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Background Clinicians play an important role in containing pharmaceutical spending at the patient level, as well as ensuring efficacy and quality outcomes, yet little research has examined how to achieve this goal. Measures Using auditing and feedback (A&F) as part of a Pharmacy and Therapeutics (P&T) Committee, we evaluated our community-based hospice program's prescribing habits for opioids, antipsychotics, and antidepressants and calculated oral pharmaceutical prescription costs per-patient-day. Quality of care was reflected by patient pain scores in electronic medical records. Intervention Our P&T Committee adopted an A&F approach to monitor and assess provider prescribing habits and cost. An already-existing pain quality improvement program assessed care quality. Outcomes Pain relief either improved or was maintained while medication costs were reduced by over $1.00 per-patient-day from 2010 to 2011. Conclusions/Lessons Learned An active, hospice P&T Committee featuring A&F can significantly affect medication costs for a hospice program while maintaining or improving patient outcomes.

BackgroundAn estimated 6,000 to 18,000 additional hospice and palliative medicine (HPM) physicians are needed in the United States. A source could be the military graduate medical education system where 15% of U.S. medical residents are trained. A community-based hospice and palliative care organization created a one-week rotation for military residents including participation in interdisciplinary group visits at patients' homes, facilities, and an inpatient hospice unit.ObjectiveOur goal was to evaluate the effectiveness of a one-week community HPM rotation for military medical residents.MethodsA mixed-methods, multi-stakeholder perspective program evaluation model was used for program years 2011 to 2013. Data were managed and analyzed using Microsoft Excel and Atlas.ti. Participants in the rotation were residents training at two local military hospitals. Program evaluation data were collected from residents, military program liaisons, and hospice clinical preceptors. Quantitative data included pre- and post-tests based on Accreditation Council for Graduate Medical Education competencies completed by residents. Qualitative data included resident essays and semi-structured interviews with hospice preceptors and military program liaisons.ResultsQuantitative and qualitative data suggested that the rotation increased military residents' knowledge, attitudes, and comfort level with HPM. Quantitative analysis of test scores indicated improvements from pre- to post-tests in each of five areas of learning. Qualitative data indicated the rotation created a greater appreciation for the overall importance of HPM and increased understanding of eligibility and methods for pain and symptom management.ConclusionsA one-week community hospice rotation for medical military residents impacts participant's knowledge of and attitudes toward HPM.

Background Validated and reproducible means to systematically improve pain documentation and outcomes in home-based hospice populations are generally lacking. This article describes a novel electronic medical record (EMR)-embedded pain monitoring and management program for home-based hospice patients. Measures Pain relief was measured by patients' self-defined pain within 48 hours of initiating care, recorded on a 0–10 pain scale. Intervention The Pain Continuous Quality Improvement Program consisted of EMR enhancements, staff engagement and training, and incentivizing techniques. Outcomes The Pain Continuous Quality Improvement Program effectively improved documentation of pain and reduced the prevalence of unresolved problematic pain (e.g., lower average pain score ratings, decrease in patients reporting problematic pain after 48 hours of initiating care). Conclusions/Lessons Learned Integrating the upgraded EMR system into routine practice and workflow was critical to facilitating rapid recognition of escalating pain and inadequate pain management as well as allowing improving monitoring of patient outcomes and staff performance.

Background A community-based non-profit hospice provider implemented "TeleCaring" as a quality improvement intervention to identify and take action on patient or caregiver needs or concerns, such as uncontrolled symptoms or prescription problems. Measures We assessed the rate of acceptance of the intervention, intensity of the intervention, escalations of calls from Specialists to Nurses, and the effect of the intervention on utilization of clinical services, clinical miles traveled, and family satisfaction with care. Intervention TeleCaring consisted of daily proactive phone calls to patients and caregivers by Specialists and Nurses. Outcomes Eighty-eight percent of new home hospice patients accepted TeleCaring when offered. A total of 5.3% of calls by Specialists were escalated to Nurses. TeleCaring participants had lower utilization of clinical services compared with non-participants. Family satisfaction increased and clinical miles decreased across the organization after the implementation of TeleCaring. Conclusions/Lessons Learned TeleCaring is a viable method to proactively identify home hospice patient or caregiver needs and adjust clinical services accordingly.

Context Outpatient nonhospice palliative care has been shown to provide many benefits to patients facing advanced illness, but such services remain uncommon in the U.S. Little is known about the association between clinic-based outpatient palliative care consultation and the timing of hospice enrollment. Objectives To determine whether there are differences in hospice length of service (LOS) between patients who were seen vs. patients who were not seen in an outpatient palliative care clinic before enrollment in hospice. Methods Using a retrospective study of medical records, a "prior palliative care clinic" group was formed of those hospice patients who had had a nonhospice clinic-based outpatient palliative care consult before hospice admission (n = 354). For those patients, "control" hospice patients without prior clinic-based palliative care were chosen who were matched by age, gender, median income of their zip code, and diagnostic group. Both groups were restricted to patients who died while enrolled in hospice. LOS for these two groups was compared using standard statistical methods of survival analysis. Results Prior palliative care clinic patients had a median LOS of 24 days, whereas control patients had a median LOS of 15 days (95% CI for difference between the medians 5–13 days). The difference between the LOS distribution curves was statistically significant by the log-rank test (P Conclusion Hospice patients who had clinic-based outpatient palliative consults before hospice enrollment tended, on average, to have a longer LOS in hospice than patients who did not.

Objective A major goal of palliative care is to provide comfort, and pain is one of the most common causes of treatable suffering in patients with advanced disease. Opioids are indispensable for pain management in palliative care and can usually be provided by the oral route, which is safe, effective, and of lowest cost in most cases. As patients near the end of life, however, the need for alternate routes of medication increases with up to 70% of patients requiring a nonoral route for opioid administration. In order to optimize patient care, it is imperative that clinicians understand existing available options of opioid administration and their respective advantages and disadvantages. Methods We performed a literature review to describe the most commonly used and available routes that can substitute for oral opioid therapy and to provide a summary of factors affecting choice of opioid for use in palliative care in terms of benefits, indications, cautions, and general considerations. Results Clinical circumstances will largely dictate appropriateness of the route selected. When the oral route is unavailable, subcutaneous, intravenous, and enteral routes are preferred in the palliative care population. The evidence supporting sublingual, buccal, rectal, and transdermal gel routes is mixed. Conclusions This review is not designed to be a critical appraisal of the quality of current evidence; rather, it is a summation of that evidence and of current clinical practices regarding alternate routes of opioid administration. In doing so, the overarching goal of this review is to support more informed clinical decision making.

Context Prescription Monitoring Programs (PMPs) are being developed and implemented in many states to deter abuse, diversion, and overdose, and physicians may use PMPs to help guide their treatment choices for individual patients. Objectives To evaluate the changes in prescribing practices and pain score outcomes in patients with cancer before and after an initial consult in an outpatient palliative care clinic. Methods This is a retrospective study with a sample of 60 consecutive patients who had been referred by oncologists for difficult-to-manage pain and whose initial palliative care consult was with either of the two physicians in the outpatient palliative care clinic. For each patient, lists were compiled of all prescriptions for controlled medications and filled for the 90-day periods immediately before and after the initial consult. Data from patient charts were combined with information from the Virginia PMP, which included prescriptions written before and after the initiation of palliative care, written by prescribers both inside and outside the palliative care clinic. Results After the palliative care consult, the proportion of patients on long-acting opioids increased from 45% to 73%. Self-reported pain outcomes, which were compiled for the subset of patients who continued palliative care for at least 60 days, showed a median decrease of two units on a 0–10 scale. A decrease was seen in the use of medications that compound acetaminophen with opioids. Conclusion Data from a PMP proved useful in understanding the changes in a population of patients. Favorable changes were observed in prescribing practices and pain outcomes.

Context Quality care for patients with cancer is a national priority—for those with noncurable cancer, the stakes are even higher. Strategies to promote integration of palliative care into oncology practice may enhance quality. We have developed a model in which palliative care services are integrated into the private, office-based oncology practice setting. We have evaluated the feasibility and assessed outcomes for both the oncologists and the patients they serve. To our knowledge, an embedded clinic in an outpatient, private practice oncology clinic has not been described previously. Objective The primary outcomes assessed were 1) quality care outcomes through assessment of symptom burden and relief achieved through palliative care consultation, 2) provider satisfaction, 3) volume determined by number of palliative care consultations over time, and 4) time saved for the oncologist as a surrogate for the bottom line of the cancer practice. Methods Measurement of: symptom burden and relief with the Edmonton Symptom Assessment System (ESAS), physician acceptance of palliative care services through a provider satisfaction survey and volume of referrals, and billing data to determine potential oncologists' time saved. Results Palliative care consultation was associated with a reduction in symptom burden by 21%, evidenced by decrease in average total ESAS score from 49.3 to 39. Median provider satisfaction scores rating components of palliative care ranged from 8.5 to 9/10, with an overall provider satisfaction of 9/10. Over the study period, the "embedded" oncology group consultation requests increased 87% (67–120), with each individual oncology provider nearly doubled. The total time saved for the oncology practice in Year 2 was just over four weeks (9720 minutes; 162 hours). Conclusion An embedded palliative care clinic integrated into an office-based oncology practice is feasible and may improve the quality of care. Formal study of this service delivery model is warranted.

Fatigue, pain, distress, and anorexia are four commonly encountered symptoms in cancer. To evaluate the usefulness of a single-item screening for these symptoms, 597 ambulatory outpatients with solid tumors were administered a self-report screening instrument within the first 12 weeks of chemotherapy. Patients rated the severity of each symptom on a 0-10 scale, at its worst over the past three days, with higher ratings associated with higher symptom levels. From this sample, 148 patients also completed a more comprehensive assessment of these symptoms. Two criteria were used to determine optimal cut-off scores on the screening items: 1) the sensitivity and specificity of each screening item to predict clinical cases using receiver-operating characteristics analysis and 2) the proportion of patients at each screening score who reported that some relief of the target symptom would significantly improve their life. Optimal cut-off scores ranged from 4 to 6 depending on the target symptom (area under the curve range=0.68-0.88). Use of single-item screening instruments for fatigue, pain, distress, and anorexia may assist routine clinical assessment in ambulatory oncology practice. In turn, such assessments may improve identification of those at risk of morbidity and decreased quality of life due to excess symptom burden.

Background: Residency programs are required to teach and evaluate trainees in the area of professionalism and medical ethics. Prior to developing a curriculum in this area, residents and fellows were surveyed to assess learning needs. Description: A case-based survey was developed based on published curricula. Residents and fellows were asked to describe their comfort level in 11 clinical scenarios on a Likert-type scale ranging from 1 (not at all comfortable) to 10 (extremely comfortable). Evaluation: 151 surveys were returned for an overall response rate of 73%. Comfort levels ranged from a low of 3.1 to a high of 8.5 on the 10-point scale. Despite additional years of clinical training, fellows only reported an increased comfort level in 1 case. Conclusion: Learning needs exist in residents and fellows in the area of medical ethics. Use of a needs assessment was instrumental in planning and designing an ethics curriculum.

A major goal of palliative care is to provide comfort, and pain is one of the most common causes of treatable suffering in patients with advanced disease. Opioids are indispensable for pain management in palliative care and can usually be provided by the oral route, which is safe, effective, and of lowest cost in most cases. As patients near the end of life, however, the need for alternate routes of medication increases with up to 70% of patients requiring a nonoral route for opioid administration. In order to optimize patient care, it is imperative that clinicians understand existing available options of opioid administration and their respective advantages and disadvantages.We performed a literature review to describe the most commonly used and available routes that can substitute for oral opioid therapy and to provide a summary of factors affecting choice of opioid for use in palliative care in terms of benefits, indications, cautions, and general considerations.Clinical circumstances will largely dictate appropriateness of the route selected. When the oral route is unavailable, subcutaneous, intravenous, and enteral routes are preferred in the palliative care population. The evidence supporting sublingual, buccal, rectal, and transdermal gel routes is mixed.This review is not designed to be a critical appraisal of the quality of current evidence; rather, it is a summation of that evidence and of current clinical practices regarding alternate routes of opioid administration. In doing so, the overarching goal of this review is to support more informed clinical decision making.

Dyspnea significantly impacts quality of life and is one of the most common symptoms in advanced illness. Systemically-administered opioids and benzodiazepines have been the most studied and utilized pharmacologic treatments for refractory dyspnea. Less attention has been given to the use of these medications and others when nebulized. This article presents a review of the literature on the use of nebulized medications for the treatment of dyspnea related to cancer, chronic obstructive pulmonary disease, cystic fibrosis, interstitial lung disease, or experimentally-induced dyspnea.A systematic review of peer-reviewed literature was conducted using Medline/PubMed, CINAHL, Cochrane, and Google Scholar.Thirty-nine publications were included in this review, including 17 high-quality clinical research studies, as defined by the GRADE system. The evidence for nebulized morphine remains mixed, whereas a potential benefit was suggested for nebulized furosemide, hydromorphone, and fentanyl. No conclusions could be drawn as to which disease population derived greatest benefit from nebulized medications, or whether jet or ultrasonic nebulizers were more effective for the delivery of these medications.More research is needed to assess the characteristics of specific diseases and the combination of different nebulizers and medications that may yield the greatest benefit, and to assess the safety and efficacy of the chronic use of nebulized opioids and furosemide. Until larger, longer-term studies are completed, the use of nebulized medications to treat dyspnea should be assessed on a case-by-case basis and may be considered if the hoped-for benefits outweigh potential harm.

Gastrointestinal obstruction is associated with nausea, vomiting, and abdominal pain. Antisecretory agents can relieve these symptoms, even in the absence of surgical or mechanical intervention. These medical management approaches are outlined, and recommendations are made.

For Amanda Bennett and her husband Terence Foley, a 7-year battle with kidney cancer resulted in a price tag of more than $600,000, most of it spent in the final 2 years of his life. Ms. Bennett's memoir, The Cost of Hope, chronicles the couple's emotional struggle and the financial irrationality she uncovered when navigating the cancer continuum. She shared her experience in her keynote address at the NCCN 18th Annual Conference, which was followed by a roundtable discussion in which panelists discussed the difficulties inherent in dealing with cancer "uncertainties," the balancing act that seeks to maintain hope in the context of a poor prognosis, and the problem of a health care system that spends too much on some aspects of care while ignoring others.

Most US citizens die in acute care hospitals, often in physical pain, without attention to emotional and spiritual suffering. This represents an ethical failure of our current health-care system. The field of palliative medicine aims to address the physical, emotional, and spiritual needs of patients with advanced disease. At the same time, a new specialty of hospitalists is emerging, providing care for acutely ill hospitalized patients, many of whom will die. Thus, the hospitalist may become the primary deliverer of palliative care. This presents many potential opportunities for dying patients and their families, including increased time and attention from a physician; enhanced knowledge and skills around the physical symptoms, and emotional and spiritual distress; perhaps more detached and therefore more accurate prognostication; and increased efficiency, leading to a more rapid discharge to home. Hospitalists could enhance the quality of care for the dying by emphasizing interdisciplinary communication and involvement of hospital-based health professionals to address emotional and spiritual distress and bereavement issues, as well as through specific quality-improvement efforts. Finally, hospitalists can provide strong role modeling of optimal care for dying patients and their families. When hospitalists are not selected and trained effectively around palliative care issues, the risks are great. Discontinuity of physicians can lead to miscommunication and misunderstanding (by professionals, patient, and family); disagreement about treatment focus (especially as it relates to a shift from curative to palliative); inappropriate deferring of advance care planning to the hospital setting; and, most worrisome, a lack of expertise in symptom control, communication skills, and attention to patient and family distress and the provision of emotional and spiritual support. This article evaluates the convergence of the 2 fields of palliative medicine and hospitalist medicine and reviews the opportunities for mutual education and improved patient care.

Context: There are many patients with terminal illness for whom hospice care would be appropriate, but they either never enroll or enroll very late. In a pre-hospice program designed to help patients make the transition into hospice, we observed that many patients did not make the transition. Objectives: To understand more about the transition to hospice and the functions of a pre-hospice program, this paper compares patients who enrolled in hospice with those who died in the pre-hospice program. Design, setting, and patients: Data were collected from a retrospective review of the charts of 123 consecutive patients who enrolled in a prehospice program between January 1, 1995, and December 31, 1996. Main outcome measures: The patient’s decision to transfer to home hospice or (perhaps, by not making a decision) to remain enrolled in the pre-hospice program until death. Results: At the end of the research period, 38 patients had transferred to hospice and 36 had died without transfer. The remaining 49 patients had uncertain outcomes at the end of the research period. Patients who transferred to hospice were older (P = .02) and more likely to have secondary insurance (P = .05). In addition, those who enrolled in hospice were more likely to live alone (P = .03) and have psychosocial concerns noted by staff on admission (P = .05). Conclusions: Many patients died in this program that was designed only for transition to hospice. We found statistically significant differences characterizing the groups associated with transferring to hospice. Further studies to find out why these differences exist will be important in order to provide excellent end-of-life care for more people.

The findings of the SUPPORT study, the largest, most comprehensive and costly study ever undertaken on decision making for critically ill patients, revealed a wide ranging gap between patient preferences and physician behavior with regard to treatment decisions for seriously ill patients. The ethical issues raised by that disparity are intensified as we enter into a market-driven managed care delivery system. This essay explores recent ethical and legal developments on several emerging issues: the decision making process; DNR orders; brain death; withdrawal of treatment; physician assisted suicide; and the constraints of managed care.

Nausea and vomiting in abdominal cancer is perhaps one of the most difficult symptom complexes to manage, especially when complicated by bowel obstruction. There are many mechanisms of nausea in advanced abdominal cancer with a number of therapeutic interventions that can significantly enhance symptom control and overall quality of life. As with pain, the ideal approach should include a mechanistic analysis of the causes of nausea beginning with a thorough history, followed by a directed physical examination, and selected laboratory studies. The symptom history, in conjunction with a physical examination and directed tests should direct appropriate pharmacologic and nonpharmacologic interventions. The result is often the amelioration of significant suffering and enhanced quality of living.

Acute massive pulmonary embolus (PE) when undiagnosed may lead to hemodynamic compromise and death. Echocardiography offers several clues to the diagnosis of PE. We describe how transesophageal echo was used in the diagnosis and management of two patients with this disorder.

70 Background: Michigan oncology practice groups that participated in MOQC [JOP 5(6):281, 2009] used the Quality Oncology Practice Initiative (QOPI) tool. Adherence to processes of disease specific care was high, but poor in domains associated with palliative care. These measures did not change over time [Health Affairs. 31(4):718, 2012]. These findings prompted us to test interventions to improve quality in palliative care domains. Methods: MOQC created a process, based on the IHI Framework for Spread, to assist oncology practice groups in establishing their own primary Palliative Care services, including the implementation of Edmonton Symptom Management Scale. 8 practice groups formed teams of local change agents to participate in the Palliative Care Demonstration (PC Demo) project. The teams participated in 3 in-person and 4 online learning sessions over 8 months, led by palliative care and quality experts. Teams were provided tools, training materials, and necessary support to implement the improvements and measure their success. The learning network facilitated the sharing of best practices and lessons learned throughout the process. The teams presented their results broadly to other MOQC participants at project conclusion. Results: Success was measured using palliative care-focused ASCO QOPI results. PC Demo sites consecutively improved their scores in many of the QOPI measures, and their rate of improvement from Fall 2011 to Spring 2012 was greater than that of their peers. Conclusions: We observed that collecting and distributing data in our consortium was insufficient to improve palliative oncology care. Providing practice groups with the appropriate infrastructure improved their capacity and capability to make the necessary changes to improve performance. [Table: see text]