Hsien Seow

Symptom burden and performance status in a population‐based cohort of ambulatory cancer patients

For ambulatory cancer patients, Ontario has standardized symptom and performance status assessment population‐wide, using the Edmonton Symptom Assessment System (ESAS) and Palliative Performance Scale (PPS). In a broad cross‐section of cancer outpatients, the authors describe the ESAS and PPS scores and their relation to patient characteristics.

Impact of community based, specialist palliative care teams on hospitalisations and emergency department visits late in life and hospital deaths: a pooled analysis

Objective To determine the pooled effect of exposure to one of 11 specialist palliative care teams providing services in patients’ homes. Design Pooled analysis of a retrospective cohort study. Setting Ontario, Canada. Participants 3109 patients who received care from specialist palliative care teams in 2009-11 (exposed) matched by propensity score to 3109 patients who received usual care (unexposed). Intervention The palliative care teams studied served different geographies and varied in team composition and size but had the same core team members and role: a core group of palliative care physicians, nurses, and family physicians who provide integrated palliative care to patients in their homes. The teams’ role was to manage symptoms, provide education and care, coordinate services, and be available without interruption regardless of time or day. Main outcome measures Patients (a) being in hospital in the last two weeks of life; (b) having an emergency department visit in the last two weeks of life; or (c) dying in hospital. Results In both exposed and unexposed groups, about 80% had cancer and 78% received end of life homecare services for the same average duration. Across all palliative care teams, 970 (31.2%) of the exposed group were in hospital and 896 (28.9%) had an emergency department visit in the last two weeks of life respectively, compared with 1219 (39.3%) and 1070 (34.5%) of the unexposed group (P<0.001). The pooled relative risks of being in hospital and having an emergency department visit in late life comparing exposed versus unexposed were 0.68 (95% confidence interval 0.61 to 0.76) and 0.77 (0.69 to 0.86) respectively. Fewer exposed than unexposed patients died in hospital (503 (16.2%) v 887 (28.6%), P<0.001), and the pooled relative risk of dying in hospital was 0.46 (0.40 to 0.52). Conclusions Community based specialist palliative care teams, despite variation in team composition and geographies, were effective at reducing acute care use and hospital deaths at the end of life.

Using more end-of-life homecare services is associated with using fewer acute care services: A population-based cohort study

Background:Healthcare systems are investing in end-of-life homecare to reduce acute care use. However, little evidence exists on the timing and amount of homecare services necessary to reduce acute care utilization. Objectives:To investigate whether admission time to homecare and the amount of services, as measured by average nursing and personal support and homemaking (PSH) hours/week (h/wk), are associated with using acute care services at end-of-life. Research Design:Retrospective observational cohort study. Subjects:Decedents admitted to end-of-life homecare in Ontario, Canada. Measures:The odds ratios (OR) of having a hospitalization or emergency room visit in the 2 weeks before death and dying in a hospital. Results:The cohort (n = 9018) used an average of 3.11 (SD = 4.87) nursing h/wk, 3.18 (SD = 6.89) PSH h/wk, and 18% were admitted to homecare for <1 month. As admission time to death and homecare services increased, the adjusted OR of an outcome decreased in a dose response manner. Patients admitted earlier than 6 months before death had a 35% (95% CI: 25%–44%) lower OR of hospitalization than those admitted 3 to 4 weeks before death; patients using more than 7 nursing h/wk and more than 7 PSH h/wk had a 50% (95% CI: 37%–60%) and 35% (95% CI: 21%–47%) lower OR of a hospitalization, respectively, than patients using 1 h/wk, controlling for other covariates. Other outcomes had similar results. Conclusion:These results suggest that early homecare admission and increased homecare services will help alleviate the demand for hospital resources at end-of-life.

Developing quality indicators for cancer end-of-life care: Proceedings from a national symposium

Quality indicators applicable to cancer end‐of‐life care exist, but have not been widely implemented. To advance this field, the authors worked with the Agency for Health Care Research and Quality and the National Cancer Institute to organize a national symposium to discuss key issues and future goals, based on a conceptual framework. Discussions focused on 8 key domains in end‐of‐life cancer care: pain; dyspnea; communication, care planning, and decision making; psychosocial care; communication about chemotherapy; depression; continuity, coordination, and care transitions; and spirituality and closure. Key themes included the need for clarity on definitions and key aspects of care within domains, the need to start implementing indicators in more developed domains, and the importance of high‐quality symptom assessment and documentation of key processes. Key areas for future work include development of more outcome indicators, methods to better incorporate indicators and patient‐reported outcomes into clinical processes of care, and coordination across domains and settings. Measuring the quality of end‐of‐life cancer care is essential to understanding how best to improve patient outcomes and care. Cancer 2009.

A review of quality of care evaluation for the palliation of dyspnea

Assessment and management of dyspnea has emerged as a priority topic for quality evaluation and improvement. Evaluating dyspnea quality of care requires valid, reliable, and responsive measures of the care provided to patients across settings and diseases. As part of an Agency for Healthcare Research and Quality Symposium, we reviewed quality of care measures for dyspnea by compiling quality measures identified in systematic searches and reviews. Systematic reviews identified only three existing quality measurement sets that included quality measures for dyspnea care. The existing dyspnea quality measures reported by retrospective evaluations of care assess only four aspects: dyspnea assessment within 48 hours of hospital admission, use of objective scales to rate dyspnea severity, identification of management plans, and evidence of dyspnea reduction. To begin to improve care, clinicians need to assess and regularly document patients experiences of dyspnea. There is no consensus on how dyspnea should be characterized for quality measurement, and although over 40 tools exist to assess dyspnea, no rating scale or instrument is ideal for palliative care. The panel recommended that dyspnea assessment should include a measure of intensity and some inquiry into the associated bother or distress experienced by the patient. A simple question into the presence or absence of dyspnea would be unlikely to help guide therapy, as complete relief of dyspnea in advanced disease would not be anticipated. Additional knowledge gaps include standards for clinical dyspnea care, assessment in the cognitively impaired, and evaluation of effectiveness of dyspnea care for patients with advanced disease.

A Framework for Assessing Quality Indicators for Cancer Care at the End of Life

Patients with advanced cancer often do not receive high-quality pain and symptom management or support with coordination of care, communication, and decision making. Implementing quality indicators that are reflective of the scope of care, feasible to implement, and supported by evidence might help to identify areas and settings most in need of improvement. However, recent reviews and policy initiatives identified only a few indicators that met these criteria. To help advance quality indicator development and implementation in this area, we developed a conceptual framework based on previous related initiatives, updated reviews of end-of-life cancer quality indicators and relevant data sources, and expert input. The framework describes five steps for developing and assessing a quality indicator for end-of-life care, defining the 1) population of focus, 2) broad quality domains, 3) specific target areas, 4) steps of the care process, and 5) evaluation criteria for quality indicators. The defined population includes seriously or terminally ill cancer patients, who are unlikely to recover or stabilize, and their families. Domains include the structure and processes of care; the physical, psychiatric, psychosocial, spiritual, and cultural aspects of care; as well as the care of the imminently dying, ethical and legal issues, and the delivery of care. Evaluation criteria include importance; scientific acceptability, including validity, evidence to improve outcomes, reliability, responsiveness, and variability; usability; and feasibility, including ready data sources. By using this conceptual framework, indicator developers, researchers, and policymakers can refine and implement indicator sets to effectively evaluate and improve care at the end of life.

Isolation of health services research from practice and policy: the example of chronic heart failure management.

This study examined how health services research connects with practice and policy, first by investigating whether successful research projects continued in their test settings and engendered replication and then by examining whether a coherent body of research helped shape public policy. Chronic heart failure (CHF) was studied because randomized, controlled trials of posthospital CHF disease management have repeatedly demonstrated patient benefits and reduced costs, yet this practice has not become standard in the United States.

Are family physician visits and continuity of care associated with acute care use at end-of-life? A population-based cohort study of homecare cancer patients:

Background: Previous end-of-life cancer research has shown an association between increased family physician continuity of care and reduced use of acute care services; however, it did not focus on a homecare population or control for homecare nursing. Aim: Among end-of-life homecare cancer patients, to investigate the association of family physician continuity with location of death and hospital and emergency department visits in the last 2 weeks of life while controlling for nursing hours. Design: Retrospective population-based cohort study. Setting/participants: Cancer patients with ≥1 family physician visit in 2006 from Ontario, Canada. Family physician continuity of care was assessed using two measures: Modified Usual Provider of Care score and visits/week. Its association with location of death and hospital and emergency department visits in the last 2 weeks of life was examined using logistic regression. Results: Of 9467 patients identified, the Modified Usual Provider of Care score demonstrated a dose–response relationship with increasing continuity associated with decreased odds of hospital death and visiting the hospital and emergency department in the last 2 weeks of life. More family physician visits/week were associated with lower odds of an emergency department visit in the last 2 weeks of life and hospital death, except for patients with greater than 4 visits/week, where they had increased odds of hospitalizations and hospital deaths. Conclusions: These results demonstrate an association between increased family physician continuity of care and decreased odds of several acute care outcomes in late life, controlling for homecare nursing and other covariates.

Do High Symptom Scores Trigger Clinical Actions? An Audit After Implementing Electronic Symptom Screening

PURPOSE Standardized, electronic, symptom assessment is purported to help identify symptom needs. However, little research examines clinical processes related to symptom management, such as whether patients with worsening symptoms receive clinical actions more often. This study examined whether patient visits with higher symptom scores are associated with higher rates of symptom documentation in the chart and symptom-specific actions being taken. METHODS Retrospective chart reviews on cancer patient visits at a regional cancer center. An electronic Edmonton Symptom Assessment Scale (ESAS), a validated tool to measure symptoms, was implemented center-wide to standardize symptom screening at every patient visit. The independent variable was ESAS scores for pain and shortness of breath, categorized by severity: 0 (none), 1-3, 4-6, 7-10 (severe). Outcomes included symptom documentation in the chart on the visit date and symptom-related action(s) taken within 1 week. RESULTS Nine hundred twelve visits were identified. Pain and shortness of breath were documented in 51.8% and 29.7% of charts, and a related-action occurred in 16.9% and 3.9% of charts, respectively. As ESAS severity score category increased from none to severe, the proportion of visits with pain documented increased significantly (36.9%, 49.2%, 55.2%, and 71.4%; P < .001). Likewise, as ESAS score severity increased, the proportion of visits with a pain-related action increased significantly (4.2%, 10.6%, 21.3%, and 37.0%; P < .001). Trends were similar for shortness of breath. CONCLUSION Results show a positive association between higher symptom scores and higher rates of documentation and clinical actions taken. However, symptom-related actions were documented in a minority of visits in which symptoms were noted as severe.

Opioid Prescription After Pain Assessment: A Population-Based Cohort of Elderly Patients With Cancer

PURPOSE The purpose of this study was to measure opioid prescription (OP) rates in elderly cancer outpatients around the time of assessment for pain and to evaluate factors associated with receiving OPs for those with severe pain. PATIENTS AND METHODS The cross-sectional cohort includes all patients with cancer in Ontario older than age 65 years who completed a pain assessment as part of a provincial initiative of systematic symptom screening. Patients were assigned to mutually exclusive categories by pain score severity: 0, 1 to 3 (mild), 4 to 6 (moderate), and 7 to 10 (severe). We linked multiple provincial health databases to examine the proportion of patients with an OP within 7 days after or 30 days before the assessment date. We examined factors associated with OPs for patients with pain scores of 7 to 10. RESULTS The proportion of patients with an OP increased as pain score severity increased: 10% of those with no pain, 24% of those with mild pain, 45% of those with moderate pain, and 67% of those with severe pain. More specifically, for those with severe pain, 41% filled an OP within 7 days of assessment for pain, and 26% had an OP from the 30 days before assessment for pain, leaving 33% without an OP. In multivariable analysis, factors associated with OPs are younger age, male sex, comorbid illness, cancer type, and assessment at home. CONCLUSION Despite a generous time window for capturing OPs, the proportion of patients without an OP seems high. Further knowledge translation is required to maximize the impact of the symptom screening initiative in Ontario and to optimize management of cancer-related pain.