Publications by authors named "David Casarett"

153 Publications

Combining multiple decedent data sources for a population-based picture of end-of-life health care utilization.

J Pain Symptom Manage 2021 Mar 12. Epub 2021 Mar 12.

Department of Medicine, Duke University School of Medicine, Durham, NC, USA.

Context: Although health systems need to track utilization and mortality, it can be difficult to obtain reliable information on patients who die outside of the health system. This leads to missing data and introduces the potential for bias.

Objectives: To evaluate the linkage of patient death data sources with a tertiary health system electronic health record (EHR) to increase the accuracy of health system end-of-life health care utilization data in the last month and six months of life METHODS: : The federal Death Master File (DMF) and North Carolina Department of Health and Human Services (NC DHHS) decedent files from 2017 and 2018 were linked to a health system EHR. Descriptive statistics and chi-square tests were utilized to define impact of additional data sources with demographic data and end-of-life utilization.

Results: A total of 65,935 patient deaths were identified through our multi-step data integration process. Approximately a quarter of patients (28.3%) had at least one health system encounter in the last six months of life. Of these, patient deaths identified only in the NC DHHS file were less likely (OR 0.45 [95%CI 0.39-0.52]) to be hospitalized in the last month of life.

Conclusion: We describe a method to supplement EHR data with decedent information across data sources. While additional decedent data improves the accuracy of death data in the health system, patient healthcare utilization is biased towards those who use the health system at the end of life.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.03.005DOI Listing
March 2021

Racial Equity in Palliative Care.

J Pain Symptom Manage 2021 Mar 17;61(3):435-437. Epub 2020 Dec 17.

Department of Medicine, Duke University School of Medicine, Durham, NC.

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http://dx.doi.org/10.1016/j.jpainsymman.2020.12.005DOI Listing
March 2021

Compassion in a Crisis: The Role of Palliative Care During the COVID-19 Pandemic.

Mayo Clin Proc 2020 11 2;95(11):2325-2326. Epub 2020 Oct 2.

Center to Advance Palliative Care, Mt Sinai School of Medicine, New York, NY.

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http://dx.doi.org/10.1016/j.mayocp.2020.08.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7531590PMC
November 2020

Operationalizing needs-focused palliative care for older adults in intensive care units: Design of and rationale for the PCplanner randomized clinical trial.

Contemp Clin Trials 2020 Nov 29;98:106163. Epub 2020 Sep 29.

School of Nursing, Duke University, Durham, NC, United States of America. Electronic address:

Introduction: The number of older adults who receive life support in an intensive care unit (ICU), now 2 million per year, is increasing while survival remains unchanged. Because the quality of ICU-based palliative care is highly variable, we developed a mobile app intervention that integrates into the electronic health records (EHR) system called PCplanner (Palliative Care planner) with the goal of improving collaborative primary and specialist palliative care delivery in ICU settings.

Objective: To describe the methods of a randomized clinical trial (RCT) being conducted to compare PCplanner vs. usual care.

Methods And Analysis: The goal of this two-arm, parallel group mixed methods RCT is to determine the clinical impact of the PCplanner intervention on outcomes of interest to patients, family members, clinicians, and policymakers over a 3-month follow up period. The primary outcome is change in unmet palliative care needs measured by the NEST instrument between baseline and 1 week post-randomization. Secondary outcomes include goal concordance of care, patient-centeredness of care, and quality of communication at 1 week post-randomization; length of stay; as well as symptoms of depression, anxiety, and post-traumatic stress disorder at 3 months post-randomization. We will use general linear models for repeated measures to compare outcomes across the main effects and interactions of the factors. We hypothesize that compared to usual care, PCplanner will have a greater impact on the quality of ICU-based palliative care delivery across domains of core palliative care needs, psychological distress, patient-centeredness, and healthcare resource utilization.
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http://dx.doi.org/10.1016/j.cct.2020.106163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686302PMC
November 2020

Education and communication are critical to effectively incorporating cannabis into cancer treatment.

Cancer 2020 Jan 28;127(1):27-30. Epub 2020 Sep 28.

Department of Medicine, Duke University, Durham, North Carolina.

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http://dx.doi.org/10.1002/cncr.33204DOI Listing
January 2020

Top Ten Tips Palliative Care Clinicians Should Know About Integrating Population Health Principles into Practice.

J Palliat Med 2020 04 13;23(4):568-572. Epub 2020 Mar 13.

Department of Medicine, Duke University Medical Center, Durham, North Carolina.

The field of palliative care (PC) has spent the past decade demonstrating that it improves outcomes for patients, clinicians, and health systems. Forward-thinking organizations preparing for a reimbursement system rooted in value have built robust inpatient PC programs and are rapidly moving toward the outpatient and community settings as well. As PC programs get larger and are increasingly tasked with leading a wide variety of diverse initiatives, population health principles can help to focus programs on high-value activities. This article, written by population health researchers and PC clinicians, seeks to provide PC teams nationally with a variety of population health strategies and tools to guide PC delivery throughout the health system and beyond.
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http://dx.doi.org/10.1089/jpm.2020.0100DOI Listing
April 2020

Standards, Guidelines, and Quality Measures for Successful Specialty Palliative Care Integration Into Oncology: Current Approaches and Future Directions.

J Clin Oncol 2020 03 5;38(9):987-994. Epub 2020 Feb 5.

Cicely Saunders Institute, London, United Kingdom.

Although robust evidence demonstrates that specialty palliative care integrated into oncology care improves patient and health system outcomes, few clinicians are familiar with the standards, guidelines, and quality measures related to integration. These types of guidance outline principles of best practice and provide a framework for assessing the fidelity of their implementation. Significant advances in the understanding of effective methods and procedures to guide integration of specialty palliative care into oncology have led to a proliferation of guidance documents around the world, with several areas of commonality but also some key differences. Commonalities originate from a shared vision for integration; differences arise from diverse roles of palliative care specialists within cancer care globally. In this review we discuss three of the most cited standards/guidelines, as well as quality measures related to integrated palliative and oncology care. We also recommend changes to the quality measurement framework for palliative care and a new way to match palliative care services to patients with advanced cancer on the basis of care complexity and patient needs, irrespective of prognosis.
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http://dx.doi.org/10.1200/JCO.18.02440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082154PMC
March 2020

A Measured Dose of Optimism for the Evolution of ICU-Based Palliative Care.

JAMA 2019 Oct 2. Epub 2019 Oct 2.

Section of Palliative Care, Department of Medicine, Duke University, Durham, North Carolina.

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http://dx.doi.org/10.1001/jama.2019.12660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864533PMC
October 2019

Pilot Study to Improve Goals of Care Conversations Among Hospitalists.

J Pain Symptom Manage 2019 11 16;58(5):864-870. Epub 2019 Aug 16.

Cancer Control and Populations Sciences, Duke Cancer Institute, Durham, North Carolina, USA; Department of Medicine, Duke School of Medicine, Durham, North Carolina, USA.

Context: Many hospitalized patients receive care that is not concordant with their goals. Teaching communication skills that better align goals and treatment can improve the care that patients receive.

Objective: To develop and test an innovative approach that encourages hospitalists to engage in goals of care (GOC) conversations with their patients.

Methods: We recruited 14 hospitalists and randomized half to receive electronic health record alerts for patients who might benefit most from a goals-of-care conversation, as well as communication coaching. The coaching required an initial meeting, then audio recording of two GOC conversations and feedback from the coach. Outcomes were the presence of GOC conversations (primary), the quality of the GOC conversations, physician perceptions of the intervention, and hospital metrics (e.g., 30-day readmissions, referrals to palliative care).

Results: We did not increase the frequency of GOC conversations but did improve the quality of the conversations. Patients of physicians who received the intervention had fewer 30-day readmission rates and were less likely to die 90 days after admission than patients of physicians in the control arm. Patients of intervention physicians also had fewer palliative care consults than patients of control physicians.

Conclusions: Teaching hospitalists to have GOC conversations translated into better skills and outcomes for patients. This pilot study shows promise and should be tested in a larger trial.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.06.007DOI Listing
November 2019

Benefit of Tetrahydrocannabinol versus Cannabidiol for Common Palliative Care Symptoms.

J Palliat Med 2019 10 6;22(10):1180-1184. Epub 2019 Aug 6.

Research Department, Strainprint Technologies Ltd., Toronto, Ontario, Canada.

To determine the relative contributions of tetrahydrocannabinol (THC) and cannabidiol (CBD) to patients' self-ratings of efficacy for common palliative care symptoms. This is an electronic record-based retrospective cohort study. Model development used logistic regression with bootstrapped confidence intervals (CIs), with standard errors clustered to account for multiple observations by each patient. This is a national Canadian patient portal. A total of 2,431 patients participated. Self-ratings of efficacy of cannabis, defined as a three-point reduction in neuropathic pain, anorexia, anxiety symptoms, depressive symptoms, insomnia, and post-traumatic flashbacks. We included 26,150 observations between October 1, 2017 and November 28, 2018. Of the six symptoms, response was associated with increased THC:CBD ratio for neuropathic pain (odds ratio [OR]: 3.58; 95% CI: 1.32-9.68;  = 0.012), insomnia (OR: 2.93; 95% CI: 1.75-4.91;  < 0.001), and depressive symptoms (OR: 1.63; 95% CI: 1.07-2.49;  = 0.022). Increased THC:CBD ratio was not associated with a greater response of post-traumatic stress disorder (PTSD)-related flashbacks (OR: 1.43; 95% CI: 0.60-3.41;  = 0.415) or anorexia (OR: 1.61; 95% CI: 0.70-3.73;  = 0.265). The response for anxiety symptoms was not significant (OR: 1.13; 95% CI: 0.77-1.64;  = 0.53), but showed an inverted U-shaped curve, with maximal benefit at a 1:1 ratio (50% THC). These preliminary results offer a unique view of real-world medical cannabis use and identify several areas for future research.
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http://dx.doi.org/10.1089/jpm.2018.0658DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6776252PMC
October 2019

Why Insurance Companies Should Pay for Medical Cannabis.

Am J Bioeth 2019 Apr;19(4):8-10

b University of California San Francisco.

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http://dx.doi.org/10.1080/15265161.2019.1567193DOI Listing
April 2019

Top Ten Tips Palliative Care Clinicians Should Know About Medical Cannabis.

J Palliat Med 2019 Mar 14;22(3):319-325. Epub 2019 Jan 14.

1 Department of Medicine and Duke University School of Medicine, Durham, North Carolina.

The use of medical cannabis is increasing significantly throughout the United States in spite of limited and sometimes contradictory data about its effectiveness. Palliative care providers are being asked to consider cannabis as part of symptom-directed treatment regimens although many providers have limited experience recommending medical cannabis and were trained before it was commercially available. This article seeks to dispel myths about medical cannabis and provides a balanced view of the benefits and burdens of this therapeutic option, providing evidence where it exists and offering practicing clinicians guidance on conditions in which medical cannabis is likely to be helpful or burdensome.
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http://dx.doi.org/10.1089/jpm.2018.0641DOI Listing
March 2019

Perceptions of hospitalized patients and their surrogate decision makers on dialysis initiation: a pilot study.

BMC Nephrol 2018 08 8;19(1):197. Epub 2018 Aug 8.

Department of Medicine at Duke University School of Medicine, Durham, NC, USA.

Background: Dialysis is often initiated in the hospital during episodes of acute kidney injury and critical illness. Little is known about how patients or their surrogate decision makers feel about dialysis initiation in the inpatient setting.

Methods: We conducted a prospective cohort study at a large academic center in the United States. All patients who initiated dialysis during a 30-day period in 2016 were approached for enrollment. Study participants were defined as individuals who provided consent for dialysis initiation - either the patient or a surrogate decision-maker. Decisional satisfaction and the degree of shared decision-making were assessed using the decisional attitude scale and the control preferences scale, respectively. These scales were incorporated into a study questionnaire along with an exploratory structured interview.

Results: A total of 31 potential participants were eligible and 21 agreed to participate in the study. Continuous renal replacement therapy was used in 14 out of 21 cases (67%) and there was 33% in-hospital mortality in the study cohort. A majority (62%) of patients were unable to participate in the consent process for dialysis initiation and had to rely on a surrogate decision-maker. The mean score for the decisional attitude scale was 4.1 (95% CI 3.8-4.3) with a score of 5 corresponding to high decisional satisfaction. Most of the decisions were classified as shared and incorporated input from clinicians as well as patients or surrogates. Although 90% of participants agreed that they had a choice in making the decision, 81% were unable to mention any alternatives to dialysis initiation.

Conclusions: Dialysis initiation was associated with high decisional satisfaction and most participants felt that the decision incorporated input from patients and providers. However, inpatient dialysis initiation was commonly associated with loss of decisional capacity and reliance on a surrogate decision-maker. This finding is likely driven by critical illness. Survivors of critical illness who remain dialysis dependent may need to revisit conversations about the rationale, risks, and benefits of dialysis.
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http://dx.doi.org/10.1186/s12882-018-0987-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6083629PMC
August 2018

Increasing Information Dissemination in Cancer Communication: Effects of Using "Palliative," "Supportive," or "Hospice" Care Terminology.

J Palliat Med 2018 06 20;21(6):820-824. Epub 2018 Apr 20.

2 Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania.

Background: When attempting to share information about comfort-oriented care, many use "palliative," "supportive," and "hospice" care terminology interchangeably, but we lack evidence about the effects of using these different terms.

Objectives: This study was designed to test whether the use of "palliative," "supportive," or "hospice" terminology can improve the dissemination of information among breast cancer patients-a large and growing oncology population. Design, Setting, and Measurement: This experimental study was conducted at a major U.S. hospital serving a diverse population. Patients visiting a cancer clinic encountered opportunities to learn more about cancer care. They were offered health materials that were described as reporting on "palliative," "supportive," or "hospice" care and the primary outcome was whether a patient decided to select or reject each. As a secondary outcome, the study measured the patient's level of interest in receiving each.

Results: Compared with alternatives, materials labeled as "supportive" care were most likely to be selected and considered valuable (p value <0.01).

Conclusions: In this study, the terminology used had a large effect and, compared with alternatives, the information labeled as being about "supportive" care was significantly more likely to be selected. If these effects are supported by additional research, there may be low-cost, highly feasible changes in language choice that increase the dissemination of relevant health information.
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http://dx.doi.org/10.1089/jpm.2017.0650DOI Listing
June 2018

Medical Marijuana Use in Older Adults.

J Am Geriatr Soc 2018 05 18;66(5):859-863. Epub 2018 Apr 18.

Division of Palliative Care, Department of General Internal Medicine, Duke University Medical Center, Durham, North Carolina.

Symptom management in older adults, including pain and distressing non-pain symptoms, can be challenging. Medications can cause side effects that worsen quality of life or create other symptoms, and polypharmacy itself can be detrimental in older adults. Cannabinoids may offer a way of managing selected symptoms with fewer side effects. Medical marijuana is an important area of study for older adults because of the side effects of other medications. It is also important for Baby Boomers, who are likely to have more experience with marijuana than older adults of previous generations. Therefore, geriatricians should understand medical marijuana's clinical indications, adverse effects, and legal context. This article reviews the evidence regarding indications for and risks of medical marijuana use in older adults.
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http://dx.doi.org/10.1111/jgs.15346DOI Listing
May 2018

The Achilles Heel of Medical Cannabis Research-Inadequate Blinding of Placebo-Controlled Trials.

Authors:
David Casarett

JAMA Intern Med 2018 01;178(1):9-10

Duke University School of Medicine, Durham, North Carolina.

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http://dx.doi.org/10.1001/jamainternmed.2017.5308DOI Listing
January 2018

Palliative Care Planner: A Pilot Study to Evaluate Acceptability and Usability of an Electronic Health Records System-integrated, Needs-targeted App Platform.

Ann Am Thorac Soc 2018 01;15(1):59-68

8 School of Nursing, Duke University, Durham, North Carolina.

Rationale: The quality and patient-centeredness of intensive care unit (ICU)-based palliative care delivery is highly variable.

Objective: To develop and pilot an app platform for clinicians and ICU patients and their family members that enhances the delivery of needs-targeted palliative care.

Methods: In the development phase of the study, we developed an electronic health record (EHR) system-integrated mobile web app system prototype, PCplanner (Palliative Care Planner). PCplanner screens the EHR for ICU patients meeting any of five prompts (triggers) for palliative care consultation, allows families to report their unmet palliative care needs, and alerts clinicians to these needs. The evaluation phase included a prospective before/after study conducted at a large academic medical center. Two control populations were enrolled in the before period to serve as context for the intervention. First, 25 ICU patients who received palliative care consults served as patient-level controls. Second, 49 family members of ICU patients who received mechanical ventilation for at least 48 hours served as family-level controls. Afterward, 14 patients, 18 family members, and 10 clinicians participated in the intervention evaluation period. Family member outcomes measured at baseline and 4 days later included acceptability (Client Satisfaction Questionnaire [CSQ]), usability (Systems Usability Scale [SUS]), and palliative care needs, assessed with the adapted needs of social nature, existential concerns, symptoms, and therapeutic interaction (NEST) scale; the Patient-Centeredness of Care Scale (PCCS); and the Perceived Stress Scale (PSS). Patient outcomes included frequency of goal concordant treatment, hospital length of stay, and discharge disposition.

Results: Family members reported high PCplanner acceptability (mean CSQ, 14.1 [SD, 1.4]) and usability (mean SUS, 21.1 [SD, 1.7]). PCplanner family member recipients experienced a 12.7-unit reduction in NEST score compared with a 3.4-unit increase among controls (P = 0.002), as well as improved mean scores on the PCCS (6.6 [SD, 5.8]) and the PSS (-0.8 [SD, 1.9]). The frequency of goal-concordant treatment increased over the course of the intervention (n = 14 [SD, 79%] vs. n = 18 [SD, 100%]). Compared with palliative care controls, intervention patients received palliative care consultation sooner (3.9 [SD, 2.7] vs. 6.9 [SD, 7.1] mean days), had a shorter mean hospital length of stay (20.5 [SD, 9.1] vs. 22.3 [SD, 16.0] patient number), and received hospice care more frequently (5 [36%] vs. 5 [20%]), although these differences were not statistically significant.

Conclusions: PCplanner represents an acceptable, usable, and clinically promising systems-based approach to delivering EHR-triggered, needs-targeted ICU-based palliative care within a standard clinical workflow. A clinical trial in a larger population is needed to evaluate its efficacy.
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http://dx.doi.org/10.1513/AnnalsATS.201706-500OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5812235PMC
January 2018

Comparing Strategies for Health Information Dissemination: Messengers That Can Help or Hinder.

Am J Health Promot 2018 05 19;32(4):932-938. Epub 2017 Oct 19.

5 Department of Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Purpose: To test the effects of different messengers on the dissemination of health information.

Design: An experimental study exposed participants to 12 news articles pertaining to 1 of 3 health topics framed from the perspective of 4 generic messengers: religious figures, doctors, celebrity patients, or ordinary patients. Participants select as many of the 12 articles as desired.

Setting: A cancer clinic within a large, urban hospital serving a sociodemographically diverse patient population.

Participants: Eighty-nine patients with a history of cancer.

Measures: The primary outcome was the frequency with which each news story was selected.

Analysis: Summary statistics and a general estimating equation model.

Results: For each health topic, news articles using celebrity messengers were the least likely to be selected; almost half of the participants (36 [41.4%] of 87) rejected all such articles. Articles linked to religious figures were equally unpopular ( P = .59). Articles that used doctors or ordinary patients as the messenger were very likely to be selected: Nearly all women (84 [96.6%] of 87) selected at least one of these. Furthermore, the odds of choosing articles linked to celebrities or religious leaders were statistically significantly lower than the odds of choosing those linked to ordinary patients or doctors ( P < .01).

Conclusion: Commonly used generic messengers had large effects on the dissemination of information. Health materials linked to celebrities or religious figures were consistently less likely to be selected than those linked to ordinary patients, or doctors.
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http://dx.doi.org/10.1177/0890117117733780DOI Listing
May 2018

Utilization of Hospice Services in a Population of Patients With Huntington's Disease.

J Pain Symptom Manage 2018 02 13;55(2):440-443. Epub 2017 Sep 13.

Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Context: Although the early and middle stages of Huntington's disease (HD) and its complications have been well described, less is known about the course of late-stage illness. In particular, little is known about the population of patients who enroll in hospice.

Objectives: Our goal is to describe the characteristics of patients with HD who enrolled in hospice.

Methods: This is a retrospective cohort study of electronic medical record data from 12 not-for-profit hospices in the United States from 2008 to 2012.

Results: Of the 164,032 patients admitted to these hospices, 101 (0.06%) had a primary diagnosis of HD. Their median age was 57 (IQR 48-65) and 53 (52.5%) were women. Most patients were cared for by a spouse (n = 36, 36.6%) or adult child (n = 20, 19.8%). At the time of admission, most patients were living either at home (n = 39, 38.6%) or in a nursing home (n = 41, 40.6%). All were either bedbound or could ambulate only with assistance. The most common symptom reported during enrollment in hospice was pain (n = 34, 33.7%) followed by anxiety (n = 30, 29.7%), nausea (n = 18, 17.8%), and dyspnea (n = 10, 9.9%). Patients had a median length of stay in hospice of 42 days, which was significantly longer than that of other hospice patients in the sample (17 days), P < 0.001. Of the 101 patients who were admitted to hospice, 73 died, 11 were still enrolled at the time of data analysis, and 17 left hospice either because they no longer met eligibility criteria (n = 14, 13.7%) or because they decided to seek treatment for other medical conditions (n = 3, 3.0%). Of the 73 patients who died while on hospice, most died either in a nursing home (n = 29; 40%) or a hospital (n = 27; 37%). Seventeen patients (23%) died at home. No patient that started in a facility died at home.

Conclusion: Patients with HD are admitted to hospice at a younger age compared with other patients (57 vs. 76 years old) but have a significant symptom burden and limited functional status. Although hospice care emphasizes the importance of helping patients to remain in their homes, only a minority of these patients were able to die at home.
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http://dx.doi.org/10.1016/j.jpainsymman.2017.09.004DOI Listing
February 2018

Palliative Care Office Hours for Patients with Hematologic Malignancies: An Innovative Model for Symptom Management and Education.

J Palliat Med 2017 10 24;20(10):1148-1151. Epub 2017 May 24.

3 Department of Medicine, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.

Background: Palliative care programs are experiencing rapid growth, with demand for consults surpassing staffing. Innovative models are needed to equip nonpalliative care providers to manage basic palliative care issues.

Objectives: To develop a novel program of palliative care office hours for hematologic oncology advanced practice providers, and to evaluate its impact on palliative care consult volume and composition.

Methods: A palliative care nurse practitioner or pharmacist was available for weekday office hours to all inpatient hematologic oncology advanced practice providers at an academic medical center to offer advice on pain, nonpain symptoms, and psychosocial distress. A retrospective study looking at outcome measures after six months of office hour utilization and palliative care consults from the hematologic oncology services.

Results: Palliative care office hours had a mean duration of 16 minutes per day (range 5 to 55). A mean of 11 patients were discussed per week (range 4 to 20). Pain, nausea, and anxiety were the issues most frequently raised. Of 299 patients discussed during office hours, 44 (14.7%) subsequently required a full palliative care consult. Overall, palliative care consults from the hematologic oncology services decreased from 19.6% to 10.2% of admissions (87/445 vs. 61/594, p < 0.001) with an increase in consults for goals of care.

Conclusion: Office hours are an efficient way to address palliative care needs when demand for palliative care consults exceeds capacity. Office hours may serve an educational function as well, enabling primary teams to manage basic palliative care issues with increasing independence over time.
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http://dx.doi.org/10.1089/jpm.2017.0091DOI Listing
October 2017

Electronic Goals of Care Alerts: An Innovative Strategy to Promote Primary Palliative Care.

J Pain Symptom Manage 2017 05 3;53(5):932-937. Epub 2017 Jan 3.

Department of Medicine at the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA. Electronic address:

Context: Given the shortage of palliative care specialists, strategies are needed to promote primary palliative care by nonpalliative care providers. Electronic reminders are frequently used in medicine to standardize practice, but their effectiveness in encouraging goals of care discussions is not well understood.

Objectives: To determine whether brief education and electronic alerts increase the frequency of goals of care discussions.

Methods: All general medicine services at a large academic medical center were included. Each medicine team received brief education on rounds about goals of care communication tool. When a newly admitted patient met predefined criteria, an electronic alert that included the tool was sent to the patient's resident and attending physicians within 48 hours.

Results: Of 352 admissions screened over a four-week period, 18% met one or more criteria. The combination of alerts and education increased documentation of goals of care in the medical record from 20.5% (15/73) to 44.6% (25/56) of patients (risk ratio 2.17, 95% CI 1.23-3.72). There were no significant changes in code status, noncode status limitations in care, or palliative care consultation.

Conclusion: The combination of brief education and electronic goals of care alerts significantly increased documented goals of care discussions. This intervention is simple and feasible in many settings, but larger studies are needed to determine impact on patient outcomes.
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http://dx.doi.org/10.1016/j.jpainsymman.2016.12.329DOI Listing
May 2017

Rationale and Design of the Randomized Evaluation of Default Access to Palliative Services (REDAPS) Trial.

Ann Am Thorac Soc 2016 09;13(9):1629-39

1 Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine.

The substantial nationwide investment in inpatient palliative care services stems from their great promise to improve patient-centered outcomes and reduce costs. However, robust experimental evidence of these benefits is lacking. The Randomized Evaluation of Default Access to Palliative Services (REDAPS) study is a pragmatic, stepped-wedge, cluster randomized trial designed to test the efficacy and costs of specialized palliative care consultative services for hospitalized patients with advanced chronic obstructive pulmonary disease, dementia, or end-stage renal disease, as well as the overall effectiveness of ordering such services by default. Additional aims are to identify the types of services that are most beneficial and the types of patients most likely to benefit, including comparisons between ward and intensive care unit patients. We hypothesize that patient-centered outcomes can be improved without increasing costs by simply changing the default option for palliative care consultation from opt-in to opt-out for patients with life-limiting illnesses. Patients aged 65 years or older are enrolled at 11 hospitals using an integrated electronic health record. As a pragmatic trial designed to enroll between 12,000 and 15,000 patients, eligibility is determined using a validated, electronic health record-based algorithm, and all outcomes are captured via the electronic health record and billing systems data. The time at which each hospital transitions from control, opt-in palliative care consultation to intervention, opt-out consultation is randomly assigned. The primary outcome is a composite measure of in-hospital mortality and length of stay. Secondary outcomes include palliative care process measures and clinical and economic outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT02505035).
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http://dx.doi.org/10.1513/AnnalsATS.201604-308OTDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5059505PMC
September 2016

Why Population Health and Palliative Care Need Each Other.

JAMA 2016 Jul;316(1):27-8

Cambia Palliative Care Center of Excellence, Division of Gerontology and Geriatrics, University of Washington, Seattle.

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http://dx.doi.org/10.1001/jama.2016.5961DOI Listing
July 2016

Which Patients Need Palliative Care Most? Challenges of Rationing in Medicine's Newest Specialty.

J Palliat Med 2016 07 31;19(7):696-7. Epub 2016 May 31.

Department of Medicine, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1089/jpm.2016.0080DOI Listing
July 2016

Development of an Assessment to Examine Training of the Hospice Primary Caregiver.

J Palliat Med 2016 06 25;19(6):639-45. Epub 2016 May 25.

5 Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania.

Background: Key to high-quality care of dying hospice patients at home is whether the hospice provides adequate training so the caregiver can safely care for the patient.

Objective: The study objective was to develop and validate a survey of hospice training for caregivers to ensure safe, high-quality care in the home setting.

Design: Our survey design was cross-sectional. Bereaved respondents of individuals who died at home under the care of hospice were surveyed three to six months postdeath.

Measurements: Items were developed based on advice of an expert panel, focus groups of hospice caregivers, and literature review, with 12 items developed for testing and examining 8 key processes of care. We examined the validity and reliability of the assessment using factor analysis, correlational analyses, and multivariable modeling.

Results: Our sample consisted of 262 primary caregivers (mean age 62.4, 76.7% female, 58.8% non-Hispanic white). Six questions focused on providing the caregiver with information, while another six focused on the training that hospice provided. Based on model fit and Cronbach's alpha, we dropped the information items. The items that examined hospice training demonstrated a one-factor solution and a Cronbach's of 0.90. We examined correlations of the multi-item composite with overall rating of quality of care (0.53), overall distress (0.31), and whether the respondent would recommend this hospice to others (0.49). There were no significant sociodemographic correlates of concerns with training.

Conclusions: Sufficient preliminary reliability and validity warrants further testing of this composite to examine the adequacy of training provided to family members to care safely for the patient.
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http://dx.doi.org/10.1089/jpm.2015.0185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4904156PMC
June 2016

Differences in Terminal Hospitalization Care Between U.S. Men and Women.

J Pain Symptom Manage 2016 08 21;52(2):205-11. Epub 2016 May 21.

Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; The Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA; The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA. Electronic address:

Context: In many settings, men and women receive different care.

Objectives: We sought to determine whether men and women receive different care during terminal hospitalizations.

Methods: We analyzed data of 98,314 adult patients who died while hospitalized in 458 acute care hospitals in the U.S. during 2011. We examined sex-based differences in lengths of stay (LOS), resuscitation status, and intensive interventions and processes of care, adjusting for patient- and hospital-level characteristics.

Results: Women represented half of the sample (48,509; 49.34%), were older than men (73.8 vs. 70.6 years, P < 0.0001), and less likely to be married (27.7% vs. 48.3%, P < 0.001). Among all patients, median LOS was four days (interquartile range 2-10); 19.1% of subjects received cardiopulmonary resuscitation; 37.6% had a do-not-resuscitate order during the admission; and 51.6% received mechanical ventilation. Compared with men, women had slightly shorter hospitalizations (adjusted LOS: -0.16 days; 95% CI -0.19, -0.12) and were more likely to have a do-not-resuscitate order (odds ratio [OR] 1.08; 95% CI 1.05, 1.11). Women remained less likely to receive care in an intensive care unit (OR 0.95; 95% CI 0.93, 0.98), cardiopulmonary resuscitation (OR 0.83; 95% CI 0.80, 0.86), mechanical ventilation (OR 0.94; 95% CI 0.91, 0.97), hemodialysis (adjusted OR 0.81; 95% CI 0.78, 0.86), or surgical procedures (OR 0.88; 95% CI 0.84, 0.93).

Conclusion: Men who die in hospitals receive more aggressive care than women. Further research should examine potential causes of this overall pattern.
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http://dx.doi.org/10.1016/j.jpainsymman.2016.01.013DOI Listing
August 2016

Interdisciplinary Team Care and Hospice Team Provider Visit Patterns during the Last Week of Life.

J Palliat Med 2016 05 22;19(5):482-7. Epub 2016 Apr 22.

5 Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania.

Background: Hospice provides intensive end-of-life care to patients and their families delivered by an interdisciplinary team of nurses, aides, chaplains, social workers, and physicians. Significant gaps remain about how team members respond to diverse needs of patients and families, especially in the last week of life.

Objective: The study objective was to describe the frequency of hospice team provider visits in the last week of life, to examine changes in frequency over time, and to identify patient characteristics that were associated with an increase in visit frequency.

Design: This was a retrospective cohort study using electronic medical record data.

Setting/subjects: From U.S. not-for-profit hospices, 92,250 records were used of patients who died at home or in a nursing home, with a length of stay of at least seven days.

Measurements: Data included basic demographic variables, diagnoses, clinical markers of illness severity, patient functioning, and number of hospice team member visits in the last seven days of life.

Results: On average the total number of hospice team member visits in the last week of life was 1.36 visits/day. Most were nurse visits, followed by aides, social workers, and chaplains. Visits increased over each day on average across the last week of life. Greater increase in visits was associated with patients who were younger, male, Caucasian, had a spouse caregiver, and shorter lengths of stay.

Conclusions: This study provides important information to help hospices align the interdisciplinary team configuration with the timing of team member visits, to better meet the needs of the patients and families they serve.
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http://dx.doi.org/10.1089/jpm.2015.0198DOI Listing
May 2016

The Science of Choosing Wisely--Overcoming the Therapeutic Illusion.

Authors:
David Casarett

N Engl J Med 2016 Mar;374(13):1203-5

From the University of Pennsylvania Perelman School of Medicine, Philadelphia.

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http://dx.doi.org/10.1056/NEJMp1516803DOI Listing
March 2016