Search

PURPOSE: Older patients with acute leukemia (AL) have a high symptom burden and poor prognosis. Although integration of palliative care (PC) with oncologic care has been shown to improve quality-of-life and end-of-life care in patients with AL, the malignant hematologists at our tertiary care hospital make limited use of PC services and do so late in the disease course. Using the Plan-Do-Study-Act (PDSA) methodology, we aimed to increase early PC utilization by older patients with newly diagnosed AL. METHODS: We instituted the following standardized criteria to trigger inpatient PC consultation: (1) age 70 years and older and (2) new AL diagnosis within 8 weeks. PC consultations were tracked during sequential PDSA cycles in 2021 and compared with baseline rates in 2019. We also assessed the frequency of subsequent PC encounters in patients who received a triggered inpatient PC consult. RESULTS: The baseline PC consultation rate before our intervention was 55%. This increased to 77% and 80% during PDSA cycles 1 and 2, respectively. The median time from diagnosis to first PC consult decreased from 49 days to 7 days. Among patients who received a triggered PC consult, 43% had no subsequent inpatient or outpatient PC encounter after discharge. CONCLUSION: Although standardized PC consultation criteria led to earlier PC consultation in older patients with AL, it did not result in sustained PC follow-up throughout the disease trajectory. Future PDSA cycles will focus on identifying strategies to maintain the integration of PC with oncologic care over time, particularly in the ambulatory setting.

PurposeThe study aims, based on the symbiotic relationship between tourism agencies and various stakeholders, to investigate what “policy-level” partners would advise their “practice-level” counterparts on, first, how the World Heritage Site (WHS) status of monuments can be made attractive for travellers, and second, what steps can be taken by stakeholders to enhance the WHS tourist experience.Design/methodology/approachA qualitative approach involving e-mail interviews was adopted. Content analyses of open-ended exploratory questions put to “policy-level” respondents yielded 10 major themes that can enhance the brand appeal of the WHS.FindingsThe findings offer in-depth solutions for better trip experiences of Heritage Tourists. Insights from the responses under ten thematic areas have direct relevance for application by tourism and hospitality facilitators.Practical implicationsAlthough this study was conducted in India, its findings hold implications for practice throughout the world. They could similarly be incorporated as elements of policy directed at incentivising communication of the value of preserving heritage for future generations.Originality/valueWhile previous research focused on stakeholders for planning and policy making, this study explores the stakeholder's perspective for a more comprehensive understanding of how using the WHS brand can generate more holistic tourism development.

PURPOSE: In December 2016, 49% of patients admitted to inpatient oncology services at University of Pittsburgh Medical Center Shadyside Hospital had cardiopulmonary resuscitation (CPR) status discussion documentation before discharge. The aim of this project was to improve the rate of CPR status conversations. METHODS: During Plan-Do-Study-Act (PDSA) cycle 1, a stakeholder workgroup was formed in January 2017 by oncology faculty, fellows, nurses, advance practice providers (APPs), medicine housestaff, and palliative care faculty. All oncology clinicians and inpatient team members were reminded weekly to discuss and document CPR status preferences. APPs received training on efficient and effective CPR status assessment from palliative care faculty. Oncology leadership received monthly e-mail updates of CPR status documentation rates and endorsed CPR status best practice guidelines. For PDSA cycle 2, patient charts without CPR status documentation in March 2018 were reviewed, and themes were shared with oncology leadership and reviewed with APPs. RESULTS: After PDSA cycle 1, CPR status assessment rates increased from 49% to greater than 80%. In 2017, more than 1,500 more CPR status discussions were documented than in 2016. The percentage of patients discharged with “comfort measures only” or “do not resuscitate” orders increased from 14.2% (95% CI, 9.5% to 19.0%) to 19.8% (95% CI, 15.6% to 24.0%). For PDSA cycle 2, charts of 60 patients without CPR assessment were reviewed. Of these, 52% were admitted overnight by nocturnists and 48% by daytime APPs. Fifty-five percent of patients (n = 33 of 60) had metastatic disease. CPR status was documented on previous admissions for 53% of patients (n = 31 of 60) in the past 12 months. Fifteen percent (n = 11 of 60) were admitted for scheduled inpatient chemotherapy. CONCLUSION: A multipronged approach significantly increased CPR status assessments. More patients transitioned to comfort measures only or do not resuscitate when their preferences were clearly assessed and documented.

25 Background: The “Surprise Question” — Would I be surprised if this patient died in the next 12 months? — was developed to help clinicians predict when patients are nearing the end of life. Limited data has shown that the “Surprise Question” is modestly predictive of mortality (CMAJ 2017 Apr 3;189(13):E484-E493), though its performance seems to be superior among cancer patients (Palliat Med 2014 Jul;28(7):959-964). Via Oncology Pathways, a platform used by UPMC Hillman Cancer Center and other institutions nationwide to guide treatment decisions, asks physicians the “Surprise Question” when a new treatment plan is implemented for patients with metastatic cancer. We assessed the “Surprise Question’s” ability to predict survival among Hillman Cancer Center patients with select stage IV diagnoses. Methods: We queried the UPMC Hillman Cancer Center Registry Information and Reporting Services for cases of colorectal, non-small cell lung, prostate, pancreatic, and breast cancer with clinic visits between 1/1/2016 and 12/31/2017 and residence in Allegheny County, the primary referral base for the UPMC Hillman Cancer Center network’s flagship facility. Results: The “Surprise Question” was completed for 1,584 patients with metastatic disease of the 5,330 patients that were screened. “No” was the response for 891 patients (56.3%). Mortality at 12 months for patients for whom the answer to the “Surprise Question” was “no” was 63.1%, compared to 32.5% for patients for whom the answer was “yes” (P < 0.0001). The sensitivity of the “Surprise Question” was 71.4% (95% CI 69.0 – 73.8%), and the specificity was 58.7% (95% CI 56.3 – 61.0%). The positive predictive value was 63.1% (95% CI 60.9 – 65.2%) and negative predictive value 67.5% (64.8% – 70.2%). Finally, the positive likelihood ratio was 1.73 (95% CI 1.58 – 1.89) and negative likelihood ratio 0.49 (0.43 – 0.55). Conclusions: While a “no” response to the “Surprise Question” for UPMC oncology patients with select stage IV diagnoses was more likely to predict 12-month mortality than a “yes” response, the “Surprise Question” was only modestly predictive of 12-month mortality. Future work will focus on determining if there are patient populations for whom the “Surprise Question” is more predictive and assessing the ability of the “Surprise Question” to predict other clinical outcomes, such as ED visits and hospitalizations.

180 Background: There is widespread recognition of the importance of having and documenting timely Goals of Care (GOC) conversations with seriously ill patients. Inpatient oncology teams at UPMC have noted the limited availability in the Electronic Medical Record (EMR) of documentation of patient preferences about end of life care. This project aims to identify the gaps in GOC communication across care settings for cancer patients at UPMC. Methods: We identified sources of information regarding goals of care available to inpatient oncology providers. Using the EMR we accessed the following for each patient of interest: CPR status, GOC documentation, scanned Advance Directives and/or POLST and last two available outpatient notes. Patients of interests were older than 65 years with metastatic cancer and 2 hospital admissions in the past year, or any cancer patient > 90 years. We reviewed outpatient notes for words suggesting that GOC conversations had occurred, and for a subset (50%), we did a detailed review identifying documentation of prognosis, treatment options, treatment decisions and patient values. Results: Of a total 114 high risk patients admitted over a 6-month period, 73 (64%) died within 6 months, with 52 (46%) dying within one month of their last hospitalization. Thirty nine (34%) patients had at least 5 admissions. Only 35% patients had GOC documented using the EMR template, and only 38% had a completed POLST. Rates of CPR status completion were high (95%). However, when tracking CPR status across multiple admissions, 73% of patients were full code on their first admission, with 31% of patients with five admissions remaining full code. The qualitative analysis of outpatient notes revealed that most documentation (87%) reflected continued treatment with minimal discussion of hospice or patient values. Conclusions: In a cohort of patients with advanced cancer, documentation of GOC discussions is limited in both inpatient and outpatient settings. Available documentation suggests minimal discussion of the limited benefits of medical interventions to prolong life. Future efforts will be designed to improve the quality and frequency of documentation of GOC conversations.

257 Background: In December 2016, 49% of patients admitted to inpatient oncology services at UPMC Shadyside had CPR status discussion documentation prior to discharge. This project aims to improve quality and rates of CPR status conversations. Methods: During Plan-Do-Study-Act (PDSA) cycle 1, a stakeholder workgroup was formed in January 2017 by oncology faculty, fellows, nurses and advance practice providers (APPs), medicine house staff, and palliative care faculty. All oncology clinicians were reminded weekly to discuss and document CPR status preferences. APPs received communication training with palliative care specialists. Oncology leadership received a monthly update of CPR status documentation rates, and endorsed CPR status best practice guidelines developed by the workgroup. For PDSA cycle 2, patient charts without CPR status documentation in March 2018 were reviewed. Results: PDSA cycle 1 resulted in CPR status assessment rates increasing from 49% to > 80%. 1400+ more CPR status discussions were documented in 2017 than 2016. The percentage of patients discharged “Comfort Measures Only” or “Do Not Resuscitate” increased from 14.2 (S.D. 2.4) to 20.0 (S.D. 2.1). For PDSA cycle 2, 60 patients without CPR assessment were reviewed. Fifty-two percent were admitted overnight by nocturnists, 48% by daytime APPs, and none by housestaff. 55% (33/60) had metastatic disease. Fifty-three percent (31/60) of patients had prior CPR status documentation in the past 12 months. Fifteen percent (11/60) of patients were admitted for scheduled inpatient chemotherapy. Conclusions: PDSA 1 showed that standardization of CPR status assessment with formal training increased CPR status assessments. More patients wanted CMO or DNR when asked, which may indicate the need for earlier goals of care discussions. PDSA 2 indicated that focusing efforts on completing CPR assessment as part of the admission process, especially for scheduled inpatient chemotherapy admissions, is critical in further improving our rates.

e18776Background: Lack of discussion and/or documentation about resuscitation preferences has led to care incongruous with patient’s wishes as previously documented or reported to providers or fami...

Hierarchical modeling (HM) is a statistical technique that has gained in popularity in health care research. It has been used for analysis of secondary data, performance profiles or benchmarking studies, and in prospective trials. The technique is used in situations in which traditional regression analysis might lead to incorrect conclusions. Specifically, data drawn from nested settings such as hospital units or hospice providers may be correlated, thus violating an assumption required for ordinary least squares regression.This article provides a description of HM, reviews two recent articles in palliative care that have used the technique, and presents an illustrative case study to further illuminate the potential of the method.When used appropriately, HM allows researchers to specify and test hypotheses that would not otherwise be possible, and avoid incorrect conclusions from nested data.

A new class of redox-switched anthraquinone derived lariat ethers 1-(1-anthraquinonyloxy) 3, 6, 9 trioxaundecane 11-ol (M1), 1-(1-anthraquinonyloxy) 3, 6 dioxaoctane 9-ol (M2), 1-(1-anthraquinonyloxy) 3 oxapentane 5-ol (M3), 1-(1-anthraquinonyloxy) 3 oxapentane 5-butane (M4), 1-(1-anthraquinonyloxy) 3, 6 dioxaoctane 9-methane (M5) and 1-(1-anthraquinonyloxy) 3 oxapentane 5-methane (M6) have been synthesized and characterized by spectral analysis. These ionophores were used in liquid membrane carrier facilitated transport of main group metal cations across supported liquid membrane (SLM). Cellulose nitrate membrane was used as membrane support. Effect of various parameters such as variation in concentration of metal as well as ionophore, effect of chain length and end group of ionophore have been studied. The sequence of metal ions transported by ionophore M1is Na+> Li+> K+> Ca2+> Mg2+and the order of metal ions transported by ionophores (M2–M6) is Li+> Na+> K+> Ca2+> Mg2+. Ionophore M1is selective for Na+, Li+, and K+and ionophores (M2–M6) are selective for Li+and Na+.

147 Background: Medical professionals are trained to provide life-sustaining and cardiac resuscitation measures for admitted hospital patients. However, not all patients desire such aggressive measures. Lack of discussion and/or documentation about resuscitation preferences has led to care incongruous with patient’s wishes as previously documented or reported to providers or family members. In December 2016, 49% of adult patients admitted to the inpatient oncology service at UPMC Shadyside had a code status discussion documented prior to discharge. The aim of this project is to improve the quality and rates of CPR status conversations. Methods: A workgroup was formed in January 2017 among key stakeholders representing oncology physicians and fellows, palliative care faculty, oncology nursing, advance practice providers (APPs), and internal medicine house staff. A quality improvement (QI) proposal was developed and approved by the UPMC Quality Improvement Committee in February 2017. All oncology faculty, fellows, housestaff, and APPs were reminded weekly to complete CPR status conversations and documentation. APPs were formally trained by palliative care specialists to discuss and document CPR/code status with all admitted patients. Hospital leadership received a monthly update of CPR status documentation rates. Results: Since project implementation, CPR status assessment rates have improved from 49% to 80% as of June 2017, and an additional 714 patients had a CPR status discussed and documented compared to June 2016. Formal system-wide expectations are being developed by the CPR assessment workgroup that all admitted patients should have CPR/Code status discussions and documentation upon admission. Conclusions: Standardization of CPR status assessment with formal training of clinicians and APPs has resulted in a significant increase in the number of CPR status assessments on the inpatient setting. A formal CPR status assessment expectations document is in the process of being developed among the workgroup. Formal trainings by palliative care specialists for APPs are ongoing. Future trainings are planned for physicians, housestaff and fellows.

Background and objectives: Healthcare providers communicate the risks and benefits of treatments using frequencies, percentages, or proportions. However, many patients lack the numerical skills needed to interpret this information accurately to make informed choices. Design, setting, participants, and measurements: We assessed numeracy, the capacity to use and comprehend numbers, in a prospective cohort study of 187 patients with stage 4 to 5 chronic kidney disease or ESRD. Patients completed a three-item numeracy test and were assessed for global mental status, cognitive function, type of hemodialysis access, and kidney transplant use. We examined the association of numeracy with healthcare use and other cognitive and sociodemographic variables. Results: Over 50% of patients answered one or fewer numeracy questions correctly. Although African Americans (P = 0.0001), women (P = 0.05), and the unemployed (P = 0.0004) demonstrated lower numeracy skills, numeracy deficits were prevalent in every subgroup. In analyses adjusted for demographics and length of follow-up, higher numeracy was significantly associated with receipt of a transplant or active waiting list status. Numeracy was not associated with dialysis modality or hemodialysis vascular access. Conclusion: Similar to prior findings in the general population, these findings indicate that poor numeracy skills are very common in patients with advanced chronic kidney disease and end-stage renal disease. Additional research is needed to further explore whether poor numeracy is a barrier to receipt of a kidney transplant. Clinicians caring for patients with kidney disease should consider using tools to enhance communication and overcome limited numeracy skills.