المؤلفون: Kim, Kyung Mi, Giannitrapani, Karleen F, Garcia, Ariadna, Boothroyd, Derek, Wu, Adela, Van Cleve, Raymond, McCaa, Matthew D, Yefimova, Maria, Aslakson, Rebecca A, Morris, Arden M, Shreve, Scott T, Lorenz, Karl A

المصدر: JAMA network open. 6(2)

مصطلحات موضوعية: Humans, Retrospective Studies, Cross-Sectional Studies, Communication, Goals, Aged, Aged, 80 and over, Advance Care Planning, Female, Male, Clinical Research, Good Health and Well Being

الوصف: ImportanceCommunication about patients' goals and planned and potential treatment is central to advance care planning. Undertaking or confirming advance care plans is also essential to preoperative preparation, particularly among patients who are frail or will undergo high-risk surgery.ObjectiveTo evaluate the association between patient risk of hospitalization or death and goals-of-care conversations documented with a completed Life-Sustaining Treatment (LST) Decisions Initiative note among veterans undergoing surgery.Design, setting, and participantsThis retrospective cross-sectional study included 190 040 veterans who underwent operations between January 1, 2017, and February 28, 2020. Statistical analysis took place from November 1, 2021, to November 17, 2022.ExposurePatient risk of hospitalization or death, evaluated with a Care Assessment Need (CAN) score (range, 0-99, with a higher score representing a greater risk of hospitalization or death), dichotomized as less than 80 or 80 or more.Main outcomes and measuresPreoperative LST note completion (30 days before or on the day of surgery) or no LST note completion within the 30-day preoperative period prior to or on the day of the index operation.ResultsOf 190 040 veterans (90.8% men; mean [SD] age, 65.2 [11.9] years), 3.8% completed an LST note before surgery, and 96.2% did not complete an LST note. In the groups with and without LST note completion before surgery, most were aged between 65 and 84 years (62.1% vs 56.7%), male (94.3% vs 90.7%), and White (82.2% vs 78.3%). Compared with patients who completed an LST note before surgery, patients who did not complete an LST note before surgery tended to be female (9.3% vs 5.7%), Black (19.2% vs 15.7%), married (50.2% vs 46.5%), and in better health (Charlson Comorbidity Index score of 0, 25.9% vs 15.2%); to have a lower risk of hospitalization or death (CAN score

URL الوصول: https://escholarship.org/uc/item/2wv1b0wm

المؤلفون: Patel, Arpan, Asch, Steven, Antonio, Anna Liza, Kanwal, Fasiha, Lorenz, Karl, Riopelle, Deborah, Dickey, Anna, Larkin, Jennifer, Lee, Martin, Walling, Anne

المصدر: Digestive Diseases and Sciences. 65(9)

مصطلحات موضوعية: Biomedical and Clinical Sciences, Clinical Sciences, Clinical Research, Digestive Diseases, Substance Misuse, Liver Disease, Management of diseases and conditions, 7.2 End of life care, Oral and gastrointestinal, Good Health and Well Being, Aged, End Stage Liver Disease, Humans, Liver Cirrhosis, Male, Middle Aged, Palliative Care, Pilot Projects, Quality Indicators, Health Care, Terminal Care, Time Factors, Treatment Outcome, Veterans Health Services, Palliative care, Cirrhosis, Healthcare quality, Veterans, End of life, Gastroenterology & Hepatology, Clinical sciences

الوصف: Background/aimsWe examined the quality of palliative care received by patients with decompensated cirrhosis using an explicit set of palliative care quality indicators (QIs) for patients with end-stage liver disease (PC-ESLD).MethodsWe identified patients newly diagnosed with decompensated cirrhosis at a single veterans health center and followed up them for 2 years or until death. We piloted measurement of PC-ESLD QIs in all patients confirmed to have ESLD using a chart abstraction tool.ResultsOut of 167 patients identified using at least one sampling strategy, 62 were confirmed to meet ESLD criteria with chart abstraction. Ninety-eight percent of veterans in the cohort were male, mean age at diagnosis was 61 years, and 74% were White. The overall QI pass rate was 68% (64% for information care planning QIs and 76% for supportive care QIs). Patients receiving specialty palliative care consultation were more likely to receive information care planning QIs (67% vs. 37%, p = 0.02). The best performing sampling strategy had a sensitivity of 62% and specificity of 60%.ConclusionMeasuring the quality of palliative care for patients with ESLD is feasible in the veteran population. Our single-center data suggest that the quality of palliative care is inadequate in the veteran population with ESLD, though patients offered specialty palliative care consultation and those affected by homelessness, drug, and alcohol abuse may receive better care. Our combination of ICD-9 codes can be used to identify a cohort of patients with ESLD, though better sensitivity and specificity may be needed.

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URL الوصول: https://escholarship.org/uc/item/7hj9v3ds

المؤلفون: Herman, Patricia M, Yuan, Anita H, Cefalu, Matthew S, Chu, Karen, Zeng, Qing, Marshall, Nell, Lorenz, Karl A, Taylor, Stephanie L

المصدر: PLOS ONE. 14(6)

مصطلحات موضوعية: Complementary and Integrative Health, Clinical Research, Health Services, Chronic Pain, Pain Research, Good Health and Well Being, Adolescent, Adult, Cohort Studies, Complementary Therapies, Female, Humans, Integrative Medicine, Linear Models, Male, Middle Aged, Musculoskeletal Pain, United States, Veterans, Young Adult, General Science & Technology

الوصف: ObjectivesTo estimate the cost-effectiveness to the US Veterans Health Administration (VA) of the use of complementary and integrative health (CIH) approaches by younger Veterans with chronic musculoskeletal disorder (MSD) pain.PerspectiveVA healthcare system.MethodsWe used a propensity score-adjusted hierarchical linear modeling (HLM), and 2010-2013 VA administrative data to estimate differences in VA healthcare costs, pain intensity (0-10 numerical rating scale), and opioid use between CIH users and nonusers. We identified CIH use in Veterans' medical records through Current Procedural Terminology, VA workload tracking, and provider-type codes.ResultsWe identified 30,634 younger Veterans with chronic MSD pain as using CIH and 195,424 with no CIH use. CIH users differed from nonusers across all baseline covariates except the Charlson comorbidity index. They also differed on annual pre-CIH-start healthcare costs ($10,729 versus $5,818), pain (4.33 versus 3.76), and opioid use (66.6% versus 54.0%). The HLM results indicated lower annual healthcare costs (-$637; 95% CI: -$1,023, -$247), lower pain (-0.34; -0.40, -0.27), and slightly higher (less than a percentage point) opioid use (0.8; 0.6, 0.9) for CIH users in the year after CIH start. Sensitivity analyses indicated similar results for three most-used CIH approaches (acupuncture, chiropractic care, and massage), but higher costs for those with eight or more CIH visits.ConclusionsOn average CIH use appears associated with lower healthcare costs and pain and slightly higher opioid use in this population of younger Veterans with chronic musculoskeletal pain. Given the VA's growing interest in the use of CIH, further, more detailed analyses of its impacts are warranted.

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URL الوصول: https://escholarship.org/uc/item/1sr8s4fm

المؤلفون: Giannitrapani, Karleen F, Glassman, Peter A, Vang, Derek, McKelvey, Jeremiah C, Thomas Day, R, Dobscha, Steven K, Lorenz, Karl A

المصدر: BMC Primary Care. 19(1)

مصطلحات موضوعية: Health Services and Systems, Health Sciences, Pain Research, Patient Safety, Health Services, Chronic Pain, Clinical Research, Prevention, 8.1 Organisation and delivery of services, Health and social care services research, Generic health relevance, Good Health and Well Being, Analgesics, Opioid, Focus Groups, Humans, Leadership, Naloxone, Narcotic Antagonists, Pain Management, Patient Care Team, Pharmacists, Primary Health Care, Professional Role, Qualitative Research, United States, United States Department of Veterans Affairs, Pain, Pain management, Clinical pharmacists, Team based care, Interdisciplinary teams, Qualitative research, Nursing, Public Health and Health Services, Public Health, Health services and systems, Public health

الوصف: BackgroundFacilitating appropriate and safe prescribing of opioid medications for chronic pain management in primary care is a pressing public health concern. Interdisciplinary team-based models of primary care are exploring the expansion of clinical pharmacist roles to support disease management for chronic conditions, e.g. pain. Our study aims to 1) identify roles clinical pharmacists can assume in primary care team based chronic pain care processes and 2) understand the barriers to assuming these expanded roles.MethodsSetting: Veterans Health Administration (VA) has implemented an interdisciplinary team-based model for primary care which includes clinical pharmacists.DesignWe employed an inductive two part qualitative approach including focus groups and semi-structured interviews with key informants.Participants60 members of VA primary care teams in two states participated in nine preliminary interdisciplinary focus groups where a semi-structured interview guide elucidated provider experiences with screening for and managing chronic pain. To follow up on emergent themes relating to clinical pharmacist roles, an additional 14 primary care providers and clinical pharmacists were interviewed individually. We evaluated focus group and interview transcripts using the method of constant comparison and produced mutually agreed upon themes.ResultsClinical pharmacists were identified by primary care providers as playing a central role with the ongoing management of opioid therapy including review of the state prescription drug monitoring program, managing laboratory screening, providing medication education, promoting naloxone use, and opioid tapering. Specific barriers to clinical pharmacists role expansion around pain care include: limitations of scopes of practice, insufficient institutional support (low staffing, dedicated time, insufficient training, lack of interdisciplinary leadership support), and challenges and opportunities for disseminating clinical pharmacists' expanded roles.ConclusionsExpanding the role of the clinical pharmacist to collaborate with providers around primary care based chronic pain management is a promising strategy for improving pain management on an interdisciplinary primary care team. However, expanded roles have to be balanced with competing responsibilities relating to other conditions. Interdisciplinary leadership is needed to facilitate training, resources, adequate staffing, as well as to prepare both clinical pharmacists and the providers they support, about expanded clinical pharmacists' scopes of practice and capabilities.

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URL الوصول: https://escholarship.org/uc/item/7jx4r3sn

المؤلفون: Evans, Elizabeth A, Herman, Patricia M, Washington, Donna L, Lorenz, Karl A, Yuan, Anita, Upchurch, Dawn M, Marshall, Nell, Hamilton, Alison B, Taylor, Stephanie L

المصدر: Women's Health Issues. 28(5)

مصطلحات موضوعية: Midwifery, Public Health, Health Sciences, Complementary and Integrative Health, Chronic Pain, Clinical Research, Aging, Pain Research, Musculoskeletal, Good Health and Well Being, Adult, Black or African American, Complementary Therapies, Ethnicity, Female, Hispanic or Latino, Humans, Male, Middle Aged, Musculoskeletal Pain, Racial Groups, Sex Factors, United States, United States Department of Veterans Affairs, Veterans, Veterans Health, White People, Paediatrics and Reproductive Medicine, Public Health and Health Services, Public health, Policy and administration

الوصف: AimsThe Veterans Health Administration promotes evidence-based complementary and integrative health (CIH) therapies as nonpharmacologic approaches for chronic pain. We aimed to examine CIH use by gender among veterans with chronic musculoskeletal pain, and variations in gender differences by race/ethnicity and age.MethodsWe conducted a secondary analysis of electronic health records provided by all women (n = 79,537) and men (n = 389,269) veterans age 18 to 54 years with chronic musculoskeletal pain who received Veterans Health Administration-provided care between 2010 and 2013. Using gender-stratified multivariate binary logistic regression, we examined predictors of CIH use, tested a race/ethnicity-by-age interaction term, and conducted pairwise comparisons of predicted probabilities.ResultsAmong veterans with chronic musculoskeletal pain, more women than men use CIH (36% vs. 26%), with rates ranging from 25% to 42% among women and 15% to 29% among men, depending on race/ethnicity and age. Among women, patients under age 44 who were Hispanic, White, or patients of other race/ethnicities are similarly likely to use CIH; in contrast, Black women, regardless of age, are least likely to use CIH. Among men, White and Black patients, and especially Black men under age 44, are less likely to use CIH than men of Hispanic or other racial/ethnic identities.ConclusionsWomen veteran patients with chronic musculoskeletal pain are more likely than men to use CIH therapies, with variations in CIH use rates by race/ethnicity and age. Tailoring CIH therapy engagement efforts to be sensitive to gender, race/ethnicity, and age could reduce differential CIH use and thereby help to diminish existing health disparities among veterans.

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URL الوصول: https://escholarship.org/uc/item/0j05t9v9

المؤلفون: Sudore, Rebecca L, Heyland, Daren K, Lum, Hillary D, Rietjens, Judith AC, Korfage, Ida J, Ritchie, Christine S, Hanson, Laura C, Meier, Diane E, Pantilat, Steven Z, Lorenz, Karl, Howard, Michelle, Green, Michael J, Simon, Jessica E, Feuz, Mariko A, You, John J

المصدر: Journal of Pain and Symptom Management. 55(2)

مصطلحات موضوعية: Good Health and Well Being, Advance Care Planning, Delphi Technique, Humans, Outcome Assessment, Health Care, Advance care planning, consensus, Delphi technique, outcome measures, Medical and Health Sciences, Anesthesiology

الوصف: ContextStandardized outcomes that define successful advance care planning (ACP) are lacking.ObjectiveThe objective of this study was to create an Organizing Framework of ACP outcome constructs and rate the importance of these outcomes.MethodsThis study convened a Delphi panel consisting of 52 multidisciplinary, international ACP experts including clinicians, researchers, and policy leaders from four countries. We conducted literature reviews and solicited attendee input from five international ACP conferences to identify initial ACP outcome constructs. In five Delphi rounds, we asked panelists to rate patient-centered outcomes on a seven-point "not-at-all" to "extremely important" scale. We calculated means and analyzed panelists' input to finalize an Organizing Framework and outcome rankings.ResultsOrganizing Framework outcome domains included process (e.g., attitudes), actions (e.g., discussions), quality of care (e.g., satisfaction), and health care (e.g., utilization). The top five outcomes included 1) care consistent with goals, mean 6.71 (±SD 0.04); 2) surrogate designation, 6.55 (0.45); 3) surrogate documentation, 6.50 (0.11); 4) discussions with surrogates, 6.40 (0.19); and 5) documents and recorded wishes are accessible when needed 6.27 (0.11). Advance directive documentation was ranked 10th, 6.01 (0.21). Panelists raised caution about whether "care consistent with goals" can be reliably measured.ConclusionA large, multidisciplinary Delphi panel developed an Organizing Framework and rated the importance of ACP outcome constructs. Top rated outcomes should be used to evaluate the success of ACP initiatives. More research is needed to create reliable and valid measurement tools for the highest rated outcomes, particularly "care consistent with goals."

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URL الوصول: https://escholarship.org/uc/item/7515x41k

المؤلفون: Walling, Anne M, Tisnado, Diana, Ettner, Susan L, Asch, Steven M, Dy, Sydney M, Pantoja, Philip, Lee, Martin, Ahluwalia, Sangeeta C, Schreibeis-Baum, Hannah, Malin, Jennifer L, Lorenz, Karl A

المصدر: Journal of Pain and Symptom Management. 52(4)

مصطلحات موضوعية: Health Services and Systems, Health Sciences, Rare Diseases, Cancer, Chronic Pain, Mind and Body, Clinical Trials and Supportive Activities, Clinical Research, Digestive Diseases, Pain Research, Management of diseases and conditions, 7.2 End of life care, Good Health and Well Being, Aged, Cohort Studies, Female, Follow-Up Studies, Humans, Least-Squares Analysis, Male, Middle Aged, Multivariate Analysis, Neoplasms, Palliative Care, Quality of Health Care, Referral and Consultation, Regression Analysis, Retrospective Studies, Specialization, Terminal Care, Time Factors, United States, United States Department of Veterans Affairs, Veterans, Advanced cancer, quality, palliative care, Medical and Health Sciences, Anesthesiology, Biomedical and clinical sciences, Health sciences

الوصف: ContextAlthough recent randomized controlled trials support early palliative care for patients with advanced cancer, the specific processes of care associated with these findings and whether these improvements can be replicated in the broader health care system are uncertain.ObjectivesThe aim of this study was to evaluate the occurrence of palliative care consultation and its association with specific processes of supportive care in a national cohort of Veterans using the Cancer Quality ASSIST (Assessing Symptoms Side Effects and Indicators of Supportive Treatment) measures.MethodsWe abstracted data from 719 patients' medical records diagnosed with advanced lung, colorectal, or pancreatic cancer in 2008 over a period of three years or until death who received care in the Veterans Affairs Health System to evaluate the association of palliative care specialty consultation with the quality of supportive care overall and by domain using a multivariate regression model.ResultsAll but 54 of 719 patients died within three years and 293 received at least one palliative care consult. Patients evaluated by a palliative care specialist at diagnosis scored seven percentage points higher overall (P

URL الوصول: https://escholarship.org/uc/item/0v82b738

المؤلفون: Singer, Adam E, Goebel, Joy R, Kim, Yan S, Dy, Sydney M, Ahluwalia, Sangeeta C, Clifford, Megan, Dzeng, Elizabeth, O'Hanlon, Claire E, Motala, Aneesa, Walling, Anne M, Goldberg, Jaime, Meeker, Daniella, Ochotorena, Claudia, Shanman, Roberta, Cui, Mike, Lorenz, Karl A

المصدر: Journal of Palliative Medicine. 19(9)

مصطلحات موضوعية: Health Services and Systems, Health Sciences, Health Services, Behavioral and Social Science, Clinical Trials and Supportive Activities, Prevention, Brain Disorders, Comparative Effectiveness Research, Clinical Research, Chronic Pain, Pain Research, Acquired Cognitive Impairment, 7.2 End of life care, Management of diseases and conditions, Respiratory, Good Health and Well Being, Caregivers, Dementia, Health Care Costs, Humans, Palliative Care, Terminal Care, Clinical Sciences, Nursing, Public Health and Health Services, Gerontology, Health services and systems

الوصف: ImportanceEvidence supports palliative care effectiveness. Given workforce constraints and the costs of new services, payers and providers need help to prioritize their investments. They need to know which patients to target, which personnel to hire, and which services best improve outcomes.ObjectiveTo inform how payers and providers should identify patients with "advanced illness" and the specific interventions they should implement, we reviewed the evidence to identify (1) individuals appropriate for palliative care and (2) elements of health service interventions (personnel involved, use of multidisciplinary teams, and settings of care) effective in achieving better outcomes for patients, caregivers, and the healthcare system.Evidence reviewSystematic searches of MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Database of Systematic Reviews databases (1/1/2001-1/8/2015).ResultsRandomized controlled trials (124) met inclusion criteria. The majority of studies in cancer (49%, 38 of 77 studies) demonstrated statistically significant patient or caregiver outcomes (e.g., p

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URL الوصول: https://escholarship.org/uc/item/1zf3x2h1

المؤلفون: Ahluwalia, Sangeeta C, Tisnado, Diana M, Walling, Anne M, Dy, Sydney M, Asch, Steven M, Ettner, Susan L, Kim, Benjamin, Pantoja, Philip, Schreibeis-Baum, Hannah C, Lorenz, Karl A

المصدر: Journal of palliative medicine. 18(10)

مصطلحات موضوعية: Humans, Neoplasms, Neoplasm Metastasis, Terminal Care, Medical Records, Multivariate Analysis, Retrospective Studies, Cohort Studies, Communication, Physician-Patient Relations, Decision Making, Time Factors, Documentation, Aged, Middle Aged, Terminally Ill, Advance Care Planning, United States, Female, Male, Veterans Health, Clinical Research, Cancer, Clinical Sciences, Nursing, Public Health and Health Services, Gerontology

الوصف: BackgroundEarly patient-physician care planning discussions may influence the intensity of end-of-life (EOL) care received by veterans with advanced cancer.ObjectiveThe study objective was to evaluate the association between medical record documentation of patient-physician care planning discussions and intensity of EOL care among veterans with advanced cancer.MethodsThis was a retrospective cohort study. Subjects were 665 veteran decedents diagnosed with stage IV colorectal, lung, or pancreatic cancer in 2008, and followed till death or the end of the study period in 2011. We estimated the effect of patient-physician care planning discussions documented within one month of metastatic diagnosis on the intensity of EOL care measured by receipt of acute care, intensive interventions, chemotherapy, and hospice care, using multivariate logistic regression models.ResultsVeterans in our study were predominantly male (97.1%), white (74.7%), with an average age at diagnosis of 66.4 years. Approximately 31% received some acute care, 9.3% received some intensive intervention, and 6.5% had a new chemotherapy regimen initiated in the last month of life. Approximately 41% of decedents received no hospice or were admitted within three days of death. Almost half (46.8%) had documentation of a care planning discussion within the first month after diagnosis and those who did were significantly less likely to receive acute care at EOL (OR: 0.67; p=0.025). Documented discussions were not significantly associated with intensive interventions, chemotherapy, or hospice care.ConclusionEarly care planning discussions are associated with lower rates of acute care use at the EOL in a system with already low rates of intensive EOL care.

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URL الوصول: https://escholarship.org/uc/item/5608g1p8

المؤلفون: Walling, Anne M, Tisnado, Diana, Asch, Steven M, Malin, Jennifer M, Pantoja, Philip, Dy, Sydney M, Ettner, Susan L, Zisser, Ann P, Schreibeis-Baum, Hannah, Lee, Martin, Lorenz, Karl A

المصدر: JAMA Internal Medicine. 173(22)

مصطلحات موضوعية: Clinical Trials and Supportive Activities, Pain Research, Cancer, Clinical Research, Health Services, Digestive Diseases, Chronic Pain, Good Health and Well Being, Aged, Colorectal Neoplasms, Female, Hospice Care, Humans, Lung Neoplasms, Male, Middle Aged, Pancreatic Neoplasms, Quality Indicators, Health Care, Retrospective Studies, United States, Veterans, Clinical Sciences, Opthalmology and Optometry, Public Health and Health Services

الوصف: ImportanceCharacterizing the quality of supportive cancer care can guide quality improvement.ObjectiveTo evaluate nonhospice supportive cancer care comprehensively in a national sample of veterans.Design, setting, and participantsUsing a retrospective cohort study design, we measured evidence-based cancer care processes using previously validated indicators of care quality in patients with advanced cancer, addressing pain, nonpain symptoms, and information and care planning among 719 veterans with a 2008 Veterans Affairs Central Cancer Registry diagnosis of stage IV colorectal (37.0%), pancreatic (29.8%), or lung (33.2%) cancer.Main outcomes and measuresWe abstracted medical records from diagnosis for 3 years or until death among eligible veterans (lived ≥ 30 days following diagnosis with ≥ 1 Veterans Affairs hospitalization or ≥ 2 Veterans Affairs outpatient visits). Each indicator identified a clinical scenario and an appropriate action. For each indicator for which a veteran was eligible, we determined whether appropriate care was provided. We also determined patient-level quality overall and by pain, nonpain symptoms, and information and care planning domains.ResultsMost veterans were older (mean age, 66.2 years), male (97.2%), and white (74.3%). Eighty-five percent received both inpatient and outpatient care, and 92.5% died. Overall, the 719 veterans triggered a mean of 11.7 quality indicators (range, 1-22) and received a mean 49.5% of appropriate care. Notable gaps in care were that inpatient pain screening was common (96.5%) but lacking for outpatients (58.1%). With opioids, bowel prophylaxis occurred for only 52.2% of outpatients and 70.5% of inpatients. Few patients had a timely dyspnea evaluation (15.8%) or treatment (10.8%). Outpatient assessment of fatigue occurred for 31.3%. Of patients at high risk for diarrhea from chemotherapy, 24.2% were offered appropriate antidiarrheals. Only 17.7% of veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63.7% had timely discussion of goals following intensive care unit admission. Most decedents (86.4%) were referred to palliative care or hospice before death. Single- vs multiple-fraction radiotherapy should have been considered in 28 veterans with bone metastasis, but none were offered this option.Conclusions and relevanceThese care gaps reflect important targets for improving the patient and family experience of cancer care.

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URL الوصول: https://escholarship.org/uc/item/5jx740qp