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.

Symptom Assessment and Early Access to Supportive and Palliative Care for Patients With Advanced Solid Tumors in Mexico

2019 ◽  
Vol 35 (1) ◽  
pp. 40-45 ◽  
Author(s):  
Mirza Jacqueline Alcalde-Castro ◽  
Enrique Soto-Perez-de-Celis ◽  
Alfredo Covarrubias-Gómez ◽  
Sofía Sánchez-Román ◽  
Paulina Quiróz-Friedman ◽  
...  
Keyword(s):  
Palliative Care ◽  
Supportive Care ◽  
Solid Tumors ◽  
Advanced Cancer ◽  
Symptom Assessment ◽  
First Year ◽  
Advanced Solid Tumors ◽  
Care Clinic ◽  
Care Services ◽  
Oncology Care

Background: Early specialized palliative care improves quality of life of patients with advanced cancer, and guidelines encourage its integration into standard oncology care. However, many patients fail to obtain timely palliative/supportive care evaluations, particularly in limited-resource settings. We aimed to determine the proportion of patients with advanced cancer who received an assessment of symptoms and were referred to supportive and palliative care services during the first year after diagnosis in a Mexican hospital. Methods: Individuals with newly diagnosed advanced solid tumors and 1 year of follow-up at the oncology clinics in the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran in Mexico City from October 2015 to April 2016 were included in this retrospective study. Results: Seventy-seven patients were included. Forty-two (54.5%) were referred to the various supportive care services during the first year after diagnosis, and 23 (29.8%) were referred to the palliative care clinic. The most commonly assessed symptoms by oncologists were pain (77.9%), anorexia (74.0%), fatigue (68.8%), and nausea (55.8%), while depression/anxiety were evaluated in 10 (12.9%) patients. The oncologist offered to clarify treatment goals in 39 (50.6%) cases and evaluated the understanding of diagnosis/illness and prognosis in 22 (28.5%). Conclusion: Palliative and supportive care services were widely underutilized, which may be related to a lack of standardized symptom assessments and poor end-of-life communication. Novel strategies are needed to improve the implementation of tools for systematic symptom assessment and to optimize the integration of supportive care interventions into oncology care in developing countries.

Care, quality, and cost implications of the timing of palliative care consultation among patients with advanced cancer.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 8-8 ◽  
Author(s):  
Colin Scibetta ◽  
Michael W. Rabow ◽  
Kathleen Kerr
Keyword(s):  
Palliative Care ◽  
Medical Care ◽  
Direct Cost ◽  
Advanced Cancer ◽  
Metastatic Cancer ◽  
Care Quality ◽  
Cost Of Care ◽  
Comprehensive Cancer Center ◽  
Inpatient Cost ◽  
Cancer Center

8 Background: ASCO recommends that early palliative care (PC) be offered alongside standard cancer care for patients with metastatic cancer and/or high symptom burden. There is limited data about how the timing of PC affects the quality, intensity, and cost of care at the end of life for patients with advanced cancer. Methods: We analyzed administrative and billing data to assess patterns of healthcare utilization for a cohort of patients at an academic comprehensive cancer center who died from cancer between Jan 1, 2010 and May 31, 2012. We examined the associations of early PC (>90 days prior to death) versus late PC (<90 days prior to death) with QOPI, NQF, and other established quality metrics and direct cost of medical care in last 6 months of life. Results: Among 978 decedents who received treatment at the cancer center, only 298 (30%) had specialty PC referrals. Of these patients, 94 (9.6% of decedents, 31.5% of referrals) had early PC while 204 (21% of decedents, 68.5% of referrals) had late PC. Patients who received early PC had a lower rate of inpatient admissions in the last month of life (33% vs. 66%, p=0.002), lower rates of ICU stay in last month of life (5% vs. 20%, p=0.0005), fewer ED visits in last month (34% vs. 54%, p=0.0002), fewer instances of hospice length of service <3 days (7% vs. 20%, p=0.0001), and a lower rate of inpatient death (15% vs. 34%, p=0.0001). Most patients (84%) who received early PC were seen as outpatients, while late PC was mostly delivered in the hospital (82.4%). Of the late PC cohort, only 52 (25.4%) were ever seen in the outpatient PC clinic, but 170 (83%) had at least one oncology office visit 91-180 days prior to death. The direct cost of inpatient medical care in the last 6 months of life for patients with early PC was reduced when compared to patients who had late PC ($19k vs. $25.7k), while the direct cost of outpatient care was higher in the early PC compared to late PC population ($13k vs. $11.5k). Conclusions: Early PC is associated with less intensive medical care and improved quality outcomes at the EOL for patients with advanced cancer. Early PC results in a significant inpatient cost savings with a modest increase in outpatient costs. Early PC is likely best delivered in the outpatient setting.

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.)

scholarly journals Challenges of Managing Advanced Cancer Patients through Phone Triaging at an Outpatient Supportive Care Clinic: A Case Series of Palliative Care Patients

2012 ◽  
Vol 6 ◽  
pp. PCRT.S10733
Author(s):  
Lindsey E. Pimentel ◽  
Sriram Yennurajalingam ◽  
Elizabeth D. Brown ◽  
Debra K. Castro
Keyword(s):  
Palliative Care ◽  
Supportive Care ◽  
Advanced Cancer ◽  
Case Reports ◽  
Care Center ◽  
Case Series ◽  
Cancer Center ◽  
Advanced Cancer Patients ◽  
Care Clinic ◽  
Outpatient Supportive Care

Palliative care strives to improve the quality of life for patients and their families by impeccable assessment and management using an interdisciplinary approach. However, patients with cancer-related pain and other symptoms tend to be undertreated because of limited follow-up visits due to late referrals and logistics. Thus, patients who present to the outpatient Supportive Care Center at The University of Texas MD Anderson Cancer Center often experience severe physical and psychological symptoms. The two case reports presented highlight the challenges of managing distressed patients with advanced cancer in the outpatient setting. These descriptions focus on addressing patient needs over the phone to enhance the care patients receive at the Supportive Care Center. Future prospective studies are needed to measure the effectiveness of using phone triaging in conjunction with standard outpatient palliative care.

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.

scholarly journals Antineoplastic therapy use in patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center

Cancer ◽  
2010 ◽  
Vol 116 (8) ◽  
pp. 2036-2043 ◽  
Author(s):  
David Hui ◽  
Ahmed Elsayem ◽  
Zhijun Li ◽  
Maxine De La Cruz ◽  
J. Lynn Palmer ◽  
...  
Keyword(s):  
Palliative Care ◽  
Antineoplastic Therapy ◽  
Advanced Cancer ◽  
Palliative Care Unit ◽  
Comprehensive Cancer Center ◽  
Cancer Center

Phase II Study of an Outpatient Palliative Care Intervention in Patients With Metastatic Cancer

2009 ◽  
Vol 27 (2) ◽  
pp. 206-213 ◽  
Author(s):  
Matthew Follwell ◽  
Debika Burman ◽  
Lisa W. Le ◽  
Kristina Wakimoto ◽  
Dori Seccareccia ◽  
...  
Keyword(s):  
Palliative Care ◽  
Patient Satisfaction ◽  
Phase Ii ◽  
Phase Ii Study ◽  
Metastatic Cancer ◽  
Symptom Control ◽  
Family Satisfaction ◽  
Care Clinic ◽  
Edmonton Symptom Assessment Scale ◽  
The Mean

Purpose Although there is increasing advocacy for timely symptom control in patients with cancer, few studies have assessed outpatient palliative care clinics. This study assessed prospectively the efficacy of an Oncology Palliative Care Clinic (OPCC) in improving patient symptom distress and satisfaction. Patients and Methods Eligible patients were new referrals to an OPCC, had metastatic cancer, were at least 18 years old, and were well enough and able to speak and read English sufficiently to provide informed consent and complete questionnaires. Patients received a consultation by a palliative care team. The primary end points of symptom control and patient satisfaction were assessed using the Edmonton Symptom Assessment Scale (ESAS) and patient-adapted Family Satisfaction with Advanced Cancer Care (FAMCARE) scale at baseline, 1 week, and 1 month. Initial and follow-up scores were compared using paired t tests. Results Of 150 patients enrolled, 123 completed 1-week assessments, and 88 completed 4-week assessments. At baseline, the mean ESAS Distress Score (EDS) was 39.5. The mean improvement in EDS was 8.8 points (P < .0001) at 1 week and 7.0 points (P < .0001) at 1 month. Statistically significant improvements were observed for pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, dyspnea, insomnia, and constipation at 1 week (all P ≤ .005) and 1 month (all P ≤ .05). The mean improvement in FAMCARE score was 6.1 points (P < .0001) at 1 week and 5.0 points (P < .0001) at 1 month. Conclusion This phase II study demonstrates efficacy of an OPCC for improvement of symptom control and patient satisfaction with care. Randomized controlled trials are indicated to further evaluate the effectiveness of specialized outpatient palliative care.

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