eCQ 11-4 Newsletter

Quarterly Newsletter

Volume 11, Issue 4

60% of Patients in Need of Palliative Care Do Not Receive It, Survey Finds

Despite a high rate of availability of palliative care services in their institutions and organizations, survey respondents re- port that fully 60% of patients who would benefit from such services are not receiv- ing them, according to a report published online by NEJM Catalyst. “Palliative care should be as ubiquitous as hospice care within the healthcare industry,” says co-author Amy Compton- Phillips, MD, executive vice president and chief clinical officer at Providence St. Joseph Health in Seattle. “If 60% of patients who would benefit aren’t receiving it, there’s a real disconnect.” NEJM Catalyst, which is produced by a division of the Massachusetts Medical So- ciety, presents innovative ideas and prac- tical applications gathered from leading healthcare experts and advisors aimed at enhancing the value of patient care and ad- dressing challenges. Results are reported in multi-format, online publications and through quarterly events. The results of the recent “care design” survey of 575 clinical leaders, clini- cians, and healthcare executives directly involved in care delivery is titled, “The Power of Palliative Care,” and comes from the NEJM Insights Council, which conducts regular surveys, analyzes the results, and publishes them online. OVERALL FINDINGS • Nearly all respondents (97%) agreed that palliative care improves the patient experience. • 94% said palliative care improves the quality of care. • 88% reported that palliative care boosts clinician satisfaction.

• 79% indicated that palliative care reduces healthcare costs. 80% of organizations represented in the survey had palliative or end-of-life care programs. Only 16% of respondents reported that patients had been involved in the development of their palliative/end-of- life care programs. An important focus for increasing pa- tient access to palliative care services is the alignment of payment incentives, note the authors. “We have data that show palliative care costs less and increases patient satis- faction,” says Compton-Phillips. “When we start paying for outcomes rather than inputs, access to palliative care should change rather quickly.” In addition, increasing the integration of palliative care into primary care settings, with provision of adequate resources, is crucial. The authors are encouraged that “many primary care physicians now rou- tinely prioritize goals-of-care conversa- tions with their patients.” Respondents’ suggestions for improving palliative care access included: • Providing additional palliative care train- ing for primary care physicians (77%) • Widening the inclusion of patient popula- tions, such as those with chronic condi- tions and non-cancer diagnoses (67%) • Supporting additional palliative care training for specialty non-palliative care physicians, such as surgeons and cardi- ologists (63%) • Expanding palliative care outpatient clin- ics (53%) The report is available at https://cata- lyst.nejm.org/power-palliative-end-of- life-care-program.

Mother’s Touch is Joint Commission Accredited.

CONTENTS

Page 1 60% of Patients in Need of Palliative Care Do Not Receive It, Survey Finds Page 2 Rate of Unplanned Hospitalizations High Among Newly Diagnosed Cancer Patients Page 3 Non-Symptom Factors Rated Highest for Quality Care of Older Adults Page 4 Clinicians Offered Approach to Engaging Patients in Shared Decision Making

Rate of Unplanned Hospitalizations High Among Newly Diagnosed Cancer Patients

planned surgery were excluded. Among all newly diagnosed patients (female, 51.7%; non-Hispanic white race/ethnicity, 61.4%), the most common cancer sites were breast (17.1%), prostate (14.4%), and lung (10.3%). More than one-third of patients were diagnosed with advanced cancer, defined as either stage III (16.4%) or stage IV (21.3%); 21.1% died within one year of diagnosis. At 32.9%, cancer was the most com- mon admitting diagnosis for unplanned hospitalizations. Cancer stage was linked to likelihood of unplanned hospitaliza- tion, with 58.3% of those with stage IV cancer being hospitalized in the year after diagnosis, compared with 21.9% of those with stage I cancer. OVERALL FINDINGS • 62%of newly diagnosed cancer patients had at least one all-cause hospitalization during the year following diagnosis. • 35% of all patients in the cohort experi- enced an unplanned hospitalization, with 67% of their total hospitalizations being unplanned. • 67%of unplanned hospitalizations origi- nated in the ED. PATIENT DATA Unplanned hospitalizations were high- est among those who were: • Aged ≥ 76 years (42.5%) • Of non-Hispanic black race/ethnicity (41.3%) • Not married (40.5%) • Uninsured (47.8%) • In the lowest (42.7%) vs highest (28.6%) socioeconomic-status quintile • Diagnosed with cancers of the brain or central nervous system (58.5%), liver, gallbladder, or pancreas (57.9%), and lung (55.0%). • Diagnosed with stage IV (58.3%) as compared with stage I (21.9%) disease NON-CANCER ADMITTING DIAGNOSES The most common non-cancer admit- ting diagnoses among unplanned hospi-

talizations included: • Infection or fever (15.8%) • Complications of a medical device or medical care (6.5%) • Gastrointestinal (5.8%), cardiovascular (5.8%), and respiratory (4.3%) admitting diagnoses. TYPES OF CANCER Types of cancer with the highest inci- dence of unplanned hospitalization for a non-cancer primary diagnosis included: • Hematologic cancer for an admitting diagnosis of infection or fever (21.0%) • Prostate cancer for cardiovascular hos- pitalizations (11.1%) • Colorectal cancer for complications of a medical device or care (9.9%) and gastrointestinal-related hospitalizations (16.4%) • Lung cancer for respiratory hospitaliza- tions (10.5%) Percentage of ED-originated admis- sions by cancer type: • Lung (78.6%) • Hepatobiliary or pancreatic (75.3%) • Other digestive cancers (73.8%) • Bone and soft tissue (49.1%) The percentage of ED-originated admissions by cancer stage varied from 53.9% for stage I to 75.7% for stage IV. The authors express hope that their find- ings may help guide targeted interventions to reduce unplanned hospitalization rates. “These findings...point to the need for a greater understanding of the predictors of unplanned hospitalizations by cancer type, particularly among sociodemographic subgroups with higher rates of [acute care] use,” they write. • Breast (48.1%) • Thyroid (22.3%)

Approximately two thirds (67%) of all- cause hospitalizations occurring among cancer patients within the year following diagnosis — a period that coincides with active treatment for many patients — are unplanned, with the majority (67%) of these originating in the emergency department (ED), according to a report published in the Journal of Oncology Practice, a journal of the American Soci- ety of Clinical Oncology. “The population burden of unplanned hospitalizations among individuals newly diagnosed with cancer is substantial. Many unplanned hospitalizations origi- nate in the ED and are associated with potentially preventable admission diag- noses,” write the authors. “Reducing po- tentially avoidable cancer hospitalizations remains an important target for improv- ing the quality and reducing the costs of cancer care.” STRATEGIES TO REDUCE ACUTE CARE USE Suggested strategies for reducing pre- ventable cancer-related acute care use include: • Timely outpatient symptommanagement • Enhanced access to urgent care • Early palliative care Hospitalization is a leading contributor to cancer-related healthcare spending, note the authors, with cancer patients more likely than patients with other dis- eases to have longer lengths of stay and higher inpatient costs. Although costs for cancer drugs and imaging continue to rise, hospitalization costs —particularly in the year following diagnosis and in the final year of life — account for more than one- half of cancer patients’ treatment costs. Investigators determined the rates of and reasons for unplanned hospitaliza- tions among a cohort of adults (n = 412,850) newly diagnosed with cancer from 2009 to 2012, using data from the California Cancer Registry linked with inpatient data. Hospitalizations for main- tenance chemotherapy, radiotherapy, or

ADDRESSING PATIENTS’ URGENT CARE NEEDS

Studies have highlighted several effec- tive ways to reduce acute care use, note Continued on Page 3

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Volume 11, Issue 4

Non-Symptom Factors Rated Highest for Quality Care of Older Adults

the following conditions: heart attack, heart disease, arthritis, diabetes, lung disease, dementia, and cancer. Investigators analyzed interview reports of bereaved proxies on care in the last month of life for participants from 2014 to 2016 (n = 477; weighted n = 1,123,887 participants) in the National Health and Aging Trends Study (NHATS), which has been following a nationally representative sample of more than 8,000 older Medicare beneficiaries yearly since 2011. Because more than 93% of American adults aged ≥ 65 years are covered under Medicare, their study can be considered to describe the last-month experiences of most community-dwelling older adults, the authors note. OVERALL FINDINGS • The majority of decedents were aged 65 to 84 years (60%), female (52%), and of white race (77%). • 24% had dementia; 48% had cancer. • 57% were enrolled in hospice. • Place of death was most often at home (44%) or in the hospital (33%). Rating of overall care quality was dichotomized as “excellent” or “not ex- cellent.” Proxy perception of each key quality domain (coordination, symptom management, shared decision making, respect, and spiritual and emotional sup-

port) was dichotomized as “positive” or “not positive.” Proxies rated overall care quality as “ex- cellent” for 54% of NHATS participants and “not excellent” for the remaining 46%. Participant characteristics associated with an “excellent” overall quality of care rating included being married at the time of death ( P = 0.007), hospice enrollment ( P = 0.04), and having a spouse as proxy ( P = 0.03). QUALITY OF OVERALL CARE WAS ASSOCIATED WITH: • Respect (adjusted odds ratio [aOR], 6.36; 95% confidence interval [CI], 3.23 to 12.52) • Care coordination (aOR, 4.49; 95% CI, 1.85 to 10.86) • Spiritual and emotional support (aOR, 2.02; 95% CI, 1.23 to 3.30) • Shared decision making (aOR, 1.97; 95% CI, 1.12 to 3.47) There was no significant association between symptom management and over- all care quality (aOR, 1.49; 95% CI, 0.81 to 2.71). The quality of overall care was negative- ly associated with dying in a setting other than home or hospital, such as a nursing home (aOR, 0.55; 95% CI, 0.034 to 0.88). Within the care coordination domain, dying in a setting other than home or hospital was perceived as significantly negative (aOR, 0.31; 95% CI, 0.11 to 0.90). Source: “Non-Symptomatic FactorsMore Strongly Associated with High-Quality End-of-Life Care Than Symptomatic Factors for Community- Dwelling Older Adults with Multiple Chronic Conditions,” Journal of Palliative Medicine; May 2019; 22(5):522–531. Kricke G, Woods D, Jordan N; Division of Quality, Northwestern Memorial HealthCare, Chicago; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago; Division of Geriatric Medicine and Gerontology, Department of Medicine, Center for Transformative Geriatrics Research, Baltimore; Armstrong Institute Center for Health Care Human Factors, Johns Hopkins University School of Medicine, Baltimore; Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago; and Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Chicago.

Proxies forMedicare beneficiaries living in the community with multiple chronic conditions (MCC) near the end of life gave higher ratings to care domains such as respect, care coordination, and emotional support than to symptommanagement, ac- cording to a report published in the Journal of Palliative Medicine. “Our findings suggest that end-of-life care providers should consider non- symptomatic domains...in addition to symptom management when providing end-of-life care, particularly respect and shared decisionmaking,” write the authors. “Prognostic uncertainty may lead older adults with MCC to receive fragmented end-of-life care in a general healthcare system focused on stabilization rather than end-of-life specific needs. “Enhancing palliative care may be one approach for addressing dying individuals’ care coordination, shared decision mak- ing, respect, and spiritual and emotional support needs while also attending to their symptoms.” MCC is defined by the National Quality Forum as “two or more concurrent chronic conditions that collectively have an adverse effect on health status, function, or quality of life, and that require complex healthcare management, decision making, or coordi- nation.” For the current study, MCC was defined as the presence of two or more of

Rate of Unplanned Hospitalizations (from page 2)

same-day appointments, and using navigators to provide additional sup- port and connect patients and caregiv- ers with community resources. Source: “Unplanned Hospitalizations Among Individuals with Cancer in the Year after Diagnosis,” Journal of Oncology Practice; January 2019; 15(1):e20–e29. Whitney RL, Bell JF, Tancredi DJ, Romano PS, Bold RJ, Wun T, Joseph JG; University of California San Francisco, Fresno; and University of California Davis, Sacramento.

the authors, by addressing patients’ urgent care needs through: • Community-based palliative care • After-hours telephone support • Evidence-based treatment guidelines • Out-of-hospital emergency teams Other suggested strategies for reducing unplanned hospitalizations include having oncology nurses tri- age patient symptoms and arrange for

Volume 11, Issue 4

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© 2019 by Quality of Life Publishing Co. May not be reproduced without permission of the publisher. 877-513-0099

Clinicians Offered Approach to Engaging Patients in Shared Decision Making

need for SDM and to prioritize its use. Prioritizing decisions needing SDM. Because patient input is not necessary for many routine clinical decisions made as part of standard care, SDM should be used for those “preference-sensitive” decisions likely to have substantial consequences. Establishing an environment that facilitates patient engagement. Explaining to patients beforehand that some of the recommendations in the encounter may be routine, but for others their participation may be needed and would be welcome, allows patients to feel more in control and free to ask questions or disagree if they wish. Making recommendations prudently. Patients will often welcome the clinician’s recommendation, but may need help in thinking through the decision. Clinicians are encouraged to use communication strategies that can help the patient reason through options. Source: “Realizing Shared Decision Making in Practice,” Journal of the American Medical Association; Epub ahead of print, July 25, 2019. DOI: 10.1001/jama.2019.9797. Beach MC, Sugarman J; Berman Institute of Bioethics, Johns Hopkins University; and Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore.

Where care and medical care come together... Mother’s Touch stands for quality and caring service in all aspects of hospice care. We employ tenured leadership and management, with many years of experience in home care nursing, home health, hospice and other forms of care for seniors. Our dedicated interdisciplinary hospice teams provide end-of-life medical, emotional and spiritual care. Our team members have focused their careers to use their extensive knowledge, professional experience, and most importantly, a mission-driven commitment to support our patients and their loved ones. Visit our website or contact us today for more information about hospice or to refer a patient to our hospice services. Shared decision making (SDM) is encouraged so that diagnostic and treatment courses will be consistent with the values and preferences of patients. Yet, “there is less SDM occurring than there should be,” according to an article pub- lished in the Journal of the American Medical Association. “[I]mposing a standard by which patients are expected to engage in all (or even most) decisions is not only unrealistic and inefficient, but also potentially burdensome to patients and clinicians,” the authors note. They suggest the following “solutions” for better realization of SDM in practice. ENCOURAGING PATIENT ENGAGEMENT IN SDM Decision aids. Well-sourced, comprehensive written ma- terials can help patients absorb the complexities of informa- tion helpful for understanding their options and participating meaningfully in decision making. Task specificity. Guidelines addressing SDM should include recommendations that clearly outline particular val- ues, risks, benefits, and consequences of different, specific decisions. This can help clinicians to better understand the

www.motherstouchmobilephysicians.com www.motherstouchhospice.com (316) 682-1232 phone (316) 612-9889 fax PO Box 783070 Wichita, KS 67278