Ahsan Azhar

Physicians’ Compassion, Communication Skills, and Professionalism With and Without Physicians’ Use of an Examination Room Computer: A Randomized Clinical Trial

This randomized controlled crossover study compares patients’ perception of physicians’ compassion and patients’ perception of physicians’ communication skills and professionalism and patients’ overall physician preference after watching two standardized scripted-video vignettes of physicians.

A double-blind, randomized, placebo-controlled trial of panax ginseng for cancer-related fatigue in patients with advanced cancer

Background: Despite the high frequency, severity, and effects of cancer-related fatigue (CRF) on the quality of life (QoL) of patients with cancer, limited treatment options are available. The primary objective of this study was to compare the effects of oral Panax ginseng extract (PG) and placebo on CRF. Secondary objectives were to determine the effects of PG on QoL, mood, and function. Methods: In this randomized, double-blind, placebo-controlled study, patients with CRF ≥4/10 on the Edmonton Symptom Assessment System (ESAS) were eligible. Based on a pilot study, we randomized patients to receive either 400 mg of standardized PG twice daily or a matching placebo for 28 days. The primary end point was change in the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) subscale from baseline to day 29. Results: Of 127 patients, 112 (88.2%) were evaluable. The mean (SD) FACIT-F subscale scores at baseline, day 15, and day 29 were 22.4 (10.1), 29.9 (10.6), and 30.1 (11.6) for PG (P<.001), and 24.0 (9.4), 30.0 (10.1), and 30.4 (11.5) for placebo (P<.001). Mean (SD) improvement in the FACIT-F subscale at day 29 was not significantly different in the PG than in the placebo group (7.5 [12.7] vs 6.5 [9.9]; P=.67). QoL, anxiety, depression, symptoms, and functional scores were not significantly different between the PG and placebo groups. Improvement in the FACIT-F subscale correlated with baseline scores (P=.0005), Hospital Anxiety and Depression Scale results (P=.032), and sex (P=.023). There were fewer any-grade toxicities in the PG versus placebo group (28/63 vs 33/64; P=.024). Conclusions: Both PG and placebo result in significant improvement in CRF. PG was not significantly superior to placebo after 4 weeks of treatment. There is no justification to recommend the use of PG for CRF. Further studies are needed. Trial Registration: ClinicalTrials.gov identifier: NCT01375114.

Impact of a Palliative Care Checklist on Clinical Documentation

PURPOSE Checklists are used in many different settings for the purpose of standardization and reduction of preventable errors in practice. Our group sought to determine whether a palliative care checklist (PCC) would improve the clinical documentation of key patient information. METHODS An initial review of 110 randomly selected medical records dictated by 10 physicians was performed. The authors identified portions of the dictated medical records that were included regularly, as well as those that were frequently missed. A PCC was drafted after final approval was obtained from the 13 faculty members. Dictations from 13 clinical faculties in the supportive care center were reviewed. A χ(2) test or Fishers exact test was applied to assess the difference in overall checked rates before and after checklist use. A paired t test was used to examine the difference in the average complete rate and checked rates before and after checklist use. RESULTS There were improvements in the documentation before and after the checklist for scores on the Cut-down, Annoyed, Guilty, Eye-opener questionnaire for alcoholism (79% v 94%; P ≤ .0001), psychosocial history (69% v 95%; P ≤ .0001), Eastern Cooperative Oncology Group performance status (38% v 81%; P ≤ .0001), advance care planning (28% v 41%; P = .0008), and overall (78% v 95%; P ≤ .0001). There was no significant improvement in the documentation for opioid-induced neurotoxicity (37% v 37%; P = .9492) or the Edmonton Symptom Assessment Scale (98% v 99%; P = .4511). CONCLUSION Our study showed that the use of a PCC improved the quality of the documentation of a patient visit in an outpatient clinical setting.

Patient Home Visits

BACKGROUND Health care professionals may have limited exposure to home-based care. There is no published literature that has described the experiences and satisfaction of participation in patient home visits (PHV). OBJECTIVE The objective of this article is to describe the characteristics of PHV, our approach, and evaluation by participants over a nine-year period. METHODS We conducted a review of surveys completed by participants in PHV from 2005-2013. All participants anonymously completed the evaluation questionnaires at the end of PHVs. Different PHV assessment forms were used for the 2005-2010 and 2011-2013 time periods. RESULTS A total of 34 PHVs were conducted with 106 patients and approximately 750 participants with a mean of 3 patients and 22 participants per PHV between 2005 and 2013. For 18 PHVs there are 317 surveys completed with 353 participants, making it a 90% response rate. Responding participants were physicians 125/543 (23%) and other professionals 418/543 (77%). In both time periods of 2005-2010 and 2011-2013 a survey with a 1 (completely agree) to 5 (completely disagree) scale was used. Agreeing that PHV was an effective teaching tool during 2005-2010 were 335/341 (98%); during 2011-2013, 191/202 (95%) agreed that PHV provided increased understanding and sharing of best practices in palliative care. CONCLUSIONS PHV was perceived by participants as an effective way of providing interactive community education. A broad range of themes were addressed, and the participants reported high levels of learning in all domains of palliative care. There were no cases of patient or relative expression of distress as a result of PHV.

Patient Home Visits: Measuring Outcomes of a Community Model for Palliative Care Education

BACKGROUND Health care professionals may have limited exposure to home-based care. There is no published literature that has described the experiences and satisfaction of participation in patient home visits (PHV). OBJECTIVE The objective of this article is to describe the characteristics of PHV, our approach, and evaluation by participants over a nine-year period. METHODS We conducted a review of surveys completed by participants in PHV from 2005-2013. All participants anonymously completed the evaluation questionnaires at the end of PHVs. Different PHV assessment forms were used for the 2005-2010 and 2011-2013 time periods. RESULTS A total of 34 PHVs were conducted with 106 patients and approximately 750 participants with a mean of 3 patients and 22 participants per PHV between 2005 and 2013. For 18 PHVs there are 317 surveys completed with 353 participants, making it a 90% response rate. Responding participants were physicians 125/543 (23%) and other professionals 418/543 (77%). In both time periods of 2005-2010 and 2011-2013 a survey with a 1 (completely agree) to 5 (completely disagree) scale was used. Agreeing that PHV was an effective teaching tool during 2005-2010 were 335/341 (98%); during 2011-2013, 191/202 (95%) agreed that PHV provided increased understanding and sharing of best practices in palliative care. CONCLUSIONS PHV was perceived by participants as an effective way of providing interactive community education. A broad range of themes were addressed, and the participants reported high levels of learning in all domains of palliative care. There were no cases of patient or relative expression of distress as a result of PHV.

Effects of high-dose Asian ginseng (Panax ginseng) to improve cancer-related fatigue: Results of a double-blind, placebo-controlled randomized controlled trial.

209 Background: Cancer related fatigue (CRF) is the most common and disabling symptom in cancer.Panax ginseng extract (PG) is frequently used as a nutraceutical treatment for fatigue. There are no well-powered placebo-controlled trials that used validated CRF outcome measures to investigate of PG effects in cancer patients. The primary objective of this trial was to evaluate the effects oral PG versus Placebo (PL) for CRF. METHODS Patients with cancer fatigue ≥ 4/10 on Edmonton Symptom Assessment Scale (ESAS) were eligible. Patients were randomized to either 400mg of standardized PG or matching PL orally twice a day for 28 days. The primary endpoint was change in the Functional Assessment of Chronic Illness-Fatigue (FACIT-F) fatigue subscale from baseline to Day 28. Secondary outcomes were Functional Assessment of Cancer Therapy-General (FACT-G), Hospital Anxiety and Depression Scale (HADS), and ESAS. RESULTS Total evaluable patients were 112 (56 for PG and PL groups). No significant differences in baseline characteristics between the two groups except cancer type (p = 0.002). There was significant improvement in FACIT fatigue and ESAS fatigue scores in PG and PL groups at Day 15 and Day 29. The mean (SD) of FACIT-F fatigue scores at baseline, Day 15, and Day 29 were 22.6 (10.4), 29.8(10.7), 30.1 (11.6) and 23.8 (9.1), 30.0 (10.1), 30.4 (11.6) for PG and PL respectively. Mean (SD) improvement in the FACIT-F subscale at Day 29 was not significantly different in PG than in the PL group [7.5 (12.7) vs 6.5 (9.9), P = 0.67]. Mean (SD) improvement in the ESAS fatigue, FACT-G, and HADS at Day 29 were also not significantly different in PG than in the PL group. In a multiple linear model analysis, the change in FACIT-F fatigue from Day 0 to Day 29 was negatively correlated with baseline FACIT-F fatigue (p = 0.0005), baseline HADS score (p = 0.032), and male gender (p = 0.023). There were a significantly higher number of any grade of toxicities in PL group than in PG group (33/62 vs. 28/64, p = 0.024). CONCLUSIONS Both PG and Placebo result in a significant improvement in CRF at Day 15 and Day 29. PG was not significantly superior to placebo after 4 weeks of treatment. Further studies are needed. CLINICAL TRIAL INFORMATION NCT01375114.

Characteristics of patients with unscheduled versus scheduled visits to outpatient supportive care center (SCC) at a comprehensive cancer center.

144 Background: There is limited literature regarding outpatient palliative care, and even more limited literature describing factors associated with unscheduled visits. Our aim was to identify clinical characteristics of patients who walk-in (present unscheduled) to the outpatient SCC with the hypothesize that the patients who present for unscheduled visits have more severe symptom distress as compared to those patients who present for scheduled appointments. METHODS We compared 183 patients with unscheduled consults (CO) vs a random sample of 361 patients with scheduled CO and 159 patients with unscheduled follow-up (FU) visits vs a random sample of 318 patients with scheduled FU visits. RESULTS Among 544 total CO visits, unscheduled visits had worse median Edmonton Symptom Assessment Scale (ESAS) symptoms (on a scale from 0 to 10): pain (6.5 vs 4.7, p < .0001), fatigue (p = .002), nausea (p = .017), depression (p = .003), anxiety (p = 0.02), sleep (p = .0002), and overall feeling of well-being (p = 0.0009). There was no statistical difference in shortness of breath, financial distress, nor spiritual pain. Daily opioid dose (MEDD in mg) was significantly higher in unscheduled CO visits (119.7 vs 62.9, p = .0004). Among 344 total FU visits, unscheduled visits had worse median ESAS symptoms: pain (5.7 vs 4.2, p = .0001), fatigue (p = .0006), depression (p = .019), anxiety (p = .014) and higher MEDD (111.3 vs 73.6, p = .0009). There was no difference in type of insurance coverage and better ECOG (p = .015) in unscheduled vs scheduled CO visits. Unscheduled CO visits were more likely to be from outside the Houston area (161/361, 45% vs. 40/133, 30%, p < 0.0001). CONCLUSIONS Patients who are either referred as unscheduled CO visits or who present as unscheduled FU visits have higher levels of physical and psychosocial distress and higher opioid dose. Outpatient palliative care centers need to provide opportunity for walk-in referrals for timely management of these issues.

Referral patterns and characteristics of uninsured versus insured patients referred to the outpatient supportive care center (SCC) at a comprehensive cancer center.

116 Background: Multiple barriers exist in providing quality palliative care to low-income patients with cancer. Such disparities may negatively influence effective management of symptoms including pain. Our objective was to compare referral patterns and characteristics (level of symptom distress) of uninsured vs insured patients. METHODS We reviewed randomly selected charts of 100 Indigent (IND) and 100 Medicaid (MC) patients and compared them with a random sample of 300 patients with insurance (INS) referred during the same time period (1/2010 to 12/2014) to our SCC. Data was collected for date of registration at the cancer center, diagnosis of Advanced Cancer (ACD), first visit to the SCC (PC1), symptom assessment (Edmonton Symptom Assessment Scale-ESAS) at PC1. We excluded self-pay patients. RESULTS Results for IND, MC and INS (n = 481) respectively are as follows: Mean (SD) Age in yrs. was 50 (12), 48 (11) and 63 (13); p < 0.001. Percentage of non-white was 44%, 51% and 19.5%; p < 0.001. Percentage of unmarried patients was 64%, 68% and 33%; p < 0.001. Mean (SD) ESAS score at PC1 for pain was 5.6 (3.2), 6.7 (2.5), 4.9 (3.2); p < 0.001. Percentage of patients on opioids upon referral was 86%, 62%, and 54%; p < 0.001. Mean (SD) for referral time in months from ACD to PC1 was 8.7 (SD 10.4), 12.3 (SD 18.1) and 12 (SD 19.9) p = 0.31; for no. of encounters with SC per month were 0.46 (0.45), 0.41 (0.46) and 0.3 (0.55); p = 0.01; for survival in months (PC1 to last contact) was 6.4 (5.8), 5.6 (6.4) & 6 (7.22) p = 0.77. CONCLUSIONS Uninsured patients had significantly higher levels of pain, were more frequently on opioids, younger, non-white and not married. They also required a larger number of SCC encounters. Insurance status did not impact timing of SCC referral or SCC follow ups at our cancer center.

Palliative care checklist: A documentation improvement tool.

142 Background: Palliative care (PC) encompasses medical, psychosocial and spiritual domains. Checklists are utilized for standardization and improvement in care, service, and safety. We implemented a PC checklist for patient encounters with the aim of improving clinical documentation. METHODS A PC checklist was drafted based on a consensus of 12 palliative care specialists. Dictations from 25 encounters for 13 clinical staff 3 months prior and 3 months post implementation of the checklist were compared using 10 items on the checklist. Improvement in documentation is not considered as a change in the delivery of care as all physicians followed the same practice patterns reinforced by academic activities like conferences, grand rounds, and interdisciplinary team meetings. RESULTS There were improvements in the documentation before and after the checklist for scores on Cut-down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire: 38% vs. 81% (p=0.0014), psychosocial history: 69% vs. 95% (p=<.0001) and overall documentation (defined as 6 out of 10 items on the checklist): 78% vs. 95% (p=<.0001). There is a trend for improvement in documentation of ECOG (p=0.009) and Memorial Delirium Assessment Scale (MDAS) (p=0.07). There was no significant improvement in the documentation for advance care planning (ACP) (p=0.328). CONCLUSIONS The implementation of the checklist has shown improvement in overall documentation. Serial reminders to the clinical staff may be needed to further improve documentation practices. [Table: see text].