Differential impact of inpatient and outpatient palliative care on end-of-life outcomes in hospitalized patients with cancer.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 24-24
Author(s):  
Arielle R. Urman ◽  
Mary K. Buss ◽  
Robert J. Besaw ◽  
Laura E. Dodge ◽  
Kathleen A. Lee ◽  
...  

24 Background: Palliative care (PC) improves outcomes for patients with advanced cancer, and current ASCO guidelines recommend early outpatient referral. However, recent data show that PC teams at many cancer centers see more inpatient consults than outpatient visits; the comparative impact of inpatient versus outpatient PC is not well-described. For this reason, we conducted a retrospective cohort study of hospitalized cancer patients to quantify exposure to inpatient/outpatient PC, and to describe associations between PC exposure and end-of-life (EOL) quality measures including hospice utilization, advance care planning (ACP), and intensity of care. Methods: We identified all patients admitted to one cancer center’s inpatient oncology unit during one fiscal year (10/1/2017-9/30/2018). Demographics, admission statistics, inpatient/outpatient PC visits, and EOL outcomes were abstracted from the electronic medical record. Decedents were identified through chart review and public obituaries. Results were summarized by descriptive statistics, and standard statistical tests were used to evaluate associations between PC exposure and EOL outcomes. Results: 842 patients were hospitalized in one year. 522 patients died by the study end-date of 10/1/2020 and were included in analysis. 50% of decedents had any PC exposure prior to death, but only 21% had an outpatient PC visit. Patients seen by PC were younger at time of death, (median: 67 vs 72 years; p <.001) and more likely to be female (52% vs 42%; p =.03). Compared to patients never seen by PC, patients with any PC exposure were significantly more likely to enroll in hospice (78% vs 44%; p <.0001), have do-not-resuscitate status (87% vs 55%; p <.0001), have scanned ACP documents (53% vs 31%; p <.0001), and die at home or inpatient hospice instead of in the hospital (67% vs 40%; p <.01). PC exposure was not associated with differences in 30-day re-admissions, systemic cancer therapy in the last 14 days of life, or intensive care (ICU) utilization in the last 30 days of life. Notably, PC exposure was associated with longer hospital length-of-stay (LOS) (8.4 vs 7.2 days), but this association was reversed for patients seen by outpatient PC versus all others (6.3 vs 8.2 days; p <.01). Patients seen by outpatient PC also had longer hospice LOS (46.5 vs 27.1 days; p <.01) and less EOL ICU use (6% vs 15%; p <.05) compared to all others. Conclusions: In this large retrospective study of hospitalized patients with cancer, PC exposure was associated with significant improvements in multiple EOL quality measures. The subset of patients seen by outpatient PC experienced additional benefits, including shorter hospital LOS, longer hospice LOS, and less EOL ICU utilization. These findings point to differential effects between inpatient and outpatient PC, underscoring the importance of early, longitudinal PC involvement.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e24069-e24069
Author(s):  
Arielle R. Urman ◽  
Mary K. Buss ◽  
Robert J. Besaw ◽  
Kathleen A. Lee ◽  
Jonathan C. Yeh

e24069 Background: Palliative care (PC) improves outcomes for patients with advanced cancer, and current ASCO guidelines recommend early outpatient referral. However, recent data show that PC teams at many cancer centers see more inpatient consults than outpatient visits; the comparative impact of inpatient versus outpatient PC is not well-described. For this reason, we conducted a retrospective cohort study of hospitalized cancer patients to quantify exposure to inpatient/outpatient PC, and to describe associations between PC exposure and end-of-life (EOL) quality measures including hospice utilization, advance care planning (ACP), and intensity of care. Methods: We identified all patients admitted to one cancer center’s inpatient oncology unit during a fiscal year (10/1/2017 - 9/30/2018). Demographics, admission statistics, inpatient/outpatient PC visits, and EOL outcomes were abstracted from the electronic medical record. Deceased patients were identified through chart review and public obituaries. Results were summarized by descriptive statistics, and standard statistical tests were used to evaluate associations between PC exposure and EOL outcomes. Results: 842 patients were hospitalized in one year. 522 patients died by the study end-date of 10/1/2020 and were included in analysis. 50% of deceased patients had any PC exposure prior to death, but only 21% had an outpatient PC visit. Patients seen by PC were younger at time of death (median: 67 vs 72 years; p < .001) and more likely to be female (52% vs 42%; p = .03). Compared to patients never seen by PC, patients with any PC exposure were significantly more likely to enroll in hospice (78% vs 44%; p < .0001), have do-not-resuscitate status (87% vs 55%; p < .0001), have scanned ACP documents (53% vs 31%; p < .0001), and die at home or inpatient hospice instead of in the hospital (67% vs 40%; p < .01). PC exposure was not associated with differences in 30-day re-admissions, systemic cancer therapy in the last 14 days of life, or intensive care (ICU) utilization in the last 30 days of life. Notably, PC exposure was associated with longer hospital length-of-stay (LOS) (8.4 vs 7.0 days), but this association was reversed for patients seen by outpatient PC versus all others (6.3 vs 8.3 days; p < .01). Patients seen by outpatient PC also had longer hospice LOS (46.5 vs 27.1 days; p < .01) and less EOL ICU use (6% vs 15%; p < .05) compared to all others. Conclusions: In this large retrospective study of hospitalized cancer patients, PC exposure was associated with significant improvements in multiple EOL quality measures. The subset of patients seen by outpatient PC experienced additional benefits, including shorter hospital LOS, longer hospice LOS, and less EOL ICU utilization. These findings point to differential effects between inpatient and outpatient PC, underscoring the importance of early, longitudinal PC involvement.


2021 ◽  
Author(s):  
Jonathan C. Yeh ◽  
Arielle R. Urman ◽  
Robert J. Besaw ◽  
Laura E. Dodge ◽  
Kathleen A. Lee ◽  
...  

PURPOSE Palliative care (PC) improves outcomes in advanced cancer, and guidelines recommend early outpatient referral. However, many PC teams see more inpatient than outpatient consults. We conducted a retrospective study of hospitalized patients with cancer to quantify exposure to inpatient and outpatient PC and describe associations between PC and end-of-life (EOL) quality measures. METHODS We identified all decedents admitted to an inpatient oncology unit in 1 year (October 1, 2017-September 30, 2018) and abstracted hospitalization statistics, inpatient and outpatient PC visits, and EOL outcomes. Descriptive statistics, univariate tests, and multivariate analysis evaluated associations between PC and patient outcomes. RESULTS In total, 522 decedents were identified. 50% saw PC; only 21% had an outpatient PC visit. Decedents seen by PC were more likely to enroll in hospice (78% v 44%; P < .001), have do-not-resuscitate status (87% v 55%; P < .001), have advance care planning documents (53% v 31%; P < .001), and die at home or inpatient hospice instead of in hospital (67% v 40%; P < .01). Decedents seen by PC had longer hospital length-of-stay (LOS; 8.4 v 7.0 days; P = .03), but this association reversed for decedents seen by outpatient PC (6.3 v 8.3 days; P < .001), who also had longer hospice LOS (46.5 v 27.1 days; P < .01) and less EOL intensive care (6% v 15%; P < .05). CONCLUSION PC was associated with significantly more hospice utilization and advance care planning. Patients seen specifically by outpatient PC had shorter hospital LOS and longer hospice LOS. These findings suggest different effects of inpatient and outpatient PC, underscoring the importance of robust outpatient PC.


2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 180-180
Author(s):  
Carolyn L. Qian ◽  
Charu Vyas ◽  
Eva Gaufberg ◽  
Emilia Kaslow-Zieve ◽  
Chinenye C. Azoba ◽  
...  

180 Background: Hospitalized patients with cancer often experience a high symptom burden, which may impact care satisfaction and healthcare utilization. However, research describing these patients’ care satisfaction, symptom burden, and health care use is lacking. We sought to investigate relationships among care satisfaction, physical and psychological symptom burden, and hospital length of stay (LOS) in hospitalized patients with cancer. Methods: We prospectively enrolled patients with cancer and unplanned hospitalizations from 9/2014 to 4/2017. Upon admission, we assessed patients’ care satisfaction (FAMCARE items: satisfaction with care coordination and the speed with which symptoms are treated) as well as their physical (Edmonton Symptom Assessment System [ESAS]) and psychological (Patient Health Questionnaire-4 [PHQ-4]) symptoms. We used regression models to identify factors associated with care satisfaction, and we also examined associations of care satisfaction with patients’ symptom burden and hospital length of stay (LOS). Results: Among 1,576 participants (median age = 65.0 years [range:19-96], 46.3% female, 70.9% with incurable cancer, 58.4% admitted to a dedicated oncology service), most reported being “satisfied” or “very satisfied” with care coordination (90.1%) and the speed with which symptoms are treated (89.0%). Older age (care coordination: B < 0.01, P = 0.022, speed with which symptoms are treated: B = 0.01, P = 0.001) and admission to a dedicated oncology service (B = 0.20, P < 0.001 for each) were associated with higher care satisfaction. Higher satisfaction with care coordination was associated with lower ESAS-physical (B = -1.28, P = 0.007), ESAS-total (B = -2.73, P < 0.001), PHQ4-depression (B = -0.14, P = 0.022), and PHQ4-anxiety (B = -0.16, P = 0.008) symptoms. Higher satisfaction with the speed with which symptoms are treated was associated with lower ESAS-physical (B = -1.32, P = 0.003), ESAS-total (B = -2.46, P < 0.001), PHQ4-depression (B = -0.14, P = 0.014), and PHQ4-anxiety (B = -0.17, P = 0.004) symptoms. Greater satisfaction with care coordination (B = -0.48, P = 0.040) and the speed with which symptoms are treated (B = -0.44, P = 0.041) were both associated with shorter LOS. Conclusions: Hospitalized patients with cancer report high care satisfaction, which correlates with older age and admission to a dedicated oncology service. Significant associations among higher care satisfaction, lower symptom burden, and shorter hospital LOS highlight the importance of improving symptom management and care coordination in this population.


2017 ◽  
Vol 71 (1-2) ◽  
pp. 1-7 ◽  
Author(s):  
Emilia Gómez-Hoyos ◽  
Martín Cuesta ◽  
Nayade Del Prado-González ◽  
Pilar Matía ◽  
Natalia Pérez-Ferre ◽  
...  

Background: The objective of the study was to determine the prevalence of hyponatremia (HN) and its associated morbimortality in hospitalized patients receiving parenteral nutrition (PN). Methods: A retrospective study including 222 patients receiving total PN (parenteral nutrition group [PNG]) over a 7-month period in a tertiary hospital and 176 matched to 179 control subjects without PN (control subjects group [CSG]). Demographic data, Charlson Comorbidity Index (CCI), date of HN detection-(serum sodium or SNa <135 mmol/L)-intrahospital mortality, and hospital length-of-stay (LOS) were registered. In the PNG, body mass index (BMI) and SNa before, during, and after PN were recorded. Results: HN was more prevalent in the PNG: 52.8 vs. 35.8% (p = 0.001), and independent of age, gender, or CCI (OR 1.8 [95% CI 1.1-2.8], p = 0.006). In patients on PN, sustained HN (75% of all intraindividual SNa <135 mmol/L) was associated with a higher mortality rate independent of age, gender, CCI, or BMI (OR 7.38 [95% CI 1.07-50.8], p = 0.042). The absence of HN in PN patients was associated with a shorter hospital LOS (<30 days) and was independent of other comorbidities (OR 3.89 [95% CI 2.11-7.18], p = 0.001). Conclusions: HN is more prevalent in patients on PN. Sustained HN is associated with a higher intrahospital mortality rate. Absence of HN is associated with a shorter hospital LOS.


2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S346-S346
Author(s):  
Sarah Norman ◽  
Sara Jones ◽  
David Reeves ◽  
Christian Cheatham

Abstract Background At the time of this writing, there is no FDA approved medication for the treatment of COVID-19. One medication currently under investigation for COVID-19 treatment is tocilizumab, an interleukin-6 (IL-6) inhibitor. It has been shown there are increased levels of cytokines including IL-6 in severe COVID-19 hospitalized patients attributed to cytokine release syndrome (CRS). Therefore, inhibition of IL-6 receptors may lead to a reduction in cytokines and prevent progression of CRS. The purpose of this retrospective study is to utilize a case-matched design to investigate clinical outcomes associated with the use of tocilizumab in severe COVID-19 hospitalized patients. Methods This was a retrospective, multi-center, case-matched series matched 1:1 on age, BMI, and days since symptom onset. Inclusion criteria included ≥ 18 years of age, laboratory confirmed positive SARS-CoV-2 result, admitted to a community hospital from March 1st – May 8th, 2020, and received tocilizumab while admitted. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay, total mechanical ventilation days, mechanical ventilation mortality, and incidence of secondary bacterial or fungal infections. Results The following results are presented as tocilizumab vs control respectively. The primary outcome of in-hospital mortality for tocilizumab (n=26) vs control (n=26) was 10 (38%) vs 11 (42%) patients, p=0.777. The median hospital length of stay for tocilizumab vs control was 14 vs 11 days, p=0.275. The median days of mechanical ventilation for tocilizumab (n=21) vs control (n=15) was 8 vs 7 days, p=0.139, and the mechanical ventilation mortality was 10 (48%) vs 9 (60%) patients, p=0.463. In the tocilizumab group, for those expired (n=10) vs alive (n=16), 10 (100%) vs 7 (50%) patients respectively had a peak ferritin &gt; 600 ng/mL, and 6 (60%) vs 8 (50%) patients had a peak D-dimer &gt; 2,000 ng/mL. The incidence of secondary bacterial or fungal infections within 7 days of tocilizumab administration occurred in 5 (19%) patients. Conclusion These findings suggest that tocilizumab may be a beneficial treatment modality for severe COVID-19 patients. Larger, prospective, placebo-controlled trials are needed to further validate results. Disclosures Christian Cheatham, PharmD, BCIDP, Antimicrobial Resistance Solutions (Shareholder)


2016 ◽  
Vol 19 (7) ◽  
pp. 728-733 ◽  
Author(s):  
Melissa A. Crosby ◽  
Lee Cheng ◽  
Alma Y. DeJesus ◽  
Elizabeth L. Travis ◽  
Maria A. Rodriguez

2021 ◽  
Vol 18 (1) ◽  
pp. 193-205
Author(s):  
Cynthia De Freitas Melo ◽  
Maria Rannielly de Araujo Lima Magalhães ◽  
Liza Maria Studart de Meneses ◽  
Railda Sabino Fernandes Alves ◽  
Ana Cristina Eberhardt Lins ◽  
...  

Introduction: In the course of an illness, when the patient receives a poor prognosis, he can be assisted with dysthanasia or palliative care. The therapeutic choice and the adherence to it are related, among other factors, to the quality of the doctor-patient relationship. The objective of this study was to evaluate the patients’ point of view of the doctor-patient relationship in the end of life process, and compare scores between patients in palliative care and those experiencing dysthanasia. Method: The design was a descriptive survey with a non-probabilistic sample composed of 234 patients with cancer in the end of life process: 117 in palliative care and 117 expriencing dysthanasia. Two instruments were used: a biodemographic questionnaire and the Questionnaire for Assessing the Doctor-Patient Relationship in the End of Life Process, and data were analyzed using descriptive and bivariate statistics in the Statistical Package for the Social Sciences software. Results: The results showed good evaluations of the doctor-patient relationship. Palliative care patients attributed better scores in terms of time dedicated, attention, confidence, understanding and communication; and patients experiencing dysthanasia made better assessments in terms of frequency of visits and continuity of care. Conclusion: It is concluded that this study represents an advance in studies on the subject and indicates that patients in palliative care perceive the doctor-patient relationship more positively than patients undergoing dysthanasia. It stressed that it is necessary to invest in training medical students and professionals to carry out interventions that prioritize the use of their oldest, simplest and most powerful technology: the relationship between professionals and patients.


2021 ◽  
pp. bmjspcare-2021-003386
Author(s):  
Michael Bonares ◽  
Kenneth Mah ◽  
David Christiansen ◽  
John Granton ◽  
Andrea Weiss ◽  
...  

ObjectivesPatients with chronic respiratory disease have significant palliative care needs, but low utilisation of specialist palliative care (SPC) services. Decreased access to SPC results in unmet palliative care needs among this patient population. We sought to determine the referral practices to SPC among respirologists in Canada.MethodsRespirologists across Canada were invited to participate in a survey about their referral practices to SPC. Associations between referral practices and demographic, professional and attitudinal factors were analysed using regression analyses.ResultsThe response rate was 64.7% (438/677). Fifty-nine per cent of respondents believed that their patients have negative perceptions of palliative care and 39% were more likely to refer to SPC earlier if it was renamed supportive care. While only 2.7% never referred to SPC, referral was late in 52.6% of referring physicians. Lower frequency of referral was associated with equating palliative care to end-of-life care (p<0.001), male sex of respirologist (p=0.019), not knowing referral criteria of SPC services (p=0.015) and agreement that SPC services prioritise patients with cancer (p=0.025); higher referral frequency was associated with satisfaction with SPC services (p=0.001). Late referral was associated with equating palliative care to end-of-life care (p<0.001) and agreement that SPC services prioritise patients with cancer (p=0.013).ConclusionsPossible barriers to respirologists’ timely SPC referral include misperceptions about palliative care, lack of awareness of referral criteria and the belief that SPC services prioritise patients with cancer. Future studies should confirm these barriers and evaluate the effectiveness of strategies to overcome them.


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