Rodney Tucker

Characteristics of an Ambulatory Palliative Care Clinic for HIV-Infected Patients

BACKGROUND Many HIV-infected patients in the current treatment era have substantial symptom burden, but few HIV palliative care clinics have been described. Our objective was to describe the University of Alabama at Birmingham (UAB) HIV palliative care clinic (HPCC) and compare it to the overall HIV clinic. METHODS We conducted a chart review of patients referred to the HPCC between April 2008 and June 2011. We evaluated the reason for referral and other issues addressed during palliative care visits. Patient Reported Outcome (PRO) data was used to assess depression (PHQ-9), anxiety (PHQ-A), and substance abuse (ASSIST). RESULTS Among 124 patients, mean age was 44 (range 27-64), and median CD4 count was 352 cells/mm(3) (IQR 209-639). Depression (43, 35%), anxiety (40, 32%), and current 8 (7%) or prior 68 (56%) substance abuse occurred at higher rates than in the overall HIV clinic (p<0.05). Pain was the most common reason for referral (118, 95%); most was chronic (113, 90%) and included back pain (26, 21%) and neuropathic pain (15, 12%). Other problems commonly addressed by the palliative team included nonpain symptoms such as depression (39, 48%) and anxiety (17, 21%), insomnia (25, 30%), and constipation (26, 32%). CONCLUSIONS This is the first description of a palliative care clinic embedded within an HIV primary care clinic in a developed country that sees patients at all stages of illness. Chronic pain and nonpain symptom management in patients with psychiatric and substance abuse comorbidities are important components of ambulatory palliative care for HIV-infected patients.

Discharge Hospice Referral and Lower 30-Day All-Cause Readmission in Medicare Beneficiaries Hospitalized for Heart Failure

Background—Heart failure (HF) is the leading cause for hospital readmission. Hospice care may help palliate HF symptoms but its association with 30-day all-cause readmission remains unknown. Methods and Results—Of the 8032 Medicare beneficiaries hospitalized for HF in 106 Alabama hospitals (1998–2001), 182 (2%) received discharge hospice referrals. Of the 7850 patients not receiving hospice referrals, 1608 (20%) died within 6 months post discharge (the hospice-eligible group). Propensity scores for hospice referral were estimated for each of the 1790 (182+1608) patients and were used to match 179 hospice-referral patients with 179 hospice-eligible patients who were balanced on 28 baseline characteristics (mean age, 79 years; 58% women; 18% non-white). Overall, 22% (1742/8032) died in 6 months, of whom 8% (134/1742) received hospice referrals. Among the 358 matched patients, 30-day all-cause readmission occurred in 5% and 41% of hospice-referral and hospice-eligible patients, respectively (hazard ratio associated with hospice referral, 0.12; 95% confidence interval, 0.06–0.24). Hazard ratios (95% confidence intervals) for 30-day all-cause readmission associated with hospice referral among the 126 patients who died and 232 patients who survived 30-day post discharge were 0.03 (0.04–0.21) and 0.17 (0.08–0.36), respectively. Although 30-day mortality was higher in the hospice referral group (43% versus 27%), it was similar at 90 days (64% versus 67% among hospice-eligible patients). Conclusions—A discharge hospice referral was associated with lower 30-day all-cause readmission among hospitalized patients with HF. However, most patients with HF who died within 6 months of hospital discharge did not receive a discharge hospice referral.

Sudden Advanced Illness An Emerging Concept Among Palliative Care and Surgical Critical Care Physicians

Background: End-of-life discussions in critically-ill patients with acute surgical conditions may be rushed and occur earlier during hospitalization. This study explores the concept of sudden advanced illness (SAI) and its relevance to patients requiring Palliative and Surgical Critical Care. Methods: Semi-structured interviews were completed with 16 physicians, querying each about (1) definitional components, (2) illustrative cases, and (3) comfort with SAI. Analysis was done by grounded theory. Results: SAI was characterized as unforeseen, emerging abruptly and producing devastating injury, often in healthy, younger patients. There is (1) prognostic uncertainty, (2) loss of capacity, and (3) unprepared surrogate decision-making. Cases are emotionally-charged and often personal. Conclusion: The emerging concept of SAI is important for understanding how Palliative Care can enhance care for this subset of patients.

Low back pain and associated imaging findings among HIV-infected patients referred to an HIV/palliative care clinic.

BACKGROUND Low back pain is a common cause of chronic pain in human immunodeficiency virus (HIV)-infected patients. The American College of Physicians and American Pain Society guidelines for diagnostic imaging in low back pain are difficult to apply to patients with chronic illnesses like HIV who may have risk factors for cancer or compression fractures, but whether imaging all such patients for low back pain improves outcomes is unknown. OBJECTIVE Our objective was to describe patients referred to a chronic pain-focused HIV/palliative care clinic (HPCC) with back pain and their associated lumbar spine imaging findings. METHODS We conducted a retrospective chart review of patients at a palliative care clinic that sees patients with HIV, most of whom have chronic pain. Charts with a diagnosis of low back pain were cross-referenced with an imaging database and any magnetic resonance imaging (MRI) of the lumbar spine with or without contrast were identified. RESULTS Seventy-six of 137 patients referred to the HPCC were found to have back pain. These patients were mainly young (median age 45, interquartile range 40-51) with well-controlled HIV. Twenty-two (29%) of these patients had an MRI of the lumbar spine, and 11 (50%) of these warranted follow-up, most of whom had degenerative disc disease, including four with findings concerning for malignancy. DISCUSSION This is the first study to explore the role of spinal imaging in HIV-infected patients. In our study, four patients had findings concerning for malignancy. These findings suggest that spinal imaging should be considered in the work up of HIV-infected patients with moderate to severe back pain.