%) patients were referred to PC. Our survey revealed that 66% (31/47) of oncology providers did not know the institution had onsite PC available and only eight (17%) knew how to place a referral. After education was provided, a second cohort revealed 24.1% (7/29) of patients were appropriately referred for early outpatient PC representing an 18.4% absolute increase. Conclusions: We significantly increased early PC referrals for HO patients with advanced or metastatic disease. However, other efforts to improve institutional awareness and change the culture of care to ensure that majority of these patients are appropriately referred. Longitudinal evaluation will further ensure that timely adjustments are made and that effects are permanent.

A trainee-led quality improvement project to improve rates of palliative care utilization in patients with advanced cancer.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 51-51
Author(s):  
Ramy Sedhom ◽  
Arjun Gupta ◽  
Mirat Shah ◽  
Kristen Marrone ◽  
Ilene S. Browner ◽  
...  
Keyword(s):  
Palliative Care ◽  
Advanced Cancer ◽  
Metastatic Cancer ◽  
Cancer Center ◽  
Care Utilization ◽  
First Year ◽  
Post Intervention ◽  
Improvement Project ◽  
Care Clinic ◽  
Ancillary Staff

51 Background: ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. 1st year oncology fellows at our institution identified low rates of palliative care in their longitudinal clinic as an avenue for improvement. Methods: A Fellow-led multidisciplinary team aimed to increase palliative care utilization for patients with advanced cancer followed in first-year fellows’ clinic from baseline 11.5% (5/43 patients, Jul-Dec, '18) to 30% over a 4-mo period. Utilization was defined as evaluation in the outpatient palliative care clinic hosted in the cancer center. The team identified several barriers to referral: orders difficult to find in EMR, multiple consulting mechanisms (EMR, by phone, in person), EMR request not activating formal consult, no centralized scheduler to contact/confirm appointment, and poor awareness of team structure. PDSA cycles were implemented based on identified opportunities. Data were obtained from the EMR. Results: The PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and dissemination of process changes. The PDSA was implemented Jan-Apr '19. Rates of palliative care use increased from 11.5% pre-intervention to 43% (27/62 patients) post-intervention. In addition, median time to evaluation in palliative care clinic after placing a consult improved from 23 days (range, 10-60 days) to 12 days (range, 6-19 days). Conclusions: A multidisciplinary approach and classic QI methodology improved palliative care use for patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stakeholders, and institutional support of efforts. Straightforward EMR interventions and ancillary staff use are effective in addressing under referrals.

scholarly journals Oncology Fellow–Led Quality Improvement Project to Improve Rates of Palliative Care Utilization in Patients With Advanced Cancer

2020 ◽  
Vol 16 (8) ◽  
pp. e814-e822 ◽  
Author(s):  
Ramy Sedhom ◽  
Arjun Gupta ◽  
Mirat Shah ◽  
Melinda Hsu ◽  
Marcus Messmer ◽  
...  
Keyword(s):  
Palliative Care ◽  
Quality Improvement ◽  
Advanced Cancer ◽  
Metastatic Cancer ◽  
Cancer Center ◽  
Care Utilization ◽  
First Year ◽  
Improvement Project ◽  
Leadership Support ◽  
Ancillary Staff

PURPOSE: ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. First-year oncology fellows at our institution identified low rates of PC utilization in their longitudinal clinic as a metric needing improvement. METHODS: A fellow-led multidisciplinary team aimed to increase PC utilization for patients with advanced cancer followed in he first-year fellows’ clinic from a baseline of 11.5% (5 of 43 patients, July to December of 2018) to 30% over a 6-month period. Utilization was defined as evaluation in the outpatient PC clinic hosted in the cancer center. The team identified the following barriers to referral: orders difficult to find in the electronic medical record (EMR), multiple consulting mechanisms (EMR, by phone, or in person), EMR request not activating formal consult, no centralized scheduler to contact or confirm appointment, and poor awareness of team structure. Plan-Do-Study-Act (PDSA) cycles were implemented based on identified opportunities. Data were obtained from the EMR. RESULTS: The first PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and disseminating process changes. PDSA cycles were implemented from January to June of 2019. Rates of PC use increased from 11.5% before the intervention to 48.4% (48 of 99 patients) after the intervention. CONCLUSION: A multidisciplinary approach and classic quality improvement methodology improved PC use in patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stakeholders, and institutional and leadership support. Straightforward EMR interventions and ancillary staff use are effective in addressing underreferrals.

Oncologists’ perceptions of rounding alongside palliative care physicians: Results of a post-intervention survey study.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e20674-e20674 ◽  
Author(s):  
Thomas William LeBlanc ◽  
James A Tulsky ◽  
Amy Pickar Abernethy ◽  
Christopher A Jones ◽  
Anthony N Galanos ◽  
...  
Keyword(s):  
Palliative Care ◽  
Solid Tumor ◽  
Hospice Care ◽  
Care Physician ◽  
Lessons Learned ◽  
Survey Study ◽  
Post Intervention ◽  
New Model ◽  
Oncology Service ◽  
Palliative Care Physician

e20674 Background: In August 2011, a new rounding model was instituted on the inpatient solid tumor oncology service at Duke. This model incorporated a palliative care physician as a second attending on service, alongside the rounding solid tumor oncologist. We sought to assess the oncologists’ perceptions of this model, and of palliative care, 1 year later. Methods: We developed a 15-item survey assessing 3 domains: (1) perceptions about palliative care in general, (2) lessons learned from palliative care colleagues, if any, and (3) changes in the experience of rounding on the solid tumor oncology service. Faculty were invited to participate by e-mail, via an anonymous web link. All oncology faculty who rounded at least 2 weeks since August 2011 were included. Results: Response rate was 73% (8 of 11). 75% (N=6) of respondents had rounded both before and after the new model was instituted. 75% reported a more positive perception of palliative care (N=6), 88% (N=7) reported learning new ways to manage cancer patients’ symptoms, and 100% agreed that the palliative care physician brings a valuable skill set to the team. Only 1 respondent felt that palliative care physicians detract from oncologic issues, and none thought the palliative care physicians discuss hospice too early. 88% (N=7) reported greater willingness to round on the service under the new model, and 100% agreed that rounding was more enjoyable since the addition of the palliative care attending to the team. 100% agreed that palliative care is a necessary component of comprehensive cancer care, and that palliative care should have a presence in the outpatient cancer clinics; 88% (N=7) reported feeling comfortable doing palliative care in their own clinical practice. All agreed that “palliative care” is different from “hospice care.” Conclusions: Rounding alongside palliative care physicians on an inpatient oncology service may improve oncologists’ perceptions of palliative care, teach them new symptom management skills, and improve their willingness to do inpatient rounding. Fears about palliative care physicians inappropriately introducing hospice too early for patients with solid tumors may be unfounded.

The practice of early palliative care: A qualitative study of patient-clinician encounters.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 2-2 ◽  
Author(s):  
Christopher Taekyu Lim ◽  
Avia Tadmor ◽  
Daisuke Fujisawa ◽  
James John MacDonald ◽  
Emily R. Gallagher ◽  
...  
Keyword(s):  
Palliative Care ◽  
Massachusetts General Hospital ◽  
Metastatic Cancer ◽  
Treatment Decision ◽  
Clinic Visit ◽  
Ambulatory Setting ◽  
Inpatient Setting ◽  
Early Integration ◽  
Early Palliative Care ◽  
The Relationship

2 Background: Studies have shown that palliative care (PC) integrated early in the course of metastatic cancer, shortly after diagnosis, leads to improved patient outcomes. Unlike PC in the inpatient setting, PC initiated early, in the ambulatory setting, had not been well studied. Our aim was to elucidate the practice of early PC through analysis of PC clinic visit transcripts. Methods: As part of an ongoing study of early PC in patients with advanced lung and gastrointestinal cancers at the Massachusetts General Hospital, we are audio-recording patients’ outpatient PC clinic visits. To capture the range of PC content, we randomly selected five patients and analyzed three clinic transcripts per patient: early, midway, and late in each patient’s clinical course. We performed thematic analysis on these clinic transcripts using NVivo 10. Results: Our analysis suggests that the elements of early PC that occur most frequently across the disease course are managing symptoms, facilitating coping, and developing the relationship with patients and their family caregivers. Elements that tend to occur during clinical transitions include advising treatment decision-making, facilitating medical understanding, and advance care planning. Our analysis also identifies four broad approaches to PC that are applied longitudinally, over the course of the patient-clinician relationship: 1) eliciting versus commenting on patients’ perspectives, 2) alluding to and preparing for the future, 3) transitioning between managing symptoms and facilitating coping, and 4) transitioning between developing the relationship and facilitating coping. Lastly, we observe three specific techniques applied by PC clinicians: 1) coordinating with oncologists, 2) providing referrals, and 3) addressing family dynamics. Conclusions: Our study identifies the predominant elements, four longitudinal approaches, and three specific techniques of early PC. These novel insights can be applied to care delivered by both PC and non-PC clinicians, well before patients approach the end of life. The longitudinal approaches in particular may help explain the significance of early integration of PC into cancer care.

An EPIC electronic decision support tool to identify percentage of patients with stage IV thoracic or gastrointestinal malignancy who would benefit from concurrent palliative care but do not currently receive it.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 133-133
Author(s):  
Kerin B. Adelson ◽  
Amelia Anne Trant ◽  
Kim Framski ◽  
Mark Swidler ◽  
Nitu Kashyap
Keyword(s):  
Palliative Care ◽  
Decision Support ◽  
Care Service ◽  
Palliative Care Service ◽  
Stage Iv ◽  
Decision Support Tool ◽  
Care Utilization ◽  
Support Tool ◽  
Early Integration ◽  
Stage Iv Disease

133 Background: In 2016 ASCO updated its guideline for early integration of palliative care (PC) into standard oncologic care for all “inpatients and outpatients with advanced cancer.” PC has been shown to improve quality of life, align care at the end of life with patient preferences, and reduce health-care utilization. In preparation for the expansion of our palliative care service into ambulatory disease-based practices at Smilow Cancer Hospital at Yale-New Haven, we sought to create a decision support tool (DST) in the EPIC Electronic Health Record (EHR) that would identify patients for PC referral. Methods: This DST identifies patients with a GI or thoracic malignancy who have had an ICD-10 diagnosis of metastatic or stage IV disease, have not had a palliative care visit in the last 6 months, and are not enrolled in hospice. If the patient meets criteria, the DST will remind providers that “this patient meets ASCO and IOM criteria for concurrent palliative care with oncologic care ” and offers a one-click option to place the referral. To understand the volume of patients this DST would refer, we ran it silently in the EHR background from 7/15/16 through 9/1/16. We tracked how many patients were seen in the clinics, how many were eligible, and how many were referred to PC. Results: See table. Conclusions: Our silent BPA indicated that only 5% of patients eligible for a palliative care consult received it at baseline; this matches national data, which suggests that most patients who would benefit from PC do not receive it. This DST has the potential to dramatically improve PC referral rates and increase adherence with ASCO and IOM guidelines. We plan to move the DST into the live clinical EHR in 2017 after the integrated PC clinics are open. We anticipate that once our BPA is activated, we will see a dramatic increase in the number of eligible patients referred to palliative care. [Table: see text]

Perceptions of palliative care: Cancer and non-cancer.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 148-148
Author(s):  
Ingrid Harle ◽  
Christine Knott
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Palliative Medicine ◽  
Clinical Pathways ◽  
Metastatic Cancer ◽  
Symptom Burden ◽  
Cost Savings ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Early Integration

148 Background: Palliative Medicine consultation is greater for cancer than non-cancer patients. Decreased symptom burden, improved survival time and quality of life, and cost savings are associated with palliative care. Most patients do not receive information about palliative care until end of life, resulting in negative outcomes. We examined perceptions and access to Palliative Medicine for persons living with advanced illnesses. The purpose was to inform the design of palliative care pathways for cancer and non-cancer diagnoses. Methods: Using Interpretive Phenomenological Analysis, patients/caregivers with metastatic cancer, chronic kidney disease, chronic obstructive pulmonary disease and advanced heart failure were interviewed. This qualitative research method explores an individual’s lived illness experience. Interviews addressed care processes, teams, understanding of palliative care and goals of care. Six reviewers read, coded, categorized interview transcripts and extracted themes. Results: Fifty interviews were completed, 36/50 with metastatic cancer or COPD. Despite different diagnoses, themes were similar. Caregiver’s responses reflected the patient’s burden and overall experience. Themes were: focused individual care; multiple dimensions of time; 24/7 home care; physical and psychological impacts; and spirituality. Perceptions about Palliative Medicine remain aligned with end of life. Conclusions: Palliative Medicine remains associated with end of life, regardless of the diagnosis. Majority had limited access to palliative care, despite pursuing information on supportive services. They also expressed high expectations of receiving such information from physicians and other providers. Results are similar to national strategies on palliative care. The project’s findings have informed the design of clinical pathways for early integration of Palliative Medicine for patients with cancer and non-cancer diagnoses.

scholarly journals Developing a “toolkit” to measure implementation of concurrent palliative care in rural community cancer centers

2017 ◽  
Vol 16 (1) ◽  
pp. 60-72 ◽  
Author(s):  
Lisa Zubkoff ◽  
J. Nicholas Dionne-Odom ◽  
Maria Pisu ◽  
Dilip Babu ◽  
Imatullah Akyar ◽  
...  
Keyword(s):  
Palliative Care ◽  
Rural Areas ◽  
Assessment Tool ◽  
Metastatic Cancer ◽  
Lessons Learned ◽  
Newly Diagnosed ◽  
National Guidelines ◽  
Cancer Centers ◽  
Early Palliative Care ◽  
Implementation Costs

ABSTRACTObjective:Despite national guidelines recommending early concurrent palliative care for individuals newly diagnosed with metastatic cancer, few community cancer centers, especially those in underserved rural areas do so. We are implementing an early concurrent palliative care model, ENABLE (Educate, Nurture, Advise, Before Life Ends) in four, rural-serving community cancer centers. Our objective was to develop a “toolkit” to assist community cancer centers that wish to integrate early palliative care for patients with newly diagnosed advanced cancer and their family caregivers.Method:Guided by the RE-AIM (Reach, Effectiveness–Adoption, Implementation, Maintenance) framework, we undertook an instrument-development process based on the literature, expert and site stakeholder review and feedback, and pilot testing during site visits.Results:We developed four instruments to measure ENABLE implementation: (1) the ENABLE RE-AIM Self-Assessment Tool to assess reach, adoption, implementation, and maintenance; (2) the ENABLE General Organizational Index to assess institutional implementation; (3) an Implementation Costs Tool; and (4) an Oncology Clinicians' Perceptions of Early Concurrent Oncology Palliative Care survey.Significance of results:We developed four measures to determine early palliative care implementation. These measures have been pilot-tested, and will be integrated into a comprehensive “toolkit” to assist community cancer centers to measure implementation outcomes. We describe the lessons learned and recommend strategies for promoting long-term program sustainability.

Early integration of palliative care in patients with pancreatic cancer: A retrospective study for quality improvement.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 72-72
Author(s):  
Nina N. Grenon
Keyword(s):  
Pancreatic Cancer ◽  
Palliative Care ◽  
Quality Improvement ◽  
Metastatic Cancer ◽  
Standards Of Care ◽  
Emotional Symptoms ◽  
Incurable Cancer ◽  
Early Integration ◽  
Course Of Illness ◽  
National Quality

72 Background: Many patients with pancreatic cancer receive palliative care only at the end of life despite the fact that the course of illness is plagued with physical, emotional symptoms and existential distress. There is strong evidence that combining palliative care with standard cancer treatment improves quality of life for those patients with in metastatic cancer and in some cases can help extend survival. Early incorporation of palliative care for patients with incurable cancer is an important focus for quality improvement. Methods: The purpose of this quality improvement study was to describe quality indicators for palliative care, and discover when palliative care was introduced during the course of illness in patients with pancreatic cancer. Domains of palliative care identified by the National Consensus Project and the National Quality Framework, provided the framework for this study. A retrospective medical record review of patients with pancreatic cancer treated at the Dana-Farber Cancer Institute (DFCI) between January 2009 to December 2011 was conducted. Time variables relevant to disease course, and palliative care referrals were collected. Other key variables included: the reason for, and frequency and timing of, palliative care discussions. Results: Medical records from 150 DFCI patients were reviewed in which the mean length of care from first visit to last note (typically death) was 414 days (SD=347). 52 (35%) records included documentation of a palliative care discussion and the majority of those occurred at the time of disease progression. Prognosis discussions were documented after a mean 177 (SD=285) days and a palliative care consult was made on average at day 343 (SD=301). Of those consults, the large majority (82%) were requested for symptom management. Conclusions: Despite evidence and standards of care that support early palliative care discussions and subsequent referrals for palliative care consults, these findings suggest such events occurred late in the trajectory and care of patients with pancreatic cancer. Future quality work and training will address provider and health system variables that can promote discussions and consults.

scholarly journals Early, integrated palliative rehabilitation improves quality of life of patients with newly diagnosed advanced cancer: The Pal-Rehab randomized controlled trial

2021 ◽  
pp. 026921632110155
Author(s):  
Lise Nottelmann ◽  
Mogens Groenvold ◽  
Tove Bahn Vejlgaard ◽  
Morten Aagaard Petersen ◽  
Lars Henrik Jensen
Keyword(s):  
Quality Of Life ◽  
Palliative Care ◽  
Advanced Cancer ◽  
Controlled Trial ◽  
Newly Diagnosed ◽  
Early Integration ◽  
Randomized Controlled ◽  
Oncology Treatment ◽  
Primary Problem

Background: Early integration of palliative care into oncology treatment is widely recommended. Palliative rehabilitation has been suggested as a paradigm which integrates enablement, self-management, and self-care into the holistic model of palliative care. Aim: We hypothesized that early integration of palliative rehabilitation could improve quality of life. Design: The Pal-Rehab study (ClinicalTrials.gov NCT02332317) was a randomized controlled trial. The 12-week intervention offered by a specialized palliative care team was two mandatory consultations and the opportunity of participating in an interdisciplinary group program. Supplementary individual consultations were offered, if needed. Setting/participants: At Vejle University Hospital, Denmark, adults diagnosed with advanced cancer within the last 8 weeks were randomized 1:1 to standard oncology care or standard care plus intervention. Assessments at baseline and after six and 12 weeks were based on the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30). At baseline participants were asked to choose a “primary problem” from a list of QLQ-C30 domains. The primary endpoint was the change in that “primary problem” measured as area under the curve across 12 weeks ( T-scores, European mean value = 50, SD = 10). Results: In all, 288 were randomized of whom 279 were included in the modified intention-to-treat analysis (146 in the standard care group and 133 in the intervention group). The between-group difference for the primary outcome was 3.0 (95% CI [0.0–6.0]; p = 0.047) favoring the intervention. Conclusion: Early integration of palliative rehabilitation into standard oncology treatment improved quality of life for newly diagnosed advanced cancer patients. Trial registration: Clinicaltrials.gov Identifier: NCT02332317, registered on December 30, 2014.

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