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

8577 Background: There is wide variation in the frequency of reported use of palliative sedation (PS) to control intractable and refractory symptoms. Institutions have established policies for midazolam infusion in cases of PS. The indications and outcomes of this procedure have not been well characterized Methods: Our midazolam policy for PS requires 1:1 nursing for the first 24 hours and documentation of discussions regarding sedation. We reviewed our PCU database for all admissions for the first 11 months of 2005. We used pharmacy records for all patients who received medications used for sedation (chlorpromazine, lorazepam, midazolam). We reviewed all charts of pts who received any of these drugs to establish if the indication had been PS. Results: 148/484 admissions died in the PCU [31%]. 65/484 admissions (13%), and 47/ 148 patients who died (32%) received PS. Median age of patients (pts) was 58, 42 pts were male [65%], and the most frequent primaries observed were lung 24 [37%], hematologic 12 [18%], head and neck 7 [11%], and gastrointestinal 7 [11%]. Results are indicated in the table. * 2 patients had more than one indication for sedation The main causes for PS in our patients were delirium 57 [88%], dyspnea 6 [9%], and bleeding 4 [6%]. 18/65 patients who received PS [35%] were discharged alive, versus 318/419 [76%] who did not receive PS [p< 0.001]. Midazolam was used in 11/65 episodes [17%]. 4/6 pts with PS for dyspnea received midazolam [66%], versus 8/57 with PS for delirium or bleeding [14%], p=0.01]. 18/54 pts who received PS using other drug were discharged alive [33%], versus 0/11 pts who received midazolam [p=0.02]. Conclusions: Palliative sedation was required in 32% of pts who died in the hospital. Reporting midazolam utilization rates for monitoring overall PS outcomes, results in significant under reporting. Midazolam was used more frequently in cases of progressive dyspnea and poor prognosis. Less restrictive policies in the use of midazolam may result in more use for PS. Data accrual continues. [Table: see text] No significant financial relationships to disclose.

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Utilization of antineoplastic therapy (ANT) in advanced cancer patients admitted to an acute palliative care unit (APCU) at a comprehensive cancer center

Journal of Clinical Oncology ◽

10.1200/jco.2009.27.15_suppl.9590 ◽

2009 ◽

Vol 27 (15_suppl) ◽

pp. 9590-9590

Author(s):

D. Hui ◽

E. Bruera ◽

Z. Li ◽

J. L. Palmer ◽

M. de la Cruz ◽

...

Keyword(s):

Palliative Care ◽

Regression Analysis ◽

Cancer Patients ◽

Univariate Analysis ◽

Palliative Care Unit ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Targeted Agents ◽

Cox Regression Analysis ◽

Younger Age

9590 Background: Cancer patients admitted to a palliative care unit generally have a poor prognosis. The role of ANT (chemotherapy and targeted agents) in these patients is unclear. We examined the frequency, trends, factors and survival associated with ANT use in hospitalized patients who required an APCU stay. Methods: All patients admitted to APCU between September 1, 2003 and August 31, 2008 were included. Demographics, cancer diagnosis and ANTs utilization from day of hospitalization to discharge, and survival information were retrieved retrospectively. Results: 2604 cancer patients had the following characteristics: median age 59 (range 18–101), male 51%, hematologic malignancy 11%, median hospital stay 11 (Q1-Q3 8–17) days, median APCU stay 7 (Q1-Q3 4–10) days and median survival 22 days. During hospitalization, 393 patients (15%) received ANTs, including chemotherapy (N=297, 11%) and targeted therapy (N=155, 6%). No significant change in frequency of ANTs was detected over the 5 year period. Multivariate logistic regression analysis ( Table ) revealed that younger age, cancer primaries and longer admissions were associated with ANT use. Patients with hematologic malignancies received more chemotherapy (38% vs. 8%, p<0.001) and targeted agents (18% vs. 4%, p<0.001) compared to patients with solid tumors. ANT use was associated with longer overall survival in univariate analysis (median 25 days vs. 21 days, p=0.001); however, this was no longer significant in multivariate Cox regression analysis. Conclusions: The use of ANT during hospitalization that included an APCU stay was limited to a highly selected group of patients, and did not increase overtime. ANT use was associated with younger age, specific cancer primaries, longer admissions, and no significant improvement in survival. The APCU at our cancer center facilitates simultaneous care where patients access palliative care while on ANT. [Table: see text] No significant financial relationships to disclose.

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Access to palliative care before death among patients treated at a comprehensive cancer center.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.34_suppl.25 ◽

2012 ◽

Vol 30 (34_suppl) ◽

pp. 25-25

Author(s):

David Hui ◽

Sun Hyun Kim ◽

Jung Hye Kwon ◽

Kimberson Cochien Tanco ◽

Tao Zhang ◽

...

Keyword(s):

Palliative Care ◽

Cancer Patients ◽

Advanced Cancer ◽

Disease Process ◽

Hematologic Malignancies ◽

Median Number ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Medical Team ◽

Missed Opportunities

25 Background: Palliative care (PC) access is a critical component of quality cancer care. Previous studies on PC access have mostly examined the timing of PC referral. The proportion of patients who actually received PC is unclear. We determined the proportion of cancer patients who received PC at our comprehensive cancer center, and the predictors of PC referral. Methods: We reviewed the charts ofconsecutive patients with advanced cancer from the Houston region seen at MD Anderson Cancer Center and died between September 2009 and February 2010. We compared patients who received PC services with those who did not receive PC services before death using univariate and multivariate logistic regression. Results: A total of 366/816 (45%) decedents had a PC consultation. The median interval between PC consultation and death was 1.4 months (interquartile range (0.5-4.2) and the median number of medical team encounters before PC was 20 (6-45). In multivariate analysis, older age, being married, and specific cancer types (gynecology, lung and head and neck) were significantly associated with a PC referral (Table). Patients with hematologic malignancies had significantly fewer PC referrals (33%), the longest interval between advanced cancer diagnosis and PC consultation (median 16 months), the shortest interval between PC consultation and death (median 0.4 month), and one of the largest number of medical team encounters (median 38) before PC. Conclusions: We found that a majority of cancer patients at our cancer center did not access PC before they die. PC referral occurs late in the disease process with many missed opportunities for referral. Further effort is needed to improve quality of end-of-life care. [Table: see text]

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System-Level Factors Associated With Use of Outpatient Specialty Palliative Care Among Patients With Advanced Cancer

Journal of Oncology Practice ◽

10.1200/jop.18.00234 ◽

2019 ◽

Vol 15 (1) ◽

pp. e10-e19 ◽

Cited By ~ 7

Author(s):

Justin A. Yu ◽

Kristin N. Ray ◽

Seo Young Park ◽

Amanda Barry ◽

Cardinale B. Smith ◽

...

Keyword(s):

Palliative Care ◽

Travel Time ◽

Solid Tumors ◽

Advanced Cancer ◽

System Level ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Cancer Type ◽

Advanced Solid Tumors ◽

Patient Travel

PURPOSE: The proportion of patients with advanced cancer who receive outpatient specialty palliative care (OSPC) is as low as 2.0%. Improved understanding of the system-level factors influencing use of OSPC could inform adaptations to the delivery of palliative care to maximize access. We examined associations between OSPC use among patients with advanced solid tumors and oncology-OSPC clinic colocation and patient travel time to an OSPC clinic. PATIENTS AND METHODS: We conducted a retrospective cohort study of patients with advanced solid tumors receiving oncologic treatment between January 1 and December 31, 2016, within a comprehensive cancer center network with well-established, oncology-specific OSPC clinics. Multivariable logistic regression analysis was used to evaluate the associations of clinic colocation and geographic access with OSPC use. RESULTS: Of 9,485 patients with advanced solid tumors, 478 (5.0%) received OSPC services in 2016. After controlling for age, sex, marital status, cancer type, insurance, treatment intent, and illness severity, patients whose oncologist practices were colocated with OSPC clinics were more likely to use OSPC (odds ratio [OR], 19.2; 95% CI, 14.1 to 26.2). Compared with patients who lived > 90 minutes from an OSPC clinic, patients with travel times of < 30 minutes (OR, 3.2; 95% CI, 2.2 to 4.6) and 31 to 60 minutes (OR, 2.4; 95% CI, 1.6 to 3.6) were also more likely to use OSPC. CONCLUSION: Among patients with advanced solid tumors, colocation of oncology and OSPC clinics and shorter patient travel time were associated with greater odds of using OSPC. Future efforts to increase OSPC use in this population should consider clinic colocation and travel burden.

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

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.31_suppl.8 ◽

2014 ◽

Vol 32 (31_suppl) ◽

pp. 8-8 ◽

Cited By ~ 1

Author(s):

Colin Scibetta ◽

Michael W. Rabow ◽

Kathleen Kerr

Keyword(s):

Palliative Care ◽

Medical Care ◽

Direct Cost ◽

Advanced Cancer ◽

Metastatic Cancer ◽

Care Quality ◽

Cost Of Care ◽

Comprehensive Cancer Center ◽

Inpatient Cost ◽

Cancer Center

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

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An oncopalliative expertise unit in a French comprehensive cancer center: Experience at one year.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e24077 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e24077-e24077

Author(s):

Christine Mateus ◽

Laurence Vigouret-Viant ◽

Sabine Voisin ◽

Sophie Laurent ◽

Perrine Renard ◽

...

Keyword(s):

Palliative Care ◽

Average Length ◽

Care Pathway ◽

Specific Treatment ◽

Palliative Care Unit ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Advanced Cancer Patients ◽

Refractory Symptoms ◽

One Year

e24077 Background: Anticipation of palliative care improves advanced cancer patients quality of life and may increase survival. It has also been associated with health costs reduction. However it is made difficult by societal taboos and reluctance of patients and caregivers to talk about therapeutic limitations and end of life. Methods: In a large French Comprehensive Cancer Center (CCC), the causes for both emergency consultations and medical hospitalizations have been analyzed, showing that repeated hospitalizations are more frequent when the level of care complexity increases and when the therapeutic project is unclear. Considering the European and international experiences of acute palliative care unit (APCU), we decided to create an APCU with reinforced onco-palliative expertise. This Onco-Palliative Expertise Unit (OPEU) main objective, besides treating refractory symptoms is to allow oncologists, palliative care specialists, pts and relatives to discuss together in order to redefine the therapeutic project. Results: One year after opening, this 10-bed unit has received 251 patients in 314 stays. 53% came directly from the home, 46% were already being followed by our palliative care team. After an average length of stay of 11.6 days, discharge was distributed between return home (41%), a palliative care unit (26%), death (22%) and other oncology units, or other hospitals (11%). At the opening, refractory symptoms were the most frequent reason for hospitalization (67% of stays). For the first 6 months period to the second one, discussing the therapeutic project increased from 23% to 34% of the hospitalization causes in the OPEU, showing the appropriation of this unit by the oncologists. A discussion about the project was carried out for almost all stays. On admission, specific cancer treatment was ongoing for 56% of stays. After assessment and multidisciplinary discussion, 49% of them decided to stop chemotherapy. Conversely, the start or resumption of treatment was recommended for 9% of stays without specific treatment on admission. The OPEU is a decompression chamber in the pt care pathway, which allows a multidisciplinary analysis of the pt’s condition on a single unit and leads to a quick and more appropriate therapeutic decision. Of the 251 pts hospitalized, only 19% were readmitted to hospital during the same one-year period, mainly for refractory symptoms. Conclusions: The creation of an OPEU in a CCC allows getting around the taboo of palliative care. It supports the dialogue between the oncologist and the pt, allows the pt to make the therapeutic project evolve toward a life project, avoiding costly unreasonable obstinacy.

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