Evaluating end-of-life (EOL) care at the University of Rochester Medical Center (URMC) using quality oncology practice initiative (QOPI) metrics.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 12-12
Author(s):  
Titas Banerjee ◽  
Jason Harold Mendler ◽  
Nabeel Badri ◽  
Dwight Hettler ◽  
Julie Ann Berkhof ◽  
...  
Keyword(s):  
End Of Life ◽  
Medical Center ◽  
Statistical Significance ◽  
Inpatient Mortality ◽  
Exact Test ◽  
Number Of Patients ◽  
Advanced Malignancies ◽  
Oncology Practice ◽  
The University ◽  
Eol Care

12 Background: Inpatient mortality, defined as death within 30 days of an acute hospital admission, is often used as a quality benchmark for healthcare institutions and is an important metric for evaluating quality of care of patients with advanced malignancies. In this study we aimed to utilize QOPI performance data to identify areas of weakness in our practice that may contribute to inpatient mortality. Methods: We analyzed 11 EOL measures within the QOPI database which we collected between 2015 and 2018. These included all EOL measures related to hospice enrollment (measure IDs 42-47), chemotherapy administered within the last 2 weeks of life (ID 48), percentage of patients who died from cancer with at least one emergency department (ED) visit in the last 30 days of life (ID 49ed), and the percentage of patients who died from cancer admitted to the Intensive Care Unit (ICU) in the last 30 days of life (ID 49icu). Our rate was calculated for each measure and compared against QOPI aggregate data. We used a fisher’s exact test to determine statistical significance for each metric. Results: The number of patients from our institution included in each analysis ranged from 27 to 46. Compared to our peers, patients treated at our institution were more likely to visit an ED in the last 30 days of life (68% vs. 32%; P < 0.0001), more likely to be admitted to the ICU in the last 30 days of life (29% vs. 9%; P = 0.0003), and more likely to be enrolled on hospice within the last 7 days of death (63% vs. 32%; P = 0.001). Conclusions: Analysis of QOPI EOL performance scores identified several metrics that may contribute to inpatient mortality at URMC. Ongoing participation in QOPI with a focus on EOL metrics will strengthen this analysis. We plan to use this data to guide quality improvement initiatives aimed at reducing impatient mortality and improving end of life care at our institution.

Palliative care training: A national survey of U.S. hematology/oncology fellows.

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 28-28
Author(s):  
Brendan F. Curley ◽  
Roby Antony Thomas ◽  
Sijin Wen ◽  
Jianjun Zhang ◽  
Jame Abraham ◽  
...  
Keyword(s):  
Palliative Care ◽  
Pearson Correlation ◽  
Statistical Significance ◽  
Fellowship Training ◽  
Categorical Variables ◽  
Exact Test ◽  
Dying Patients ◽  
Oncology Practice ◽  
Eol Care

28 Background: The American Society of Clinical Oncology (ASCO) has recommended integration of palliative care into oncology practice at the time of diagnosis of advanced cancer. The attitudes, knowledge, and skills of Hematology/Oncology fellows in palliative medicine to implement this recommendation have not been assessed. Methods: In 2013 we surveyed current US Hematology/Oncology fellows to assess their attitudes and the quality of teaching in palliative care received during fellowship and their perceived preparedness to care for patients at End of Life (EOL). Trainees at all US programs were surveyed via Research Electronic Data Capture. The survey was IRB approved, anonymous and voluntary. Results: 176 surveys were collected. Statistical analysis was performed with t-test for numeric and Fisher’s exact test for categorical variables. 98% of respondents felt that providing care for dying patients was important. 99% indicated that physicians have a responsibility to help patients at EOL. Fellows felt their overall training in fellowship was superior to their quality of training (p<0.0001) or teaching (p <0.0001) on EOL. Pearson correlation showed that those with training in palliative care felt more prepared caring for patients at EOL (p <0.0001). Fellows who had training in palliative care during fellowship (45.4% of those surveyed) felt they had better teaching on managing a patient at EOL than those who did not (p<0.0001). There was no statistical significance noted with self-identified roles of spirituality or religion in attitudes, knowledge, or skills. 64% reported having conducted over ten family meetings regarding EOL. Only 18.9% were supervised (p<0.0001) and only 13.1% were given feedback more than ten times (p<0.0001). 89.7% of fellows surveyed stated they have disagreed with treatment without palliative care on at least one occasion. 40% of respondents did not know how to respond to a request to stop chemotherapy. Conclusions: Hematology/Oncology fellows believe that EOL care is important. Education about EOL is not at the same level of their overall fellowship training despite the recognition of the benefit of palliative care in Oncology. Educational initiatives need to be introduced to improve training on EOL care.

scholarly journals End-of-Life Decision-Making in Intensive Care Ten Years after a Law on Advance Directives in Germany

Medicina ◽  
2021 ◽  
Vol 57 (9) ◽  
pp. 930
Author(s):  
Jan A. Graw ◽  
Fanny Marsch ◽  
Claudia D. Spies ◽  
Roland C. E. Francis
Keyword(s):  
Decision Making ◽  
Intensive Care ◽  
End Of Life ◽  
Advance Directives ◽  
Advance Directive ◽  
Medical Center ◽  
Relevant Information ◽  
Number Of Patients ◽  
Before And After ◽  
Ethical Approval

Background and Objectives: Mortality on Intensive Care Units (ICUs) is high and death frequently occurs after decisions to limit life-sustaining therapies. An advance directive is a tool meant to preserve patient autonomy by guiding anticipated future treatment decisions once decision-making capacity is lost. Since September 2009, advance directives are legally binding for the caregiver team and the patients’ surrogate decision-maker in Germany. The change in frequencies of end-of-life decisions (EOLDs) and completed advance directives among deceased ICU patients ten years after the enactment of a law on advance directives in Germany is unknown. Materials and Methods: Retrospective analysis on all deceased patients of surgical ICUs of a German university medical center from 08/2008 to 09/2009 and from 01/2019 to 09/2019. Frequency of EOLDs and advance directives and the process of EOLDs were compared between patients admitted before and after the change in legislation. (No. of ethical approval EA2/308/20) Results: Significantly more EOLDs occurred in the 2019 cohort compared to the 2009 cohort (85.8% vs. 70.7% of deceased patients, p = 0.006). The number of patients possessing an advance directive to express a living or therapeutic will was higher in the 2019 cohort compared to the 2009 cohort (26.4% vs. 8.9%; difference: 17.5%, p < 0.001). Participation of the patients’ family in the EOLD process (74.7% vs. 60.9%; difference: 13.8%, p = 0.048) and the frequency of documentation of EOLD-relevant information (50.0% vs. 18.7%; difference: 31.3%, p < 0.001) increased from 2009 to 2019. Discussion: During a ten-year period from 2009 to 2019, the frequency of EOLDs and the completion rate of advance directives have increased considerably. In addition, EOLD-associated communication and documentation have further improved.

End-of-Life Costs and Hospice Utilization in Patients with Head and Neck Cancer

2019 ◽  
Vol 161 (3) ◽  
pp. 439-441 ◽  
Author(s):  
Michelle M. Chen ◽  
Eben L. Rosenthal ◽  
Vasu Divi
Keyword(s):  
Head And Neck Cancer ◽  
Head And Neck ◽  
End Of Life ◽  
Neck Cancer ◽  
Inpatient Services ◽  
Oncology Practice ◽  
Insured Patients ◽  
Eol Care ◽  
Privately Insured

The Quality Oncology Practice Initiative has several metrics related to end-of life (EOL) care, including hospice enrollment ≤3 days, with lower scores signaling better performance. Of privately insured patients with head and neck cancer, 3.5% were enrolled in hospice prior to death and 21.3% spent ≤3 days in hospice, indicating aggressive EOL care. Patients with late hospice enrollment had higher spending in the last 30 days of life (DOL). Patients in hospice ≤3 days spent $37,426, while those in hospice >3 days spent $24,418 ( P = .002). The largest portion of this difference was attributable to inpatient services. Patients in hospice ≤3 days spent $22,089 on inpatient services in the last 30 DOL, while those in hospice >3 days spent $8361 ( P < .001). Further research is needed to determine if more high-value care can be provided with earlier hospice enrollment and to ensure that goal concordance is included in defining high-value care.

A cost analysis of practicing oncology via telemedicine

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 6143-6143
Author(s):  
G. C. Doolittle ◽  
A. O. Spaulding ◽  
A. R. Williams
Keyword(s):  
Average Cost ◽  
Administrative Support ◽  
Medical Center ◽  
Substantial Reduction ◽  
Fiscal Year ◽  
Traditional Practice ◽  
Efficient Alternative ◽  
Cost Efficient ◽  
Oncology Practice ◽  
The University

6143 Background: The University of Kansas Medical Center (KUMC) has offered oncology services via interactive tele-video (ITV) to patients in rural Kansas for over a decade. A KUMC oncologist utilizes ITV technology to connect with patients at Hays Medical Center (HMC), which is approximately 265 west of KUMC. The technology enables the oncologist to conduct a complete patient visit without being in physical proximity to the patient. To date, two cost-tracking studies have been conducted to determine expenses associated with the tele-oncology practice. A third study recently analyzed costs incurred during fiscal year 2005 (FY05). Methods: In order to determine the costs of the practice during FY05, HMC and KUMC expenses were monitored for oncology services rendered via telemedicine. An analysis revealed expenses common to a traditional oncology practice and additional expenses unique to a telemedicine practice. Administrative support staff salaries, the oncologist’s contract fees, and nursing staff salaries made up the majority of the traditional practice-related expenses. Costs unique to a tele-oncology practice were those associated with technology including expenses for telemedicine equipment, telecommunication charges, and technician time. Results: Expenses for the tele-oncology practice on the KUMC side totaled $22,848, with $7,331 attributed to technology-related costs and $15,517 attributed to practice-related costs. For HMC, $5,803 in technology-related costs and $30,430 in practice-related costs totaled $36,233. At 235 tele-oncology consults and a combined total expense of $59,081 between KUMC and HMC, the FY05 analysis resulted in an average cost of $251 per consult. When compared to prior studies, this shows a substantial reduction in costs related to the practice of telemedicine. Conclusions: The average cost of a tele-oncology visit in Kansas has consistently decreased significantly since the practice’s 1995 inception. Analyses have revealed that the costs of providing oncology services via telemedicine are closely tied to utilization, as the majority of the expenses are related to personnel rather than technology. Telemedicine has proven itself to be a cost-efficient alternative to offering regular outreach clinics. No significant financial relationships to disclose.

Evaluating end of life care: The Quality Oncology Practice Initiative (QOPI) experience

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 8573-8573 ◽  
Author(s):  
M. N. Neuss ◽  
J. O. Jacobson ◽  
C. Earle ◽  
C. E. Desch ◽  
K. McNiff ◽  
...  
Keyword(s):  
End Of Life ◽  
Cancer Patients ◽  
Population Based ◽  
Administrative Databases ◽  
Self Assessment ◽  
Web Based ◽  
Oncology Practice ◽  
High Level ◽  
Eol Care

8573 Background: Little is known about the quality of end-of-life (EOL) care provided to cancer patients, with data largely available only from administrative databases. QOPI is a practice-based system of quality self-assessment now available to any ASCO physician wishing to participate. QOPI methodology allows comparison of EOL care among practices and provides a basis for self-improvement. Methods: In Summer 2005, during the pilot phase of QOPI, several EOL questions were included in the survey instrument. Practices were requested to review the records of at least 15 patients who had died. Practice members performed standardized chart abstractions and data were entered directly on to a secure web-based application. A total of 455 charts were abstracted from 22 practices. Results: See table. Conclusion : QOPI provides an effective mechanism for collecting practice-specific EOL data. Aggregate data from the 22 QOPI pilot practices demonstrate a high level of performance compared with results reported from population-based studies. Significant variation among practices is present, representing an opportunity to improve the EOL care of cancer patients. [Table: see text] No significant financial relationships to disclose.

End-of-life (EOL) care in medical oncology fellows' clinics.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 75-75 ◽  
Author(s):  
Yang Liu ◽  
Chethan Ramamurthy ◽  
Fern Anari ◽  
Asya Varshavsky ◽  
James Martin ◽  
...  
Keyword(s):  
End Of Life ◽  
Medical Oncology ◽  
Critical Time ◽  
Fellowship Training ◽  
Care Utilization ◽  
Advanced Directives ◽  
Exact Test ◽  
Code Status ◽  
Eol Care ◽  
Communication Methods

75 Background: Medical oncology fellowship training presents a critical time for developing skills necessary for discussing end of life (EOL) care preferences with patients and delivering EOL care. There is little data exploring the delivery of EOL care by fellows in practice. We describe our fellows’ experience and identify areas to improve delivery of EOL care and communication. Methods: We retrospectively reviewed electronic medical records (EMR) of patients at our center with advanced (metastatic or recurrent) solid tumors who received care in fellows’ clinics and died between 7/1/2016 and 6/7/2017. We used Fisher’s exact test to determine associations between variables. Results: We included 103 patients from 46 distinct fellow clinics covered by 16 fellows. 54 (52%) were male; median age was 70 (37-94) years. 42 (40%) had a gastrointestinal malignancy, 31 (30%) had lung cancer. Median duration of advanced cancer was 12 (0.5-120) months. Patients received a median of 2 (1-10) lines of chemotherapy. 10 (10%) received chemotherapy within 14 days of death. 10 (10%) used outpatient palliative care (PC). 48 (47%) had EOL/hospice discussions in the outpatient clinic, while 10 (10%) had code status documented in a clinic encounter, and 20 (19%) had a copy of an advanced directive in the EMR. Median time from EOL discussion to death was 30 days (4-171). 69 (67%) enrolled in hospice and median length of stay on hospice was 18 days (1-142). 58 (56%) were hospitalized and 13 (13%) admitted to the ICU within 30 days of death. Of patients not enrolled in hospice, 8 (8%) died at home without hospice, 23 (22%) died in a hospital or ICU, 3 (3%) died in other or unknown places. Patients who had EOL discussions in clinic were more likely to enter hospice (p = .006) and less likely to be hospitalized (p = 0.016) within 30 days of death. Conclusions: Fellows at our center have significant exposure to outpatient EOL discussions and delivery of EOL care. EOL discussions in clinic were associated with decreased rates of health care utilization within 30 days of death. There were low rates of outpatient code status discussions and documentation of advanced directives, and few patients received outpatient PC, which represent potential areas to enhance fellow training and improve patient EOL care.

Achieving life milestones in Duchenne/Becker muscular dystrophy: A retrospective analysis

2020 ◽  
pp. 10.1212/CPJ.0000000000000970
Author(s):  
Andrew Donaldson ◽  
Debra Guntrum ◽  
Emma Ciafaloni ◽  
Jeffrey Statland
Keyword(s):  
End Of Life ◽  
Transition To Adulthood ◽  
Administrative Support ◽  
High School Graduates ◽  
Medical Center ◽  
Retrospective Chart Review ◽  
Becker Muscular Dystrophy ◽  
A Prospective Study ◽  
The University ◽  
Record Review

AbstractObjective:To understand the milestones achieved in the transition from childhood to adulthood for patients with Duchenne and Becker Muscular Dystrophies (DMD/BMD).Methods:We performed a retrospective chart review on patients ≥ 15 years of age with a clinical diagnosis of DMD/BMD who received care from January 1, 2008 to 2018 at the University of Kansas Medical Center and the University of Rochester Medical Centers. Participants were identified using local MDA-funded clinic lists, neuromuscular research databases, and electronic medical record review. Data was abstracted using a uniform template on education, employment, community resources, relationships, and end of life discussions, and is presented as mean, median or frequency with associated 95% confidence interval (CI).Results:109 patients were identified: patients ranged in age from 15 to 56 years with a median of 24, and covered a 5-state region and Ontario, Canada. Seventy-eight percent of patients had DMD, and were, on average, 8.5 years younger than BMD patients. Over half (56.9%, 95% CI 47.6, 66.2) were high school graduates or beyond. Sixteen percent did not have their highest level of education documented. Only 20.0% had an occupation (95% CI 12.7, 27.7), most frequently in education and administrative support (34%). The majority were still living with parents (80.7%, 95% CI, 73.3, 88.1). A minority reported having end of life discussions (17.4%, 95% CI 10.3, 24.6).Conclusion:Psychosocial elements reflecting the transition to adulthood are inconsistently reported in clinical documentation. A prospective study will further elucidate this transition.

The Fragility of Statistically Significant Findings From Randomized Trials in Sports Surgery: A Systematic Survey

2016 ◽  
Vol 45 (9) ◽  
pp. 2164-2170 ◽  
Author(s):  
Moin Khan ◽  
Nathan Evaniew ◽  
Mark Gichuru ◽  
Anthony Habib ◽  
Olufemi R. Ayeni ◽  
...  
Keyword(s):  
Sports Medicine ◽  
Data Extraction ◽  
Statistical Significance ◽  
Arthroscopic Surgery ◽  
Fisher Exact Test ◽  
Fragility Index ◽  
Exact Test ◽  
Orthopaedic Care ◽  
Bivariate Correlation ◽  
Number Of Patients

Background: High-quality, evidence-based orthopaedic care relies on the generation and translation of robust research evidence. The Fragility Index is a novel method for evaluating the robustness of statistically significant findings from randomized controlled trials (RCTs). It is defined as the minimum number of patients in 1 arm of a trial that would have to change status from a nonevent to an event to alter the results of the trial from statistically significant to nonsignificant. Purpose: To calculate the Fragility Index of statistically significant results from clinical trials in sports medicine and arthroscopic surgery to characterize the robustness of the RCTs in these fields. Methods: A search was conducted in Medline, EMBASE, and PubMed for RCTs related to sports medicine and arthroscopic surgery from January 1, 2005, to October 30, 2015. Two reviewers independently assessed titles and abstracts for study eligibility, performed data extraction, and assessed risk of bias. The Fragility Index was calculated using the Fisher exact test for all statistically significant dichotomous outcomes from parallel-group RCTs. Bivariate correlation was performed to evaluate associations between the Fragility Index and trial characteristics. Results: A total of 48 RCTs were included. The median sample size was 64 (interquartile range [IQR], 48.5-89.5), and the median total number of outcome events was 19 (IQR, 10-27). The median Fragility Index was 2 (IQR, 1-2.8), meaning that changing 2 patients from a nonevent to an event in the treatment arm changed the result to a statistically nonsignificant result, or P ≥ .05. Conclusion: Most statistically significant RCTs in sports medicine and arthroscopic surgery are not robust because their statistical significance can be reversed by changing the outcome status on only a few patients in 1 treatment group. Future work is required to determine whether routine reporting of the Fragility Index enhances clinicians’ ability to detect trial results that should be viewed cautiously.

scholarly journals Physicians’ approach to end of life care: comparison of two tertiary care university hospitals in Lebanon

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
George Dabar ◽  
Imad Bou Akl ◽  
Mirella Sader
Keyword(s):  
End Of Life ◽  
Medical Center ◽  
Tertiary Care ◽  
Medical Culture ◽  
University Hospitals ◽  
American University ◽  
American University Of Beirut ◽  
European Training ◽  
Eol Care ◽  
Attending Physicians

Abstract Background The care of terminally ill patients is fraught with ethical and medical dilemmas carried by healthcare professionals. The present study aims to explore the approaches of Lebanese attending physicians towards palliative care, end of life (EOL) care, and patient management in two tertiary care university hospitals with distinct medical culture. Methods Four hundred attending physicians from the American University of Beirut Medical Center (AUBMC) and Hotel Dieu de France (HDF) were recruited. Participants were Medical Doctors in direct contact with adult patients that could be subject to EOL situations providing relevant demographic, educational, religious as well as personal, medical or patient-centric data. Results The majority of physicians in both establishments were previously exposed to life-limiting decisions but remains uncomfortable with the decision to stop or limit resuscitation. However, physicians with an American training (AUBMC) were significantly more likely to exhibit readiness to initiate and discuss DNR with patients (p<0.0001). While the paternalistic medicinal approach was prevalent in both groups, physicians with a European training (HDF) more often excluded patient involvement based on family preference (p<0.0001) or to spare them from a traumatic situation (p=0.003). The majority of respondents reported that previous directives from the patient were fundamental to life-limiting decisions. However, the influence of patient and medical factors (e.g. culture, religion, life expectancy, age, socioeconomic status) was evidenced in the HDF group. Conclusion Early physician-initiated EOL discussions remain challenged in Lebanon. Paternalistic attitudes limit shared decision making and are most evident in European-trained physicians. Establishing a sound and effective framework providing legal, ethical and religious guidance is thus needed in Lebanon.

Can Elimination of Total Body Irradiation (TBI) in Conditioning Regimens for Autologous Stem Cell Transplantation (SCT) in Patients with Hodgkin and Non-Hodgkin Lymphoma Decrease the Risk of Secondary AML/MDS(sAML/MDS)? A Retrospective Case-Control Study at the University of Nebraska Medical Center.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 682-682
Author(s):  
Lori J. Maness ◽  
F. R. Loberiza ◽  
W. Sanger ◽  
M. P. DeVetten ◽  
P. Bierman ◽  
...  
Keyword(s):  
Stem Cell ◽  
Stem Cell Transplantation ◽  
Cell Transplantation ◽  
Autologous Stem Cell Transplantation ◽  
Medical Center ◽  
Disease Stage ◽  
Nebraska Medical ◽  
Number Of Patients ◽  
Conditioning Regimens ◽  
The University

Abstract Background: Patients with HD and NHL have been treated with autologous stem cell transplantation (SCT) since the 1980s at the University of Nebraska Medical Center. A wide variety of conditioning regimens have been used. TBI was a standard component until the mid-1990s. AML and MDS are known risks following chemotherapy, radiotherapy and transplant. Cases of sAML/MDS following autologous SCT have ranged from 4–15%. Various patient- and treatment-specific factors have been shown to increase that risk, such as specific chemotherapy drugs, number of pre-auto SCT regimens, TBI vs non-TBI containing conditioning regimens, and prior cytogenetic abnormalities. The development of sAML/MDS leads to poor prognosis. M&M: All patients who received their first autologous SCT between 1985–2003 for HD or NHL who survived and/or had follow-up data for at least 17 months post-transplant at UNMC were reviewed. Patients who developed sAML/MDS following SCT were assessed and its incidence computed. Risk factors at the time of auto-SCT were evaluated for their association with the development of sAML/MDS and include: age, sex, race, HD vs NHL, interval time from diagnosis to transplant, disease stage, number of prior chemotherapy regimens, chemosensitivity, bone marrow involvement, extranodal involvement, LDH levels, graft type, year of transplant, and conditioning regimen- TBI vs non-TBI. Results: 910 patients were eligible for review. Sixty-two cases of sAML/MDS were identified. The incidence rate was 6.9% at 5 years. Mean time to develop sAML/MDS post-SCT was 52 months (range 12–168). The following factors were associated with increased risk based on univariate analysis: older age (49 vs 43, p=0.003), longer interval from diagnosis to transplant (27 vs. 20 mos, p=0.03), TBI vs non-TBI based conditioning regimens (p&lt;0.001), and number of regimens pre-transplant (&lt;3 vs. ≥3, p&lt;0.001). Overall survival at 8 years post-SCT was better for those without versus those with sAML/MDS (60 vs. 21%, p&lt;0.001). A small number of patients (n=9 allo, n=1 auto) received second transplants during their disease course and showed a modest early survival advantage (within 1 year post-2nd SCT) than those who did not have second transplants Figure Figure Conclusions: In the absence of a prospective cohort study it appears that elimination of TBI from auto-SCT conditioning regimens at UNMC has decreased the risk of sAML/MDS as shown by fewer occurrences after the mid-1990s and in those who did not receive TBI in comparison to those who did. In addition, fewer chemotherapeutic regimens pre-transplant, shorter interval from diagnosis to transplant, and younger age at the time of transplant have lesser risk for development of sAML/MDS. Perhaps these variables, as well as others not yet identified, can be manipulated to further decrease the risk. Donor SCT following autoSCT for sAML/MDS or relapsed disease warrants further investigation.

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