- Email: [email protected]
Factors Predicting Red Blood Cell Transfusions at the End of Life in Cancer Patients (TH320C)
Vol. 53 No. 2 February 2017
Schedule With Abstracts
Appropriateness Panel to review the latest guidelines and evidence and judge appropriateness of various treatment regimens as it pertained to their practice. These results were compared to current (7/2012-6/2013) practice patterns and presented to the faculty group. This exercise informed a template-based point of care intervention led by a clinical champion and leadership that focused on key aspects of clinical and patient-centered care including whether the bone metastases were complicated or uncomplicated, patient prognosis, extent of disease, and travel distance for the patient to the treatment site. We compared rates of lower burden treatment regimens (less than 10 fractions) for 81 pre-intervention patients with 107 metastases treated between 7/2012-6/2013 and 75 post-intervention patients with 94 metastases treated between 5/2015-1/2016. Results. Overall, painful bone metastases were treated with less than 10 fractions more often in the post-intervention period (38% v. 63%, p<0.001). Uncomplicated bone metastases treated with conformal radiation were also more likely to be treated with less than 10 fractions in the post- intervention period (19% v. 52%, p<0.001). One quarter of metastases were treated with SBRT during both the pre and post intervention periods. Conclusion. Leadership support, provider engagement in integrating guidelines into practice, and a note template with point of care clinical reminders can improve rates of appropriate, low-burden radiation oncology treatments for patients with advanced cancer. Implications for research, policy or practice. This strategy can be used to improve appropriateness of radiation therapy.
The Impact of Social Work Encounters on Risk of ICU Admission, ICU Death, and CPR Among Hospitalized Patients with Cancer at End of Life (TH320B) Ivan Chik, MPH, University of Hawaii at Manoa, John A. Burns School of Medicine, Honolulu, HI. Daniel Fischberg, MD PhD FAAHPM, John A Burns School of Medicine, Honolulu, HI. Ilan Bernstein, MD, University of Hawaii at Manoa, John A. Burns School of Medicine, Honolulu, HI. Objectives Describe the role of a social worker in an end-oflife setting.
325
Identify three areas of patient outcomes that can be improved with the presence of social work evaluations. Original Research Background. As hospital based palliative care teams strive to expand their interdisciplinary services, they are often tasked with providing outcomes data to justify additional staff. Research highlighting improvement in patient outcomes can support the need for multiple disciplines within a palliative care team. Research Objectives. The authors of this study aim to determine whether social workers impact the risk of ICU admission, ICU death, and cardiopulmonary resuscitation (CPR) events among hospital decedents followed by a Palliative Care practitioner. Methods. A retrospective chart review was done using data collected between January 1, 2010 and February 29th, 2016 by the Pain and Palliative Care Department at the Queen’s Medical Center. The study population included hospitalized patients with cancer who were followed by the Pain and Palliative Care service prior to any ICU transfer and ultimately died in the inpatient setting. Charts were evaluated for social work visits, ICU admissions, location of death, and CPR. Results. Of the 256 patients who met the inclusion criteria, 196 patients were evaluated by social workers. 11 of 196 (6%) who were seen by a social worker were later admitted to the ICU. Alternatively, 17 of 60 (28%) patients who had not received a social work evaluation were admitted to the ICU. Social work exposure between ICU admits and non-ICU admits was statistically significant OR ¼ .1504 (p<.0001). Similarly, risk of ICU death and presence of CPR was reduced among those who had social work intervention OR ¼ .1538 (p<.0001) and OR ¼ .2841 (p<.05), respectively. Conclusion. Incorporating social workers in the care of patients followed by the Palliative Care team is associated with a significant reduction in risk of ICU admission, ICU death, and CPR.
Implications for research, policy or practice. Growth of interdisciplinary Palliative Care teams to include a higher staffing ratio of social workers may result in fewer ICU admissions at end of life.
Factors Predicting Red Blood Cell Transfusions at the End of Life in Cancer Patients (TH320C) Jason Meadows, MD, Memorial Sloan-Kettering Cancer Center, New York, NY. Jessica Goldberg, MS MSN NP, Memorial Sloan Kettering Cancer Center,
326
Schedule With Abstracts
New York, NY. Raymond Baser, MS, Memorial Sloan Kettering Cancer Center, New York, NY. Objectives Identify 3 factors that predict increased RBC transfusion at end of life in cancer patients. Identify 3 factors that do not predict RBC transfusion at end of life in cancer patients. Original Research Background. In many situations, transfusions clearly improve longevity and/or quality of life (QOL). In terminal cancer patients the riskbenefit balance may sometimes be unclear. Research Objectives. We undertook this retrospective study to understand which non-laboratory factors may predict red blood cell (RBC) transfusion in the last 7 days of life. Methods. Between 10/1/2013 and 9/30/2015, 1248 in-patients with cancer died on medical oncology services at our institution. The primary endpoint was number of RBC units received within 7 days before death. Predictors included patient sex, age, race, religion, state/country of origin, cancer diagnosis, intensive care unit (ICU) death, length of stay (LOS), Do Not Resuscitate status, chaplaincy visits, and palliative medicine consultation. Associations between the predictors and number of RBC units received were evaluated using zero-hurdle negative binomial models to account for large numbers of patients who received zero RBC units. Results. Patients were mostly Caucasian (73%), Christian (58%), local residents (92% from NY/NJ/CT), and male (52%). Just under half (49%) were seen by palliative medicine within 7 days before death. Thirty-eight percent received 1-6 RBC units and 3% received 7 or more units (range 7-23) within 7 days before death. In the multivariable model, patients with leukemia, lymphoma, myeloma, and genitourinary cancers were significantly more likely to receive RBC transfusion. ICU death predicted both receipt of RBC transfusion (OR¼4.7) and higher number of units received (RR¼1.5). Female sex was associated with receiving transfusion (OR¼1.6). In unadjusted analysis, patients who had a palliative medicine consultation were less to likely to receive a transfusion (OR¼0.72) and tended to receive fewer units (RR¼0.72), but this was not significant in multivariable analysis. Conclusion. Sex, cancer type, and ICU death seem to influence end-of-life (EOL) transfusions whereas race, religion, and state/country of origin do not. Palliative consultation may reduce RBC transfusion at EOL for some patients but more research is needed to identify subgroups most impacted.
Implications for research, policy or practice. Research assessing transfusions and longevity/QOL at EOL are needed.
Vol. 53 No. 2 February 2017
Depression and Health Care Utilization at End-of-Life Among Older Adults with NonSmall Cell Lung Cancer (TH320D) Cara McDermott, PharmD PhD, University of Washington, Fred Hutch, Seattle, WA. Scott Ramsey, MD PhD, Fred Hutchinson Cancer Center, Seattle, WA. Aasthaa Bansal, PhD, University of Washington, Seattle, WA. Gary Lyman, MD MPH, Fred Hutchinson Cancer Research Center, Seattle, WA. Sean Sullivan, PhD, University of Washington, Seattle, WA. Objectives Describe the prevalence of pre-existing depression in this population. Characterize the relationship between pre-existing depression, hospice and EOL services in this population. Original Research Background. Depression is common among cancer patients. While research has explored the association between psychological distress during and after cancer treatment and use of high intensity end-of-life (EOL) care, there are limited data available regarding depression existing prior to a lung cancer diagnosis and health care utilization at EOL. Research Objectives. To evaluate the association between depression occurring in the year prior to a diagnosis of stage 3B/4 non-small cell lung cancer (NSCLC), hospice enrollment after diagnosis, and utilization of emergency room (ER) services, hospitalization, and chemotherapy in the last 30 days of life. Methods. We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database with claims from 2007-2013. We identified subjects with depression using International Classification of Diseases, version 9 (ICD-9) codes and prescriptions for antidepressants from the Medicare Part D claims file. Results. Subjects with pre-existing depression (n¼2082, 14%) were more likely to be female, unmarried, white, Medicaid-eligible, and have higher comorbidity scores compared to 12,303 subjects (86%) without depression. Accounting for competing risk of death, depressed subjects were more likely to enroll in hospice care (subhazard ratio 1.19, 95% confidence interval (CI) 1.09-1.30) and less likely to die in hospital (adjusted odds ratio (AOR 0.79, 95% CI 0.65-0.97). We found no association between pre-existing depression and ER services (AOR 0.91, 95% CI 0.77-1.07), inpatient admission (AOR 1.06, 95% CI 0.90-1.25), or chemotherapy (AOR 0.84, 95% CI 0.68-1.05) in the last 30 days of life. Conclusion. Older adults with depression prior to a diagnosis of advanced stage NSCLC were more likely to utilize hospice services compared to those without depression, were less likely to die in the hospital,
Schedule With Abstracts
Appropriateness Panel to review the latest guidelines and evidence and judge appropriateness of various treatment regimens as it pertained to their practice. These results were compared to current (7/2012-6/2013) practice patterns and presented to the faculty group. This exercise informed a template-based point of care intervention led by a clinical champion and leadership that focused on key aspects of clinical and patient-centered care including whether the bone metastases were complicated or uncomplicated, patient prognosis, extent of disease, and travel distance for the patient to the treatment site. We compared rates of lower burden treatment regimens (less than 10 fractions) for 81 pre-intervention patients with 107 metastases treated between 7/2012-6/2013 and 75 post-intervention patients with 94 metastases treated between 5/2015-1/2016. Results. Overall, painful bone metastases were treated with less than 10 fractions more often in the post-intervention period (38% v. 63%, p<0.001). Uncomplicated bone metastases treated with conformal radiation were also more likely to be treated with less than 10 fractions in the post- intervention period (19% v. 52%, p<0.001). One quarter of metastases were treated with SBRT during both the pre and post intervention periods. Conclusion. Leadership support, provider engagement in integrating guidelines into practice, and a note template with point of care clinical reminders can improve rates of appropriate, low-burden radiation oncology treatments for patients with advanced cancer. Implications for research, policy or practice. This strategy can be used to improve appropriateness of radiation therapy.
The Impact of Social Work Encounters on Risk of ICU Admission, ICU Death, and CPR Among Hospitalized Patients with Cancer at End of Life (TH320B) Ivan Chik, MPH, University of Hawaii at Manoa, John A. Burns School of Medicine, Honolulu, HI. Daniel Fischberg, MD PhD FAAHPM, John A Burns School of Medicine, Honolulu, HI. Ilan Bernstein, MD, University of Hawaii at Manoa, John A. Burns School of Medicine, Honolulu, HI. Objectives Describe the role of a social worker in an end-oflife setting.
325
Identify three areas of patient outcomes that can be improved with the presence of social work evaluations. Original Research Background. As hospital based palliative care teams strive to expand their interdisciplinary services, they are often tasked with providing outcomes data to justify additional staff. Research highlighting improvement in patient outcomes can support the need for multiple disciplines within a palliative care team. Research Objectives. The authors of this study aim to determine whether social workers impact the risk of ICU admission, ICU death, and cardiopulmonary resuscitation (CPR) events among hospital decedents followed by a Palliative Care practitioner. Methods. A retrospective chart review was done using data collected between January 1, 2010 and February 29th, 2016 by the Pain and Palliative Care Department at the Queen’s Medical Center. The study population included hospitalized patients with cancer who were followed by the Pain and Palliative Care service prior to any ICU transfer and ultimately died in the inpatient setting. Charts were evaluated for social work visits, ICU admissions, location of death, and CPR. Results. Of the 256 patients who met the inclusion criteria, 196 patients were evaluated by social workers. 11 of 196 (6%) who were seen by a social worker were later admitted to the ICU. Alternatively, 17 of 60 (28%) patients who had not received a social work evaluation were admitted to the ICU. Social work exposure between ICU admits and non-ICU admits was statistically significant OR ¼ .1504 (p<.0001). Similarly, risk of ICU death and presence of CPR was reduced among those who had social work intervention OR ¼ .1538 (p<.0001) and OR ¼ .2841 (p<.05), respectively. Conclusion. Incorporating social workers in the care of patients followed by the Palliative Care team is associated with a significant reduction in risk of ICU admission, ICU death, and CPR.
Implications for research, policy or practice. Growth of interdisciplinary Palliative Care teams to include a higher staffing ratio of social workers may result in fewer ICU admissions at end of life.
Factors Predicting Red Blood Cell Transfusions at the End of Life in Cancer Patients (TH320C) Jason Meadows, MD, Memorial Sloan-Kettering Cancer Center, New York, NY. Jessica Goldberg, MS MSN NP, Memorial Sloan Kettering Cancer Center,
326
Schedule With Abstracts
New York, NY. Raymond Baser, MS, Memorial Sloan Kettering Cancer Center, New York, NY. Objectives Identify 3 factors that predict increased RBC transfusion at end of life in cancer patients. Identify 3 factors that do not predict RBC transfusion at end of life in cancer patients. Original Research Background. In many situations, transfusions clearly improve longevity and/or quality of life (QOL). In terminal cancer patients the riskbenefit balance may sometimes be unclear. Research Objectives. We undertook this retrospective study to understand which non-laboratory factors may predict red blood cell (RBC) transfusion in the last 7 days of life. Methods. Between 10/1/2013 and 9/30/2015, 1248 in-patients with cancer died on medical oncology services at our institution. The primary endpoint was number of RBC units received within 7 days before death. Predictors included patient sex, age, race, religion, state/country of origin, cancer diagnosis, intensive care unit (ICU) death, length of stay (LOS), Do Not Resuscitate status, chaplaincy visits, and palliative medicine consultation. Associations between the predictors and number of RBC units received were evaluated using zero-hurdle negative binomial models to account for large numbers of patients who received zero RBC units. Results. Patients were mostly Caucasian (73%), Christian (58%), local residents (92% from NY/NJ/CT), and male (52%). Just under half (49%) were seen by palliative medicine within 7 days before death. Thirty-eight percent received 1-6 RBC units and 3% received 7 or more units (range 7-23) within 7 days before death. In the multivariable model, patients with leukemia, lymphoma, myeloma, and genitourinary cancers were significantly more likely to receive RBC transfusion. ICU death predicted both receipt of RBC transfusion (OR¼4.7) and higher number of units received (RR¼1.5). Female sex was associated with receiving transfusion (OR¼1.6). In unadjusted analysis, patients who had a palliative medicine consultation were less to likely to receive a transfusion (OR¼0.72) and tended to receive fewer units (RR¼0.72), but this was not significant in multivariable analysis. Conclusion. Sex, cancer type, and ICU death seem to influence end-of-life (EOL) transfusions whereas race, religion, and state/country of origin do not. Palliative consultation may reduce RBC transfusion at EOL for some patients but more research is needed to identify subgroups most impacted.
Implications for research, policy or practice. Research assessing transfusions and longevity/QOL at EOL are needed.
Vol. 53 No. 2 February 2017
Depression and Health Care Utilization at End-of-Life Among Older Adults with NonSmall Cell Lung Cancer (TH320D) Cara McDermott, PharmD PhD, University of Washington, Fred Hutch, Seattle, WA. Scott Ramsey, MD PhD, Fred Hutchinson Cancer Center, Seattle, WA. Aasthaa Bansal, PhD, University of Washington, Seattle, WA. Gary Lyman, MD MPH, Fred Hutchinson Cancer Research Center, Seattle, WA. Sean Sullivan, PhD, University of Washington, Seattle, WA. Objectives Describe the prevalence of pre-existing depression in this population. Characterize the relationship between pre-existing depression, hospice and EOL services in this population. Original Research Background. Depression is common among cancer patients. While research has explored the association between psychological distress during and after cancer treatment and use of high intensity end-of-life (EOL) care, there are limited data available regarding depression existing prior to a lung cancer diagnosis and health care utilization at EOL. Research Objectives. To evaluate the association between depression occurring in the year prior to a diagnosis of stage 3B/4 non-small cell lung cancer (NSCLC), hospice enrollment after diagnosis, and utilization of emergency room (ER) services, hospitalization, and chemotherapy in the last 30 days of life. Methods. We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database with claims from 2007-2013. We identified subjects with depression using International Classification of Diseases, version 9 (ICD-9) codes and prescriptions for antidepressants from the Medicare Part D claims file. Results. Subjects with pre-existing depression (n¼2082, 14%) were more likely to be female, unmarried, white, Medicaid-eligible, and have higher comorbidity scores compared to 12,303 subjects (86%) without depression. Accounting for competing risk of death, depressed subjects were more likely to enroll in hospice care (subhazard ratio 1.19, 95% confidence interval (CI) 1.09-1.30) and less likely to die in hospital (adjusted odds ratio (AOR 0.79, 95% CI 0.65-0.97). We found no association between pre-existing depression and ER services (AOR 0.91, 95% CI 0.77-1.07), inpatient admission (AOR 1.06, 95% CI 0.90-1.25), or chemotherapy (AOR 0.84, 95% CI 0.68-1.05) in the last 30 days of life. Conclusion. Older adults with depression prior to a diagnosis of advanced stage NSCLC were more likely to utilize hospice services compared to those without depression, were less likely to die in the hospital,