Joshua Barclay

Association of Hospice Patients' Income and Care Level With Place of Death

IMPORTANCE Terminally ill patients with lower incomes are less likely to die at home, even with hospice care. OBJECTIVES To examine the relationship between income and transfer from home before death and the interaction between income and level of hospice care as a predictor of transfer from home in patients admitted to routine home hospice care. DESIGN We matched zip codes to US census tracts to generate median annual household incomes and divided the measure into

Do Palliative Care Clinics Screen for Substance Abuse and Diversion? Results of a National Survey

10,000 increments (≤

CARE Track for Advanced Cancer: Impact and Timing of an Outpatient Palliative Care Clinic.

20,000 to >

Screening for substance abuse and diversion in Virginia hospices.

50,000). We abstracted data from the central administrative and clinical database of a hospice care provider. We analyzed the relationship between income and transfer from home before death using logistic regression adjusted for demographics, diagnosis, region, and length of stay. Level of hospice care was examined as any continuous care vs none. Unlike routine care, which includes periodic visits by hospice, continuous care is a higher level of care used for short periods of crisis to keep a patient at home and includes hospice services in the home at least 8 hours in a 24-hour period. SETTING A for-profit hospice provider, VITAS Healthcare, operating 26 programs in 8 states. PARTICIPANTS Hospice patients admitted to routine care in a private residence from January 1, 1999, through December 31, 2003. MAIN OUTCOME MEASURE Transfer from hospice care in a private residence to hospice care in a site outside the home before death. RESULTS Of the 61,063 enrollees admitted to routine care in a private residence, 13,804 (22.61%) transferred from home to another location (ie, inpatient hospice unit or nursing home) with hospice care before death. Patients who transferred had a lower mean median household income (

Cancer patient-reported outcomes assessment using wireless touch screen tablet computers

42,585 vs

Impact and timing of palliative care referral.

46,777; P < .001) and were less likely to have received any continuous care (49.38% vs 30.61%; P < .001). The median number of days of continuous care was 4. For patients who did not receive continuous care, the odds of transfer from home before death increased with decreasing median annual household incomes (odds ratio range, 1.26-1.76). For patients who received continuous care, income was not a predictor of transfer from home. CONCLUSIONS AND RELEVANCE Patients with limited resources may be less likely to die at home, especially if they are not able to access needed support beyond what is available with routine hospice care.

Communication Strategies and Cultural Issues in the Delivery of Bad News

BACKGROUND Opioids are the mainstay of treatment of cancer pain. With increased use there have been concerns about rising rates of prescription drug abuse and diversion. Although there has been an increase in research and practice guidelines about the scope of the problem for chronic, nonmalignant pain, less information is available about both the frequency of the problem and current practices regarding screening for substance abuse and diversion in patients and family members seen in palliative care clinics. OBJECTIVE The aim of this study was to evaluate the degree to which palliative programs felt that substance abuse and diversion was an issue, and to identify practices regarding care of patients with potential substance misuse issues. METHODS We sent a survey regarding substance abuse perception, policies, training, and screening to 94 accredited palliative medicine fellowship program directors as obtained by the Accreditation Council for Graduate Medical Education (ACGME) directory. RESULTS We received usable responses from 38 (40.4%) programs. Policies for screening patients (40.5%) or family members (16.2%), dealing with diversion (27%), and use of a screening tool (32.4%) were reported infrequently. Despite this, one-half of respondents indicated that substance abuse and diversion was an issue for their clinics, with only 25% indicating substance abuse was not an issue. Additionally, the majority of fellows (83%) and about half (47%) of staff received mandatory training for dealing with substance misuse. All programs provided some screening of patients, with 48.7% screening all patients for abuse. Screening of family members was relatively rare, as was routine use of the urine drug screen (UDS). CONCLUSION Despite increased concerns about substance abuse, the majority of programs did not have substance abuse and diversion policies or report screening all patients, with screening of caregivers rarely reported. Consensus guidelines addressing substance abuse and diversion for palliative patients are needed to address this growing problem.

Screening for substance abuse risk in cancer patients using the Opioid Risk Tool and urine drug screen

BACKGROUND Studies suggest that outpatient palliative care can reduce hospitalization and increase hospice utilization for patients with cancer, however there are insufficient resources to provide palliative care to all patients from time of diagnosis. It is also unclear whether inpatient consultation alone provides similar benefits. A better understanding of the timing, setting, and impact of palliative care for patients with cancer is needed. OBJECTIVES The purpose of this study was to measure timing of referral to outpatient palliative care and impact on end-of-life (EOL) care. DESIGN The Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track) program is a phased intervention integrating outpatient palliative care into cancer care. In Year 1 patients were referred at the discretion of their oncologist. SETTING Academic medical center. MEASUREMENTS We compared EOL hospitalization, hospice utilization, and costs of care for CARE Track patients compared to those never seen by palliative care or seen only in hospital. RESULTS Patients were referred a median of 72.5 days prior to death. CARE Track patients had few hospitalizations at end of life, were less likely to die in hospital, had increased hospice utilization, and decreased costs of care; these results were significant even after controlling for differences between groups. Inpatient consultation alone did not impact these variables. However, only approximately half of patients with incurable cancers were referred to this program. CONCLUSION Referral outpatient palliative care within 3 months of death improved EOL care and reduced costs, benefits not seen with inpatient care only. However, many patients were never referred, and methods of systematically identifying appropriate patients are needed.

Will a Better Mousetrap Help when You Work in a Lion’s Den? What is the Role of Abuse Deterrent Pharmaceuticals in Hospice and Palliative Care? (FR460)

BACKGROUND Although inadequate treatment of pain is a problem for hospice patients, increases in the medical use of opioids have been accompanied by increasing levels of abuse and diversion in the community. Balancing pain relief with concerns about abuse and diversion is a difficult issue for hospices. OBJECTIVES The aim of this study was to determine policies and practices in Virginia hospices regarding substance abuse and diversion in patients and their families. METHODS A survey was conducted of Virginia hospices about policies, perceptions, and training regarding substance abuse and diversion. RESULTS Twenty-three of 63 hospice agencies responded (36.5%). Less than half (43.8%) required mandatory substance abuse training. Only 43.5% had policies regarding screening for substance abuse in patients; 30.4% had a policy regarding screening for substance abuse in family members. Policies regarding screening for diversion in patients (21.7%), and families (17.4%) were rare. Policies regarding opioid use in patients with a history of substance abuse or diversion were uncommon (33.3%, 30.4%, respectively); 30.4% had policies regarding use of opioids in patients whose family members had a history of diversion or abuse. Thirty-eight percent of hospices agreed that substance abuse and diversion was a problem for their agency, and these agencies were more likely to have written policies or mandatory training. CONCLUSION Most Virginia hospices lack mandatory training and policies regarding substance abuse and diversion in patients and family members. More than one-third felt that abuse and diversion were problems in their agencies. A national conversation regarding policies toward substance abuse and diversion in hospice agencies is needed.

Outcomes of a Re-engineered Palliative Care and Radiation Therapy Care Model

PurposeTo assess the feasibility of collecting patient-reported outcomes data with wireless touch screen tablet computers in the adult oncology palliative care setting.MethodsPatients were provided with tablet computers during scheduled clinic visits and answered online queries about their experience over the past week in the health domains of anxiety, depression, fatigue, pain interference, physical function, instrumental social support, sleep impairment, diarrhea, constipation, nausea, vomiting, anorexia, dyspnea, neuropathy, and spiritual values.ResultsContent analysis of patient interviews indicates that wireless touch screen tablet computers are a feasible approach for collecting patient-reported outcome measures by palliative care cancer patients presenting in clinic. Most patients indicated that the questionnaire was easy to answer. However, all but one patient requested some form of assistance, and many reported difficulties attributable to a lack of familiarity with the device, interpretation of certain questions, and wireless connectivity-related issues.ConclusionsThis feasibility study demonstrates that tablet computers have the potential to efficiently and reliably collect patient-reported health status measures among palliative care cancer patients presenting in clinics. The use of these devices may lead to substantial improvements by making patient-reported outcomes available for clinical decision-making.