Publications by authors named "Karl Lorenz"

169 Publications

Supporting Indian and other South Asians facing COVID-19 and other serious illnesses.

J Pain Symptom Manage 2021 Jul 13. Epub 2021 Jul 13.

Center for Innovation to Implementation, VA Palo Alto Health Care System; Section of Palliative Care, Division of Primary Care and Population Health, Stanford University.

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http://dx.doi.org/10.1016/j.jpainsymman.2021.06.024DOI Listing
July 2021

Long-term care service mix in the Veterans Health Administration after home care expansion.

Health Serv Res 2021 Jun 3. Epub 2021 Jun 3.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.

Objective: To determine whether the Veterans Health Administration's (VHA) efforts to expand access to home- and community-based services (HCBS) after the 2001 Millennium Act significantly changed Veterans' utilization of institutional, paid home, and unpaid home care relative to a non-VHA user Medicare population that was not exposed to HCBS expansion efforts.

Data Sources: We used linkages between the Health and Retirement Study and VHA administrative data from 1998 until 2012.

Study Design: We conducted a retrospective-matched cohort study using coarsened exact matching to ensure balance on observable characteristics for VHA users (n = 943) and nonusers (n = 6106). We used a difference-in-differences approach with a person fixed-effects estimator.

Data Collection/extraction Methods: Individuals were eligible for inclusion in the analysis if they were age 65 or older and indicated that they were covered by Medicare insurance in 1998. Individuals were excluded if they were covered by Medicaid insurance at baseline. Individuals were considered exposed to VHA HCBS expansion efforts if they were enrolled in the VHA and used VHA services.

Principal Findings: Theory predicts that an increase in the public allocation of HCBS will decrease the utilization of its substitutes (e.g., institutional care and unpaid caregiving). We found that after the Millennium Act was passed, there were no observed differences between VHA users and nonusers in the probability of using institutional long-term care (0.7% points, 95% CI: -0.009, 0.022) or in receiving paid help with activities of daily living (0.06% points, 95% CI: -0.011, 0.0125). VHA users received more hours of unpaid care post-Millennium Act (1.48, 95% CI: -0.232, 3.187), though this effect was not significant once we introduced controls for mental health.

Conclusions: Our findings indicate that mandating access to HCBS services does not necessarily imply that access to these services will follow suit.
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http://dx.doi.org/10.1111/1475-6773.13687DOI Listing
June 2021

Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach.

Palliat Med 2021 Jun 3:2692163211020473. Epub 2021 Jun 3.

Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.

Background: The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient's treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations.

Aim: Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative.

Design: A qualitative thematic analysis of semi-structured interviews.

Setting/participants: Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers.

Results: Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can "overwhelm" providers.

Conclusions: Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.
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http://dx.doi.org/10.1177/02692163211020473DOI Listing
June 2021

Opportunities for improving opioid disposal practices in the Veterans Health Administration.

Am J Health Syst Pharm 2021 06;78(13):1216-1222

Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA.

Purpose: The potentially vast supply of unused opioids in Americans' homes has long been a public health concern. We conducted a needs assessment of how Veterans Affairs (VA) facilities address and manage disposal of unused opioid medications to identify opportunities for improvement.

Methods: We used rapid qualitative content analysis methods with team consensus to synthesize findings. Data were collected in 2 waves: (1) semistructured interviews with 19 providers in October 2019 and (2) structured questions to 21 providers in March to April of 2020 addressing how coronavirus disease 2019 (COVID-19) changed disposal priorities.

Results: While many diverse strategies have been tried in the VA, we found limited standardization of advice on opioid disposal and practices nationally. Providers offered the following recommendations: target specific patient scenarios for enhanced disposal efforts, emphasize mail-back envelopes, keep recommendations to providers and patients consistent and reinforce existing guidance, explore virtual modalities to monitor disposal activity, prioritize access to viable disposal strategies, and transition from pull to push communication. These themes were identified in the fall of 2019 and remained salient in the context of the COVID-19 pandemic.

Conclusion: A centralized VA national approach could include proactive communication with patients and providers, interventions tailored to specific settings and populations, and facilitated access to disposal options. All of the above strategies are feasible in the context of an extended period of social distancing.
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http://dx.doi.org/10.1093/ajhp/zxab163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8083266PMC
June 2021

Expert Stakeholder Prioritization of Process Quality Measures to Achieve Patient- and Family-Centered Palliative and End-of-Life Cancer Care.

J Palliat Med 2021 Feb 19. Epub 2021 Feb 19.

VA Greater Los Angeles Health Care System, Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, California, USA.

Quality measures of palliative and end-of-life care relevant to patients with advanced cancer have been developed, but few are in routine use. It is unclear which of these measures are most important for providing patient- and family-centered care and have high potential for improving quality of care. To prioritize process quality measures for assessing delivery of patient- and family-centered palliative and end-of-life cancer care in US Veterans Affairs (VA) health care facilities. A panel of 10 palliative and cancer care expert stakeholders (7 physicians, 2 nurses, 1 social worker) rated process quality measure concepts before and after a 1-day meeting. Panelists rated 64 measure concepts on a nine-point scale on: (1) importance to providing patient- and family-centered care, and (2) potential for quality improvement (QI). Panelists also nominated five highest priority measure concepts ("top 5") on each attribute. Panelists rated most measure concepts (54 premeeting, 56 post-meeting) as highly important to patient- and family-centered care (median rating ≥7). Considerably fewer (17 premeeting, 22 post-meeting) were rated as having high potential for QI. Measure concepts having postpanel median ratings ≥7 and nominated by one or more panelists as "top 5" on either attribute comprised a shortlist of 20 measure concepts. A panel of expert stakeholders helped prioritize 64 measure concepts into a shortlist of 20. Half of the shortlisted measures were related to communication about patient preferences and decision making, and half were related to symptom assessment and treatment.
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http://dx.doi.org/10.1089/jpm.2020.0633DOI Listing
February 2021

How Patients and Providers Weigh the Risks and Benefits of Long-Term Opioid Therapy for Cancer Pain.

JCO Oncol Pract 2021 Jul 3;17(7):e1038-e1047. Epub 2021 Feb 3.

VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA.

Purpose: To understand how patients and providers weigh the risks and benefits of long-term opioid therapy (LTOT) for cancer pain.

Methods: Researchers used VA approved audio-recording devices to record interviews. ATLAS t.i., a qualitative analysis software, was used for analysis of transcribed interview data. Participants included 20 Veteran patients and 20 interdisciplinary providers from primary care- and oncology-based practice settings. We conducted semistructured interviews and analyzed transcripts used thematic qualitative methods. Interviews explored factors that affect decision making about appropriateness of LTOT for cancer related pain. We saturated themes for providers and patients separately.

Results: Factors affecting patient decision-making included influence from various information sources, persuasion from trusted providers, and sometimes deferral of the decision to their provider. Relative prioritization of pain management as the focal patient concern varied with some patients describing comparatively more fear of chemotherapy than opioid analgesics, comparatively more knowledge of opioids in relation to other drugs;patients expressed a preference to spend the limited time they have with their oncologist discussing cancer treatment rather than opioid use. Factors affecting provider decision making included prognosis, patient goals, patient characteristics, and provider experience and biases. Providers differed in how they weigh the relative importance of alleviating pain or avoiding opioids in the face of treating patients with cancer and histories of substance abuse.

Conclusion: Divergent perspectives on factors need to be considered when weighing risks and benefits. Policies and interventions should be designed to reduce variation in practice to promote equal access to adequate pain management. Improved shared decision-making initiatives will take advantage of patient decision-making factors and priorities.
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http://dx.doi.org/10.1200/OP.20.00679DOI Listing
July 2021

Facility-Level Variation in Dialysis Use and Mortality Among Older Veterans With Incident Kidney Failure.

JAMA Netw Open 2021 01 4;4(1):e2034084. Epub 2021 Jan 4.

Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.

Importance: Current guidelines lack consensus regarding the treatment of patients who may not benefit from dialysis; this lack of consensus may be associated with the substantial variation in dialysis use and outcomes across health care facilities.

Objective: To assess the degree to which variation in dialysis use and mortality was associated with patient rather than facility characteristics and to distinguish which features identified the US Department of Veterans Affairs (VA) facilities with high rates of dialysis use.

Design, Setting, And Participants: This cohort study analyzed data of veterans with stage 3 or 4 chronic kidney disease that progressed to kidney failure between January 1, 2011, and December 31, 2014. These patients received care from VA facilities across the US. Data sources included laboratory and administrative records from the VA, Medicare, and United States Renal Data System. Data analysis was conducted from August 1, 2019, to September 1, 2020.

Exposures: The primary exposure was the VA facility in which patients received most of their care before the onset of incident kidney failure defined as the first occurrence of either a sustained estimated glomerular filtration rate of less than 15 mL/min/1.73 m2 or the initiation of maintenance dialysis.

Main Outcomes And Measures: The primary outcomes were dialysis use and mortality within 2 years of incident kidney failure. Median rate ratio was used to quantify facility-level variation, and variance partition coefficient was used to quantify the sources of unexplained variation.

Results: The cohort included 8695 older veterans with a mean (SD) age of 78.8 (7.5) years who were predominantly male (8573 [99%]) and White (6102 [70%]) individuals treated at 108 VA facilities. The observed frequency of dialysis use across facilities ranged from 25.0% to 81.4%, with a median (interquartile range [IQR]) rate of 51.7% (48.4%-60.0%). The observed frequency of mortality across facilities ranged from 27.2% to 60.0%, with a median (IQR) rate of 45.2% (41.2%-48.6%). The median rate ratio (adjusted for multiple patient and facility characteristics) was 1.40 for dialysis use and 1.08 for mortality. The unexplained variation in both outcomes mainly derived from patient characteristics rather than facility characteristics. No correlation was found between dialysis use and mortality at the facility level (correlation coefficient = 0.03).

Conclusions And Relevance: This study found sizable variation in dialysis use for older adults that was poorly correlated with facility-level mortality rates and was not accounted for by differences in measured patient and facility characteristics. These findings suggest opportunities to improve the degree to which dialysis use practices align with the values, goals, and preferences of older adults with kidney failure.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.34084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811178PMC
January 2021

End-of-Life Cost Trajectories in Cancer Patients Treated by Medicare versus the Veterans Health Administration.

J Am Geriatr Soc 2021 Apr 24;69(4):916-923. Epub 2020 Dec 24.

Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA.

Background/objectives: To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA).

Design: A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equations to evaluate monthly cost trajectories experienced by patients in their last year of life, with patients nested within hospital referral region.

Setting: Care received at VA facilities or by Medicare-reimbursed providers nationwide.

Participants: A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare.

Measurements: We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12 months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life.

Results: All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care.

Conclusion: Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.
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http://dx.doi.org/10.1111/jgs.16941DOI Listing
April 2021

Barriers and Facilitators of Using Quality Improvement To Foster Locally Initiated Innovation in Palliative Care Services in India.

J Gen Intern Med 2021 02 8;36(2):366-373. Epub 2020 Sep 8.

Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA.

Background: Quality improvement (QI) methods represent a vehicle for fostering locally initiated innovation cycles. We partnered with palliative care services from seven diverse practice settings in India to foster locally initiated improvement projects.

Objective: To evaluate the implementation experiences of locally initiated palliative care improvement projects at seven diverse sites and understand the barriers and facilitators of using QI to improve palliative care in India.

Participants: We use a quota sampling approach to capture the perspectives of 44 local stakeholders in each of the following three categories (organizational leaders, clinic leaders, and clinical team members) through a semi-structured interview guide informed by the consolidated framework for implementation research (CFIR). We use standard qualitative methods to identify facilitators and barriers to using QI methods in seven diverse palliative care contexts.

Results: Across all sites, respondents emphasized the following factors important in the success of quality improvement initiative: leveraging clinic level data, QI methods training, provider buy-in, engaged mentors, committed leadership, team support, interdepartmental coordination, collaborations with other providers, local champions, and having a structure for accountability. Barriers to using QI methods to improve palliative care services included lack of designated staff, high patient volume, resources, patient population geographic constraints, general awareness and acceptance of palliative care, and culture.

Conclusions: Empowering local leaders and medical personnel to champion, design, and iterate using QI methods represents a promising powerful tool to spread palliative care services in developing countries.
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http://dx.doi.org/10.1007/s11606-020-06152-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878595PMC
February 2021

The Palliative Care-Promoting Access and Improvement of the Cancer Experience (PC-PAICE) Project in India: A Multisite International Quality Improvement Collaborative.

J Pain Symptom Manage 2021 01 25;61(1):190-197. Epub 2020 Aug 25.

Stanford Healthcare, Palo Alto, California, USA.

Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care-Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care-Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.08.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7445485PMC
January 2021

Hospital patients' perspectives on what is essential to enable optimal palliative care: A qualitative study.

Palliat Med 2020 12 28;34(10):1402-1415. Epub 2020 Aug 28.

Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia.

Background: The majority of expected deaths in high income countries occur in hospital where optimal palliative care cannot be assured. In addition, a large number of patients with palliative care needs receive inpatient care in their last year of life. International research has identified domains of inpatient care that patients and carers perceive to be important, but concrete examples of how these might be operationalised are scarce, and few studies conducted in the southern hemisphere.

Aim: To seek the perspectives of Australian patients living with palliative care needs about their recent hospitalisation experiences to determine the relevance of domains noted internationally to be important for optimal inpatient palliative care and how these can be operationalised.

Design: An exploratory qualitative study using semi-structured interviews.

Setting/participants: Participants were recruited through five hospitals in New South Wales, Australia.

Results: Twenty-one participants took part. Results confirmed and added depth of understanding to domains previously identified as important for optimal hospital palliative care, including: Effective communication and shared decision making; Expert care; Adequate environment for care; Family involvement in care provision; Financial affairs; Maintenance of sense of self/identity; Minimising burden; Respectful and compassionate care; Trust and confidence in clinicians and Maintenance of patient safety. Two additional domains were noted to be important: Nutritional needs; and Access to medical and nursing specialists.

Conclusions: Taking a person-centred focus has provided a deeper understanding of how to strengthen inpatient palliative care practices. Future work is needed to translate the body of evidence on patient priorities into policy reforms and practice points.
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http://dx.doi.org/10.1177/0269216320947570DOI Listing
December 2020

Implementing Goals-of-Care Conversations: Lessons From High- and Low-Performing Sites From a VA National Initiative.

J Pain Symptom Manage 2021 02 8;61(2):262-269. Epub 2020 Aug 8.

Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.

Context: The Veterans Health Administration (VA) National Center for Ethics in Healthcare implemented the Life-Sustaining Treatment Decisions Initiative, including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning via goals-of-care conversations for seriously ill veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017.

Objectives: Our goal was to describe the range of early implementation experiences among the pilot sites, and compare them with spread sites that implemented LSTDI about two years later, identifying cross-site best practices and pitfalls.

Methods: We conducted semistructured interviews with 32 key stakeholders from 12 sites to identify cross-site best practices and pitfalls related to implementation.

Results: Three primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships.

Conclusion: Learning health care systems need multilevel interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.07.040DOI Listing
February 2021

Measure Scan and Synthesis of Palliative and End-of-Life Process Quality Measures for Advanced Cancer.

JCO Oncol Pract 2021 02 6;17(2):e140-e148. Epub 2020 Aug 6.

Veterans Affairs Greater Los Angeles Health Care System, Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA.

Purpose: Monitoring and improving the quality of palliative and end-of-life cancer care remain pressing needs in the United States. Among existing measures that assess the quality of palliative and end-of-life care, many operationalize similar concepts. We identified existing palliative care process measures and synthesized these measures to aid stakeholder prioritization that will facilitate health system implementation in patients with advanced cancer.

Methods: We reviewed MEDLINE/PubMed-indexed articles for process quality measures related to palliative and end-of-life care for patients with advanced cancer, supplemented by expert input. Measures were inductively grouped into "measure concepts" and higher-level groups.

Results: Literature review identified 226 unique measures from 23 measure sources, which we grouped into 64 measure concepts within 12 groups. Groups were advance care planning (11 measure concepts), pain (7), dyspnea (9), palliative care-specific issues (6), other specific symptoms (17), comprehensive assessment (2), symptom assessment (1), hospice/palliative care referral (1), spiritual care (2), mental health (5), information provision (2), and culturally appropriate care (1).

Conclusion: Measure concepts covered the spectrum of care from acute symptom management to advance care planning and psychosocial needs, with variability in the number of measure concepts per group. This taxonomy of process quality measure concepts can be used by health systems seeking stakeholder input to prioritize targets for improving palliative and end-of-life care quality in patients with advanced cancer.
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http://dx.doi.org/10.1200/OP.20.00240DOI Listing
February 2021

Developing Unique Insights From Narrative Responses to Bereaved Family Surveys.

J Pain Symptom Manage 2020 10 16;60(4):699-708. Epub 2020 May 16.

Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.

Context: Although bereaved family surveys (BFS) are routinely used quantitatively for quality assessment, open-ended and narrative responses are rarely systematically analyzed. Analysis of narrative responses may identify opportunities for improving end-of-life (EOL) care delivery.

Objectives: To highlight the value of routine and systematic analysis of narrative responses and to thematically summarize narrative responses to the BFS of Veterans Affairs.

Methods: We analyzed more than 4600 open-ended responses to the BFS for all 2017 inpatient decedents across Veterans Affairs facilities. We used a descriptive qualitative approach to identify major themes.

Results: Thematic findings clustered into three domains: patient needs, family needs, and facility and organizational characteristics. Patient needs include maintenance of veteran's hygiene, appropriately prescribing medications, adhering to patient wishes, physical presence in patient's final hours, and spiritual and religious care at EOL. Family and caregiver needs included enhanced communication with the patient's care team, assistance with administrative and logistical challenges after death, emotional support, and displays of respect and gratitude for the patient's life. Facility and organizational characteristics included care team coordination, optimal staffing, the importance of nonclinical staff to care, and optimizing facilities to be welcoming, equipped for individuals with disabilities, and able to provide high-quality food.

Conclusion: Systematic analysis of narrative survey data yields unique findings not routinely available through quantitative data collection and analysis. Organizations may benefit from the collection and regular analysis of narrative survey responses, which facilitate identification of needed improvements in palliative and EOL care that may improve the overall experiences for patients and families.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.05.007DOI Listing
October 2020

Pilot of the Life-Sustaining Treatment Decisions Initiative Among Veterans With Serious Illness.

Am J Hosp Palliat Care 2021 Jan 8;38(1):68-76. Epub 2020 May 8.

Center for Innovation to Implementation, 19977VA Palo Alto Health Care System, Menlo Park, CA, USA.

Background: Prior to national spread, the Department of Veterans Affairs implemented a pilot of the life-sustaining treatment decisions initiative (LSTDI) to promote proactive goals of care conversations (GoCC) with seriously ill patients, including policy and practice standards, an electronic documentation template and order set, and implementation support.

Aim: To describe a 2-year pilot of the LSTDI at 4 demonstration sites.

Design: Prospective observational study.

Setting/participants: A total of 6664 patients who had at least one GoCC.

Results: Descriptive statistics characterized patient demographics, goals of care, LST decisions, and risk of hospitalization or mortality among patients with at least one GoCC. Participants were on average 71.4 years old, 93.2% male, 87.1% white, and 64.7% urban; 27.3% died by the end of the pilot period. Fifteen percent lacked decision-making capacity (DMC). Nonmutually exclusive goals included to be cured (7.6%), to prolong life (34%), to improve/maintain quality of life (61.5%), to be comfortable (53%), to obtain support for family/caregiver (8.4%), to achieve life goals (2.1%), and other (10.5%). Many GoCCs resulted in a do not resuscitate (DNR) order (58.8%). Patients without DMC were more likely to have comfort-oriented goals (77.3% vs 48.8%) and a DNR (84% vs 52.6%). Chart abstraction supported content validity of GoCC documentation.

Conclusion: The pilot demonstrated that standardizing practices for eliciting and documenting GoCCs resulted in customized documentation of goals of care and LST decisions of a large number of seriously ill patients and established the feasibility of spreading standardized practices throughout a large integrated health care system.
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http://dx.doi.org/10.1177/1049909120923595DOI Listing
January 2021

Perceptions of Facilitators and Barriers to Measuring and Improving Quality in Palliative Care Programs.

Am J Hosp Palliat Care 2020 Dec 27;37(12):1022-1028. Epub 2020 Apr 27.

1466Johns Hopkins School of Medicine, Baltimore, MD, USA.

Objective: To examine perceptions of facilitators and barriers to quality measurement and improvement in palliative care programs and differences by professional and leadership roles.

Methods: We surveyed team members in diverse US and Canadian palliative care programs using a validated survey addressing teamwork and communication and constructs for educational support and training, leadership, infrastructure, and prioritization for quality measurement and improvement. We defined key facilitators as constructs rated ≥4 (agree) and key barriers as those ≤3 (disagree) on 1 to 5 scales. We conducted multivariable linear regressions for associations between key facilitators and barriers and (1) professional and (2) leadership roles, controlling for key program and respondent factors and clustering by program.

Results: We surveyed 103 respondents in 11 programs; 45.6% were physicians and 50% had leadership roles. Key facilitators across sites included teamwork, communication, the implementation climate (or environment), and program focus on quality improvement. Key barriers included educational support and incentives, particularly for quality measurement, and quality improvement infrastructure such as strategies, systems, and skilled staff. In multivariable analyses, perceptions did not differ by leadership role, but physicians and nurse practitioners/nurses/physician assistants rated most constructs statistically significantly more negatively than other team members, especially for quality improvement (6 of the 7 key constructs).

Conclusions: Although participants rated quality improvement focus and environment highly, key barriers included lack of infrastructure, especially for quality measurement. Building on these facilitators and measuring and addressing these barriers might help programs enhance palliative care quality initiatives' acceptability, particularly for physicians and nurses.
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http://dx.doi.org/10.1177/1049909120916702DOI Listing
December 2020

"Asking Is Never Bad, I Would Venture on That": Patients' Perspectives on Routine Pain Screening in VA Primary Care.

Pain Med 2020 10;21(10):2163-2171

VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, California.

Objective: Screening for pain in routine care is one of the efforts that the Veterans Health Administration has adopted in its national pain management strategy. We aimed to understand patients' perspectives and preferences about the experience of being screened for pain in primary care.

Design: Semistructured interviews captured patient perceptions and preferences of pain screening, assessment, and management.

Subjects: We completed interviews with 36 patients: 29 males and seven females ranging in age from 28 to 94 years from three geographically distinct VA health care systems.

Methods: We evaluated transcripts using constant comparison and identified emergent themes.

Results: Theme 1: Pain screening can "determine the tone of the examination"; Theme 2: Screening can initiate communication about pain; Theme 3: Screening can facilitate patient recall and reflection; Theme 4: Screening for pain may help identify under-reported psychological pain, mental distress, and suicidality; Theme 5: Patient recommendations about how to improve screening for pain.

Conclusion: Our results indicate that patients perceive meaningful, positive impacts of routine pain screening that as yet have not been considered in the literature. Specifically, screening for pain may help capture mental health concerns that may otherwise not emerge.
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http://dx.doi.org/10.1093/pm/pnaa016DOI Listing
October 2020

Concurrent Hospice Care and Cancer-Directed Treatment for Advanced Lung Cancer and Receipt of Aggressive Care at the End of Life in the Veteran's Health Administration.

J Palliat Med 2020 08 2;23(8):1038-1044. Epub 2020 Mar 2.

National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut, USA.

Aggressive care at the end of life (EOL) is a persistent issue for patients with stage IV nonsmall cell lung cancer (NSCLC). We evaluated the use of concurrent care (CC) with hospice care and cancer-directed treatment simultaneously within the Veteran's Health Administration (VHA) and aggressive care at the EOL. To determine whether VHA facility-level CC is associated with changes in aggressive care at the EOL. Veterans with stage IV NSCLC who died between 2006 and 2012 and received lung cancer care within the VHA. The primary outcome was aggressive care at EOL (i.e., hospital admissions, chemotherapy, and intensive care unit) within the last month of life. To compare aggressive care across VHA facilities, we used a random intercept multilevel logistic regression model to examine the association between facility-level CC within each study year (<10%, 10% to 19%, and ≥20%) and aggressive care at the EOL among the decedents as a binary outcome. In total, 18,371 veterans with NSCLC at 154 VHA facilities were identified. Facilities delivering CC for ≥20% of veterans (high CC) increased from 20.0% in 2006 to 43.2% in 2012 ( < 0.001). Overall, hospice care significantly increased and aggressive care at EOL decreased over the study period. However, facility-level CC adoption was not associated with any difference in aggressive care at EOL (adjusted odds ratio high CC vs. low CC: 0.91 [95% CI, 0.79 to 1.05],  = 0.21). Although the VHA adoption of CC increased hospice use among patients with NSCLC, additional measures may be needed to decrease aggressive care at the EOL.
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http://dx.doi.org/10.1089/jpm.2019.0485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7404822PMC
August 2020

Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU.

Implement Sci 2020 02 22;15(1):12. Epub 2020 Feb 22.

Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.

Background: Innovations to improve quality and safety in healthcare are increasingly complex, targeting multiple disciplines and organizational levels, and often requiring significant behavior change by those delivering care. Learning health systems must tackle the crucial task of understanding the implementation and effectiveness of complex interventions, but may be hampered in their efforts by limitations in study design imposed by business-cycle timelines and implementation into fast-paced clinical environments. Rapid assessment procedures are a pragmatic option for producing timely, contextually rich evaluative information about complex interventions implemented into dynamic clinical settings.

Methods: We describe our adaptation of rapid assessment procedures and introduce a rapid team-based analysis process using an example of an evaluation of an intensive care unit (ICU) redesign initiative aimed at improving patient safety in four academic medical centers across the USA. Steps in our approach included (1) iteratively working with stakeholders to develop evaluation questions; (2) integration of implementation science frameworks into field guides and analytic tools; (3) selecting and training a multidisciplinary site visit team; (4) preparation and trust building for 2-day site visits; (5) engaging sites in a participatory approach to data collection; (6) rapid team analysis and triangulation of data sources and methods using a priori charts derived from implementation frameworks; and (7) validation of findings with sites.

Results: We used the rapid assessment approach at each of the four ICU sites to evaluate the implementation of the sites' innovations. Though the ICU projects all included three common components, they were individually developed to suit the local context and had mixed implementation outcomes. We generated in-depth case summaries describing the overall implementation process for each site; implementation barriers and facilitators for all four sites are presented. One of the site case summaries is presented as an example of findings generated using the method.

Conclusions: A rapid team-based approach to qualitative analysis using charts and team discussion using validation techniques, such as member-checking, can be included as part of rapid assessment procedures. Our work demonstrates the value of including rapid assessment procedures for implementation research when time and resources are limited.
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http://dx.doi.org/10.1186/s13012-020-0972-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7036173PMC
February 2020

Risk of opioid misuse in people with cancer and pain and related clinical considerations: a qualitative study of the perspectives of Australian general practitioners.

BMJ Open 2020 02 17;10(2):e034363. Epub 2020 Feb 17.

Medicine - Primary Care and Population Health, Stanford University, Stanford, California, USA.

Objective: To explore the perspectives of general practitioners (GPs) concerning the risk of opioid misuse in people with cancer and pain and related clinical considerations.

Design: A qualitative approach using semistructured telephone interviews. Analysis used an integrative approach.

Setting: Primary care.

Participants: Australian GPs with experience of prescribing opioids for people with cancer and pain.

Results: Twenty-two GPs participated, and three themes emerged. Theme 1 () contextualised misuse as a relatively minor concern compared with pain control and toxicity, and highlighted underlying systemic factors, including limitations in continuity of care and doctor expertise. Theme 2 () captured participants' relative comfort in prescribing opioids for pain in cancer versus non-cancer contexts, and acknowledgement that compassion and greater perceived community acceptance were driving factors, in addition to scientific support for mechanisms and clinical efficacy. Participant attitudes towards prescribing for people with cancer versus non-cancer pain differed most when cancer was in the palliative phase, when they were unconcerned by misuse. Participants were equivocal about the risk-benefit ratio of long-term opioid therapy in the chronic phase of cancer, and were reluctant to prescribe for disease-free survivors. Theme 3 () captured participants' acknowledgement that they sometimes prescribed opioids for cancer pain as a default, easier option compared with more holistic pain management.

Conclusions: Findings highlight the role of specific clinical considerations in distinguishing risk of opioid misuse in the cancer versus non-cancer population, rather than diagnosis per se. Further efforts are needed to ensure continuity of care where opioid prescribing is shared. Greater evidence is needed to guide opioid prescribing in disease-free survivors and the chronic phase of cancer, especially in the context of new treatments for metastatic disease.
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http://dx.doi.org/10.1136/bmjopen-2019-034363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044941PMC
February 2020

Measuring the Quality of Palliative Care for Patients with End-Stage Liver Disease.

Dig Dis Sci 2020 09 11;65(9):2562-2570. Epub 2020 Jan 11.

West Los Angeles Veterans Affairs Medical Center, Los Angeles, USA.

Background/aims: We examined the quality of palliative care received by patients with decompensated cirrhosis using an explicit set of palliative care quality indicators (QIs) for patients with end-stage liver disease (PC-ESLD).

Methods: We identified patients newly diagnosed with decompensated cirrhosis at a single veterans health center and followed up them for 2 years or until death. We piloted measurement of PC-ESLD QIs in all patients confirmed to have ESLD using a chart abstraction tool.

Results: Out of 167 patients identified using at least one sampling strategy, 62 were confirmed to meet ESLD criteria with chart abstraction. Ninety-eight percent of veterans in the cohort were male, mean age at diagnosis was 61 years, and 74% were White. The overall QI pass rate was 68% (64% for information care planning QIs and 76% for supportive care QIs). Patients receiving specialty palliative care consultation were more likely to receive information care planning QIs (67% vs. 37%, p = 0.02). The best performing sampling strategy had a sensitivity of 62% and specificity of 60%.

Conclusion: Measuring the quality of palliative care for patients with ESLD is feasible in the veteran population. Our single-center data suggest that the quality of palliative care is inadequate in the veteran population with ESLD, though patients offered specialty palliative care consultation and those affected by homelessness, drug, and alcohol abuse may receive better care. Our combination of ICD-9 codes can be used to identify a cohort of patients with ESLD, though better sensitivity and specificity may be needed.
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http://dx.doi.org/10.1007/s10620-019-05983-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223418PMC
September 2020

Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review.

J Gen Intern Med 2020 07 9;35(7):2107-2117. Epub 2020 Jan 9.

Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (152-MPD), Menlo Park, CA, USA.

Background: Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience).

Methods: We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes.

Results: Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands.

Discussion: Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.
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http://dx.doi.org/10.1007/s11606-019-05525-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351919PMC
July 2020

Palliative Care and End-of-Life Outcomes Following High-risk Surgery.

JAMA Surg 2020 02;155(2):138-146

Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.

Importance: Palliative care has the potential to improve care for patients and families undergoing high-risk surgery.

Objective: To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation.

Design, Setting, And Participants: This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included.

Exposures: Palliative-care consultation within 30 days before or 90 days after surgery.

Main Outcomes And Measures: The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes.

Results: A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery.

Conclusions And Relevance: Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.
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http://dx.doi.org/10.1001/jamasurg.2019.5083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990868PMC
February 2020

Quality Measurement of Serious Illness Communication: Recommendations for Health Systems Based on Findings from a Symposium of National Experts.

J Palliat Med 2020 01 13;23(1):13-21. Epub 2019 Nov 13.

Harvard Medical School, Boston, Massachusetts.

Communication between clinicians and patients fundamentally shapes the experience of serious illness. There is increasing recognition that health systems should routinely implement structures and processes to assure high-quality serious illness communication (SIC) and measure the effectiveness of their efforts on key outcomes. The absence, underdevelopment, or limited applicability of quality measures related specifically to SIC, and their limited application only to those seen by specialist palliative and hospice care teams, hinder efforts to improve care planning, service delivery, and health outcomes for all seriously ill patients. We convened an expert stakeholder symposium and subsequently surveyed participants to consider challenges, opportunities, priorities, and strategies to improve quality measurement specific to SIC. We identified several barriers and opportunities to improving quality measurement of SIC. These include issues related to the definition of SIC, methodological challenges related to measuring SIC and related outcomes, underutilization of technologies that can facilitate measurement, and measurement development, and dissemination. Patients, clinicians, and health systems increasingly align around the importance of high-quality communication in serious illness. We offer recommendations for various stakeholder groups to advance SIC quality measurement. Enthusiasm and a sense of urgency among health systems to drive and measure communication improvements inform our proposal for a set of example measures for implementation now.
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http://dx.doi.org/10.1089/jpm.2019.0335DOI Listing
January 2020

"Sometimes you wonder, is this really true?": Clinician assessment of patients' subjective experience of pain.

J Eval Clin Pract 2020 Jun 3;26(3):1048-1053. Epub 2019 Nov 3.

Behavioral and Policy Sciences Department, RAND Corporation, Santa Monica, California.

Background: Pain is a subjective experience that must be translated by clinicians into an objective assessment to guide intervention.

Objective: To understand how patients' subjective experience of pain is translated by primary care clinicians into an objective clinical assessment of pain to effectively guide intervention.

Methods: We conducted nine multidisciplinary focus groups with a combined total of 60 Veteran affair (VA) primary care providers and staff from two large VA medical centers in California and Oregon. We used content analysis methods to identify key themes pertaining to clinical assessment of a subjective experience.

Results: We present four emergent themes. Theme 1: Pain is a highly individualized and subjective experience not adequately captured by a simple numeric scale; Theme 2: Conflict commonly exists between the patient's reported experience of pain and the clinician's observations and expectations of pain; Theme 3: Providers attempt to recalibrate the patient's reported experience to reflect their own understanding of pain; and Theme 4: Providers perceive that some patients may overreport their pain because they do not know how to standardize their subjective experience.

Conclusions: A persistent challenge to pain assessment and management is how clinicians reconcile a patient's subjective self-reported experience with their own clinical assessment and personal biases. Future work should explore these themes from the patient perspective.
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http://dx.doi.org/10.1111/jep.13298DOI Listing
June 2020

Medical Record Documentation of Goals-of-Care Discussions Among Older Veterans With Incident Kidney Failure.

Am J Kidney Dis 2020 05 1;75(5):744-752. Epub 2019 Nov 1.

Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA; Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA.

Rationale & Objective: Elicitation and documentation of patient preferences is at the core of shared decision making and is particularly important among patients with high anticipated mortality. The extent to which older patients with incident kidney failure undertake such discussions with their providers is unknown and its characterization was the focus of this study.

Study Design: Retrospective cohort study.

Setting & Participants: A random sample of veterans 67 years and older with incident kidney failure receiving care from the US Veterans Health Administration between 2005 and 2010.

Exposures: Demographic and facility characteristics, as well as predicted 6-month mortality risk after dialysis initiation and documentation of resuscitation preferences.

Outcomes: Documented discussions of dialysis treatment and supportive care.

Analytical Approach: We reviewed medical records over the 2 years before incident kidney failure and up to 1 year afterward to ascertain the frequency and timing of documented discussions about dialysis treatment, supportive care, and resuscitation. Logistic regression was used to identify factors associated with these documented discussions.

Results: The cohort of 821 veterans had a mean age of 80.9±7.2 years, and 37.2% had a predicted 6-month mortality risk>20% with dialysis. Documented discussions addressing dialysis treatment and resuscitation were present in 55.6% and 77.1% of patients, respectively. Those addressing supportive care were present in 32.4%. The frequency of documentation varied by mortality risk and whether the patient ultimately started dialysis. In adjusted analyses, the frequency and pattern of documentation were more strongly associated with geographic location and receipt of outpatient nephrology care than with patient demographic or clinical characteristics.

Limitations: Documentation may not fully reflect the quality and content of discussions, and generalizability to nonveteran patients is limited.

Conclusions: Among older veterans with incident kidney failure, discussions of dialysis treatment are decoupled from other aspects of advance care planning and are suboptimally documented, even among patients at high risk for mortality.
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http://dx.doi.org/10.1053/j.ajkd.2019.07.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781075PMC
May 2020

Health System and Beneficiary Costs Associated With Intensive End-of-Life Medical Services.

JAMA Netw Open 2019 09 4;2(9):e1912161. Epub 2019 Sep 4.

Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles.

Importance: Despite recommendations to reduce intensive medical treatment at the end of life, many patients with cancer continue to receive such services.

Objective: To quantify expected beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life.

Design, Setting, And Participants: This retrospective cohort study used data collected nationally from Medicare and the Veterans Health Administration for care provided in fiscal years 2010 to 2014. Participants were 48 937 adults aged 66 years or older who died of solid tumor and were continuously enrolled in fee-for-service Medicare and the Veterans Health Administration in the 12 months prior to death. The data were analyzed from February to August 2019.

Exposures: American Society of Clinical Oncology metrics regarding medically intensive services provided in the last month of life, including hospital stay, intensive care unit stay, chemotherapy, 2 or more emergency department visits, or hospice for 3 or fewer days.

Main Outcomes And Measures: Costs in the last month of life associated with receipt of intensive medical services were evaluated for both beneficiaries and the health system. Costs were estimated from generalized linear models, adjusting for patient demographics and comorbidities and conditioning on geographic region.

Results: Of 48 937 veterans who received care through the Veterans Health Administration and Medicare, most were white (90.8%) and male (98.9%). More than half (58.9%) received at least 1 medically intensive service in the last month of life. Patients who received no medically intensive service generated a mean (SD) health system cost of $7660 ($1793), whereas patients who received 1 or more medically intensive services generated a mean (SD) health system cost of $23 612 ($5528); thus, the additional financial consequence to the health care system for medically intensive services was $15 952 (95% CI, $15 676-$16 206; P < .001). The biggest contributor to these differences was $21 093 (95% CI, $20 364-$21 689) for intensive care unit stay, while the smallest contributor was $3460 (95% CI, $2927-$3880) for chemotherapy. Mean (SD) expected beneficiary costs for the last month of life were $133 ($50) for patients with no medically intensive service and $1257 ($408) for patients with at least 1 medically intensive service (P < .001).

Conclusions And Relevance: Given the low income of many elderly patients in the United States, the financial consequences of medically intensive services may be substantial. Costs of medically intensive services at the end of life, including patient financial consequences, should be considered by both physicians and families.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.12161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6777391PMC
September 2019

A Multicenter, Randomized Controlled Trial of Perioperative Palliative Care Surrounding Cancer Surgery for Patients and Their Family Members (PERIOP-PC).

J Palliat Med 2019 09;22(S1):44-57

Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, Maryland.

Despite positive outcomes associated with specialist palliative care (PC) in diverse medical populations, little research has investigated specialist PC in surgical ones. Although cancer surgery is predominantly safe, operations can be extensive and unpredictable perioperative morbidity and mortality persist, particularly for patients with upper gastrointestinal (GI) cancers. Our objective is to complete a multicenter, randomized controlled trial comparing surgeon-PC co-management with surgeon-alone management among patients pursuing curative-intent surgery for upper GI cancers. We hypothesize that perioperative PC will improve patient postsurgical quality of life. This study and design are based on >8 years of engagement and research with patients, family members, and clinicians surrounding major cancer surgery and advance care planning/PC for surgical patients. Randomized controlled superiority trial with two study arms (surgeon-PC team co-management and surgeon-alone management) and five data collection points over six months. The principal investigator and analysts are blinded to randomization. Four, geographically diverse, academic tertiary care hospitals. Data collection began December 20, 2018 and continues to December 2020. Patients recruited from surgical oncology clinics who are undergoing curative-intent surgery for an upper GI cancer. In the intervention arm, patients receive care from both their surgical team and a specialist PC team; the PC is provided before surgery, immediately after surgery, and at least monthly until three months postsurgery. Patients randomized to the usual care arm receive care from only the surgical team. Primary outcome: patient quality of life. Secondary outcomes: patient: symptom experience, spiritual distress, prognostic awareness, health care utilization, and mortality. Caregiver: quality of life, caregiver burden, spiritual distress, and prognostic awareness. Intent-to-treat analysis will be used. This study has been approved by the institutional review boards of all study sites and is registered on clinicaltrials.gov (NCT03611309, First received: August 2, 2018).
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http://dx.doi.org/10.1089/jpm.2019.0130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366274PMC
September 2019

Signature Informed Consent for Long-Term Opioid Therapy in Patients With Cancer: Perspectives of Patients and Providers.

J Pain Symptom Manage 2020 01 30;59(1):49-57. Epub 2019 Aug 30.

Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University School of Medicine, Palo Alto, California, USA.

Context: Signature informed consent (SIC) is a part of a Veterans Health Administration ethics initiative for patient education and shared decision making with long-term opioid therapy (LTOT). Historically, patients with cancer-related pain receiving LTOT are exempt from this process.

Objectives: Our objective is to understand patients' and providers' perspectives on using SIC for LTOT in patients with cancer-related pain.

Methods: Semistructured interviews with 20 opioid prescribers and 20 patients who were prescribed opioids at two large academically affiliated Veterans Health Administration Medical Centers. We used a combination of deductive and inductive approaches in content analysis to produce emergent themes.

Results: Potential advantages of SIC are that it can clarify and help patients comprehend LTOT risks and benefits, provide clear upfront boundaries and expectations, and involve the patient in shared decision making. Potential disadvantages of SIC include time delay to treatment, discouragement from recommended opioid use, and impaired trust in the patient-provider relationship. Providers and patients have misconceptions about the definition of SIC. Providers and patients question if SIC for LTOT is really informed consent. Providers and patients advocate for strategies to improve comprehension of SIC content. Providers had divergent perspectives on exemptions from SIC. Oncologists want SIC for LTOT to be tailored for patients with cancer.

Conclusion: Provider and patient interviews highlight various aspects about the advantages and disadvantages of requiring SIC for LTOT in cancer-related pain. Tailoring SIC for LTOT to be specific to cancer-related concerns and to have an appropriate literacy level are important considerations.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.08.020DOI Listing
January 2020

The use of complementary and integrative health approaches for chronic musculoskeletal pain in younger US Veterans: An economic evaluation.

PLoS One 2019 5;14(6):e0217831. Epub 2019 Jun 5.

Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America.

Objectives: To estimate the cost-effectiveness to the US Veterans Health Administration (VA) of the use of complementary and integrative health (CIH) approaches by younger Veterans with chronic musculoskeletal disorder (MSD) pain.

Perspective: VA healthcare system.

Methods: We used a propensity score-adjusted hierarchical linear modeling (HLM), and 2010-2013 VA administrative data to estimate differences in VA healthcare costs, pain intensity (0-10 numerical rating scale), and opioid use between CIH users and nonusers. We identified CIH use in Veterans' medical records through Current Procedural Terminology, VA workload tracking, and provider-type codes.

Results: We identified 30,634 younger Veterans with chronic MSD pain as using CIH and 195,424 with no CIH use. CIH users differed from nonusers across all baseline covariates except the Charlson comorbidity index. They also differed on annual pre-CIH-start healthcare costs ($10,729 versus $5,818), pain (4.33 versus 3.76), and opioid use (66.6% versus 54.0%). The HLM results indicated lower annual healthcare costs (-$637; 95% CI: -$1,023, -$247), lower pain (-0.34; -0.40, -0.27), and slightly higher (less than a percentage point) opioid use (0.8; 0.6, 0.9) for CIH users in the year after CIH start. Sensitivity analyses indicated similar results for three most-used CIH approaches (acupuncture, chiropractic care, and massage), but higher costs for those with eight or more CIH visits.

Conclusions: On average CIH use appears associated with lower healthcare costs and pain and slightly higher opioid use in this population of younger Veterans with chronic musculoskeletal pain. Given the VA's growing interest in the use of CIH, further, more detailed analyses of its impacts are warranted.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0217831PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6550429PMC
February 2020
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