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Kamal, Arif H

Overview:

health services and outcomes research, information-technology enabled registries, supportive oncology and palliative care, quality assessment and improvement

Positions:

Associate Professor of Medicine

Medicine, Medical Oncology
School of Medicine

Associate Professor of Business Administratin

Fuqua School of Business
Fuqua School of Business

Member of the Duke Cancer Institute

Duke Cancer Institute
School of Medicine

Member in the Duke Clinical Research Institute

Duke Clinical Research Institute
School of Medicine

Education:

M.D. 2005

M.D. — University of Missouri - Kansas City School of Medicine

M.H.S. 2015

M.H.S. — Duke University

M.B.A. 2016

M.B.A. — University of Massachusetts at Amherst

News:

Grants:

Which palliative care quality measures improve patient-centered outcomes?

Administered By
Duke Cancer Institute
AwardedBy
Agency for Healthcare Research and Quality
Role
Principal Investigator
Start Date
September 30, 2015
End Date
September 29, 2020

Which palliative care quality measures improve patient-centered outcome?

Administered By
Duke Cancer Institute
AwardedBy
Cambia Health Foundation
Role
Principal Investigator
Start Date
October 15, 2014
End Date
April 15, 2017

A Pilot Study on H.O.P.E: Helping Ovarian Cancer Patients Cope with Disease Recurrence

Administered By
Obstetrics and Gynecology, Gynecologic Oncology
AwardedBy
Foundation for Women's Cancer
Role
Co Investigator
Start Date
April 01, 2014
End Date
March 31, 2016

Development of national registry for patients receiving primary care in the home

Administered By
Duke Clinical Research Institute
AwardedBy
University of California - San Francisco
Role
Principal Investigator
Start Date
May 01, 2014
End Date
December 15, 2015

Increasing Patient and System Value with Community Based Palliative Care

Administered By
Duke Clinical Research Institute
AwardedBy
Four Seasons
Role
Co Investigator
Start Date
September 01, 2014
End Date
August 31, 2015

Integrating Palliative Care in Oncology Practice

Administered By
Duke Clinical Research Institute
AwardedBy
American Society of Clinical Oncology
Role
Principal Investigator
Start Date
August 19, 2013
End Date
November 30, 2014
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Publications:

One Size Does Not Fit All: Disease Profiles of Serious Illness Patients Receiving Specialty Palliative Care.

Understanding the symptom profiles of seriously ill patients who receive palliative care, especially noncancer diagnoses where the data are sparse and are critical to better targeting our resources to the needs of patients.We performed a retrospective, multicohort study of patients evaluated during their first consultative palliative care visit in a community-based palliative care registry. We placed into one of seven major disease categories based on clinician-reported primary diagnosis for consultation. Our primary aim of this analysis was to determine the univariate association between several patient-specific characteristics (e.g., demographics, care of setting, initial screening score) and the primary diagnosis.We evaluated the first visit consultation records of 1615 patients. Most prevalent diagnosis was Neurologic (564; 35%), followed by Cardiovascular (266; 16%), Pulmonary (229; 14%), and Cancer (208; 13%). Patients in the study with the highest symptom burden were those diagnosed with cancer or pulmonary disease, with 45% and 37% of cancer and pulmonary patients, respectively, having two or more moderate-to-severe symptoms; 26% of cardiovascular disease patients reported two or more moderate-to-severe symptoms, whereas 11% reported three or more. Patients with a neurologic or infectious diagnosis had less symptom burden, but a large percentage of neurologic patients were unable to respond.This study is one of the first to describe symptom burden and functional scores by diagnostic categories and care settings across a community-based interdisciplinary specialty palliative care program. Results demonstrated statistically significant and clinically relevant differences among settings of care, functional status, and symptom profiles between patients with various serious illnesses.

Authors
Kamal, AH; Taylor, DH; Neely, B; Harker, M; Bhullar, P; Morris, J; Bonsignore, L; Bull, J
MLA Citation
Kamal, AH, Taylor, DH, Neely, B, Harker, M, Bhullar, P, Morris, J, Bonsignore, L, and Bull, J. "One Size Does Not Fit All: Disease Profiles of Serious Illness Patients Receiving Specialty Palliative Care." Journal of pain and symptom management 54.4 (October 2017): 476-483.
PMID
28751079
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
54
Issue
4
Publish Date
2017
Start Page
476
End Page
483
DOI
10.1016/j.jpainsymman.2017.07.035

Redesigning Oncology Care Delivery: Early Wins, Lessons Learned, and a Roadmap.

Authors
Kamal, AH
MLA Citation
Kamal, AH. "Redesigning Oncology Care Delivery: Early Wins, Lessons Learned, and a Roadmap." Medical care 55.10 (October 2017): 871-872.
PMID
28906312
Source
epmc
Published In
Medical Care
Volume
55
Issue
10
Publish Date
2017
Start Page
871
End Page
872
DOI
10.1097/mlr.0000000000000799

Redesigning Oncology Care Delivery: Early Wins, Lessons Learned, and a Roadmap.

Authors
Kamal, AH
MLA Citation
Kamal, AH. "Redesigning Oncology Care Delivery: Early Wins, Lessons Learned, and a Roadmap." Medical care (September 15, 2017).
PMID
28922299
Source
epmc
Published In
Medical Care
Publish Date
2017
DOI
10.1097/mlr.0000000000000799

Oncology and Palliative Care Integration: Cocreating Quality and Value in the Era of Health Care Reform.

Recent payment reforms in health care have spurred thinking regarding how strengthened partnerships can cocreate quality and value. Oncology is an important area in which to consider further collaborations in patient care, as a result of increasing treatment complexity from an expanding armamentarium of interventions, large resource expenditures related to cancer care, and a growing disease prevalence related to an aging population. Many have highlighted the important role of palliative care in the routine care of patients with advanced cancer and high symptom burden. Yet, how integration can occur that translates research into usual clinical practice while prioritizing the right patients and settings to maximize outcomes of interest has been inadequately described. We review the evidence for integration of palliative care into routine oncology care and then map the benefits to the requirements put forward by the Centers for Medicare and Medicaid Services Oncology Care Model as a use case; we also discuss applications to other evolving payment models.

Authors
Kaufmann, TL; Kamal, AH
MLA Citation
Kaufmann, TL, and Kamal, AH. "Oncology and Palliative Care Integration: Cocreating Quality and Value in the Era of Health Care Reform." Journal of oncology practice 13.9 (September 2017): 580-588.
PMID
28682666
Source
epmc
Published In
Journal of Oncology Practice
Volume
13
Issue
9
Publish Date
2017
Start Page
580
End Page
588
DOI
10.1200/jop.2017.023762

Improvements in Patient and Health System Outcomes Using an Integrated Oncology and Palliative Medicine Approach on a Solid Tumor Inpatient Service.

Early palliative care (PC) improves outcomes for outpatients with advanced cancer. Its effect on hospitalized patients with cancer is unknown. Herein, we report on the influence of a novel, fully integrated inpatient medical oncology and PC partnership at a tertiary medical center during its first year of implementation.We conducted a retrospective, longitudinal, pre- and postintervention cohort study at Duke University Hospital. Pre- and postintervention cohorts were defined as all patients admitted to the solid tumor inpatient service from September 1, 2009, to June 30, 2010, and September 1, 2011 to June 30, 2012, respectively. We extracted patient data, including demographics, cancer diagnosis, disease status, length of stay, intensive care unit transfer rate, discharge disposition, time to emergency department return, time to readmission, and 7- and 30-day emergency department return and readmission rates. Nursing and physician surveys assessed satisfaction. Descriptive statistics, and Kruskal-Wallis and Χ2 tests were used to describe and compare cohorts. A generalized estimating equation accounted for repeated measures.Pre- and postintervention analysis cohorts included 731 and 783 patients, respectively, representing a total of 1,514 patients and 2,353 encounters. Cohorts were similar in baseline characteristics. Statistically significant lower odds in 7-day readmission rates were observed in the postintervention cohort (adjusted odds ratio, 0.76; 95% CI, 0.58 to 1.00; P = .0482). Patients in the postintervention group had a decrease in mean length of stay (-0.30 days; 95% CI, -0.62 to 0.02); P = .0651). We observed a trend for increasing hospice referrals ( P = .0837) and a 15% decrease in intensive care unit transfers ( P = .61). Physicians and nurses universally favored the model.A fully integrated inpatient partnership between PC and medical oncology is associated with significant and clinically meaningful improvements in key health system-related outcomes and indicators of quality cancer care.

Authors
Riedel, RF; Slusser, K; Power, S; Jones, CA; LeBlanc, TW; Kamal, AH; Desai, D; Allen, D; Yu, Y; Wolf, S; Galanos, AN
MLA Citation
Riedel, RF, Slusser, K, Power, S, Jones, CA, LeBlanc, TW, Kamal, AH, Desai, D, Allen, D, Yu, Y, Wolf, S, and Galanos, AN. "Improvements in Patient and Health System Outcomes Using an Integrated Oncology and Palliative Medicine Approach on a Solid Tumor Inpatient Service." Journal of oncology practice 13.9 (September 2017): e738-e748.
PMID
28796559
Source
epmc
Published In
Journal of Oncology Practice
Volume
13
Issue
9
Publish Date
2017
Start Page
e738
End Page
e748
DOI
10.1200/jop.2017.022749

Standardization and Scaling of a Community-Based Palliative Care Model.

Although limited, the descriptions of Community-Based Palliative Care (CBPC) demonstrates variability in team structures, eligibility, and standardization across care settings.In 2014, Four Seasons Compassion for Life, a nonprofit hospice and palliative care (PC) organization in Western North Carolina (WNC), was awarded a Centers for Medicare and Medicaid Services Health Care Innovation (CMMI) Award to expand upon their existing innovative model to implement, evaluate, and demonstrate CBPC in the United States. The objective of this article is to describe the processes and challenges of scaling and standardizing the CBPC model.Four Season's CBPC model serves patients in both inpatient and outpatient settings using an interdisciplinary team to address symptom management, psychosocial/spiritual care, advance care planning, and patient/family education. Medicare beneficiaries who are ≥65 years of age with a life-limiting illness were eligible for the CMMI project.The CBPC model was scaled across numerous counties in WNC and Upstate South Carolina. Over the first two years of the project, scaling occurred into 21 counties with the addition of 2 large hospitals, 52 nursing facilities, and 2 new clinics. To improve efficiency and effectiveness, a PC screening referral guide and a risk stratification approach were developed and implemented. Care processes, including patient referral and initial visit, were mapped.This article describes an interdisciplinary CBPC model in all care settings to individuals with life-limiting illness and offers guidance for risk stratification assessments and mapping care processes that may help PC programs as they develop and work to improve efficiencies.

Authors
Bull, J; Kamal, AH; Harker, M; Taylor, DH; Bonsignore, L; Morris, J; Massie, L; Bhullar, PS; Howell, M; Hendrix, M; Bennett, D; Abernethy, A
MLA Citation
Bull, J, Kamal, AH, Harker, M, Taylor, DH, Bonsignore, L, Morris, J, Massie, L, Bhullar, PS, Howell, M, Hendrix, M, Bennett, D, and Abernethy, A. "Standardization and Scaling of a Community-Based Palliative Care Model." Journal of palliative medicine (August 16, 2017).
PMID
28813635
Source
epmc
Published In
Journal of Palliative Medicine
Publish Date
2017
DOI
10.1089/jpm.2017.0027

Quality Improvement Pearls for the Palliative Care and Hospice Professional.

Rapid changes in how palliative care clinicians are evaluated and paid present an imperative for clinicians to adeptly and routinely perform quality improvement in usual practice. Like empathic communication and facilitating goals of care discussions, quality improvement skills must be learned, honed, and practiced so identifying problems and brainstorming solutions becomes a natural component of delivering serious illness care. Using our experience in both failures and successes in performing quality improvement, herein we provide a prioritized list of ten pearls specifically aimed to palliative care and hospice professionals. We aim to demystify quality improvement, highlight areas where rigor and a systematic approach are needed for success, and offer our own lessons learned and mistakes made to promote success for our colleagues and our field.

Authors
Kamal, AH; Nicolla, JM; Power, S
MLA Citation
Kamal, AH, Nicolla, JM, and Power, S. "Quality Improvement Pearls for the Palliative Care and Hospice Professional." Journal of pain and symptom management (August 11, 2017).
PMID
28807707
Source
epmc
Published In
Journal of Pain and Symptom Management
Publish Date
2017
DOI
10.1016/j.jpainsymman.2017.07.040

Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care.

Authors
Chino, F; Peppercorn, JM; Rushing, C; Kamal, AH; Altomare, I; Samsa, G; Zafar, SY
MLA Citation
Chino, F, Peppercorn, JM, Rushing, C, Kamal, AH, Altomare, I, Samsa, G, and Zafar, SY. "Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care." JAMA oncology (August 10, 2017).
PMID
28796862
Source
epmc
Published In
JAMA oncology
Publish Date
2017
DOI
10.1001/jamaoncol.2017.2148

A survey to evaluate facilitators and barriers to quality measurement and improvement: Adapting tools for implementation research in palliative care programs.

Though critical for improving patient outcomes, palliative care quality indicators are not yet widely used. Better understanding of facilitators and barriers to palliative care quality measurement and improvement might improve their use and program quality.Development of a survey tool to assess palliative care team perspectives on facilitators and barriers to quality measurement and improvement in palliative care programs.We used the adapted Consolidated Framework for Implementation Research to define domains and constructs to select instruments. We assembled a draft survey and assessed content validity through pilot testing and cognitive interviews with experts and front-line practitioners for key items. We analyzed responses using a constant comparative process to assess survey item issues and potential solutions. We developed a final survey using these results.The survey includes five published instruments and two additional item sets. Domains include organizational characteristics, individual and team characteristics, intervention characteristics and process of implementation. Survey modules include Quality Improvement in Palliative Care, Implementing Quality Improvement in the Palliative Care Program, Teamwork and Communication, Measuring the Quality of Palliative Care, and Palliative Care Quality in Your Program. Key refinements from cognitive interviews included item wording on palliative care team members, programs and quality issues.This novel, adaptable instrument assesses palliative care team perspectives on barriers and facilitators for quality measurement and improvement in palliative care programs. Next steps include evaluation of the survey's construct validity and how survey results correlate with findings from program quality initiatives.

Authors
Dy, SM; Al Hamayel, NA; Hannum, SM; Sharma, R; Isenberg, SR; Kuchinad, K; Zhu, J; Smith, K; Lorenz, KA; Kamal, AH; Walling, AM; Weaver, SJ
MLA Citation
Dy, SM, Al Hamayel, NA, Hannum, SM, Sharma, R, Isenberg, SR, Kuchinad, K, Zhu, J, Smith, K, Lorenz, KA, Kamal, AH, Walling, AM, and Weaver, SJ. "A survey to evaluate facilitators and barriers to quality measurement and improvement: Adapting tools for implementation research in palliative care programs." Journal of pain and symptom management (August 8, 2017).
PMID
28801007
Source
epmc
Published In
Journal of Pain and Symptom Management
Publish Date
2017
DOI
10.1016/j.jpainsymman.2017.06.008

The quality improvement environment: Results of the 2016 AAHPM/HPNA membership needs assessment survey.

The American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA) convened the Measuring What Matters (MWM) initiative in 2013, which recommended ten quality performance measures; yet, little is known about the quality improvement (QI) environment and implementation of the MWM among hospices and palliative care services.To describe the findings of the 2016 AAHPM/HPNA Needs Assessment survey exploring the QI environment among hospice and palliative care services.An online survey was distributed to approximately 16,500 AAHPM and HPNA members and other hospice and palliative care organizations were invited to respond. Summary data and individual write-in responses were collated and analyzed. Data analysis included generating descriptive statistics and analyzing individual write-in responses for additional information and themes.Over 1,000 responses were received. Most organizations had a designated QI leader and used an electronic medical record. Less than 50% of systems had fields for palliative care information. The top three MWM measures collected through an electronic medical record were: pain treatment (66%), screening for physical symptoms (55%) and comprehensive assessment (54%). The most common barrier to implementing QI was time constraint. Most respondents had received no training and education in how to implement QI.The 2016 AAHPM/HPNA Needs Assessment survey provided important information about the QI systems and measurement environment within hospice and palliative care services. Survey insights can aid AAHPM/HPNA in developing resources to empower hospice and palliative care clinicians to make QIs that matter for their patients and families.

Authors
Lindley, LC; Rotella, JD; Ast, K; Matzo, M; Kamal, AH
MLA Citation
Lindley, LC, Rotella, JD, Ast, K, Matzo, M, and Kamal, AH. "The quality improvement environment: Results of the 2016 AAHPM/HPNA membership needs assessment survey." Journal of pain and symptom management (July 24, 2017).
PMID
28751078
Source
epmc
Published In
Journal of Pain and Symptom Management
Publish Date
2017
DOI
10.1016/j.jpainsymman.2017.07.031

Tracking Patients in Community Based Palliative Care through the Centers for Medicare and Medicaid Services Healthcare Innovation Project.

Although limited, the evidence base for Community Based Palliative Care (CBPC) has shown that it improves patient health outcomes, increases satisfaction, and decreases cost. Minimal data exist comparing points of entry into palliative care and patient transition outcomes.In 2014, Four Seasons Compassion for Life was awarded a Centers for Medicare & Medicaid Services Healthcare Innovation Award to expand an existing CBPC model into additional counties and to propose a new payment approach. The goal of this article is to evaluate the tracking of point of entry into palliative care and patient transition outcomes in the model.All participant transition outcomes are tracked from point of entry, including large and small hospitals, nursing facilities, and home/clinic. Evaluation of tracking data was conducted over the first two years of the project (September 1, 2014-September 1, 2016).A total of 2482 patients entered the project, 905 through smaller hospitals (<300 beds, 32%), 474 through larger hospital systems (>500 beds, 17%), 823 from nursing facilities (29%), and 640 in the home/clinic (22%). Hospice transition was highest with home/clinic referrals, followed by nursing facilities, smaller hospitals, and larger hospitals. Palliative care deaths and discharges are higher in larger hospitals. Re-enrollment back into palliative care after previous discharge occurred in 177 (17.8%) of discharged patients.CBPC leads to the highest percentage of hospice transitions coming from the home/clinic setting. Differences between small and large hospitals demonstrate a different patient population with higher transitions to hospice and lower palliative care deaths in smaller hospitals.

Authors
Bull, J; Kamal, AH; Harker, M; Bonsignore, L; Morris, J; Massie, L; Bhullar, PS; Hendrix, M; Bennett, D; Taylor, D
MLA Citation
Bull, J, Kamal, AH, Harker, M, Bonsignore, L, Morris, J, Massie, L, Bhullar, PS, Hendrix, M, Bennett, D, and Taylor, D. "Tracking Patients in Community Based Palliative Care through the Centers for Medicare and Medicaid Services Healthcare Innovation Project." Journal of palliative medicine (July 7, 2017).
PMID
28686512
Source
epmc
Published In
Journal of Palliative Medicine
Publish Date
2017
DOI
10.1089/jpm.2017.0080

Unmet Needs of African Americans and Whites at the Time of Palliative Care Consultation.

Differences among patient populations that present to consultative palliative care are not known. Such an appreciation would inform health-care delivery tailored to unique populations.We aimed to compare characteristics and palliative care needs of African Americans (AAs) and whites during initial palliative care consultation.We analyzed patient-reported, clinician-entered clinical encounter data from a large, multisite community-based, nonhospice palliative care collaborative. We included first specialty palliative care consultations from January 1, 2014, to July 2, 2015, across 15 sites within the Global Palliative Care Quality Alliance registry. Demographics, disease, performance status, advance care planning, and symptom prevalence/severity were compared.Of 775 patients, 12.9% (N = 100) were AA. African Americans were younger (63 vs 75.4 years, P < .0001). A larger proportion of AAs had a diagnosis of cancer (45.0% vs 36.3%, P = .09) and in the hospital (71% vs 61.8%, P = .07). African Americans were more likely to have a Palliative Performance Score of 0 to 30 (35.6% vs 23.7%, P = .049). Around 50% in both racial groups were full code; slightly more than 40% had an advance directive. Nearly two-thirds in both racial groups reported 3 or more symptoms of any severity; one-third reported 3 or more moderate or severe symptoms. A larger proportion of Africans than whites reported pain of any severity (66.0% vs 56.1%, P = .06).All patients present to palliative care consultations with significant symptom and advance care planning needs. Further research is needed to identify how to deliver palliative care: earlier, in noncancer conditions, and improve pain management in AA populations.

Authors
Kamal, AH; Bull, J; Wolf, SP; Portman, D; Strand, J; Johnson, KS
MLA Citation
Kamal, AH, Bull, J, Wolf, SP, Portman, D, Strand, J, and Johnson, KS. "Unmet Needs of African Americans and Whites at the Time of Palliative Care Consultation." The American journal of hospice & palliative care 34.5 (June 2017): 461-465.
PMID
26888883
Source
epmc
Published In
American Journal of Hospice & Palliative Medicine
Volume
34
Issue
5
Publish Date
2017
Start Page
461
End Page
465
DOI
10.1177/1049909116632508

Addressing Palliative Care Clinician Burnout in Organizations: A Workforce Necessity, an Ethical Imperative.

Clinician burnout reduces the capacity for providers and health systems to deliver timely, high quality, patient-centered care and increases the risk that clinicians will leave practice. This is especially problematic in hospice and palliative care: patients are often frail, elderly, vulnerable, and complex; access to care is often outstripped by need; and demand for clinical experts will increase as palliative care further integrates into usual care. Efforts to mitigate and prevent burnout currently focus on individual clinicians. However, analysis of the problem of burnout should be expanded to include both individual- and systems-level factors as well as solutions; comprehensive interventions must address both. As a society, we hold organizations responsible for acting ethically, especially when it relates to deployment and protection of valuable and constrained resources. We should similarly hold organizations responsible for being ethical stewards of the resource of highly trained and talented clinicians through comprehensive programs to address burnout.

Authors
Harrison, KL; Dzeng, E; Ritchie, CS; Shanafelt, TD; Kamal, AH; Bull, JH; Tilburt, JC; Swetz, KM
MLA Citation
Harrison, KL, Dzeng, E, Ritchie, CS, Shanafelt, TD, Kamal, AH, Bull, JH, Tilburt, JC, and Swetz, KM. "Addressing Palliative Care Clinician Burnout in Organizations: A Workforce Necessity, an Ethical Imperative." Journal of pain and symptom management 53.6 (June 2017): 1091-1096.
PMID
28196784
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
53
Issue
6
Publish Date
2017
Start Page
1091
End Page
1096
DOI
10.1016/j.jpainsymman.2017.01.007

Comparing the Palliative Care Needs of Those With Cancer to Those With Common Non-Cancer Serious Illness.

Historically, palliative care has been focused on those with cancer. Although these ties persist, palliative care is rapidly integrating into the care of patients with common, non-cancer serious illnesses. Despite this, the bulk of literature informing palliative care practices stems from the care of cancer patients.We compared functionality, advanced care planning, hospital admissions, prognosis, quality of life, pain, dyspnea, fatigue, and depression between patients with cancer and three non-cancer diagnoses-end-stage renal disease (ESRD), heart failure (HF), and chronic obstructive pulmonary disease (COPD).We conducted a cross-sectional, retrospective analysis of the characteristics and symptoms of patient's with ESRD, HF, COPD, and cancer at time of first specialty palliative care referral. Using a web-based point of care quality assessment and reporting tool, Quality Data and Collection Tool-Palliative care, this analysis evaluated all eligible patients who received a palliative care consultation between October 1, 2012 and November 25, 2014. Data were obtained from 13 participating sites. The primary outcome for the study was functionality using the palliative performance scale. Hospital admission in the last 30 days, prognosis, patient's understanding of prognosis, advanced care planning including code status and appointed decision maker, pain, fatigue, depression, and dyspnea were also evaluated as secondary outcomes. We tested for an association between our outcomes with disease type (cancer vs. non-cancer) fitting multivariable logistic regression models.We found that the patients with primary diagnoses other than cancer were less functional at time of referral (odds ratio: 1.6; 95% CI: 1.1, 2.3; P < 0.05).Patients with COPD, ESRD, and HF were less functional and more likely to be hospitalized at time of referral to palliative care than cancer patients. These findings may be reflective of the slower and more varied trajectory of non-cancer serious illness. One aim of palliative care for those with non-cancer severe illness should be directed toward improving and assisting with functionality and decreasing frequency of hospital admissions. These interventions could take place in the palliative care office, but could also be integrated into hospital discharge plans.

Authors
Bostwick, D; Wolf, S; Samsa, G; Bull, J; Taylor, DH; Johnson, KS; Kamal, AH
MLA Citation
Bostwick, D, Wolf, S, Samsa, G, Bull, J, Taylor, DH, Johnson, KS, and Kamal, AH. "Comparing the Palliative Care Needs of Those With Cancer to Those With Common Non-Cancer Serious Illness." Journal of pain and symptom management 53.6 (June 2017): 1079-1084.e1.
PMID
28457746
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
53
Issue
6
Publish Date
2017
Start Page
1079
End Page
1084.e1
DOI
10.1016/j.jpainsymman.2017.02.014

Why Burnout Is So Hard to Fix.

Authors
Back, AL; Steinhauser, KE; Kamal, AH; Jackson, VA
MLA Citation
Back, AL, Steinhauser, KE, Kamal, AH, and Jackson, VA. "Why Burnout Is So Hard to Fix." Journal of oncology practice 13.6 (June 2017): 348-351.
PMID
28493762
Source
epmc
Published In
Journal of Oncology Practice
Volume
13
Issue
6
Publish Date
2017
Start Page
348
End Page
351
DOI
10.1200/jop.2017.021964

"It Is Like Heart Failure. It Is Chronic … and It Will Kill You": A Qualitative Analysis of Burnout Among Hospice and Palliative Care Clinicians.

Although prior surveys have identified rates of self-reported burnout among palliative care clinicians as high as 62%, limited data exist to elucidate the causes, ameliorators, and effects of this phenomenon.We explored burnout among palliative care clinicians, specifically their experiences with burnout, their perceived sources of burnout, and potential individual, interpersonal, organizational, and policy-level solutions to address burnout.During the 2014 American Academy of Hospice and Palliative Medicine/Hospice and Palliative Nurses Association Annual Assembly, we conducted three focus groups to examine personal narratives of burnout, how burnout differs within hospice and palliative care, and strategies to mitigate burnout. Two investigators independently analyzed data using template analysis, an inductive/deductive qualitative analytic technique.We interviewed 20 palliative care clinicians (14 physicians, four advanced practice providers, and two social workers). Common sources of burnout included increasing workload, tensions between nonspecialists and palliative care specialists, and regulatory issues. We heard grave concerns about the stability of the palliative care workforce and concerns about providing high-quality palliative care in light of a distressed and overburdened discipline. Participants proposed antiburnout solutions, including promoting the provision of generalist palliative care, frequent rotations on-and-off service, and organizational support for self-care. We observed variability in sources of burnout between clinician type and by practice setting, such as role monotony among full-time clinicians.Our results reinforce and expand on the severity and potential ramifications of burnout on the palliative care workforce. Future research is needed to confirm our findings and investigate interventions to address or prevent burnout.

Authors
Kavalieratos, D; Siconolfi, DE; Steinhauser, KE; Bull, J; Arnold, RM; Swetz, KM; Kamal, AH
MLA Citation
Kavalieratos, D, Siconolfi, DE, Steinhauser, KE, Bull, J, Arnold, RM, Swetz, KM, and Kamal, AH. ""It Is Like Heart Failure. It Is Chronic … and It Will Kill You": A Qualitative Analysis of Burnout Among Hospice and Palliative Care Clinicians." Journal of pain and symptom management 53.5 (May 2017): 901-910.e1.
PMID
28063867
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
53
Issue
5
Publish Date
2017
Start Page
901
End Page
910.e1
DOI
10.1016/j.jpainsymman.2016.12.337

Making the Right Thing Easier to Do: Standardized Integration of Oncology and Palliative Care.

Authors
Kamal, AH; Kaufmann, T
MLA Citation
Kamal, AH, and Kaufmann, T. "Making the Right Thing Easier to Do: Standardized Integration of Oncology and Palliative Care." Journal of oncology practice 13.5 (May 2017): 291-292.
PMID
28414555
Source
epmc
Published In
Journal of Oncology Practice
Volume
13
Issue
5
Publish Date
2017
Start Page
291
End Page
292
DOI
10.1200/jop.2017.021717

Assessing Psychological Toxicity and Patient-Reported Distress as the Sixth Vital Sign in Cancer Care and Clinical Trials.

As the number of available cancer therapies continues to grow, there is increasing interest in their impact on cancer patients' lived experiences. Screening for distress is one way to measure psychological dimensions of cancer patients' experiences, and doing so is increasingly part of standard operations at major cancer centers across the US. To date, however, most clinical trials have not adequately captured patients' experiences as part of their outcome assessments, so clinicians lack data needed to guide their responses to psychological features of patients' illness experiences. As distress becomes the "sixth vital sign" in routine cancer care, we argue that clinical trials should assess patients' experiences in the same way that they robustly screen for adverse events and toxicities. New interventions are needed to address distress.

Authors
LeBlanc, TW; Kamal, AH
MLA Citation
LeBlanc, TW, and Kamal, AH. "Assessing Psychological Toxicity and Patient-Reported Distress as the Sixth Vital Sign in Cancer Care and Clinical Trials." AMA journal of ethics 19.5 (May 2017): 460-466.
PMID
28553903
Source
epmc
Published In
AMA journal of ethics
Volume
19
Issue
5
Publish Date
2017
Start Page
460
End Page
466
DOI
10.1001/journalofethics.2017.19.5.stas1-1705

Remembering Our True North: Realizing Exceptional Cancer Quality in an Era of Exceptional Change.

Authors
Kamal, AH
MLA Citation
Kamal, AH. "Remembering Our True North: Realizing Exceptional Cancer Quality in an Era of Exceptional Change." Journal of oncology practice 13.4 (April 2017): 217-218.
PMID
28245146
Source
epmc
Published In
Journal of Oncology Practice
Volume
13
Issue
4
Publish Date
2017
Start Page
217
End Page
218
DOI
10.1200/jop.2016.020131

Operationalizing the Measuring What Matters Spirituality Quality Metric in a Population of Hospitalized, Critically Ill Patients and Their Family Members

Authors
Aslakson, RA; Kweku, J; Kinnison, M; Singh, S; Crowe, TY; Aslakson, RA; Ast, K; Elk, R; Garner, KK; Gramling, R; Grudzen, C; Kamal, AH; Lamba, S; LeBlanc, TW; Rhodes, RL; Roeland, E; Schulman-Green, D; Unroe, KT
MLA Citation
Aslakson, RA, Kweku, J, Kinnison, M, Singh, S, Crowe, TY, Aslakson, RA, Ast, K, Elk, R, Garner, KK, Gramling, R, Grudzen, C, Kamal, AH, Lamba, S, LeBlanc, TW, Rhodes, RL, Roeland, E, Schulman-Green, D, and Unroe, KT. "Operationalizing the Measuring What Matters Spirituality Quality Metric in a Population of Hospitalized, Critically Ill Patients and Their Family Members." Journal of Pain and Symptom Management 53.3 (March 2017): 650-655.
Source
crossref
Published In
Journal of Pain and Symptom Management
Volume
53
Issue
3
Publish Date
2017
Start Page
650
End Page
655
DOI
10.1016/j.jpainsymman.2016.12.323

Future of the Palliative Care Workforce: Preview to an Impending Crisis.

Authors
Kamal, AH; Bull, JH; Swetz, KM; Wolf, SP; Shanafelt, TD; Myers, ER
MLA Citation
Kamal, AH, Bull, JH, Swetz, KM, Wolf, SP, Shanafelt, TD, and Myers, ER. "Future of the Palliative Care Workforce: Preview to an Impending Crisis." The American journal of medicine 130.2 (February 2017): 113-114.
PMID
27687068
Source
epmc
Published In
The American Journal of Medicine
Volume
130
Issue
2
Publish Date
2017
Start Page
113
End Page
114
DOI
10.1016/j.amjmed.2016.08.046

Non-metastatic and metastatic breast cancer patients' priorities when considering a treatment decision

Authors
Buzaglo, JS; Miller, MF; Longacre, M; Kamal, AH
MLA Citation
Buzaglo, JS, Miller, MF, Longacre, M, and Kamal, AH. "Non-metastatic and metastatic breast cancer patients' priorities when considering a treatment decision." February 2017.
Source
wos-lite
Published In
Cancer Research
Volume
77
Publish Date
2017
DOI
10.1158/1538-7445.SABCS16-P4-19-01

Physician Aid in Dying in the US South: What Does the Future Hold?

Authors
Swetz, KM; Barnett, MD; Kamal, AH; Mansel, JK
MLA Citation
Swetz, KM, Barnett, MD, Kamal, AH, and Mansel, JK. "Physician Aid in Dying in the US South: What Does the Future Hold?." Southern medical journal 110.1 (January 2017): 9-10.
PMID
28052167
Source
epmc
Published In
Southern Medical Journal
Volume
110
Issue
1
Publish Date
2017
Start Page
9
End Page
10
DOI
10.14423/smj.0000000000000582

Concordance Between Veterans' Self-Report and Documentation of Surrogate Decision Makers: Implications for Quality Measurement

Authors
Garner, KK; Dubbert, P; Lensing, S; Sullivan, DH; Aslakson, RA; Ast, K; Elk, R; Garner, KK; Gramling, R; Grudzen, C; Kamal, AH; Lamba, S; LeBlanc, TW; Rhodes, RL; Roeland, E; Schulman-Green, D; Unroe, KT
MLA Citation
Garner, KK, Dubbert, P, Lensing, S, Sullivan, DH, Aslakson, RA, Ast, K, Elk, R, Garner, KK, Gramling, R, Grudzen, C, Kamal, AH, Lamba, S, LeBlanc, TW, Rhodes, RL, Roeland, E, Schulman-Green, D, and Unroe, KT. "Concordance Between Veterans' Self-Report and Documentation of Surrogate Decision Makers: Implications for Quality Measurement." Journal of Pain and Symptom Management 53.1 (January 2017): 1-4.
Source
crossref
Published In
Journal of Pain and Symptom Management
Volume
53
Issue
1
Publish Date
2017
Start Page
1
End Page
4
DOI
10.1016/j.jpainsymman.2016.10.356

Top 10 Tips for Using Advance Care Planning Codes in Palliative Medicine and Beyond.

Although recommended for all persons with serious illness, advance care planning (ACP) has historically been a charitable clinical service. Inadequate or unreliable provisions for reimbursement, among other barriers, have spurred a gap between the evidence demonstrating the importance of timely ACP and recognition by payers for its delivery.1 For the first time, healthcare is experiencing a dramatic shift in billing codes that support increased care management and care coordination. ACP, chronic care management, and transitional care management codes are examples of this newer recognition of the value of these types of services. ACP discussions are an integral component of comprehensive, high-quality palliative care delivery. The advent of reimbursement mechanisms to recognize these services has an enormous potential to impact palliative care program sustainability and growth. In this article, we highlight 10 tips to effectively using the new ACP codes reimbursable under Medicare. The importance of documentation, proper billing, and nuances regarding coding is addressed.

Authors
Jones, CA; Acevedo, J; Bull, J; Kamal, AH
MLA Citation
Jones, CA, Acevedo, J, Bull, J, and Kamal, AH. "Top 10 Tips for Using Advance Care Planning Codes in Palliative Medicine and Beyond." Journal of palliative medicine 19.12 (December 2016): 1249-1253.
PMID
27682147
Source
epmc
Published In
Journal of Palliative Medicine
Volume
19
Issue
12
Publish Date
2016
Start Page
1249
End Page
1253
DOI
10.1089/jpm.2016.0202

"Who Does What?" Ensuring High-Quality and Coordinated Palliative Care With Our Oncology Colleagues.

Authors
Kamal, AH
MLA Citation
Kamal, AH. ""Who Does What?" Ensuring High-Quality and Coordinated Palliative Care With Our Oncology Colleagues." Journal of pain and symptom management 52.6 (December 2016): e1-e2. (Letter)
PMID
27686601
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
52
Issue
6
Publish Date
2016
Start Page
e1
End Page
e2
DOI
10.1016/j.jpainsymman.2016.08.001

Performance of Consultative Palliative Care Model in Achieving Quality Metrics in the ICU.

Quality metrics for intensive care unit (ICU)-based palliative care have been proposed, but it is unknown how consultative palliative care can contribute to performance on these measures.Assess adherence to proposed quality metrics of ICU-based palliative care by palliative care specialists.Surrogates for 9/14 patient-level quality metrics were assessed in all patients who received an initial palliative care specialist consult while in an ICU from 10/26/2012 to 1/16/2015 in the Global Palliative Care Quality Alliance, a nationwide palliative care quality registry.Two hundred fifty-four patients received an initial palliative care consultation in an ICU setting. Mean (SD) age was 67.5 (17.3) years, 52% were female. The most common reasons for consultation were symptom management (33%) and end-of-life transition (24%). Adherence to ICU quality metrics for palliative care was variable: clinicians documented presence or absence of advance directives in 36% of encounters, assessed pain in 52.0%, dyspnea in 50.8%, spiritual support in 62%, and reported an intervention for pain in 100% of patients with documented moderate to severe intensity pain.Palliative care consultations in an ICU setting are characterized by variable adherence to candidate ICU palliative care quality metrics. Although symptom management was the most common reason for palliative care consultation, consultants infrequently documented symptom assessments. Palliative care consultants performed better in offering spiritual support and managing documented symptoms. These results highlight specific competencies of consultative palliative care that should be complimented by ICU teams to ensure high-quality comprehensive care for the critically ill.

Authors
Wysham, NG; Hochman, MJ; Wolf, SP; Cox, CE; Kamal, AH
MLA Citation
Wysham, NG, Hochman, MJ, Wolf, SP, Cox, CE, and Kamal, AH. "Performance of Consultative Palliative Care Model in Achieving Quality Metrics in the ICU." Journal of pain and symptom management 52.6 (December 2016): 873-877.
PMID
27697569
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
52
Issue
6
Publish Date
2016
Start Page
873
End Page
877
DOI
10.1016/j.jpainsymman.2016.05.026

Adherence to Measuring What Matters Items When Caring for Patients With Hematologic Malignancies Versus Solid Tumors.

Measuring What Matters (MWM) prioritizes quality measures in palliative care practice. Hematologic malignancy patients are less likely to access palliative care, yet little is known about their unique needs. Differences in MWM adherence may highlight opportunities to improve palliative care in hematology.To assess adherence to MWM measures by palliative care clinicians caring for patients with hematologic malignancies, compared to those with solid tumors.We used the Quality Data Collection Tool to assess completion of MWM measures across nine sites.We included data from 678 patients' first visits and various care settings; 64 (9.4%) had a hematologic malignancy, whereas 614 (90.6%) had a solid tumor. Hematology patients were more likely to be seen in a hospital (52 or 81.3% vs. 420 or 68%), whereas solid tumor patients were more frequently seen at home or in clinics (160 or 26% vs. 7 or 10.9%). Of the nine MWM measures we assessed, high adherence (>90%) was seen regardless of tumor type in measures #3 (Pain Treatment), #7 (Spiritual Concerns), #8 (Treatment Preferences), and #9 (Care Consistent With Preferences). Clinicians seeing hematology patients were significantly less likely to meet measures #2 (Screening for Physical Symptoms; 57.8% vs. 84.2%, P < 0.001), and #5 (Discussion of Emotional Needs; 56.3% vs. 70.0%, P = 0.03).MWM adherence regarding symptom assessment and meeting emotional needs was lower for patients with hematologic malignancies compared to those with solid tumors. This finding suggests two key areas for quality improvement initiatives in palliative care for patients with hematologic malignancies.

Authors
LeBlanc, TW; Ritchie, CS; Friedman, F; Bull, J; Kutner, JS; Johnson, KS; Kamal, AH; AAHPM Research Committee Writing Group,
MLA Citation
LeBlanc, TW, Ritchie, CS, Friedman, F, Bull, J, Kutner, JS, Johnson, KS, Kamal, AH, and AAHPM Research Committee Writing Group, . "Adherence to Measuring What Matters Items When Caring for Patients With Hematologic Malignancies Versus Solid Tumors." Journal of pain and symptom management 52.6 (December 2016): 775-782.
PMID
27810570
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
52
Issue
6
Publish Date
2016
Start Page
775
End Page
782
DOI
10.1016/j.jpainsymman.2016.09.004

Performance of Consultative Palliative Care Model in Achieving Quality Metrics in the ICU

Authors
Wysham, NG; Hochman, MJ; Wolf, SP; Cox, CE; Kamal, AH
MLA Citation
Wysham, NG, Hochman, MJ, Wolf, SP, Cox, CE, and Kamal, AH. "Performance of Consultative Palliative Care Model in Achieving Quality Metrics in the ICU." JOURNAL OF PAIN AND SYMPTOM MANAGEMENT 52.6 (December 2016): 873-877.
Source
wos-lite
Published In
Journal of Pain and Symptom Management
Volume
52
Issue
6
Publish Date
2016
Start Page
873
End Page
877
DOI
10.1016/j.jpainsymman.2016.05.026

Development of the Quality Data Collection Tool for Prospective Quality Assessment and Reporting in Palliative Care.

Assessing and reporting the quality of care provided are increasingly important in palliative care, but we currently lack practical, efficient approaches for collection and reporting.In response, the Global Palliative Care Quality Alliance ("Alliance") sought to create a Quality Data Collection Tool for Palliative Care (QDACT-PC).We collaboratively and iteratively developed QDACT-PC, an electronic, point-of-care quality monitoring system for palliative care that supports prospective quality assessment and reporting in any clinical setting. QDACT-PC is the web-based data collection and reporting interface. Quality measures selected to be used in QDACT-PC were derived from a systematic review summarizing all published palliative care quality measure sets; Alliance clinical providers prioritized measures to be included in QDACT-PC to ensure maximal clinical relevance. Data elements and variables required to ascertain conformance to all selected quality measures were included in the QDACT-PC data dictionary. Whenever possible, variables collected in QDACT-PC align with validated surveys and/or nationally recognized common data elements. QDACT-PC data elements and software programmed business rules inform real-time assessments of conformance to selected quality measures. Data are deposited into a centralized registry for future analyses.QDACT-PC can be used to report on >80% of all published palliative care quality measures and 100% of high-priority measure.Electronic methods for collecting point-of-care quality monitoring data can be developed using collaborative partnerships between community and academic palliative care providers. Feasibility testing and creation of feedback reports are ongoing.

Authors
Kamal, AH; Bull, J; Kavalieratos, D; Nicolla, JM; Roe, L; Adams, M; Abernethy, AP
MLA Citation
Kamal, AH, Bull, J, Kavalieratos, D, Nicolla, JM, Roe, L, Adams, M, and Abernethy, AP. "Development of the Quality Data Collection Tool for Prospective Quality Assessment and Reporting in Palliative Care." Journal of palliative medicine 19.11 (November 2016): 1148-1155.
PMID
27348507
Source
epmc
Published In
Journal of Palliative Medicine
Volume
19
Issue
11
Publish Date
2016
Start Page
1148
End Page
1155
DOI
10.1089/jpm.2016.0036

Anticholinergic Drug Burden in Noncancer Versus Cancer Patients Near the End of Life.

Anticholinergic drugs can cause several side effects, impairing cognition and quality of life (QOL). Cancer patients are often exposed to increasing cumulative anticholinergic load (ACL) as they approach death, but this burden has not been examined in patients with nonmalignant diseases.To determine ACL and its impact in noncancer versus cancer palliative care patients.We performed a secondary analysis of 244 subjects enrolled in a randomized controlled trial. ACL was quantified with the Anticholinergic Drug Scale. We used multivariable regression to calculate the effect of ACL on key outcomes, including drowsiness, fatigue, and QOL. Patients were stratified by diagnosis, and drugs were grouped as symptom management (SM) or disease management (DM).Overall, ACL in cancer and noncancer patients was not significantly different (2.6 vs. 2.4; P = 0.23). SM drugs caused greater anticholinergic exposure than DM drugs in both cancer and noncancer patients (2.3 vs. 0.5, and 1.5 vs. 1.3, respectively; both P < 0.05); however, DM drugs exposed noncancer patients to relatively more ACL than cancer patients (1.2 vs. 0.6, P < 0.0001). ACL was associated with worse fatigue (odds ratio, 1.08; CI, 1.002-1.17) and worse QOL (odds ratio, 0.89; CI, 0.80-0.98).ACL is associated with worse fatigue and QOL and may not differ significantly between cancer and noncancer patients nearing end of life. SM drugs are more responsible for ACL in cancer and noncancer patients, although DM drugs contribute significantly to ACL in the latter group. We recommend more attention to reducing anticholinergic use in all patients with life-limiting illness.

Authors
Hochman, MJ; Kamal, AH; Wolf, SP; Samsa, GP; Currow, DC; Abernethy, AP; LeBlanc, TW
MLA Citation
Hochman, MJ, Kamal, AH, Wolf, SP, Samsa, GP, Currow, DC, Abernethy, AP, and LeBlanc, TW. "Anticholinergic Drug Burden in Noncancer Versus Cancer Patients Near the End of Life." Journal of pain and symptom management 52.5 (November 2016): 737-743.e3.
PMID
27663186
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
52
Issue
5
Publish Date
2016
Start Page
737
End Page
743.e3
DOI
10.1016/j.jpainsymman.2016.03.020

Cancer Cachexia: Beyond Weight Loss.

Cancer cachexia is a multifactorial syndrome characterized by skeletal muscle loss leading to progressive functional impairment. Despite the ubiquity of cachexia in clinical practice, prevention, early identification, and intervention remain challenging. The impact of cancer cachexia on quality of life, treatment-related toxicity, physical function, and mortality are well established; however, establishing a clinically meaningful definition has proven challenging because of the focus on weight loss alone. Attempts to more comprehensively define cachexia through body composition, physical functioning, and molecular biomarkers, while promising, are yet to be routinely incorporated into clinical practice. Pharmacologic agents that have not been approved by the US Food and Drug Administration but that are currently used in cancer cachexia (ie, megestrol, dronabinol) may improve weight but not outcomes of interest such as muscle mass, physical activity, or mortality. Their routine use is limited by adverse effects. For the practicing oncologist, early identification and management of cachexia is critical. Oncologists must recognize cachexia beyond weight loss alone, focusing instead on body composition and physical functioning. In fact, becoming emaciated is a late sign of cachexia that characterizes its refractory stage. Given that cachexia is a multifactorial syndrome, it requires early identification and polymodal intervention, including optimal cancer therapy, symptom management, nutrition, exercise, and psychosocial support. Consequently, oncologists have a role in ensuring that these resources are available to their patients. In addition, in light of the promising investigational agents, it remains imperative to refer patients with cachexia to clinical trials so that available options can be expanded to effectively treat this pervasive problem.

Authors
Bruggeman, AR; Kamal, AH; LeBlanc, TW; Ma, JD; Baracos, VE; Roeland, EJ
MLA Citation
Bruggeman, AR, Kamal, AH, LeBlanc, TW, Ma, JD, Baracos, VE, and Roeland, EJ. "Cancer Cachexia: Beyond Weight Loss." Journal of oncology practice 12.11 (November 2016): 1163-1171. (Review)
PMID
27858548
Source
epmc
Published In
Journal of Oncology Practice
Volume
12
Issue
11
Publish Date
2016
Start Page
1163
End Page
1171
DOI
10.1200/jop.2016.016832

Association of Practice-Level Hospital Use With End-of-Life Outcomes, Readmission, and Weekend Hospitalization Among Medicare Beneficiaries With Cancer.

To determine the relationships between hospital use of treating oncology practices and patient outcomes.Retrospective analysis of 397,646 Medicare beneficiaries who received anticancer therapy in 2012. Each beneficiary was associated with a practice; practices were ranked on the basis of risk-adjusted hospital use, that is, inpatient intensity. Outcomes included 30-day readmission, weekend admissions, intensive care unit stays in the last month of life, and hospice stay of ≥ 7 days. Outcomes were measured for each quartile of practice-level inpatient intensity. We fit multivariable logistic regression models to calculate adjusted odds ratios (ORs) for each outcome for each quartile of inpatient intensity.Total 30-day readmissions were 22.8% and 31.9% (OR, 1.45; 95% CI, 1.39 to 1.50) for patients in practices with the lowest versus highest quartiles of inpatient intensity, respectively; unplanned readmissions were 19.8% and 27.1% (OR, 1.36; 95% CI, 1.31 to 1.41), respectively. The proportion of admissions that occurred on weekends was similar across quartiles. Patients of practices in the highest quartiles of inpatient intensity had higher rates of death in an ICU stay in the last month of life (25.5% versus 18.0%; OR, 1.33; 95% CI, 1.19 to 1.49) and a lower rate of hospice stay of at least 7 days (50.9% to 42.5%; OR, 0.79; 95% CI, 0.74 to 0.86).Medical oncology practices that seek to reduce hospitalizations should consider focusing initially on processes related to end-of-life care and care transitions.

Authors
Clough, JD; Strawbridge, LM; LeBlanc, TW; Hammill, BG; Kamal, AH
MLA Citation
Clough, JD, Strawbridge, LM, LeBlanc, TW, Hammill, BG, and Kamal, AH. "Association of Practice-Level Hospital Use With End-of-Life Outcomes, Readmission, and Weekend Hospitalization Among Medicare Beneficiaries With Cancer." Journal of oncology practice 12.10 (October 2016): e933-e943.
PMID
27531384
Source
epmc
Published In
Journal of Oncology Practice
Volume
12
Issue
10
Publish Date
2016
Start Page
e933
End Page
e943
DOI
10.1200/jop.2016.013102

Accessibility and Barriers to Oncology Appointments at 40 National Cancer Institute-Designated Comprehensive Cancer Centers: Results of a Mystery Shopper Project.

Patients turn to National Cancer Institute (NCI) -designated comprehensive cancer centers because of perceived better quality and more timely access to care. However, recent studies have found that patients at various institutions may struggle to gain access to an appointment or obtain consistent information from attendants. Our study employs a mystery shopper format to identify and quantify barriers faced by patients seeking to make a first consultation appointment across a homogenous sample of 40 NCI-designated comprehensive cancer centers.Five mystery shoppers used a standardized call script to inquire about first available appointment times and service offerings.When inquiring about a date for a first available appointment, 29% of callers were unable to secure an estimated date without registering into the center's database, 51% were able to secure an estimated date, and 20% were provided with an actual date. Of estimated or actual dates for a first available appointment, 74% were greater than 1 week away. There was no statistically significant variation between appointment availability across insurance type or US region.Our study highlights the difficulty of accessing information about appointment availability. Although not statistically significant, inquiries regarding first available appointments for Medicaid patients resulted in longer estimated or actual wait times than those for patients with private insurance, and Medicaid shoppers noted qualitative differences. Although our study was limited by small sample size and imperfect analytic methods, our results suggest the need for more efficient and accessible care for patients at our nation's top cancer centers.

Authors
Hamlyn, GS; Hutchins, KE; Johnston, AL; Thomas, RT; Tian, J; Kamal, AH
MLA Citation
Hamlyn, GS, Hutchins, KE, Johnston, AL, Thomas, RT, Tian, J, and Kamal, AH. "Accessibility and Barriers to Oncology Appointments at 40 National Cancer Institute-Designated Comprehensive Cancer Centers: Results of a Mystery Shopper Project." Journal of oncology practice 12.10 (October 2016): e884-e900.
PMID
27650838
Source
epmc
Published In
Journal of Oncology Practice
Volume
12
Issue
10
Publish Date
2016
Start Page
e884
End Page
e900
DOI
10.1200/jop.2016.014159

Defining High-Quality Palliative Care in Oncology Practice: An American Society of Clinical Oncology/American Academy of Hospice and Palliative Medicine Guidance Statement.

Integrated into routine oncology care, palliative care can improve symptom burden, quality of life, and patient and caregiver satisfaction. However, not all oncology practices have access to specialist palliative medicine. This project endeavored to define what constitutes high-quality primary palliative care as delivered by medical oncology practices.An expert steering committee outlined 966 palliative care service items, in nine domains, each describing a candidate element of primary palliative care delivery for patients with advanced cancer or high symptom burden. Using modified Delphi methodology, 31 multidisciplinary panelists rated each service item on three constructs: importance, feasibility, and scope within medical oncology practice.Panelists endorsed the highest proportion of palliative care service items in the domains of End-of-Life Care (81%); Communication and Shared Decision Making (79%); and Advance Care Planning (78%). The lowest proportions were in Spiritual and Cultural Assessment and Management (35%) and Psychosocial Assessment and Management (39%). In the largest domain, Symptom Assessment and Management, there was consensus that all symptoms should be assessed and managed at a basic level, with more comprehensive management for common symptoms such as nausea, vomiting, diarrhea, dyspnea, and pain. Within the Appropriate Palliative Care and Hospice Referral domain, there was consensus that oncology practices should be able to describe the difference between palliative care and hospice to patients and refer patients appropriately.This statement describes the elements comprising high-quality primary palliative care for patients with advanced cancer or high symptom burden, as delivered by oncology practices. Oncology providers wishing to enhance palliative care delivery may find this information useful to inform operational changes and quality improvement efforts.

Authors
Bickel, KE; McNiff, K; Buss, MK; Kamal, A; Lupu, D; Abernethy, AP; Broder, MS; Shapiro, CL; Acheson, AK; Malin, J; Evans, T; Krzyzanowska, MK
MLA Citation
Bickel, KE, McNiff, K, Buss, MK, Kamal, A, Lupu, D, Abernethy, AP, Broder, MS, Shapiro, CL, Acheson, AK, Malin, J, Evans, T, and Krzyzanowska, MK. "Defining High-Quality Palliative Care in Oncology Practice: An American Society of Clinical Oncology/American Academy of Hospice and Palliative Medicine Guidance Statement." Journal of oncology practice 12.9 (September 2016): e828-e838.
PMID
27531376
Source
epmc
Published In
Journal of Oncology Practice
Volume
12
Issue
9
Publish Date
2016
Start Page
e828
End Page
e838
DOI
10.1200/jop.2016.010686

Is advanced imaging in early-stage breast cancer ever warranted? Reconciling clinical judgment with common quality measures

© JNCCN-Journal of the National Comprehensive Cancer Network. Background: The American Board of Internal Medicine Foundation's Choosing Wisely initiative aims to reduce unnecessary advanced imaging for early-stage breast cancer (ESBC). Additionally, NCCN Clinical Practice Guidelines in Oncology for Breast Cancer permit such images when oncologists perceive clinical clues of advanced disease. The utility of advanced imaging in ESBC is not known. Patients and Methods: We analyzed all patients with ESBC from January 2010 to June 2012 at a large tertiary cancer center. Early-stage was defined as stage IIb or less. We included advanced imaging within 60 days after diagnosis. Three independent reviewers manually abstracted a sample of charts to determine reason for ordering. Results: A total of 1,143 ESBC cases were identified; 21.8% of which had at least one advanced imaging procedure performed. Imaging modalities varied widely (38% CT, 21% PET, 34% bone scans, and 6% MRI). Patients who underwent advanced imaging were more likely to have triple-negative disease, be younger (age < 50 years), and have higher stage disease (stage IIb vs. stage IIa; all P < .001). A total of 100 cases (40%) were abstracted; 5 were excluded due to bilateral disease. Of the 95 cases remaining, 62% of the imaging studies were performed for staging, 17% for significant concurrent disease, and 22% for findings atypical of ESBC. Of the studies performed for staging, 15% produced clinically meaningful findings. Overall, 45% of studies were ordered for suspicious findings, complex history, or produced a meaningful result. Conclusions: Of patients with ESBC, 21.8% had at least one advanced imaging procedure within 60 days of diagnosis; almost half were clinically useful. Chart abstraction helped clarify intent. Conversations between clinicians and patients are needed to balance patient preferences and clinician judgment.

Authors
Kamal, A; Zhang, T; Power, S; Marcom, PK
MLA Citation
Kamal, A, Zhang, T, Power, S, and Marcom, PK. "Is advanced imaging in early-stage breast cancer ever warranted? Reconciling clinical judgment with common quality measures." JNCCN Journal of the National Comprehensive Cancer Network 14.8 (August 1, 2016): 993-998.
Source
scopus
Published In
Journal of the National Comprehensive Cancer Network : JNCCN
Volume
14
Issue
8
Publish Date
2016
Start Page
993
End Page
998

Building Resilience for Palliative Care Clinicians: An Approach to Burnout Prevention Based on Individual Skills and Workplace Factors.

For palliative care (PC) clinicians, the work of caring for patients with serious illness can put their own well-being at risk. What they often do not learn in training, because of the relative paucity of evidence-based programs, are practical ways to mitigate this risk. Because a new study indicates that burnout in PC clinicians is increasing, we sought to design an acceptable, scalable, and testable intervention tailored to the needs of PC clinicians. In this article, we describe our paradigm for approaching clinician resilience, our conceptual model, and curriculum for a workplace resilience intervention for hospital-based PC teams. Our paradigm for approaching resilience is based on upstream, early intervention. Our conceptual model posits that clinician well-being is influenced by personal resources and work demands. Our curriculum for increasing clinician resilience is based on training in eight resilience skills that are useful for common challenges faced by clinicians. To address workplace issues, our intervention also includes material for the team leader and a clinician perception survey of work demands and workplace engagement factors. The intervention will focus on individual skill building and will be evaluated with measures of resilience, coping, and affect. For PC clinicians, resilience skills are likely as important as communication skills and symptom management as foundations of expertise. Future work to strengthen clinician resilience will likely need to address system issues more directly.

Authors
Back, AL; Steinhauser, KE; Kamal, AH; Jackson, VA
MLA Citation
Back, AL, Steinhauser, KE, Kamal, AH, and Jackson, VA. "Building Resilience for Palliative Care Clinicians: An Approach to Burnout Prevention Based on Individual Skills and Workplace Factors." Journal of pain and symptom management 52.2 (August 2016): 284-291.
PMID
26921494
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
52
Issue
2
Publish Date
2016
Start Page
284
End Page
291
DOI
10.1016/j.jpainsymman.2016.02.002

Top 10 Tips About the Physician Quality Reporting System for Palliative Care Professionals.

The U.S. healthcare system is shifting from a fee-for-service (FFS) system to a valued-based reimbursement system focused on improving the quality of healthcare. The Centers for Medicare and Medicaid Services (CMS) implemented the Physician Quality Reporting System (PQRS) as an important component of this transition. All clinicians, including physicians, nurse practitioners, or physician assistants who bill to Medicare Part B FFS, should submit quality data to the PQRS in 2015 or they will receive up to a 4% negative reimbursement penalty in 2017. As implementing and reporting PQRS measures can be a daunting task, especially for palliative care professionals, this article provides high priority tips identified by the authors for PQRS reporting in the palliative care field.

Authors
Bull, J; Kamal, AH; Jones, C; Bonsignore, L; Acevedo, J
MLA Citation
Bull, J, Kamal, AH, Jones, C, Bonsignore, L, and Acevedo, J. "Top 10 Tips About the Physician Quality Reporting System for Palliative Care Professionals." Journal of palliative medicine 19.8 (August 2016): 806-813.
PMID
27139259
Source
epmc
Published In
Journal of Palliative Medicine
Volume
19
Issue
8
Publish Date
2016
Start Page
806
End Page
813
DOI
10.1089/jpm.2015.0413

Measuring Burnout in Palliative Care: Authors' Reply.

Authors
Kamal, AH; Shanafelt, TD
MLA Citation
Kamal, AH, and Shanafelt, TD. "Measuring Burnout in Palliative Care: Authors' Reply." Journal of pain and symptom management 52.2 (August 2016): e2-. (Letter)
PMID
27401506
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
52
Issue
2
Publish Date
2016
Start Page
e2
DOI
10.1016/j.jpainsymman.2016.05.011

Is Advanced Imaging in Early-Stage Breast Cancer Ever Warranted? Reconciling Clinical Judgment With Common Quality Measures.

The American Board of Internal Medicine Foundation's Choosing Wisely initiative aims to reduce unnecessary advanced imaging for early-stage breast cancer (ESBC). Additionally, NCCN Clinical Practice Guidelines in Oncology for Breast Cancer permit such images when oncologists perceive clinical clues of advanced disease. The utility of advanced imaging in ESBC is not known.We analyzed all patients with ESBC from January 2010 to June 2012 at a large tertiary cancer center. Early-stage was defined as stage IIb or less. We included advanced imaging within 60 days after diagnosis. Three independent reviewers manually abstracted a sample of charts to determine reason for ordering.A total of 1,143 ESBC cases were identified; 21.8% of which had at least one advanced imaging procedure performed. Imaging modalities varied widely (38% CT, 21% PET, 34% bone scans, and 6% MRI). Patients who underwent advanced imaging were more likely to have triple-negative disease, be younger (age <50 years), and have higher stage disease (stage IIb vs ≤ stage IIa; all P<.001). A total of 100 cases (40%) were abstracted; 5 were excluded due to bilateral disease. Of the 95 cases remaining, 62% of the imaging studies were performed for staging, 17% for significant concurrent disease, and 22% for findings atypical of ESBC. Of the studies performed for staging, 15% produced clinically meaningful findings. Overall, 45% of studies were ordered for suspicious findings, complex history, or produced a meaningful result.Of patients with ESBC, 21.8% had at least one advanced imaging procedure within 60 days of diagnosis; almost half were clinically useful. Chart abstraction helped clarify intent. Conversations between clinicians and patients are needed to balance patient preferences and clinician judgment.

Authors
Kamal, A; Zhang, T; Power, S; Marcom, PK
MLA Citation
Kamal, A, Zhang, T, Power, S, and Marcom, PK. "Is Advanced Imaging in Early-Stage Breast Cancer Ever Warranted? Reconciling Clinical Judgment With Common Quality Measures." Journal of the National Comprehensive Cancer Network : JNCCN 14.8 (August 2016): 993-998.
PMID
27496115
Source
epmc
Published In
Journal of the National Comprehensive Cancer Network : JNCCN
Volume
14
Issue
8
Publish Date
2016
Start Page
993
End Page
998
DOI
10.6004/jnccn.2016.0106

Better Palliative Care for All: Improving the Lived Experience With Cancer.

Authors
Kamal, AH; LeBlanc, TW; Meier, DE
MLA Citation
Kamal, AH, LeBlanc, TW, and Meier, DE. "Better Palliative Care for All: Improving the Lived Experience With Cancer." JAMA 316.1 (July 2016): 29-30.
PMID
27244674
Source
epmc
Published In
JAMA : the journal of the American Medical Association
Volume
316
Issue
1
Publish Date
2016
Start Page
29
End Page
30
DOI
10.1001/jama.2016.6491

Usability Testing of an Electronic Patient-Reported Outcome System for Survivors of Critical Illness.

Web-based electronic patient-reported outcomes (ePRO) measures are increasingly used to facilitate patient-centered health assessments. However, it is unknown if ePRO completion is feasible for recently ill intensive care unit (ICU) survivors and their families.To develop and evaluate the usability of a novel ePRO system (ePRO to Support People and Enhance Recovery [ePROSPER]) among ICU survivors and their families within an ongoing clinical trial.Paper-based PROs were iteratively adapted to electronic forms (ePROs). Then, the usability of ePROSPER was assessed among 60 patients, their family members, and PRO and programming experts via questionnaires (eg, Systems Usability Scale), "think aloud" open-ended feedback, task completion times, and error rates.Input from patients and their families was used to incorporate user-experience modifications into ePROSPER. This feedback also led to inclusion of automated reminders for questionnaire completion and real-time alerts for staff triggered by high symptom levels. Median usability scores increased over testing cycles from 40 to 73 to 95, nearing the maximum score and showing excellent usability. All users completed ePROSPER within 20 minutes; 87% preferred it to a written version. ePROSPER was then implemented in a clinical trial without data errors.Automated ePRO systems can be successfully integrated in a post-ICU clinical trial setting. The value of integrating such systems in direct clinical care should be assessed in future studies.

Authors
Cox, CE; Wysham, NG; Kamal, AH; Jones, DM; Cass, B; Tobin, M; White, DB; Kahn, JM; Hough, CL; Carson, SS
MLA Citation
Cox, CE, Wysham, NG, Kamal, AH, Jones, DM, Cass, B, Tobin, M, White, DB, Kahn, JM, Hough, CL, and Carson, SS. "Usability Testing of an Electronic Patient-Reported Outcome System for Survivors of Critical Illness." American journal of critical care : an official publication, American Association of Critical-Care Nurses 25.4 (July 2016): 340-349.
PMID
27369033
Source
epmc
Published In
American journal of critical care : an official publication, American Association of Critical-Care Nurses
Volume
25
Issue
4
Publish Date
2016
Start Page
340
End Page
349
DOI
10.4037/ajcc2016952

Assessing Emotional Suffering in Palliative Care: Use of a Structured Note Template to Improve Documentation

Authors
Lamba, S; Berlin, A; Goett, R; Ponce, CB; Holland, B; Walther, S; Aslakson, RA; Ast, K; Elk, R; Garner, KK; Gramling, R; Grudzen, C; Kamal, AH; Lamba, S; LeBlanc, TW; Rhodes, RL; Roeland, E; Schulman-Green, D; Unroe, KT
MLA Citation
Lamba, S, Berlin, A, Goett, R, Ponce, CB, Holland, B, Walther, S, Aslakson, RA, Ast, K, Elk, R, Garner, KK, Gramling, R, Grudzen, C, Kamal, AH, Lamba, S, LeBlanc, TW, Rhodes, RL, Roeland, E, Schulman-Green, D, and Unroe, KT. "Assessing Emotional Suffering in Palliative Care: Use of a Structured Note Template to Improve Documentation." Journal of Pain and Symptom Management 52.1 (July 2016): 1-7.
Source
crossref
Published In
Journal of Pain and Symptom Management
Volume
52
Issue
1
Publish Date
2016
Start Page
1
End Page
7
DOI
10.1016/j.jpainsymman.2016.01.017

Comparing Unmet Needs to Optimize Quality: Characterizing Inpatient and Outpatient Palliative Care Populations.

Palliative care (PC) consultation services are available in most hospitals; outpatient services are rapidly growing to meet the needs of patients at earlier stages of the disease trajectory.We aimed to compare the unmet needs of PC patients by location of care to better characterize these populations.This cross-sectional secondary analysis examined patients receiving hospital and outpatient-based PC across 10 community and academic organizations in the Global Palliative Care Quality Alliance. We identified unmet symptom, advance care planning, and functional needs within our database from October 23, 2012 to January 22, 2015. Kruskal-Wallis, chi-square, and Fisher exact tests were performed.We evaluated 633 unique patients. Inpatients (n = 216) were older than outpatients (n = 417; 73 vs. 64 years, P < 0.0001). Seventy-six inpatients (38%) had a Palliative Performance Scale score ≤30%; no outpatients did (P < 0.0001). More inpatients rated their quality of life as poor compared with outpatients (39% vs. 21%, P = 0.0001). We found that outpatients presented with more unresolved pain than inpatients (58.5% vs. 4.1%, P < 0.0001). Conversely, more inpatients presented with unresolved anorexia (52.3% vs. 35.8%, P = 0.002) and dysphagia (28.1% vs. 5.4%, P < 0.0001) than outpatients. We found that inpatient setting was independently associated with lower performance status (odds ratio = 0.068, 95% confidence interval = 0.038-0.120, P < 0.0001).Compared with inpatients, outpatients are more burdened by pain at first PC encounter yet experience higher quality of life and better performance status. These findings suggest different clinician skillsets, and assessments are needed depending on the setting of PC consultation.

Authors
Hochman, MJ; Wolf, S; Zafar, SY; Portman, D; Bull, J; Kamal, AH
MLA Citation
Hochman, MJ, Wolf, S, Zafar, SY, Portman, D, Bull, J, and Kamal, AH. "Comparing Unmet Needs to Optimize Quality: Characterizing Inpatient and Outpatient Palliative Care Populations." Journal of pain and symptom management 51.6 (June 2016): 1033-1039.e3.
PMID
27046299
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
51
Issue
6
Publish Date
2016
Start Page
1033
End Page
1039.e3
DOI
10.1016/j.jpainsymman.2015.12.338

The Cambia Sojourns Scholars Leadership Program: Project Summaries from the Inaugural Scholar Cohort.

As palliative care grows and evolves, robust programs to train and develop the next generation of leaders are needed. Continued integration of palliative care into the fabric of usual health care requires leaders who are prepared to develop novel programs, think creatively about integration into the current health care environment, and focus on sustainability of efforts. Such leadership development initiatives must prepare leaders in clinical, research, and education realms to ensure that palliative care matures and evolves in diverse ways.The Cambia Health Foundation designed the Sojourns Scholar Leadership Program to facilitate leadership development among budding palliative care leaders.The background, aims, and results to date of each of the projects from the scholars of the inaugural cohort are presented.

Authors
Kamal, AH; Anderson, WG; Boss, RD; Brody, AA; Campbell, TC; Creutzfeldt, CJ; Hurd, CJ; Kinderman, AL; Lindenberger, EC; Reinke, LF
MLA Citation
Kamal, AH, Anderson, WG, Boss, RD, Brody, AA, Campbell, TC, Creutzfeldt, CJ, Hurd, CJ, Kinderman, AL, Lindenberger, EC, and Reinke, LF. "The Cambia Sojourns Scholars Leadership Program: Project Summaries from the Inaugural Scholar Cohort." Journal of palliative medicine 19.6 (June 2016): 591-600.
PMID
27168030
Source
epmc
Published In
Journal of Palliative Medicine
Volume
19
Issue
6
Publish Date
2016
Start Page
591
End Page
600
DOI
10.1089/jpm.2016.0086

Integrating Palliative Care in the Intensive Care Unit. Evidence Gaps and Quality Gaps.

Authors
Wysham, NG; Kamal, AH
MLA Citation
Wysham, NG, and Kamal, AH. "Integrating Palliative Care in the Intensive Care Unit. Evidence Gaps and Quality Gaps." Annals of the American Thoracic Society 13.5 (May 2016): 595-597.
PMID
27144791
Source
epmc
Published In
Annals of the American Thoracic Society
Volume
13
Issue
5
Publish Date
2016
Start Page
595
End Page
597
DOI
10.1513/annalsats.201601-061ed

Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S.

Many clinical disciplines report high rates of burnout, which lead to low quality of care. Palliative care clinicians routinely manage patients with significant suffering, aiming to improve quality of life. As a major role of palliative care clinicians involves educating patients and caregivers regarding identifying priorities and balancing stress, we wondered how clinician self-management of burnout matches against the emotionally exhaustive nature of the work.We sought to understand the prevalence and predictors of burnout using a discipline-wide survey.We asked American Academy of Hospice and Palliative Medicine clinician members to complete an electronic survey querying demographic factors, job responsibilities, and the Maslach Burnout Inventory. We performed univariate and multivariate regression analyses to identify predictors of high rates of burnout.We received 1357 responses (response rate 30%). Overall, we observed a burnout rate of 62%, with higher rates reported by nonphysician clinicians. Most burnout stemmed from emotional exhaustion, with depersonalization comprising a minor portion. Factors associated with higher rates of burnout include working in smaller organizations, working longer hours, being younger than 50 years, and working weekends. We did not observe different rates between palliative care clinicians and hospice clinicians. Higher rated self-management activities to mitigate burnout include participating in interpersonal relationships and taking vacations.Burnout is a major issue facing the palliative care clinician workforce. Strategies at the discipline-wide and individual levels are needed to sustain the delivery of responsive, available, high-quality palliative care for all patients with serious illness.

Authors
Kamal, AH; Bull, JH; Wolf, SP; Swetz, KM; Shanafelt, TD; Ast, K; Kavalieratos, D; Sinclair, CT; Abernethy, AP
MLA Citation
Kamal, AH, Bull, JH, Wolf, SP, Swetz, KM, Shanafelt, TD, Ast, K, Kavalieratos, D, Sinclair, CT, and Abernethy, AP. "Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S." Journal of pain and symptom management 51.4 (April 2016): 690-696.
PMID
26620234
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
51
Issue
4
Publish Date
2016
Start Page
690
End Page
696
DOI
10.1016/j.jpainsymman.2015.10.020

Concordance of Advance Care Plans With Inpatient Directives in the Electronic Medical Record for Older Patients Admitted From the Emergency Department.

Measuring What Matters identified quality indicators to examine the percentage of patients with documentation of a surrogate decision maker and preferences for life-sustaining treatments.To determine the rate of advance care planning in older adults presenting to the emergency department (ED) and translation into medical directives in the electronic medical record (EMR).A convenience sample of adults 65 years or older was recruited from a large urban ED beginning in January 2012. We administered a baseline interview and survey in English or Spanish, including questions about whether patients had a documented health care proxy or living will. For patients admitted to the hospital who had a health care proxy or living will, chart abstraction was performed to determine whether their advance care preferences were documented in the EMR.From February 2012 to May 2013, 53.8% (367 of 682) of older adults who completed the survey in the ED reported having a health care proxy, and 40.2% (274 of 682) had a living will. Of those admitted to the hospital, only 4% (4 of 94) of patients who said they had a living will had medical directives documented in the EMR. Similarly, only 4% (5 of 115) of patients who had a health care proxy had the person's name or contact information documented in their medical record.About half of the patients 65 years or older arriving in the ED have done significant advance care planning, but most plans are not recorded in the EMR.

Authors
Grudzen, CR; Buonocore, P; Steinberg, J; Ortiz, JM; Richardson, LD; AAHPM Research Committee Writing Group,
MLA Citation
Grudzen, CR, Buonocore, P, Steinberg, J, Ortiz, JM, Richardson, LD, and AAHPM Research Committee Writing Group, . "Concordance of Advance Care Plans With Inpatient Directives in the Electronic Medical Record for Older Patients Admitted From the Emergency Department." Journal of pain and symptom management 51.4 (April 2016): 647-651.
PMID
26891604
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
51
Issue
4
Publish Date
2016
Start Page
647
End Page
651
DOI
10.1016/j.jpainsymman.2015.12.318

Characterizing the Hospice and Palliative Care Workforce in the U.S.: Clinician Demographics and Professional Responsibilities.

Palliative care services are growing at an unprecedented pace. Yet, the characteristics of the clinician population who deliver these services are not known. Information on the roles, motivations, and future plans of the clinician workforce would allow for planning to sustain and grow the field.To better understand the characteristics of clinicians within the field of hospice and palliative care.From June through December 2013, we conducted an electronic survey of American Academy of Hospice and Palliative Medicine members. We queried information on demographics, professional roles and responsibilities, motivations for entering the field, and future plans. We compared palliative care and hospice populations alongside clinician roles using chi-square analyses. Multivariable logistic regression was used to identify predictors of leaving the field early.A total of 1365 persons, representing a 30% response rate, participated. Our survey findings revealed a current palliative care clinician workforce that is older, predominantly female, and generally with less than 10 years clinical experience in the field. Most clinicians have both clinical hospice and palliative care responsibilities. Many cite personal or professional growth or influential experiences during training or practice as motivations to enter the field.Palliative care clinicians are a heterogeneous group. We identified motivations for entering the field that can be leveraged to sustain and grow the workforce.

Authors
Kamal, AH; Bull, J; Wolf, S; Samsa, GP; Swetz, KM; Myers, ER; Shanafelt, TD; Abernethy, AP
MLA Citation
Kamal, AH, Bull, J, Wolf, S, Samsa, GP, Swetz, KM, Myers, ER, Shanafelt, TD, and Abernethy, AP. "Characterizing the Hospice and Palliative Care Workforce in the U.S.: Clinician Demographics and Professional Responsibilities." Journal of pain and symptom management 51.3 (March 2016): 597-603.
PMID
26550934
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
51
Issue
3
Publish Date
2016
Start Page
597
End Page
603
DOI
10.1016/j.jpainsymman.2015.10.016

A Blue Ocean Strategy for Palliative Care: Focus on Family Caregivers.

Authors
Kamal, AH; Dionne-Odom, JN
MLA Citation
Kamal, AH, and Dionne-Odom, JN. "A Blue Ocean Strategy for Palliative Care: Focus on Family Caregivers." Journal of pain and symptom management 51.3 (March 2016): e1-e3. (Letter)
PMID
26708165
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
51
Issue
3
Publish Date
2016
Start Page
e1
End Page
e3
DOI
10.1016/j.jpainsymman.2015.12.305

Adherence to Measuring What Matters Measures Using Point-of-Care Data Collection Across Diverse Clinical Settings.

Measuring What Matters (MWM) for palliative care has prioritized data collection efforts for evaluating quality in clinical practice. How these measures can be implemented across diverse clinical settings using point-of-care data collection on quality is unknown.To evaluate the implementation of MWM measures by exploring documentation of quality measure adherence across six diverse clinical settings inherent to palliative care practice.We deployed a point-of-care quality data collection system, the Quality Data Collection Tool, across five organizations within the Palliative Care Research Cooperative Group. Quality measures were recorded by clinicians or assistants near care delivery.During the study period, 1989 first visits were included for analysis. Our population was mostly white, female, and with moderate performance status. About half of consultations were seen on hospital general floors. We observed a wide range of adherence. The lowest adherence involved comprehensive assessments during the first visit in hospitalized patients in the intensive care unit (2.71%); the highest adherence across all settings, with an implementation of >95%, involved documentation of management of moderate/severe pain. We observed differences in adherence across clinical settings especially with MWM Measure #2 (Screening for Physical Symptoms, range 45.7%-81.8%); MWM Measure #5 (Discussion of Emotional Needs, range 46.1%-96.1%); and MWM Measure #6 (Documentation of Spiritual/Religious Concerns, range 0-69.6%).Variations in clinician documentation of adherence to MWM quality measures are seen across clinical settings. Additional studies are needed to better understand benchmarks and acceptable ranges for adherence tailored to various clinical settings.

Authors
Kamal, AH; Bull, J; Ritchie, CS; Kutner, JS; Hanson, LC; Friedman, F; Taylor, DH; AAHPM Research Committee Writing Group,
MLA Citation
Kamal, AH, Bull, J, Ritchie, CS, Kutner, JS, Hanson, LC, Friedman, F, Taylor, DH, and AAHPM Research Committee Writing Group, . "Adherence to Measuring What Matters Measures Using Point-of-Care Data Collection Across Diverse Clinical Settings." Journal of pain and symptom management 51.3 (March 2016): 497-503.
PMID
26854995
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
51
Issue
3
Publish Date
2016
Start Page
497
End Page
503
DOI
10.1016/j.jpainsymman.2015.12.313

Feasibility and effectiveness of a pilot program to facilitate quality improvement learning in oncology: Experience of the American Society of Clinical Oncology Quality Training Program

© 2016 by American Society of Clinical Oncology. Purpose Studies have demonstrated that structured training programs can improve health professionals' skills in performing clinical care or research.Wesought to develop and test a novel quality training program (QTP) tailored to oncology clinicians. Methods The American Society of Clinical Oncology QTP consisted of three in-person learning sessions and four phases: prework, planning, implementation, and sustain and spread. We measured two primary outcomes: program feasibility and effectiveness. Feasibility was evaluated by recording participation. Effectiveness was measured using the Kirkpatrick model, which evaluates four outcomes: reaction, learning, behavior, and results. We collected qualitative feedback through a focus group of participants and mixed quantitative-qualitative results from a 6-month follow-up evaluation survey. Results are presented using descriptive statistics. Results We received feedback from of 80% of participants who took part in 92% of in-person program days. QTP deliverables were completed by 100% of teams; none withdrew from the program. Regarding reaction, 100% of respondents expressed interest in actively contributing to future QTP courses. For learning, most teams continued to use the core methodology tools (eg, project charter, aims statements) after the program. Regarding behavior, when asked about intention to serve as a local quality improvement leader, a majority said they "definitely will" serve as: team leader on a specific project (75%), project champion or sponsor (75%), or teacher or trainer for others (64%). In evaluating outcomes, 50% reported applying learned methodology to new projects at their local institution. Conclusion We demonstrate one of the first feasible and effective training programs to facilitate quality improvement learning for oncology clinicians.

Authors
Kamal, AH; Quinn, D; Gilligan, TD; Davis, BC; Dalby, CK; Bretsch, J; McNiff, KK; Jacobson, JO
MLA Citation
Kamal, AH, Quinn, D, Gilligan, TD, Davis, BC, Dalby, CK, Bretsch, J, McNiff, KK, and Jacobson, JO. "Feasibility and effectiveness of a pilot program to facilitate quality improvement learning in oncology: Experience of the American Society of Clinical Oncology Quality Training Program." Journal of Oncology Practice 12.2 (February 1, 2016): e215-e223.
Source
scopus
Published In
Journal of Oncology Practice
Volume
12
Issue
2
Publish Date
2016
Start Page
e215
End Page
e223
DOI
10.1200/JOP.2015.004762;

ReCAP: Feasibility and Effectiveness of a Pilot Program to Facilitate Quality Improvement Learning in Oncology: Experience of the American Society of Clinical Oncology Quality Training Program.

Studies have demonstrated that structured training programs can improve health professionals' skills in performing clinical care or research. We sought to develop and test a novel quality training program (QTP) tailored to oncology clinicians.The American Society of Clinical Oncology QTP consisted of three in-person learning sessions and four phases: prework, planning, implementation, and sustain and spread. We measured two primary outcomes: program feasibility and effectiveness. Feasibility was evaluated by recording participation. Effectiveness was measured using the Kirkpatrick model, which evaluates four outcomes: reaction, learning, behavior, and results. We collected qualitative feedback through a focus group of participants and mixed quantitative–qualitative results from a 6-month follow-up evaluation survey. Results are presented using descriptive statistics.We received feedback from of 80% of participants who took part in 92% of in-person program days. QTP deliverables were completed by 100% of teams; none withdrew from the program. Regarding reaction, 100% of respondents expressed interest in actively contributing to future QTP courses. For learning, most teams continued to use the core methodology tools (eg, project charter, aims statements) after the program. Regarding behavior, when asked about intention to serve as a local quality improvement leader, a majority said they “definitely will” serve as: team leader on a specific project (75%), project champion or sponsor (75%), or teacher or trainer for others (64%). In evaluating outcomes, 50% reported applying learned methodology to new projects at their local institution.We demonstrate one of the first feasible and effective training programs to facilitate quality improvement learning for oncology clinicians.

Authors
Kamal, AH; Quinn, D; Gilligan, TD; Davis, BC; Dalby, CK; Bretsch, J; McNiff, KK; Jacobson, JO; Kamal, AH; Quinn, D; Gilligan, TD; Corning Davis, B; Dalby, CK; Bretsch, J; McNiff, KK; Jacobson, JO
MLA Citation
Kamal, AH, Quinn, D, Gilligan, TD, Davis, BC, Dalby, CK, Bretsch, J, McNiff, KK, Jacobson, JO, Kamal, AH, Quinn, D, Gilligan, TD, Corning Davis, B, Dalby, CK, Bretsch, J, McNiff, KK, and Jacobson, JO. "ReCAP: Feasibility and Effectiveness of a Pilot Program to Facilitate Quality Improvement Learning in Oncology: Experience of the American Society of Clinical Oncology Quality Training Program." Journal of oncology practice 12.2 (February 2016): 177-e223.
PMID
26286099
Source
epmc
Published In
Journal of Oncology Practice
Volume
12
Issue
2
Publish Date
2016
Start Page
177
End Page
e223
DOI
10.1200/jop.2015.004762

The Burden of Polypharmacy in Patients Near the End of Life.

Patients with advanced illness are prescribed multiple medications in the last year of life, intensifying the risk of negative consequences related to polypharmacy.To describe the medication burden of patients near the end of life and identify potential areas for improvement in clinician prescribing practices.This was a prespecified secondary analysis of data from a prospective trial. Eligible participants were adults with less than 12 months estimated prognosis taking a statin medication for primary prevention of cardiovascular disease. Participants were enrolled from 15 sites, randomized to continue or discontinue statin medications, and followed for up to a year. Concomitant medications were recorded at least monthly from study enrollment through death. Prescribed medications were categorized by class and subclass. Descriptive statistics were calculated.On average, participants (n = 244) were 74.3 years old (SD 11.5) and lived 264 days (SD 128); 47.5% of the patients had a primary diagnosis of malignant tumor. This population was exposed to medications across 51 classes, 192 subclasses, and 423 individual medications. Patients took an average of 11.5 (SD 5) medications at the time of enrollment and 10.7 (SD 5) medications at death or study termination. The five most common classes of medications prescribed near the end of life were antihypertensives, broncholytics/bronchodilators, laxatives, antidepressants, and gastric protection agents.There is a significant medication burden placed on patients with advanced illness. Although most medications were prescribed for supportive care, we observed a high prevalence of medications for managing non-life-threatening comorbidities.

Authors
McNeil, MJ; Kamal, AH; Kutner, JS; Ritchie, CS; Abernethy, AP
MLA Citation
McNeil, MJ, Kamal, AH, Kutner, JS, Ritchie, CS, and Abernethy, AP. "The Burden of Polypharmacy in Patients Near the End of Life." Journal of pain and symptom management 51.2 (February 2016): 178-83.e2.
PMID
26432571
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
51
Issue
2
Publish Date
2016
Start Page
178
End Page
83.e2
DOI
10.1016/j.jpainsymman.2015.09.003

Methodological Research Priorities in Palliative Care and Hospice Quality Measurement.

Quality measurement is a critical tool for improving palliative care and hospice, but significant research is needed to improve the application of quality indicators. We defined methodological priorities for advancing the science of quality measurement in this field based on discussions of the Technical Advisory Panel of the Measuring What Matters consensus project of the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association and a subsequent strategy meeting to better clarify research challenges, priorities, and quality measurement implementation strategies. In this article, we describe three key priorities: 1) defining the denominator(s) (or the population of interest) for palliative care quality indicators, 2) developing methods to measure quality from different data sources, and 3) conducting research to advance the development of patient/family-reported indicators. We then apply these concepts to the key quality domain of advance care planning and address relevance to implementation of indicators in improving care. Developing the science of quality measurement in these key areas of palliative care and hospice will facilitate improved quality measurement across all populations with serious illness and care for patients and families.

Authors
Dy, SM; Herr, K; Bernacki, RE; Kamal, AH; Walling, AM; Ersek, M; Norton, SA
MLA Citation
Dy, SM, Herr, K, Bernacki, RE, Kamal, AH, Walling, AM, Ersek, M, and Norton, SA. "Methodological Research Priorities in Palliative Care and Hospice Quality Measurement." Journal of pain and symptom management 51.2 (February 2016): 155-162.
PMID
26596877
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
51
Issue
2
Publish Date
2016
Start Page
155
End Page
162
DOI
10.1016/j.jpainsymman.2015.10.019

Comparison of Quality Oncology Practice Initiative (QOPI) Measure Adherence Between Oncology Fellows, Advanced Practice Providers, and Attending Physicians.

Quality improvement measures are uniformly applied to all oncology providers, regardless of their roles. Little is known about differences in adherence to these measures between oncology fellows, advance practice providers (APP), and attending physicians. We investigated conformance across Quality Oncology Practice Initiative (QOPI) measures for oncology fellows, advance practice providers, and attending physicians at the Durham Veterans Affairs Medical Center (DVAMC). Using data collected from the Spring 2012 and 2013 QOPI cycles, we abstracted charts of patients and separated them based on their primary provider. Descriptive statistics and the chi-square test were calculated for each QOPI measure between fellows, advanced practice providers (APPs), and attending physicians. A total of 169 patients were reviewed. Of these, 31 patients had a fellow, 39 had an APP, and 99 had an attending as their primary oncology provider. Fellows and attending physicians performed similarly on 90 of 94 QOPI metrics. High-performing metrics included several core QOPI measures including documenting consent for chemotherapy, recommending adjuvant chemotherapy when appropriate, and prescribing serotonin antagonists when prescribing emetogenic chemotherapies. Low-performing metrics included documentation of treatment summary and taking action to address problems with emotional well-being by the second office visit. Attendings documented the plan for oral chemotherapy more often (92 vs. 63%, P=0.049). However, after the chart audit, we found that fellows actually documented the plan for oral chemotherapy 88% of the time (p=0.73). APPs and attendings performed similarly on 88 of 90 QOPI measures. The quality of oncology care tends to be similar between attendings and fellows overall; some of the significant differences do not remain significant after a second manual chart review, highlighting that the use of manual data collection for QOPI analysis is an imperfect system, and there may be significant inter-observer variability.

Authors
Zhu, J; Zhang, T; Shah, R; Kamal, AH; Kelley, MJ
MLA Citation
Zhu, J, Zhang, T, Shah, R, Kamal, AH, and Kelley, MJ. "Comparison of Quality Oncology Practice Initiative (QOPI) Measure Adherence Between Oncology Fellows, Advanced Practice Providers, and Attending Physicians." Journal of cancer education : the official journal of the American Association for Cancer Education 30.4 (December 2015): 774-778.
PMID
25686787
Source
epmc
Published In
Journal of Cancer Education
Volume
30
Issue
4
Publish Date
2015
Start Page
774
End Page
778
DOI
10.1007/s13187-015-0798-z

Usability and Acceptability of the QDACT-PC, an Electronic Point-of-Care System for Standardized Quality Monitoring in Palliative Care.

Few resources exist to support collaborative quality monitoring in palliative care. These tools, if proven efficient through technology-enabled methods, may begin to routinize data collection on quality during usual palliative care delivery. Usability testing is a common approach to assess how easily and effectively users can interact with a newly developed tool.We performed usability testing of the Quality Data Collection Tool for Palliative Care (QDACT-PC) a novel, point-of-care quality monitoring tool for palliative care.We used a mixed methods approach to assess community palliative care clinicians' evaluations of five domains of usability. These approaches included clinician surveys after recording mock patient data to assess satisfaction; review of entered data for accuracy and time to completion; and thematic review of "think aloud" protocols to determine issues, barriers, and advantages to the electronic system.We enrolled 14 palliative care clinicians for the study. Testing the electronic system vs. paper-based methods demonstrated similar error rates and time to completion. Overall, 68% of the participants believed that the electronic interface would not pose a moderate or major burden during usual clinical activities, and 65% thought it would improve the care they provided. Thematic analysis revealed significant issues with paper-based methods alongside training needs for future participants on using novel technologies that support the QDACT-PC.The QDACT-PC is a usable electronic system for quality monitoring in palliative care. Testing reveals equivalence with paper for data collection time, but with less burden overall for electronic methods across other domains of usability.

Authors
Kamal, AH; Kavalieratos, D; Bull, J; Stinson, CS; Nicolla, J; Abernethy, AP
MLA Citation
Kamal, AH, Kavalieratos, D, Bull, J, Stinson, CS, Nicolla, J, and Abernethy, AP. "Usability and Acceptability of the QDACT-PC, an Electronic Point-of-Care System for Standardized Quality Monitoring in Palliative Care." Journal of pain and symptom management 50.5 (November 2015): 615-621.
PMID
26166184
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
50
Issue
5
Publish Date
2015
Start Page
615
End Page
621
DOI
10.1016/j.jpainsymman.2015.05.013

Evolving the Palliative Care Workforce to Provide Responsive, Serious Illness Care.

Authors
Kamal, AH; Maguire, JM; Meier, DE
MLA Citation
Kamal, AH, Maguire, JM, and Meier, DE. "Evolving the Palliative Care Workforce to Provide Responsive, Serious Illness Care." Annals of internal medicine 163.8 (October 2015): 637-638.
PMID
26258800
Source
epmc
Published In
Annals of internal medicine
Volume
163
Issue
8
Publish Date
2015
Start Page
637
End Page
638
DOI
10.7326/m15-0071

Improving the Quality of Palliative Care Through National and Regional Collaboration Efforts.

The measurement and reporting of the quality of care in the field of palliation has become a required task for many health care leaders and specialists in palliative care. Such efforts are aided when organizations collaborate together to share lessons learned.The authors reviewed examples of quality-improvement collaborations in palliative care to understand the similarities, differences, and future directions of quality measurement and improvement strategies in the discipline.Three examples were identified that showed areas of robust and growing quality-improvement collaboration in the field of palliative care: the Global Palliative Care Quality Alliance, Palliative Care Quality Network, and Project Educate, Nurture, Advise, Before Life Ends. These efforts exemplify how shared-improvement activities can inform improved practice for organizations participating in collaboration.National and regional collaboratives can be used to enhance the quality of palliative care and are important efforts to standardize and improve the delivery of palliative care for persons with serious illness, along with their friends, family, and caregivers.

Authors
Kamal, AH; Harrison, KL; Bakitas, M; Dionne-Odom, JN; Zubkoff, L; Akyar, I; Pantilat, SZ; O'Riordan, DL; Bragg, AR; Bischoff, KE; Bull, J
MLA Citation
Kamal, AH, Harrison, KL, Bakitas, M, Dionne-Odom, JN, Zubkoff, L, Akyar, I, Pantilat, SZ, O'Riordan, DL, Bragg, AR, Bischoff, KE, and Bull, J. "Improving the Quality of Palliative Care Through National and Regional Collaboration Efforts." Cancer control : journal of the Moffitt Cancer Center 22.4 (October 2015): 396-402. (Review)
PMID
26678966
Source
epmc
Published In
Cancer control : journal of the Moffitt Cancer Center
Volume
22
Issue
4
Publish Date
2015
Start Page
396
End Page
402

Symptom Burden of Chronic Lung Disease Compared with Lung Cancer at Time of Referral for Palliative Care Consultation.

A growing evidence base supports provision of palliative care services alongside life-prolonging care. Whereas palliative care processes have been implemented widely in the care of patients with lung cancer, the same is not true for patients with chronic, progressive lung disease.To compare the symptom burden of chronic lung disease with that of lung cancer at the time of initial palliative care consultation.Data were abstracted from the Carolinas Palliative Care Consortium's Quality Data Collection Tool, an electronic database used by seven academic and community palliative care practices in multiple states for quality improvement purposes. We analyzed data derived from first palliative care encounters collected during a 2-year period, including the primary diagnosis of chronic lung disease or lung cancer, unresolved symptoms, setting of initial palliative care encounter, Palliative Performance Scale status, and on that basis we estimated prognosis for survival. We compared key clinical variables between chronic lung disease and lung cancer using Kruskal-Wallis and χ(2) tests.We identified 152 patients with lung cancer and 86 patients with chronic lung disease. Of the total sample, 53% were women and 87% were white. Patients with chronic lung disease were more likely than those with lung cancer to have the initial palliative care encounter occur in the intensive care unit (17% vs. 6%; P = 0.005) and less likely as an outpatient (20% vs. 56%; P < 0.0001). Patients with chronic lung disease were also less likely to have a high Palliative Performance Scale status (14% vs. 30%; P = 0.009) but more likely to have an estimated prognosis for survival longer than 6 months (51% vs. 28%; P = 0.002). The most prevalent symptoms were dyspnea (55% vs. 42%) and pain (40% vs. 52%), neither of which differed between groups (P = 0.08).Patients with chronic lung disease have symptom burdens similar to those of patients with lung cancer at the time of first palliative care encounter. Given the population burden of chronic lung disease and limitations in the palliative care workforce, attention should be focused on ensuring that pulmonologists are prepared to assess and manage the common palliative care needs of patients with chronic lung disease.

Authors
Wysham, NG; Cox, CE; Wolf, SP; Kamal, AH
MLA Citation
Wysham, NG, Cox, CE, Wolf, SP, and Kamal, AH. "Symptom Burden of Chronic Lung Disease Compared with Lung Cancer at Time of Referral for Palliative Care Consultation." Annals of the American Thoracic Society 12.9 (September 2015): 1294-1301.
PMID
26161449
Source
epmc
Published In
Annals of the American Thoracic Society
Volume
12
Issue
9
Publish Date
2015
Start Page
1294
End Page
1301
DOI
10.1513/annalsats.201503-180oc

Priorities for Evaluating Palliative Care Outcomes in Intensive Care Units.

Defining the quality of intensive care unit (ICU) care when patients are dying is challenging. Palliative care has been recommended to improve outcomes of dying ICU patients; however, traditional ICU quality indicators do not always align with palliative care. Evidence suggests that some aspects of ICU care improve when palliative care is integrated; however, consensus is lacking concerning the outcomes that should be measured. Overcoming challenges to measuring palliative care will require consensus development and rigorous research on the best way to evaluate ICU palliative care services.

Authors
Bakitas, M; Dionne-Odom, JN; Kamal, A; Maguire, JM
MLA Citation
Bakitas, M, Dionne-Odom, JN, Kamal, A, and Maguire, JM. "Priorities for Evaluating Palliative Care Outcomes in Intensive Care Units." Critical care nursing clinics of North America 27.3 (September 2015): 395-411. (Review)
PMID
26333759
Source
epmc
Published In
Critical Care Nursing Clinics of North America
Volume
27
Issue
3
Publish Date
2015
Start Page
395
End Page
411
DOI
10.1016/j.cnc.2015.05.001

Oncology Care Model: Short- and Long-Term Considerations in the Context of Broader Payment Reform.

Authors
Clough, JD; Kamal, AH
MLA Citation
Clough, JD, and Kamal, AH. "Oncology Care Model: Short- and Long-Term Considerations in the Context of Broader Payment Reform." Journal of oncology practice 11.4 (July 2015): 319-321.
PMID
26060221
Source
epmc
Published In
Journal of Oncology Practice
Volume
11
Issue
4
Publish Date
2015
Start Page
319
End Page
321
DOI
10.1200/jop.2015.005777

Polypharmacy in patients with advanced cancer and the role of medication discontinuation.

Polypharmacy is a well known problem in elderly patients in general, but its prevalence and effects in patients with cancer are less clear, particularly in end-of-life settings. This Review examines the existing literature on polypharmacy in advanced cancer and end-of-life settings by reviewing evidence-based approaches to reduce polypharmacy, and outlining the potential benefits of decreasing the number of drugs that patients with cancer can take, with emphasis on the need for thoughtful discontinuation initiatives in the context of life-limiting malignant disease. In view of the apparent burden of polypharmacy in patients with advanced cancer, we expect that greater attention to polypharmacy could lead to improvements in adverse drug events, cost, and possibly quality of life. However, few data for specific interventions in the advanced cancer population are available, and thus more research is warranted.

Authors
LeBlanc, TW; McNeil, MJ; Kamal, AH; Currow, DC; Abernethy, AP
MLA Citation
LeBlanc, TW, McNeil, MJ, Kamal, AH, Currow, DC, and Abernethy, AP. "Polypharmacy in patients with advanced cancer and the role of medication discontinuation." The Lancet. Oncology 16.7 (July 2015): e333-e341. (Review)
PMID
26149885
Source
epmc
Published In
The Lancet Oncology
Volume
16
Issue
7
Publish Date
2015
Start Page
e333
End Page
e341
DOI
10.1016/s1470-2045(15)00080-7

Symptom Burden and Performance Status among Community-Dwelling Patients with Serious Illness.

Predicting when burdensome symptoms will arise or worsen is important to preserving quality of life in patients with serious illness.We explored the relationship between prevalence and severity of symptoms and underlying performance status.We performed a retrospective cohort analysis of patients receiving community palliative care, investigating relationships between symptom burden and performance status. Patient data were obtained from the Carolinas Palliative Care Consortium Database, a central registry of community consultation data for research and quality improvement. We measured symptom prevalence and severity using the McCorkle Symptom Distress Scale and performance status using the Palliative Performance Scale.We analyzed data of 4994 patients, most (90%) with noncancer, serious illnesses. Thirty percent had one or more moderate/severe symptoms. In addition to identifying the high prevalence of fatigue and pain, we found distinct groupings of symptoms with high burden associated with different levels of performance status. This includes high prevalence of fatigue, anorexia, and dyspnea in patients with high performance. Patients with low performance status, however, reported more pain, depression, and constipation.Bothersome symptoms change as patients' performance status worsens. Using performance status as a common language, both medical professionals and informal caregivers can monitor impending changes in symptom burden. This should inform development of community-based delivery systems to detect and manage distress in patients with palliative care needs.

Authors
Kamal, AH; Nipp, RD; Bull, J; Stinson, CS; Abernethy, AP
MLA Citation
Kamal, AH, Nipp, RD, Bull, J, Stinson, CS, and Abernethy, AP. "Symptom Burden and Performance Status among Community-Dwelling Patients with Serious Illness." Journal of palliative medicine 18.6 (June 2015): 542-544.
PMID
25789759
Source
epmc
Published In
Journal of Palliative Medicine
Volume
18
Issue
6
Publish Date
2015
Start Page
542
End Page
544
DOI
10.1089/jpm.2014.0381

The Population Burden of Chronic Symptoms that Substantially Predate the Diagnosis of a Life-Limiting Illness.

Many people in our communities live with symptoms for years or decades, something of relevance to hospice/palliative care clinicians and researchers. The proportion of people in the community at large who have a chronic symptom is likely to approximate the proportion of people referred to hospice/palliative care services with that same chronic symptom that pre-dates their life-limiting illness. Such patients may have different responsiveness to, and expectations from, symptomatic therapies, thus requiring more advanced approaches to symptom control. For researchers evaluating the impact of hospice/palliative care services, failing to account for people with long-term refractory symptoms pre-dating their life-limiting illness may systematically underestimate services' benefits. Observational symptom prevalence studies reported in hospice/palliative care to date have not accounted for people with long-term refractory symptoms, potentially systematically overestimating symptoms attributed to life-limiting illnesses. Cross-sectional community prevalence rates of key chronic refractory symptoms largely unrelated to their life-limiting illness reflect the likely prevalence on referral to hospice/palliative care: fatigue (up to 35%); pain (12%-31%); pain with neuropathic characteristics (9%); constipation (2%-29%); dyspnea (4%-9%); cognitive impairment (>10% of people >65 years old; >30% of people >85 years old); anxiety (4%); and depression (lifetime incidence 2%-15%; one year prevalence 3%). Prospective research is needed to establish (1) the prevalence and severity of chronic symptoms that pre-date the diagnosis of a life-limiting illness in people referred to hospice/palliative care services, comparing this to whole-of-population estimates; and (2) whether this group is disproportionately represented in people with refractory symptoms.

Authors
Currow, DC; Clark, K; Kamal, A; Collier, A; Agar, MR; Lovell, MR; Phillips, JL; Ritchie, C
MLA Citation
Currow, DC, Clark, K, Kamal, A, Collier, A, Agar, MR, Lovell, MR, Phillips, JL, and Ritchie, C. "The Population Burden of Chronic Symptoms that Substantially Predate the Diagnosis of a Life-Limiting Illness." Journal of palliative medicine 18.6 (June 2015): 480-485. (Review)
PMID
25859908
Source
epmc
Published In
Journal of Palliative Medicine
Volume
18
Issue
6
Publish Date
2015
Start Page
480
End Page
485
DOI
10.1089/jpm.2014.0444

Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial.

For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy.To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting.This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach.Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins.Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings.A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, -3.5% to 10.5%; P=.36) and did not meet the noninferiority end point. Total QOL was better for the group discontinuing statin therapy (mean McGill QOL score, 7.11 vs 6.85; P=.04). Few participants experienced cardiovascular events (13 in the discontinuation group vs 11 in the continuation group). Mean cost savings were $3.37 per day and $716 per patient.This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs. Thoughtful patient-provider discussions regarding the uncertain benefit and potential decrement in QOL associated with statin continuation in this setting are warranted.clinicaltrials.gov Identifier: NCT01415934.

Authors
Kutner, JS; Blatchford, PJ; Taylor, DH; Ritchie, CS; Bull, JH; Fairclough, DL; Hanson, LC; LeBlanc, TW; Samsa, GP; Wolf, S; Aziz, NM; Currow, DC; Ferrell, B; Wagner-Johnston, N; Zafar, SY; Cleary, JF; Dev, S; Goode, PS; Kamal, AH; Kassner, C; Kvale, EA; McCallum, JG; Ogunseitan, AB; Pantilat, SZ; Portenoy, RK; Prince-Paul, M; Sloan, JA; Swetz, KM; Von Gunten, CF; Abernethy, AP
MLA Citation
Kutner, JS, Blatchford, PJ, Taylor, DH, Ritchie, CS, Bull, JH, Fairclough, DL, Hanson, LC, LeBlanc, TW, Samsa, GP, Wolf, S, Aziz, NM, Currow, DC, Ferrell, B, Wagner-Johnston, N, Zafar, SY, Cleary, JF, Dev, S, Goode, PS, Kamal, AH, Kassner, C, Kvale, EA, McCallum, JG, Ogunseitan, AB, Pantilat, SZ, Portenoy, RK, Prince-Paul, M, Sloan, JA, Swetz, KM, Von Gunten, CF, and Abernethy, AP. "Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial." JAMA internal medicine 175.5 (May 2015): 691-700.
PMID
25798575
Source
epmc
Published In
JAMA Internal Medicine
Volume
175
Issue
5
Publish Date
2015
Start Page
691
End Page
700
DOI
10.1001/jamainternmed.2015.0289

Signposts along the journey toward high-quality palliative care: the value of measuring what matters.

Authors
Kamal, AH
MLA Citation
Kamal, AH. "Signposts along the journey toward high-quality palliative care: the value of measuring what matters." Journal of pain and symptom management 49.5 (May 2015): e1-e2. (Letter)
PMID
25827852
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
49
Issue
5
Publish Date
2015
Start Page
e1
End Page
e2
DOI
10.1016/j.jpainsymman.2015.03.002

Correlation between the international consensus definition of the Cancer Anorexia-Cachexia Syndrome (CACS) and patient-centered outcomes in advanced non-small cell lung cancer.

The cancer anorexia-cachexia syndrome (CACS) is common in patients with advanced solid tumors and is associated with adverse outcomes including poor quality of life (QOL), impaired functioning, and shortened survival.To apply the recently posed weight-based international consensus CACS definition to a population of patients with advanced non-small cell lung cancer (NSCLC) and explore its impact on patient-reported outcomes.Ninety-nine patients participated in up to four study visits over a six-month period. Longitudinal assessments included measures of physical function, QOL, and other clinical variables such as weight and survival.Patients meeting the consensus CACS criteria at Visit 1 had a significantly shorter median survival (239.5 vs. 446 days; hazard ratio, 2.06, P < 0.05). Physical function was worse in the CACS group (mean Karnofsky Performance Status score 68 vs. 77, Eastern Cooperative Oncology Group Performance Status score 1.8 vs. 1.3, P < 0.05 for both), as was QOL (Functional Assessment of Cancer Therapy-General [FACT-G] Lung Cancer subscale of 17.2 vs. 19.9, Anorexia/Cachexia subscale of 31.4 vs. 37.9, P < 0.05 for both). Differences in the FACT-G and the Functional Assessment of Chronic Illness Therapy-Fatigue subscale approached but did not reach statistical significance. Longitudinally, all measures of physical function and QOL worsened regardless of CACS status, but the rate of decline was more rapid in the CACS group.The weight-based component of the recently proposed international consensus CACS definition is useful in identifying patients with advanced NSCLC who are likely to have significantly inferior survival and who will develop more precipitous declines in physical function and QOL. This definition may be useful for clinical screening purposes and identify patients with high palliative care needs.

Authors
LeBlanc, TW; Nipp, RD; Rushing, CN; Samsa, GP; Locke, SC; Kamal, AH; Cella, DF; Abernethy, AP
MLA Citation
LeBlanc, TW, Nipp, RD, Rushing, CN, Samsa, GP, Locke, SC, Kamal, AH, Cella, DF, and Abernethy, AP. "Correlation between the international consensus definition of the Cancer Anorexia-Cachexia Syndrome (CACS) and patient-centered outcomes in advanced non-small cell lung cancer." Journal of pain and symptom management 49.4 (April 2015): 680-689.
PMID
25461669
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
49
Issue
4
Publish Date
2015
Start Page
680
End Page
689
DOI
10.1016/j.jpainsymman.2014.09.008

Top ten inpatient palliative medicine billing and coding mistakes (and how to fix them this week).

Palliative care (PC) has undergone incredible growth in the last 10 years, having gained subspecialty status and penetration into 85% of hospitals over 300 beds. The comprehensive services provided by multiple members of the PC team combined with low reimbursement for nonprocedural medical care challenges all PC teams to operate with financial sustainability. Accurately and compliantly documenting and coding services provided to patients can help to maximize PC programs' revenues and limit operating subsidies received from health care systems or hospice programs. In this article we share common billing and coding mistakes made by our programs and colleagues while providing inpatient, consultative palliative care. Each mistake is explained and paired with a straightforward fix to enable compliant, efficient practice. This will allow clinicians to more accurately communicate to payers the complex care provided to inpatients by the PC team. This fuller picture of the complexity of care provided can increase reimbursements received by your PC program from payers. Understanding how to accurately document, code, and receive appropriate reimbursement will allow our field to continue to grow, broadening the reach of PC nationally to improve quality of life for all patients and families in need.

Authors
Jones, CA; Bull, J; Acevedo, J; Kamal, AH
MLA Citation
Jones, CA, Bull, J, Acevedo, J, and Kamal, AH. "Top ten inpatient palliative medicine billing and coding mistakes (and how to fix them this week)." Journal of palliative medicine 18.3 (March 2015): 211-216.
PMID
25671789
Source
epmc
Published In
Journal of Palliative Medicine
Volume
18
Issue
3
Publish Date
2015
Start Page
211
End Page
216
DOI
10.1089/jpm.2015.0005.18.3

The quality imperative for palliative care

© 2015 American Academy of Hospice and Palliative Medicine. Palliative medicine must prioritize the routine assessment of the quality of clinical care we provide. This includes regular assessment, analysis, and reporting of data on quality. Assessment of quality informs opportunities for improvement and demonstrates to our peers and ourselves the value of our efforts. In fact, continuous messaging of the value of palliative care services is needed to sustain our discipline; this requires regularly evaluating the quality of our care. As the reimbursement mechanisms for health care in the U.S. shift from fee-for-service to fee-for-value models, palliative care will be expected to report robust data on quality of care. We must move beyond demonstrating to our constituents (including patients and referrers), "here is what we do," and increase the focus on "this is how well we do it" and "let us see how we can do it better." It is incumbent on palliative care professionals to lead these efforts. This involves developing standardized methods to collect data without adding additional burden, comparing and sharing our experiences to promote discipline-wide quality assessment and improvement initiatives, and demonstrating our intentions for quality improvement on the clinical frontline.

Authors
Kamal, AH; Hanson, LC; Casarett, DJ; Dy, SM; Pantilat, SZ; Lupu, D; Abernethy, AP
MLA Citation
Kamal, AH, Hanson, LC, Casarett, DJ, Dy, SM, Pantilat, SZ, Lupu, D, and Abernethy, AP. "The quality imperative for palliative care." Journal of Pain and Symptom Management 49.2 (February 1, 2015): 243-253.
Source
scopus
Published In
Journal of Pain and Symptom Management
Volume
49
Issue
2
Publish Date
2015
Start Page
243
End Page
253
DOI
10.1016/j.jpainsymman.2014.06.008

The quality imperative for palliative care.

Palliative medicine must prioritize the routine assessment of the quality of clinical care we provide. This includes regular assessment, analysis, and reporting of data on quality. Assessment of quality informs opportunities for improvement and demonstrates to our peers and ourselves the value of our efforts. In fact, continuous messaging of the value of palliative care services is needed to sustain our discipline; this requires regularly evaluating the quality of our care. As the reimbursement mechanisms for health care in the U.S. shift from fee-for-service to fee-for-value models, palliative care will be expected to report robust data on quality of care. We must move beyond demonstrating to our constituents (including patients and referrers), "here is what we do," and increase the focus on "this is how well we do it" and "let us see how we can do it better." It is incumbent on palliative care professionals to lead these efforts. This involves developing standardized methods to collect data without adding additional burden, comparing and sharing our experiences to promote discipline-wide quality assessment and improvement initiatives, and demonstrating our intentions for quality improvement on the clinical frontline.

Authors
Kamal, AH; Hanson, LC; Casarett, DJ; Dy, SM; Pantilat, SZ; Lupu, D; Abernethy, AP
MLA Citation
Kamal, AH, Hanson, LC, Casarett, DJ, Dy, SM, Pantilat, SZ, Lupu, D, and Abernethy, AP. "The quality imperative for palliative care." Journal of pain and symptom management 49.2 (February 2015): 243-253.
PMID
25057987
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
49
Issue
2
Publish Date
2015
Start Page
243
End Page
253
DOI
10.1016/j.jpainsymman.2014.06.008

Quality of palliative care for patients with advanced cancer in a community consortium.

Measuring quality of care delivery is essential to palliative care program growth and sustainability. We formed the Carolinas Consortium for Palliative Care and collected a quality data registry to monitor our practice and inform quality improvement efforts.We analyzed all palliative care consultations in patients with cancer in our quality registry from March 2008 through October 2011 using 18 palliative care quality measures. Descriptive metric adherence was calculated after analyzing the relevant population for measurement.We used a paper-based, prospective method to monitor adherence for quality measures in a community-based palliative care consortium.We demonstrate that measures evaluating process assessment (range 63%-100%), as opposed to interventions (range 3%-17%), are better documented.Analyzing data on quality is feasible and valuable in community-based palliative care. Overall, processes to collect data on quality using nontechnology methods may underestimate true adherence to quality measures.

Authors
Kamal, AH; Nipp, RD; Bull, JH; Stinson, CS; Lowery, AW; Nicolla, JM; Abernethy, AP
MLA Citation
Kamal, AH, Nipp, RD, Bull, JH, Stinson, CS, Lowery, AW, Nicolla, JM, and Abernethy, AP. "Quality of palliative care for patients with advanced cancer in a community consortium." Journal of pain and symptom management 49.2 (February 2015): 289-292.
PMID
25220048
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
49
Issue
2
Publish Date
2015
Start Page
289
End Page
292
DOI
10.1016/j.jpainsymman.2014.05.024

Comparison of Quality Oncology Practice Initiative (QOPI) Measure Adherence Between Oncology Fellows, Advanced Practice Providers, and Attending Physicians

© 2015, Springer Science+Business Media New York.Quality improvement measures are uniformly applied to all oncology providers, regardless of their roles. Little is known about differences in adherence to these measures between oncology fellows, advance practice providers (APP), and attending physicians. We investigated conformance across Quality Oncology Practice Initiative (QOPI) measures for oncology fellows, advance practice providers, and attending physicians at the Durham Veterans Affairs Medical Center (DVAMC). Using data collected from the Spring 2012 and 2013 QOPI cycles, we abstracted charts of patients and separated them based on their primary provider. Descriptive statistics and the chi-square test were calculated for each QOPI measure between fellows, advanced practice providers (APPs), and attending physicians. A total of 169 patients were reviewed. Of these, 31 patients had a fellow, 39 had an APP, and 99 had an attending as their primary oncology provider. Fellows and attending physicians performed similarly on 90 of 94 QOPI metrics. High-performing metrics included several core QOPI measures including documenting consent for chemotherapy, recommending adjuvant chemotherapy when appropriate, and prescribing serotonin antagonists when prescribing emetogenic chemotherapies. Low-performing metrics included documentation of treatment summary and taking action to address problems with emotional well-being by the second office visit. Attendings documented the plan for oral chemotherapy more often (92 vs. 63 %, P = 0.049). However, after the chart audit, we found that fellows actually documented the plan for oral chemotherapy 88 % of the time (p = 0.73). APPs and attendings performed similarly on 88 of 90 QOPI measures. The quality of oncology care tends to be similar between attendings and fellows overall; some of the significant differences do not remain significant after a second manual chart review, highlighting that the use of manual data collection for QOPI analysis is an imperfect system, and there may be significant inter-observer variability.

Authors
Zhu, J; Zhang, T; Shah, R; Kamal, AH; Kelley, MJ
MLA Citation
Zhu, J, Zhang, T, Shah, R, Kamal, AH, and Kelley, MJ. "Comparison of Quality Oncology Practice Initiative (QOPI) Measure Adherence Between Oncology Fellows, Advanced Practice Providers, and Attending Physicians." Journal of Cancer Education 30.4 (2015): 774-778.
Source
scival
Published In
Journal of Cancer Education
Volume
30
Issue
4
Publish Date
2015
Start Page
774
End Page
778
DOI
10.1007/s13187-015-0798-z

The Symptom Burden Of Patients With Non-Malignant Lung Disease As Compared To Lung Cancer: Lessons From A Learning Health System In Palliative Care

Authors
Wysham, NG; Wolf, SP; Kamal, AH
MLA Citation
Wysham, NG, Wolf, SP, and Kamal, AH. "The Symptom Burden Of Patients With Non-Malignant Lung Disease As Compared To Lung Cancer: Lessons From A Learning Health System In Palliative Care." 2015.
Source
wos-lite
Published In
American journal of respiratory and critical care medicine
Volume
191
Publish Date
2015

Integrating the biopsychosocial model into quality measures in palliative care: a case for improving the hospice item set.

Authors
Webb, JA; Kamal, AH
MLA Citation
Webb, JA, and Kamal, AH. "Integrating the biopsychosocial model into quality measures in palliative care: a case for improving the hospice item set." Journal of pain and symptom management 48.1 (July 2014): e1-e2. (Letter)
PMID
24863155
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
48
Issue
1
Publish Date
2014
Start Page
e1
End Page
e2
DOI
10.1016/j.jpainsymman.2014.05.002

Quality measures for palliative care in patients with cancer: a systematic review.

Quality assessment is a critical component of determining the value of medical services, including palliative care. Characterization of the current portfolio of measures that assess the quality of palliative care delivered in oncology is necessary to identify gaps and inform future measure development.We performed a systematic review of MEDLINE/PubMed and the gray literature for quality measures relevant to palliative care. Measures were categorized into National Quality Forum domains and reviewed for methodology of development and content. Measures were additionally analyzed to draw summative conclusions on scope and span.Two hundred eighty-four quality measures within 13 measure sets were identified. The most common domains for measure content were Physical Aspects of Care (35%) and Structure and Processes of Care (22%). Of symptom-related measures, pain (36%) and dyspnea (26%) were the most commonly addressed. Spiritual (4%) and Cultural (1%) Aspects of Care were least represented domains. Generally, measures addressed processes of care, did not delineate benchmarks for success, and often did not specify intended interventions to address unmet needs. This was most evident regarding issues of psychosocial and spiritual assessment and management.Within a large cohort of quality measures for palliative, care is often a focus on physical manifestations of disease and adverse effects of therapy; relatively little attention is given to the other aspects of suffering commonly observed among patients with advanced cancer, including psychological, social, and spiritual distress.

Authors
Kamal, AH; Gradison, M; Maguire, JM; Taylor, D; Abernethy, AP
MLA Citation
Kamal, AH, Gradison, M, Maguire, JM, Taylor, D, and Abernethy, AP. "Quality measures for palliative care in patients with cancer: a systematic review." Journal of oncology practice 10.4 (July 2014): 281-287. (Review)
PMID
24917264
Source
epmc
Published In
Journal of Oncology Practice
Volume
10
Issue
4
Publish Date
2014
Start Page
281
End Page
287
DOI
10.1200/jop.2013.001212

Rituximab for follicular lymphoma: watch and wait, watch and worry, or watch and live?

Authors
LeBlanc, T; Kamal, A; Abernethy, A
MLA Citation
LeBlanc, T, Kamal, A, and Abernethy, A. "Rituximab for follicular lymphoma: watch and wait, watch and worry, or watch and live?." The Lancet. Oncology 15.7 (June 2014): e251-e252. (Letter)
PMID
24872108
Source
epmc
Published In
The Lancet Oncology
Volume
15
Issue
7
Publish Date
2014
Start Page
e251
End Page
e252
DOI
10.1016/s1470-2045(14)70215-3

Preparedness planning before mechanical circulatory support: a "how-to" guide for palliative medicine clinicians.

The role of palliative medicine in the care of patients with advanced heart failure, including those who receive mechanical circulatory support, has grown dramatically in the last decade. Previous literature has suggested that palliative medicine providers are well poised to assist cardiologists, cardiothoracic surgeons, and the multidisciplinary cardiovascular team with promotion of informed consent and initial and iterative discussions regarding goals of care. Although preparedness planning has been described previously, the actual methods that can be used to complete a preparedness plan have not been well defined. Herein, we outline several key aspects of this approach and detail strategies for engaging patients who are receiving mechanical circulatory support in preparedness planning.

Authors
Swetz, KM; Kamal, AH; Matlock, DD; Dose, AM; Borkenhagen, LS; Kimeu, AK; Dunlay, SM; Feely, MA
MLA Citation
Swetz, KM, Kamal, AH, Matlock, DD, Dose, AM, Borkenhagen, LS, Kimeu, AK, Dunlay, SM, and Feely, MA. "Preparedness planning before mechanical circulatory support: a "how-to" guide for palliative medicine clinicians." J Pain Symptom Manage 47.5 (May 2014): 926-935.e6.
PMID
24094703
Source
pubmed
Published In
Journal of Pain and Symptom Management
Volume
47
Issue
5
Publish Date
2014
Start Page
926
End Page
935.e6
DOI
10.1016/j.jpainsymman.2013.06.006

Comparing unmet needs between community-based palliative care patients with heart failure and patients with cancer.

As the role of palliative care (PC) has yet to be clearly defined in patients with heart failure (HF), such patients may face barriers regarding PC referral. In order to maximally meet the needs of HF patients, it is necessary to understand how they compare to the classic PC population: patients with cancer.To characterize the unresolved symptom and treatment needs with which patients with HF and those with cancer present to PC.We used data from the Palliative Care Research Registry (PCRR), a repository of quality improvement data from three community-based PC organizations. We abstracted first PC visit data from the PCRR for patients with primary diagnoses of HF or cancer seen between 2008 and 2012. We assessed the association of primary diagnosis (i.e., HF or cancer) on three outcomes: unresolved symptoms, treatment gaps, and a composite indicator of symptom control and quality of life. Analyses included descriptive statistics and multivariate Poisson regression.Our analytic sample comprised 334 patients with HF and 697 patients with cancer, the majority of whom were white and male. Compared to patients with cancer, patients with HF presented with fewer unresolved symptoms, both overall and at moderate/severe distress levels. Patients with HF more commonly reported moderately/severely distressful dyspnea (25% versus 18%, p=0.02), and more commonly experienced dyspnea-related treatment gaps (17% versus 8%, p<0.001).Patients with HF possess care needs that are squarely within the purview of PC. Future work is needed to delineate how PC referral policies should be refined to optimize PC access for patients with HF.

Authors
Kavalieratos, D; Kamal, AH; Abernethy, AP; Biddle, AK; Carey, TS; Dev, S; Reeve, BB; Weinberger, M
MLA Citation
Kavalieratos, D, Kamal, AH, Abernethy, AP, Biddle, AK, Carey, TS, Dev, S, Reeve, BB, and Weinberger, M. "Comparing unmet needs between community-based palliative care patients with heart failure and patients with cancer." Journal of palliative medicine 17.4 (April 2014): 475-481.
PMID
24588568
Source
epmc
Published In
Journal of Palliative Medicine
Volume
17
Issue
4
Publish Date
2014
Start Page
475
End Page
481
DOI
10.1089/jpm.2013.0526

Optimizing the quality of breast cancer biomarker use at Duke Cancer Institute.

Advances in identifying biomarker profiles in patients with early-stage breast cancer have improved 5-year curative rates. Identification of the HER2 receptor provides valuable information that has been shown to extend survival in adjuvant and metastatic settings. Current clinical guidelines discuss when confirmatory testing may be inappropriate. Using a quality improvement approach, the team at Duke Cancer Institute determined HER2 ordering practices in a large academic cancer center. HER2 ordering using immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) was abstracted from the charts of 314 patients with early-stage breast cancer. Qualitative responses to current clinical practices were obtained from clinicians. Of the patients included, duplicate IHC was performed for 36% and in triplicate for 6%; repeat testing resulted in clinically significant change in HER2 status for approximately 20%. Repeat biomarker testing on metastatic biopsy sites "all of the time" was favored by the surveyed physicians. FISH was ordered for each grade of IHC: 0+ (>20% of cases), 1+ (>20%), 2+ (99%), 3+ (54%). Most physicians "strongly" or "somewhat" favored solutions that integrate order sets and care pathways into the electronic medical record. This quality improvement project identified root causes and solutions to practice variance in breast cancer biomarker ordering and interpretation. Further investigations are planned to standardize best practices while appreciating the clinical challenges posed by discordant test results.

Authors
Kamal, AH; Power, S; Broadwater, G; Holland, AR; Marcom, PK
MLA Citation
Kamal, AH, Power, S, Broadwater, G, Holland, AR, and Marcom, PK. "Optimizing the quality of breast cancer biomarker use at Duke Cancer Institute." Journal of the National Comprehensive Cancer Network : JNCCN 12 Suppl 1 (February 2014): S21-S24.
PMID
24614047
Source
epmc
Published In
Journal of the National Comprehensive Cancer Network : JNCCN
Volume
12 Suppl 1
Publish Date
2014
Start Page
S21
End Page
S24
DOI
10.6004/jnccn.2014.0209

Getting to proven: Evaluating quality across all of palliative care

Authors
Kamal, AH
MLA Citation
Kamal, AH. "Getting to proven: Evaluating quality across all of palliative care." Journal of Pain and Symptom Management 47.1 (January 1, 2014). (Letter)
Source
scopus
Published In
Journal of Pain and Symptom Management
Volume
47
Issue
1
Publish Date
2014
DOI
10.1016/j.jpainsymman.2013.09.007

Preparedness planning before mechanical circulatory support: A "how-to" guide for palliative medicine clinicians

The role of palliative medicine in the care of patients with advanced heart failure, including those who receive mechanical circulatory support, has grown dramatically in the last decade. Previous literature has suggested that palliative medicine providers are well poised to assist cardiologists, cardiothoracic surgeons, and the multidisciplinary cardiovascular team with promotion of informed consent and initial and iterative discussions regarding goals of care. Although preparedness planning has been described previously, the actual methods that can be used to complete a preparedness plan have not been well defined. Herein, we outline several key aspects of this approach and detail strategies for engaging patients who are receiving mechanical circulatory support in preparedness planning. © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Authors
Swetz, KM; Kamal, AH; Matlock, DD; Dose, AM; Borkenhagen, LS; Kimeu, AK; Dunlay, SM; Feely, MA
MLA Citation
Swetz, KM, Kamal, AH, Matlock, DD, Dose, AM, Borkenhagen, LS, Kimeu, AK, Dunlay, SM, and Feely, MA. "Preparedness planning before mechanical circulatory support: A "how-to" guide for palliative medicine clinicians." Journal of Pain and Symptom Management 47.5 (January 1, 2014).
Source
scopus
Published In
Journal of Pain and Symptom Management
Volume
47
Issue
5
Publish Date
2014
DOI
10.1016/j.jpainsymman.2013.06.006

Integrating the biopsychosocial model into quality measures in palliative care: A case for improving the hospice item set

Authors
Webb, JA; Kamal, AH
MLA Citation
Webb, JA, and Kamal, AH. "Integrating the biopsychosocial model into quality measures in palliative care: A case for improving the hospice item set." Journal of Pain and Symptom Management 48.1 (January 1, 2014). (Letter)
Source
scopus
Published In
Journal of Pain and Symptom Management
Volume
48
Issue
1
Publish Date
2014
DOI
10.1016/j.jpainsymman.2014.05.002

Time to define high-quality palliative care in oncology.

Authors
Kamal, AH
MLA Citation
Kamal, AH. "Time to define high-quality palliative care in oncology." J Clin Oncol 31.24 (August 20, 2013): 3047-. (Letter)
PMID
23878297
Source
pubmed
Published In
Journal of Clinical Oncology
Volume
31
Issue
24
Publish Date
2013
Start Page
3047
DOI
10.1200/JCO.2013.50.2484

Community-based palliative care: the natural evolution for palliative care delivery in the U.S.

Palliative care in the U.S. has evolved from a system primarily reliant on community-based hospices to a combined model that includes inpatient services at most large hospitals. However, these two dominant approaches leave most patients needing palliative care-those at home (including nursing homes) but not yet ready for hospice-unable to access the positive impacts of the palliative care approach. We propose a community-based palliative care (CPC) model that spans the array of inpatient and outpatient settings in which palliative care is provided and links seamlessly to inpatient care; likewise, it would span the full trajectory of advanced illness rather than focusing on the period just before death. Examples of CPC programs are developing organically across the U.S. As our understanding of CPC expands, standardization is needed to ensure replicability, consistency, and the ability to relate intervention models to outcomes. A growing body of literature examining outpatient palliative care supports the role of CPC in improving outcomes, including reduction in symptom burden, improved quality of life, increased survival, better satisfaction with care, and reduced health care resource utilization. Furthermore the examination of how to operationalize CPC is needed before widespread implementation can be realized. This article describes the key characteristics of CPC, highlighting its role in longitudinal care across patient transitions. Distinguishing features include consistent care across the disease trajectory independent of diagnosis and prognosis; inclusion of inpatient, outpatient, long-term care, and at-home care delivery; collaboration with other medical disciplines, nursing, and allied health; and full integration into the health care system (rather than parallel delivery).

Authors
Kamal, AH; Currow, DC; Ritchie, CS; Bull, J; Abernethy, AP
MLA Citation
Kamal, AH, Currow, DC, Ritchie, CS, Bull, J, and Abernethy, AP. "Community-based palliative care: the natural evolution for palliative care delivery in the U.S." J Pain Symptom Manage 46.2 (August 2013): 254-264.
PMID
23159685
Source
pubmed
Published In
Journal of Pain and Symptom Management
Volume
46
Issue
2
Publish Date
2013
Start Page
254
End Page
264
DOI
10.1016/j.jpainsymman.2012.07.018

Timing of end-of-life care discussion with performance on end-of-life quality indicators in ovarian cancer.

OBJECTIVES: (1) To describe the prevalence, timing and setting of documented end-of-life (EOL) discussions in patients with advanced ovarian cancer; and (2) to assess the impact of timing and setting of documented end-of-life discussions on EOL quality care measures. METHODS: A retrospective study of women who died of ovarian cancer diagnosed between 1999 and 2008 was conducted. The following are the EOL quality measures assessed: chemotherapy in the last 14 days of life, >1 hospitalization in the last 30 days, >1 ER visit in the last 30 days, intensive care unit (ICU) admission in the last 30 days, dying in an acute care setting, admitted to hospice ≤3 days. RESULTS: One hundred seventy-seven (80%) patients had documented end-of-life discussions. Median interval from EOL discussion until death was 29 days. Seventy-eight patients (44%) had EOL discussions as outpatient and 99 (56%) as inpatient. Sixty-four out of 220 (29%) patients' care did not conform to at least one EOL quality measure. An EOL discussion at least 30 days before death was associated with a lower incidence of: chemotherapy in the last 14 days of life (p=0.003), >1 hospitalization in the last 30 days (p<0.001), ICU admission in the last 30 days (p=0.005), dying in acute care setting (p=0.01), admitted to hospice ≤3 days (p=0.02). EOL discussion as outpatient was associated with fewer patients hospitalized >1 in the last 30days of life (p<0.001). CONCLUSIONS: End-of-life care discussions are occurring too late in the disease process. Conformance with EOL quality measures can be achieved with earlier end-of-life care discussions.

Authors
Lopez-Acevedo, M; Havrilesky, LJ; Broadwater, G; Kamal, AH; Abernethy, AP; Berchuck, A; Alvarez Secord, A; Tulsky, JA; Valea, F; Lee, PS
MLA Citation
Lopez-Acevedo, M, Havrilesky, LJ, Broadwater, G, Kamal, AH, Abernethy, AP, Berchuck, A, Alvarez Secord, A, Tulsky, JA, Valea, F, and Lee, PS. "Timing of end-of-life care discussion with performance on end-of-life quality indicators in ovarian cancer." Gynecol Oncol 130.1 (July 2013): 156-161.
PMID
23587882
Source
pubmed
Published In
Gynecologic Oncology
Volume
130
Issue
1
Publish Date
2013
Start Page
156
End Page
161
DOI
10.1016/j.ygyno.2013.04.010

Prevalence and impact of correlative science in breast cancer phase II trials.

Correlative science (CS) can potentially augment clinical trial results by identifying biomarkers of response and resistance to a novel intervention. We evaluated recently published breast cancer phase II trials (BP2T) to determine prevalence, characteristics, and outcomes of CS. Through Pubmed, we identified BP2T of systemic therapy published between June 2005 and June 2010. A study-specific abstraction tool recorded trial characteristics, CS endpoints, source of tissue, adequacy of samples, biopsy safety, and CS outcomes. BP2T authors were contacted to verify abstraction results. Results were abstracted from 298 eligible trials enrolling 18,782 patients, of which 81 (27.2 %) involved CS. Of these, 57 (70.4 %) included tissue with 16 (28 %) using optional research biopsies and 17 (30 %) requiring mandatory research biopsies. No trial addressed biopsy safety issues. Trials were more likely to include CS if they were: industry versus non-industry sponsored (33.7 % vs. 17.1 %, p = 0.0017), neoadjuvant versus metastatic setting (47 % vs. 21.2 %, p = 0.0001), or U.S. versus non-U.S. trials (37 % vs. 21 %, p = 0.005). A minority of phase II breast cancer trials include CS representing a missed opportunity to learn more from clinical research. When CS is included, consistent reporting of endpoints, feasibility, outcomes, and safety is needed.

Authors
Zhang, T; Schneider, A; Hamilton, EP; Patel, K; Kamal, AH; Lyman, GH; Peppercorn, JM
MLA Citation
Zhang, T, Schneider, A, Hamilton, EP, Patel, K, Kamal, AH, Lyman, GH, and Peppercorn, JM. "Prevalence and impact of correlative science in breast cancer phase II trials." Breast cancer research and treatment 139.3 (June 15, 2013): 845-850.
PMID
23771715
Source
epmc
Published In
Breast Cancer Research and Treatment
Volume
139
Issue
3
Publish Date
2013
Start Page
845
End Page
850
DOI
10.1007/s10549-013-2590-2

Conformance with supportive care quality measures is associated with better quality of life in patients with cancer receiving palliative care.

PURPOSE: As palliative care further integrates into cancer care, descriptions of how supportive care quality measures improve patient outcomes are necessary to establish best practices. METHODS: We assessed the relationship between conformance to 18 palliative care quality measures and quality of life from data obtained using our novel point-of-care, electronic quality monitoring system, the Quality Data Collection Tool for Palliative Care (QDACT-PC). All patients with cancer from January 2008 through March 2011 seen in the Carolinas Palliative Care Consortium were evaluated for demographic, disease, prognostic, performance status, and measure conformance variables. Using univariate and multivariate regression, we examined the relationship between these variable and high quality of life at the initial specialty palliative care consultation. RESULTS: Our cohort included 459 patients, the majority of whom were over age 65 years (66%) and white (84%). Lung (29.1%) and GI (24.7%) cancers were most common. In univariate analyses, conformance to assessment of comprehensive symptoms, fatigue and constipation assessment, timely management of pain and constipation, and timely emotional well-being assessment were associated with highest levels of quality of life (all Ps < .05). In a multivariate model (C-stat = 0.66), performance status (odds ratio [OR], 5.21; P = .003), estimated life expectancy (OR, 22.6; P = .003), conformance to the measure related to emotional well-being assessment (OR, 1.60; P = .026), and comprehensive screening of symptoms (OR, 1.74, P = .008) remained significant. CONCLUSION: Oncology care pathways that routinely incorporate supportive care principles, such as comprehensive symptom and emotional well-being assessments, may improve patient outcomes.

Authors
Kamal, AH; Bull, J; Stinson, CS; Blue, DL; Abernethy, AP
MLA Citation
Kamal, AH, Bull, J, Stinson, CS, Blue, DL, and Abernethy, AP. "Conformance with supportive care quality measures is associated with better quality of life in patients with cancer receiving palliative care." J Oncol Pract 9.3 (May 2013): e73-e76.
PMID
23942504
Source
pubmed
Published In
Journal of Oncology Practice
Volume
9
Issue
3
Publish Date
2013
Start Page
e73
End Page
e76
DOI
10.1200/JOP.2013.000948

Evolution of the Quality Oncology Practice Initiative supportive care quality measures portfolio and conformance at a Veterans Affairs medical center.

A growing set of quality measures is being implemented to evaluate all components of cancer care, from diagnosis through the end of life. We investigated the Quality Oncology Practice Initiative (QOPI) quality measures portfolio. Additionally, we explored the effect of quality measure type on conformance.We performed QOPI data collections twice per year from fall 2007 through fall 2010 and spring 2012, using chart review of the Durham Veterans Administration outpatient oncology clinic. We categorized QOPI measures as nontreatment-related supportive care (NTSC), treatment-related supportive care (TSC), diagnostic, or therapeutic. Descriptive statistics and χ(2) were used to compare longitudinal conformance.The majority of QOPI measures in spring 2012 assess processes of chemotherapy treatment (therapeutic, 54.3%; TSC, 8.7%) or diagnostic modalities (19.6%). Measures targeting NTSC are few (17.4%) but increased from three measures in fall 2007 to eight measures in spring 2012. During those 5 years, average conformance to NTSC, TSC, diagnostic, and therapeutic measures was 71.4%, 86.1%, 89.3%, and 75.4%, respectively (P < .001). Within the NTSC measures, emotional well-being and constipation assessment were least documented (41.0% and 46.3%, respectively). In spring 2012, NTSC measure conformance (75.8%) remained significantly lower than diagnostic measure conformance (91.5%; P < .001).Most QOPI quality measures assess diagnosis or treatment processes of care and not supportive care. Aggregate conformance to the NTSC measures was lower than that of other categories. The differential conformance demonstrates the necessity of standardized documentation methods and quality improvement efforts that remain commensurate with the increasing portfolio of supportive care measures.

Authors
Nipp, RD; Kelley, MJ; Williams, CD; Kamal, AH
MLA Citation
Nipp, RD, Kelley, MJ, Williams, CD, and Kamal, AH. "Evolution of the Quality Oncology Practice Initiative supportive care quality measures portfolio and conformance at a Veterans Affairs medical center." Journal of oncology practice 9.3 (May 2013): e86-e89.
PMID
23942507
Source
epmc
Published In
Journal of Oncology Practice
Volume
9
Issue
3
Publish Date
2013
Start Page
e86
End Page
e89
DOI
10.1200/jop.2013.000923

The generalizability paradox within palliative care clinical trials.

We are increasingly recognizing that personalized advanced and chronic illness care requires meticulous assessment and management of supportive care needs across the entire disease trajectory. This requires drawing clinical decisions from a research evidence base that is presumably generalizable to a heterogeneous patient population, often with poor performance status, multi-morbidity, and a large symptom distress profile. As sometimes this is not the case, how do we improve evidence generation that can be consistently applied to all patients with advanced disease?

Authors
Kamal, AH; Peppercorn, JM
MLA Citation
Kamal, AH, and Peppercorn, JM. "The generalizability paradox within palliative care clinical trials." Annals of palliative medicine 2.2 (April 2013): 101-104.
PMID
25841935
Source
epmc
Published In
Annals of palliative medicine
Volume
2
Issue
2
Publish Date
2013
Start Page
101
End Page
104
DOI
10.3978/j.issn.2224-5820.2013.02.06

Getting to Proven: Evaluating Quality Across All of Palliative Care

Authors
Kamal, AH
MLA Citation
Kamal, AH. "Getting to Proven: Evaluating Quality Across All of Palliative Care." Journal of Pain and Symptom Management (2013).
PMID
24291298
Source
scopus
Published In
Journal of Pain and Symptom Management
Publish Date
2013

Timing of end-of-life care discussion with performance on end-of-life quality indicators in ovarian cancer

Objectives (1) To describe the prevalence, timing and setting of documented end-of-life (EOL) discussions in patients with advanced ovarian cancer; and (2) to assess the impact of timing and setting of documented end-of-life discussions on EOL quality care measures. Methods A retrospective study of women who died of ovarian cancer diagnosed between 1999 and 2008 was conducted. The following are the EOL quality measures assessed: chemotherapy in the last 14 days of life, > 1 hospitalization in the last 30 days, > 1 ER visit in the last 30 days, intensive care unit (ICU) admission in the last 30 days, dying in an acute care setting, admitted to hospice ≤ 3 days. Results One hundred seventy-seven (80%) patients had documented end-of-life discussions. Median interval from EOL discussion until death was 29 days. Seventy-eight patients (44%) had EOL discussions as outpatient and 99 (56%) as inpatient. Sixty-four out of 220 (29%) patients' care did not conform to at least one EOL quality measure. An EOL discussion at least 30 days before death was associated with a lower incidence of: chemotherapy in the last 14 days of life (p = 0.003), > 1 hospitalization in the last 30 days (p < 0.001), ICU admission in the last 30 days (p = 0.005), dying in acute care setting (p = 0.01), admitted to hospice ≤ 3 days (p = 0.02). EOL discussion as outpatient was associated with fewer patients hospitalized > 1 in the last 30 days of life (p < 0.001). Conclusions End-of-life care discussions are occurring too late in the disease process. Conformance with EOL quality measures can be achieved with earlier end-of-life care discussions. © 2013 Elsevier Inc.

Authors
Lopez-Acevedo, M; Havrilesky, LJ; Broadwater, G; Kamal, AH; Abernethy, AP; Berchuck, A; Secord, AA; Tulsky, JA; Valea, F; Lee, PS
MLA Citation
Lopez-Acevedo, M, Havrilesky, LJ, Broadwater, G, Kamal, AH, Abernethy, AP, Berchuck, A, Secord, AA, Tulsky, JA, Valea, F, and Lee, PS. "Timing of end-of-life care discussion with performance on end-of-life quality indicators in ovarian cancer." Gynecologic Oncology 130.1 (2013): 156-161.
Source
scival
Published In
Gynecologic Oncology
Volume
130
Issue
1
Publish Date
2013
Start Page
156
End Page
161
DOI
10.1016/j.ygyno.2013.04.010

Prevalence and impact of correlative science in breast cancer phase II trials

Correlative science (CS) can potentially augment clinical trial results by identifying biomarkers of response and resistance to a novel intervention. We evaluated recently published breast cancer phase II trials (BP2T) to determine prevalence, characteristics, and outcomes of CS. Through Pubmed, we identified BP2T of systemic therapy published between June 2005 and June 2010. A study-specific abstraction tool recorded trial characteristics, CS endpoints, source of tissue, adequacy of samples, biopsy safety, and CS outcomes. BP2T authors were contacted to verify abstraction results. Results were abstracted from 298 eligible trials enrolling 18,782 patients, of which 81 (27.2 %) involved CS. Of these, 57 (70.4 %) included tissue with 16 (28 %) using optional research biopsies and 17 (30 %) requiring mandatory research biopsies. No trial addressed biopsy safety issues. Trials were more likely to include CS if they were: industry versus non-industry sponsored (33.7 % vs. 17.1 %, p = 0.0017), neoadjuvant versus metastatic setting (47 % vs. 21.2 %, p = 0.0001), or U.S. versus non-U.S. trials (37 % vs. 21 %, p = 0.005). A minority of phase II breast cancer trials include CS representing a missed opportunity to learn more from clinical research. When CS is included, consistent reporting of endpoints, feasibility, outcomes, and safety is needed. © 2013 Springer Science+Business Media New York.

Authors
Zhang, T; Schneider, A; Hamilton, EP; Patel, K; Kamal, AH; Lyman, GH; Peppercorn, JM
MLA Citation
Zhang, T, Schneider, A, Hamilton, EP, Patel, K, Kamal, AH, Lyman, GH, and Peppercorn, JM. "Prevalence and impact of correlative science in breast cancer phase II trials." Breast Cancer Research and Treatment 139.3 (2013): 845-850.
Source
scival
Published In
Breast Cancer Research and Treatment
Volume
139
Issue
3
Publish Date
2013
Start Page
845
End Page
850
DOI
10.1007/s10549-013-2590-2

Community-based palliative care: the natural evolution for palliative care delivery in the U.S.

Palliative care in the U.S. has evolved from a system primarily reliant on community-based hospices to a combined model that includes inpatient services at most large hospitals. However, these two dominant approaches leave most patients needing palliative care - those at home (including nursing homes) but not yet ready for hospice - unable to access the positive impacts of the palliative care approach. We propose a community-based palliative care (CPC) model that spans the array of inpatient and outpatient settings in which palliative care is provided and links seamlessly to inpatient care; likewise, it would span the full trajectory of advanced illness rather than focusing on the period just before death. Examples of CPC programs are developing organically across the U.S. As our understanding of CPC expands, standardization is needed to ensure replicability, consistency, and the ability to relate intervention models to outcomes. A growing body of literature examining outpatient palliative care supports the role of CPC in improving outcomes, including reduction in symptom burden, improved quality of life, increased survival, better satisfaction with care, and reduced health care resource utilization. Furthermore the examination of how to operationalize CPC is needed before widespread implementation can be realized. This article describes the key characteristics of CPC, highlighting its role in longitudinal care across patient transitions. Distinguishing features include consistent care across the disease trajectory independent of diagnosis and prognosis; inclusion of inpatient, outpatient, long-term care, and at-home care delivery; collaboration with other medical disciplines, nursing, and allied health; and full integration into the health care system (rather than parallel delivery). © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Authors
Kamal, AH; Currow, DC; Ritchie, CS; Bull, J; Abernethy, AP
MLA Citation
Kamal, AH, Currow, DC, Ritchie, CS, Bull, J, and Abernethy, AP. "Community-based palliative care: the natural evolution for palliative care delivery in the U.S." Journal of Pain and Symptom Management 46.2 (2013): 254-264.
Source
scival
Published In
Journal of Pain and Symptom Management
Volume
46
Issue
2
Publish Date
2013
Start Page
254
End Page
264
DOI
10.1016/j.jpainsymman.2012.07.018

Should Bisphosphonates Be Used Routinely to Manage Pain and Skeletal Complications in Other Conditions?

Authors
Maguire, JM; Kamal, A; Currow, DC; Abernethy, AP
MLA Citation
Maguire, JM, Kamal, A, Currow, DC, and Abernethy, AP. "Should Bisphosphonates Be Used Routinely to Manage Pain and Skeletal Complications in Other Conditions?." (December 1, 2012): 65-69. (Chapter)
Source
scopus
Publish Date
2012
Start Page
65
End Page
69
DOI
10.1016/B978-1-4377-3796-7.00013-6

When Should Corticosteroids Be Used to Manage Pain?

Authors
Abernethy, AP; Wheeler, JL; Kamal, A; Currow, DC
MLA Citation
Abernethy, AP, Wheeler, JL, Kamal, A, and Currow, DC. "When Should Corticosteroids Be Used to Manage Pain?." (December 1, 2012): 44-48. (Chapter)
Source
scopus
Publish Date
2012
Start Page
44
End Page
48
DOI
10.1016/B978-1-4377-3796-7.00009-4

Should Bisphosphonates Be Used Routinely to Manage Pain and Skeletal Complications in Cancer?

Authors
Kamal, A; Maguire, JM; Currow, DC; Abernethy, AP
MLA Citation
Kamal, A, Maguire, JM, Currow, DC, and Abernethy, AP. "Should Bisphosphonates Be Used Routinely to Manage Pain and Skeletal Complications in Cancer?." (December 1, 2012): 59-64. (Chapter)
Source
scopus
Publish Date
2012
Start Page
59
End Page
64
DOI
10.1016/B978-1-4377-3796-7.00012-4

What Interventions Are Effective for Managing Dyspnea in Cancer?

Authors
Abernethy, AP; Kamal, A; Maguire, JM; Currow, DC
MLA Citation
Abernethy, AP, Kamal, A, Maguire, JM, and Currow, DC. "What Interventions Are Effective for Managing Dyspnea in Cancer?." (December 1, 2012): 103-110. (Chapter)
Source
scopus
Publish Date
2012
Start Page
103
End Page
110
DOI
10.1016/B978-1-4377-3796-7.00020-3

When Should Nonsteroidal Antiinflammatory Drugs Be Used to Manage Pain?

Authors
Abernethy, AP; Kamal, A; Currow, DC
MLA Citation
Abernethy, AP, Kamal, A, and Currow, DC. "When Should Nonsteroidal Antiinflammatory Drugs Be Used to Manage Pain?." (December 1, 2012): 49-53. (Chapter)
Source
scopus
Publish Date
2012
Start Page
49
End Page
53
DOI
10.1016/B978-1-4377-3796-7.00010-0

Demonstration of a sustainable community-based model of care across the palliative care continuum.

CONTEXT: In the U.S., the number of hospital-based palliative care programs has increased rapidly, but availability of outpatient palliative care remains limited. Multiple barriers impede the financial viability of these programs. Four Seasons, a nonprofit organization in western North Carolina, delivers a full spectrum of palliative care in hospitals, nursing homes, assisted living facilities, patients' homes, and outpatient clinics; its catchment area encompasses approximately 350,000 people. Initially focused on hospice care, Four Seasons added its palliative care program in 2003. Before the inquiry described herein, financial losses from outpatient palliative care (2003-2008) were escalating. OBJECTIVES: We explored organizational and financial barriers to sustainability of palliative care, so as to 1) identify reasons for financial losses; 2) devise and implement solutions; and 3) develop a sustainable model for palliative care delivery across settings, including the outpatient setting. METHODS: In 2008, Four Seasons's palliative care program served 305 patients per day (average) with 10.5 providers (physicians, nurse practitioners, and physician assistants); financial losses approached $400,000 per year. We used Quality Assessment and Performance Improvement cycles to identify challenges to and inefficiencies in service provision, developed targeted strategies for overcoming identified barriers to cost-efficiency, instituted these measures, and tracked results. RESULTS: In 2011, Four Seasons served 620 palliative care patients per day (average) with 14 providers; financial losses decreased by 40%. CONCLUSION: With health care reform promoting integration of care across settings, outpatient palliative care will gain importance in the health care continuum. Process changes can help reduce financial losses that currently impede outpatient palliative care programs.

Authors
Bull, JH; Whitten, E; Morris, J; Hooper, RN; Wheeler, JL; Kamal, A; Abernethy, AP
MLA Citation
Bull, JH, Whitten, E, Morris, J, Hooper, RN, Wheeler, JL, Kamal, A, and Abernethy, AP. "Demonstration of a sustainable community-based model of care across the palliative care continuum." J Pain Symptom Manage 44.6 (December 2012): 797-809.
PMID
22771124
Source
pubmed
Published In
Journal of Pain and Symptom Management
Volume
44
Issue
6
Publish Date
2012
Start Page
797
End Page
809
DOI
10.1016/j.jpainsymman.2011.12.278

Integrating technology into palliative care research.

PURPOSE OF REVIEW: As palliative care research evolves and grows within resource-strained environments, further integration of novel methods to assist in completing protocols is needed. Technology-assisted techniques, including the use of software and hardware, to aid in data collection, analysis and reporting are increasingly being incorporated into research investigations in palliative care. Reviewing reported successes of technology use in palliative care research is important to communicate lessons learned and principles to guide further implementation. RECENT FINDINGS: There is a growing body of evidence that technology can be effectively integrated into palliative care research. We review four diverse examples of the use of software and hardware technology for data collection from patients and other research participants. Early successes and challenges with technology are also discussed. In addition, seven guiding principles for technology design, implementation and upgrading are appraised to advise readers of the important pitfalls that can plague any well intentioned technology-based research programme. SUMMARY: Technology has been successfully integrated into some aspects of palliative care research. The growth of both palliative care research and use of electronic methods for data collection predict increased incorporation between the two fields.

Authors
Kamal, AH; Swetz, KM; Dy, S; Tien, AY; Temel, JS; Abernethy, AP
MLA Citation
Kamal, AH, Swetz, KM, Dy, S, Tien, AY, Temel, JS, and Abernethy, AP. "Integrating technology into palliative care research." Curr Opin Support Palliat Care 6.4 (December 2012): 525-532. (Review)
PMID
23080307
Source
pubmed
Published In
Current Opinion in Supportive and Palliative Care
Volume
6
Issue
4
Publish Date
2012
Start Page
525
End Page
532
DOI
10.1097/SPC.0b013e32835998c6

Left Brain, Right Brain

Authors
Kamal, AH
MLA Citation
Kamal, AH. "Left Brain, Right Brain." JOURNAL OF PALLIATIVE MEDICINE 15.8 (August 2012): 951-951.
Source
wos-lite
Published In
Journal of Palliative Medicine
Volume
15
Issue
8
Publish Date
2012
Start Page
951
End Page
951
DOI
10.1089/jpm.2012.0065

Similar survival with single-agent capecitabine or taxane in first-line therapy for metastatic breast cancer.

Capecitabine is often offered as a first-line chemotherapy option for metastatic breast cancer (MBC). In this study, we compare characteristics of and survival among women prescribed first-line capecitabine or taxane monotherapy for MBC. Women receiving first-line chemotherapy for MBC from 1998 to 2005 were identified from the North Carolina tumor registry linked with Medicaid and Medicare claims records, and were followed through the end of 2005 with survival data from the National Death Index. T Tests and Chi-square tests were used to compare baseline characteristics. Overall survival and cancer-specific survival were examined using Cox proportional hazard modeling. There were 257 patients with MBC starting first-line chemotherapy with capecitabine (n=71) or a taxane (n=186). No differences in age, race, or Charlson comorbidity status were observed between groups. Hormone receptor negative tumors (31.0 vs. 17.7%, p=0.02) and patients insured by Medicaid (28 vs. 12%, p=0.002) were more prevalent in the capecitabine group. Time from metastasis to first-line chemotherapy was longer in the capecitabine group (52 vs. 26% began after 3 months, p<0.001). In multivariate analysis, treatment received was not associated with overall or cancer-specific survival. Among standard demographics, age was the only factor significantly associated with overall survival (HR 1.02, p=04). In this population-based study, women who received capecitabine as first-line treatment for MBC were more often hormone receptor negative and insured by Medicaid. In multivariate analysis, first-line capecitabine and taxane for MBC yielded similar overall and cancer-specific survival outcomes.

Authors
Kamal, AH; Camacho, F; Anderson, R; Wei, W; Balkrishnan, R; Kimmick, G
MLA Citation
Kamal, AH, Camacho, F, Anderson, R, Wei, W, Balkrishnan, R, and Kimmick, G. "Similar survival with single-agent capecitabine or taxane in first-line therapy for metastatic breast cancer." Breast Cancer Res Treat 134.1 (July 2012): 371-378.
PMID
22460617
Source
pubmed
Published In
Breast Cancer Research and Treatment
Volume
134
Issue
1
Publish Date
2012
Start Page
371
End Page
378
DOI
10.1007/s10549-012-2037-1

In the clinic. Palliative care.

Authors
Swetz, KM; Kamal, AH
MLA Citation
Swetz, KM, and Kamal, AH. "In the clinic. Palliative care." Ann Intern Med 156.3 (February 7, 2012): ITC2-T15. (Review)
PMID
22312158
Source
pubmed
Published In
Annals of internal medicine
Volume
156
Issue
3
Publish Date
2012
Start Page
ITC2
End Page
T15
DOI
10.7326/0003-4819-156-3-201202070-01002

Improving the management of dyspnea in the community using rapid learning approaches.

Patients with chronic pulmonary disease often suffer from breathlessness or dyspnea. Traditional evidence generation techniques to expand upon current treatment paradigms are limited by the significant delay between study initiation and clinical implementation of findings. Rapid learning health care is a novel approach to health care delivery that relies on intelligent and continuous integration of clinical and research data sets to deliver personalized medicine using the most current evidence available. Results of important studies in the management of chronic respiratory disease are presented in brief; however, the focus of this review is on evidence supporting the implementation of a rapid learning model for symptom management. Recent findings suggest that a rapid learning system is feasible and acceptable to patients with advanced illness, helps monitor symptoms overtime, facilitates study of the impact of novel interventions, and can identify unrecognized needs and concerns. A rapid learning model improves comprehensive assessment, timeliness of intervention, and accrual of contemporaneous data to support best practice that tailors care specific to the needs of patients as their disease and lifestyle change overtime. Using the rapid learning health care model, data collected in the process of routine care can simultaneously function both as clinical information and as a resource for research on patient-centered experiences and outcomes.

Authors
Kamal, AH; Miriovsky, BJ; Currow, DC; Abernethy, AP
MLA Citation
Kamal, AH, Miriovsky, BJ, Currow, DC, and Abernethy, AP. "Improving the management of dyspnea in the community using rapid learning approaches." Chron Respir Dis 9.1 (February 2012): 51-61. (Review)
PMID
22308555
Source
pubmed
Published In
Chronic Respiratory Disease
Volume
9
Issue
1
Publish Date
2012
Start Page
51
End Page
61
DOI
10.1177/1479972311433576

Dyspnea review for the palliative care professional: treatment goals and therapeutic options.

Although dyspnea is frequently encountered in the palliative care setting, its optimal management remains uncertain. Clinical approaches begin with accurate assessment, as delineated in part one of this two-part series. Comprehensive dyspnea assessment, which encompasses the physical, emotional, social, and spiritual aspects of this complex symptom, guide the clinician in choosing therapeutic approaches herein presented as part two. Global management of dyspnea is appropriate both as complementary to disease-targeted treatments that target the underlying etiology, and as the sole focus when the symptom has become intractable, disease is maximally treated, and goals of care shift to comfort and quality of life. In this setting, current evidence supports the use of oral or parenteral opioids as the mainstay of dyspnea management, and of inhaled furosemide and anxiolytics as adjuncts. Nonpharmacologic interventions such as acupuncture and pulmonary rehabilitation have potential effectiveness, although further research is needed, and use of a simple fan warrants consideration given its potential benefit and minimal burden and cost.

Authors
Kamal, AH; Maguire, JM; Wheeler, JL; Currow, DC; Abernethy, AP
MLA Citation
Kamal, AH, Maguire, JM, Wheeler, JL, Currow, DC, and Abernethy, AP. "Dyspnea review for the palliative care professional: treatment goals and therapeutic options." J Palliat Med 15.1 (January 2012): 106-114. (Review)
PMID
22268406
Source
pubmed
Published In
Journal of Palliative Medicine
Volume
15
Issue
1
Publish Date
2012
Start Page
106
End Page
114
DOI
10.1089/jpm.2011.0110

Further data supporting that paclitaxel-associated acute pain syndrome is associated with development of peripheral neuropathy: North Central Cancer Treatment Group trial N08C1

BACKGROUND: Paclitaxel causes an acute pain syndrome (P-APS), occurring within days after each dose and usually abating within days. Paclitaxel also causes a more classic peripheral neuropathy, which steadily increases in severity with increasing paclitaxel total doses. Little detail is available regarding the natural history of these 2 syndromes, or any relationship between them, although a recent publication does provide natural history data about weekly paclitaxel, supporting an association between the severity of P-APS and eventual peripheral neuropathy symptoms. METHODS: Patients entering this study were about to receive paclitaxel and carboplatin every 3 weeks. Daily questionnaires were completed for the first week after every chemotherapy dose, and European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire, Chemotherapy-Induced Peripheral Neuropathy 20-item instruments were completed weekly. RESULTS: The P-APS severity peaked on day 4 after the initial chemotherapy dose, with 12%, 29%, 23%, and 36% of patients having maximal pain scores of 0, 1 to 4, 5 or 6, or 7 to 10 during the first week after the first dose of therapy, respectively. Patients with P-APS scores of 0 to 4 with the first dose of chemotherapy had less eventual sensory neuropathy than did patients with P-APS scores of 5 to 10 (P = 0.001). With regard to the more peripheral neuropathy, sensory neuropathy was more problematic than was either motor or autonomic neuropathy. Numbness and tingling were more common components of the sensory neuropathy than was pain. CONCLUSIONS: Patients with worse P-APS severities appear to have more eventual chemotherapy-induced peripheral neuropathy. This provides support for the concept that P-APS is a form of nerve pathology. Copyright © 2012 American Cancer Society.

Authors
Reeves, BN; Dakhil, SR; Sloan, JA; Wolf, SL; Burger, KN; Kamal, A; Le-Lindqwister, NA; Soori, GS; Jaslowski, AJ; Kelaghan, J; Novotny, PJ; Lachance, DH; Loprinzi, CL
MLA Citation
Reeves, BN, Dakhil, SR, Sloan, JA, Wolf, SL, Burger, KN, Kamal, A, Le-Lindqwister, NA, Soori, GS, Jaslowski, AJ, Kelaghan, J, Novotny, PJ, Lachance, DH, and Loprinzi, CL. "Further data supporting that paclitaxel-associated acute pain syndrome is associated with development of peripheral neuropathy: North Central Cancer Treatment Group trial N08C1." Cancer 118.20 (2012): 5171-5178.
PMID
22415454
Source
scival
Published In
Cancer
Volume
118
Issue
20
Publish Date
2012
Start Page
5171
End Page
5178
DOI
10.1002/cncr.27489

Palliative care needs of patients with cancer living in the community.

PURPOSE: With improved effectiveness of early detection and treatment, many patients with cancer are now living with advanced disease and associated symptoms. As cancer becomes a chronic illness, adequate attention to patients' symptoms and psychosocial needs in the community setting requires positioning of palliative care alongside cancer care. This article describes the current palliative care needs of a population of community-dwelling patients with advanced cancer who are not yet ready for transition to hospice. METHODS: This secondary analysis used quality-monitoring data collected in three community-based palliative care organizations. Analyses focused on people with cancer-related diagnoses who were receiving palliative care during 2008 to 2011. RESULTS: The analytic data set included 4,980 people, 10% of whom had cancer. Median age was 71 years. Forty-eight percent had been hospitalized at least once in the 6 months before palliative care referral. Forty-nine percent had a Palliative Performance Score (PPS) of 40% to 60%; 40% had PPS ≤ 30%. Although 81% had an estimated prognosis of ≤ 6 months, 58% were expected to live weeks to months. Thirty-three percent had no identified healthcare surrogate; 59% had no do-not-resuscitate order despite declining functional status and limited prognosis. Ninety-five percent reported ≥ 1 symptom, and 67% reported ≥ 3 symptoms; a substantial proportion did not receive treatment for symptoms. CONCLUSIONS: Patients referred to community-based palliative care experience multiple often-severe symptoms that have been insufficiently addressed. They tend to have declining performance status. Earlier palliative care intervention could improve outcomes but will require delivery models that better coordinate inpatient/outpatient oncology and community-based palliative care.

Authors
Kamal, AH; Bull, J; Kavalieratos, D; Taylor, DH; Downey, W; Abernethy, AP
MLA Citation
Kamal, AH, Bull, J, Kavalieratos, D, Taylor, DH, Downey, W, and Abernethy, AP. "Palliative care needs of patients with cancer living in the community." J Oncol Pract 7.6 (November 2011): 382-388.
PMID
22379422
Source
pubmed
Published In
Journal of Oncology Practice
Volume
7
Issue
6
Publish Date
2011
Start Page
382
End Page
388
DOI
10.1200/JOP.2011.000455

Collecting data on quality is feasible in community-based palliative care.

BACKGROUND: Quality measurement in palliative care requires robust data from standardized data collection processes. We developed and tested the feasibility of the Quality Data Collection Tool version 1.0 (QDACTv1.0) for use in community-based palliative care. MEASURES: To evaluate for implementation barriers, we tested feasibility, acceptability, and utility of the QDACTv1.0 by reviewing use patterns, surveying clinician users, and reporting conformance with quality metrics. INTERVENTION: Comprising 37 questions within five domains, QDACTv1.0 was launched in May 2008 for data collection at point of care. OUTCOMES: Through March 2011, data on 5959 patients in 19,734 visits have been collected. We observed steady quarterly growth in data collection, positive clinician feedback, and successful mapping of data to quality metrics. Information gathered characterized practice variations and suggested quality improvement initiatives. Clinician feedback has driven updating to Quality Data Collection Tool version 2.0. CONCLUSIONS/LESSONS LEARNED: Standardized data collection is feasible in routine community-based palliative care and is valuable for quality monitoring.

Authors
Kamal, AH; Bull, J; Stinson, C; Blue, D; Smith, R; Hooper, R; Kelly, M; Kinsella, J; Philbrick, M; Gblokpor, A; Wheeler, JL; Downey, W; Abernethy, AP
MLA Citation
Kamal, AH, Bull, J, Stinson, C, Blue, D, Smith, R, Hooper, R, Kelly, M, Kinsella, J, Philbrick, M, Gblokpor, A, Wheeler, JL, Downey, W, and Abernethy, AP. "Collecting data on quality is feasible in community-based palliative care." J Pain Symptom Manage 42.5 (November 2011): 663-667.
PMID
22045369
Source
pubmed
Published In
Journal of Pain and Symptom Management
Volume
42
Issue
5
Publish Date
2011
Start Page
663
End Page
667
DOI
10.1016/j.jpainsymman.2011.07.003

Dyspnea review for the palliative care professional: assessment, burdens, and etiologies.

BACKGROUND: Dyspnea is a common symptom experienced by many patients with chronic, life-threatening, and/or life-limiting illnesses. Although it can be defined and measured in several ways, dyspnea is best described directly by patients through regular assessment, as its burdens exert a strong influence on the patient's experience throughout the trajectory of serious illness. Its significance is amplified due to its impact on family and caregivers. DISCUSSION: Anatomic and physiologic changes associated with dyspnea, and cognitive perceptions related to patients and the underlying disease, provide insights into how to shape interventions targeting this oppressive symptom. Additionally, as described in the concept of "total dyspnea," the complex etiology and manifestation of this symptom require multidisciplinary treatment plans that focus on psychological, social, and spiritual distress as well as physical components. Several validated assessment tools are available for clinical and research use, and choice of method should be tailored to the individual patient, disease, and care setting in the context of patient-centered care. CONCLUSION: This article, the first in a two-part series, reviews the identification and assessment of dyspnea, the burden it entails, and the underlying respiratory and nonrespiratory etiologies that may cause or exacerbate it.

Authors
Kamal, AH; Maguire, JM; Wheeler, JL; Currow, DC; Abernethy, AP
MLA Citation
Kamal, AH, Maguire, JM, Wheeler, JL, Currow, DC, and Abernethy, AP. "Dyspnea review for the palliative care professional: assessment, burdens, and etiologies." J Palliat Med 14.10 (October 2011): 1167-1172. (Review)
PMID
21895451
Source
pubmed
Published In
Journal of Palliative Medicine
Volume
14
Issue
10
Publish Date
2011
Start Page
1167
End Page
1172
DOI
10.1089/jpm.2011.0109

The value of data collection within a palliative care program.

Collecting reliable and valid data is an increasing expectation within palliative care. Data remain the crux for demonstrating value and quality of care, which are the critical steps to program sustainability. Parallel goals of conducting research and performing quality assessment and improvement can also ensure program growth, financial health, and viability in an increasingly competitive environment. Mounting expectations by patients, hospitals, and payers and inevitable pay-for-performance paradigms have transitioned data collection procedures from novel projects to expected standard operation within usual palliative care delivery. We present types of data to collect, published guides for data collection, and how data can inform quality, value, and research within a palliative care organization. Our experiences with the Quality Data Collection Tool (QDACT) in the Carolinas Palliative Care Consortium to collect data on quality have led to valuable lessons learned in creating a data collection system. Suggested steps in forming data-sharing collaborations and building data collection procedures are shared.

Authors
Kamal, AH; Currow, DC; Ritchie, C; Bull, J; Wheeler, JL; Abernethy, AP
MLA Citation
Kamal, AH, Currow, DC, Ritchie, C, Bull, J, Wheeler, JL, and Abernethy, AP. "The value of data collection within a palliative care program." Curr Oncol Rep 13.4 (August 2011): 308-315. (Review)
PMID
21556703
Source
pubmed
Published In
Current Oncology Reports
Volume
13
Issue
4
Publish Date
2011
Start Page
308
End Page
315
DOI
10.1007/s11912-011-0178-8

Management of dyspnea within a rapid learning healthcare model.

PURPOSE OF REVIEW: This review addresses a distressing symptom experienced by many palliative care patients, for which available interventions have been only partially effective. A new model of healthcare delivery and research - rapid learning healthcare - provides a potential framework for improving clinical care for and outcomes of dyspnea. This review places dyspnea management in palliative care within the new systems approach offered by rapid learning healthcare. RECENT FINDINGS: Results of important studies in dyspnea are briefly presented, though the focus of this review is on evidence supporting implementation of a rapid learning model for palliative symptom management. Recent findings suggest that a rapid learning system is feasible and acceptable to patients with advanced illness, helps monitor symptoms over time, facilitates study of the impact of novel interventions, and can identify unrecognized needs and concerns. SUMMARY: A rapid learning model could improve comprehensive assessment, timeliness of intervention, accrual of data to support best practice, and tailoring of care to patients' needs as their disease and experiences change over time. Data collected in the process of routine care in a rapid learning model can simultaneously function as clinical information and a resource for research on patient-centered experiences and outcomes.

Authors
Abernethy, AP; Kamal, AH; Wheeler, JL; Cox, C
MLA Citation
Abernethy, AP, Kamal, AH, Wheeler, JL, and Cox, C. "Management of dyspnea within a rapid learning healthcare model." Curr Opin Support Palliat Care 5.2 (June 2011): 101-110. (Review)
PMID
21455072
Source
pubmed
Published In
Current Opinion in Supportive and Palliative Care
Volume
5
Issue
2
Publish Date
2011
Start Page
101
End Page
110
DOI
10.1097/SPC.0b013e32834582b3

Palliative care consultations in patients with cancer: a mayo clinic 5-year review.

PURPOSE: We sought to characterize the aggregate features and survival of patients who receive inpatient palliative care consultation, particularly focusing on patients with cancer, to identify opportunities to improve clinical outcomes. METHODS: We reviewed prospectively collected data on patients seen by the Palliative Care Inpatient Consult Service at Mayo Clinic (Rochester, MN) from January 2003 to September 2008. Demographics, consultation characteristics, and survival were analyzed using Kaplan-Meier survival curves and Cox survival models. RESULTS: Cancer was the most common primary diagnosis (47%) in the 1,794 patients seen over the 5-year period. A significant growth in the annual number of palliative care consultations has been observed (113 in 2003 v 414 in 2007), despite stable total hospital admissions. Frequently encountered reasons for consultation included clarification of care goals (29%), assistance with dismissal planning (19%), and pain control (17%). Although patients with cancer had the highest median survival after consultation in this cohort versus patients with other diagnoses, we observed a 5-year trend of decreasing survival from admission to death and from consultation to death. Median time from admission to death for patients with cancer was 36 days in 2003 and only 19 days in 2008 (P < .01). Median time from consultation to death decreased from 33 days in 2003 to only 11.5 days in 2008 (P < .01). CONCLUSION: Patients with cancer often have complex needs that must be met within a short window for intervention. We highlight opportunities for improved multidisciplinary care for patients with advanced cancer and their families, including opportunity for earlier palliative care involvement, even in the outpatient setting.

Authors
Kamal, AH; Swetz, KM; Carey, EC; Cheville, AL; Liu, H; Ruegg, SR; Moynihan, TJ; Sloan, JA; Kaur, JS
MLA Citation
Kamal, AH, Swetz, KM, Carey, EC, Cheville, AL, Liu, H, Ruegg, SR, Moynihan, TJ, Sloan, JA, and Kaur, JS. "Palliative care consultations in patients with cancer: a mayo clinic 5-year review." J Oncol Pract 7.1 (January 2011): 48-53.
PMID
21532811
Source
pubmed
Published In
Journal of Oncology Practice
Volume
7
Issue
1
Publish Date
2011
Start Page
48
End Page
53
DOI
10.1200/JOP.2010.000067

Large gallstone ileus.

Authors
Kamal, AH; Baron, TH
MLA Citation
Kamal, AH, and Baron, TH. "Large gallstone ileus." J Hosp Med 6.1 (January 2011): 47-.
PMID
21241040
Source
pubmed
Published In
Journal of Hospital Medicine
Volume
6
Issue
1
Publish Date
2011
Start Page
47
DOI
10.1002/jhm.593

Breast medical oncologists' use of standard prognostic factors to predict a 21-gene recurrence score.

BACKGROUND: Half of all breast cancers are early stage, lymph node negative, and hormone receptor positive. A 21-gene (Oncotype DX®; Genomic Health, Inc., Redwood City, CA) recurrence score (RS) is prognostic for recurrence and predictive of chemotherapy benefit. We explored the ability of oncologists to predict the RS using standard prognostic criteria. METHODS: Standard demographic and tumor prognostic criteria were obtained from patients with an available RS. Two academic pathologists provided tumor grade, histologic type, and hormone receptor status. Six academic oncologists predicted the RS category (low, intermediate, or high) and provided a recommendation for therapy. The oncologists were then given the actual RS and provided recommendations for therapy. Analysis for agreement was performed. RESULTS: Thirty-one cases, including nine additional cases with variant pathology reads, were presented. There was substantial agreement in oncologists' ability to discriminate between true low or true intermediate and true high (κ = 0.75; p < .0001). Predictions between low and intermediate were not consistent. The most common discrepancies were predictions of a low RS risk when cases were true intermediate and predictions of an intermediate RS risk when cases were true low. The actual RS resulted in a change in the treatment recommendations in 19% of cases. Of the 186 scenarios and six oncologists in aggregate, five fewer chemotherapy recommendations resulted with the actual RS. CONCLUSIONS: Oncologists are able to differentiate between a low or intermediate RS and a high RS using standard prognostic criteria. However, provision of the actual RS changed the treatment recommendations in nearly 20% of cases, suggesting that the RS may reduce chemotherapy use. This effect was observed in particular in intermediate-risk cases. Prospective clinical trials are necessary to determine whether decisions based on the RS change outcomes.

Authors
Kamal, AH; Loprinzi, CL; Reynolds, C; Dueck, AC; Geiger, XJ; Ingle, JN; Carlson, RW; Hobday, TJ; Winer, EP; Goetz, MP
MLA Citation
Kamal, AH, Loprinzi, CL, Reynolds, C, Dueck, AC, Geiger, XJ, Ingle, JN, Carlson, RW, Hobday, TJ, Winer, EP, and Goetz, MP. "Breast medical oncologists' use of standard prognostic factors to predict a 21-gene recurrence score." Oncologist 16.10 (2011): 1359-1366.
PMID
21934103
Source
pubmed
Published In
The oncologist
Volume
16
Issue
10
Publish Date
2011
Start Page
1359
End Page
1366
DOI
10.1634/theoncologist.2011-0048

Natural history of paclitaxel-associated acute pain syndrome: Prospective cohort study NCCTG N08C1

The characteristics and natural history of the paclitaxel-acute pain syndrome (P-APS) and paclitaxel's more chronic neuropathy have not been well delineated. Methods: Patients receiving weekly paclitaxel (70 to 90 mg/m2) completed daily questionnaires and weekly European Organisation for Research and Treatment of Cancer (EORTC) Chemotherapy-Induced Peripheral Neuropathy (CIPN) -20 instruments during the entire course of therapy. Results: P-APS symptoms peaked 3 days after chemotherapy. Twenty percent of patients had pain scores of 5 to 10 of 10 with the first dose of paclitaxel. Sensory neuropathy symptoms were more prominent than were motor or autonomic neuropathy symptoms. Of the sensory neuropathy symptoms, numbness and tingling were more prominent than was shooting or burning pain. Patients with higher P-APS pain scores with the first dose of paclitaxel appeared to have more chronic neuropathy. Conclusion: These data support that the P-APS is related to nerve pathology as opposed to being arthralgias and/or myalgias. Numbness and tingling are more prominent chronic neuropathic symptoms than is shooting or burning pain. © 2011 by American Society of Clinical Oncology.

Authors
Loprinzi, CL; Reeves, BN; Dakhil, SR; Sloan, JA; Wolf, SL; Burger, KN; Kamal, A; Le-Lindqwister, NA; Soori, GS; Jaslowski, AJ; Novotny, PJ; Lachance, DH
MLA Citation
Loprinzi, CL, Reeves, BN, Dakhil, SR, Sloan, JA, Wolf, SL, Burger, KN, Kamal, A, Le-Lindqwister, NA, Soori, GS, Jaslowski, AJ, Novotny, PJ, and Lachance, DH. "Natural history of paclitaxel-associated acute pain syndrome: Prospective cohort study NCCTG N08C1." Journal of Clinical Oncology 29.11 (2011): 1472-1478.
PMID
21383290
Source
scival
Published In
Journal of Clinical Oncology
Volume
29
Issue
11
Publish Date
2011
Start Page
1472
End Page
1478
DOI
10.1200/JCO.2010.33.0308

Idiopathic systemic capillary leak syndrome (Clarkson's disease): the Mayo clinic experience.

OBJECTIVE: To determine clinical features, natural history, and outcome of a well-defined cohort of 25 consecutive patients with idiopathic systemic capillary leak syndrome (SCLS) evaluated at a tertiary care center. PATIENTS AND METHODS: Records of patients diagnosed as having SCLS from November 1, 1981, through April 30, 2008, were reviewed. Descriptive statistics were used to analyze patient demographics, clinical features, complications, and therapeutic interventions. RESULTS: Of the 34 patients whose records were reviewed, 25 fulfilled all diagnostic criteria for SCLS. The median age at diagnosis of SCLS was 44 years. Median follow-up of surviving patients was 4.9 years, and median time to diagnosis from symptom onset was 1.1 years (interquartile range, 0.5-4.1 years). Flulike illness or myalgia was reported by 14 patients (56%) at onset of an acute attack of SCLS, and rhabdomyolysis developed in 9 patients (36%). Patients with a greater decrease in albumin level had a higher likelihood of developing rhabdomyolysis (p=.03). Monoclonal gammopathy, predominantly of the IgG-κ type, was found in 19 patients (76%). The progression rate to multiple myeloma was 0.7% per person-year of follow-up. The overall response rate to the different therapies was 76%, and 24% of patients sustained durable (>2 years) complete remission. The estimated 5-year overall survival rate was 76% (95% confidence interval, 59%-97%). CONCLUSION: Systemic capillary leak syndrome, a rare disease that occurs in those of middle age, is usually diagnosed after a considerable delay from onset of symptoms. The degree of albumin decrement during an attack correlates with development of rhabdomyolysis. A reduction in the frequency and/or the severity of attacks was seen in nearly three-fourths of patients who were offered empirical therapies. The rate of progression to multiple myeloma appears to be comparable to that of monoclonal gammopathy of undetermined significance.

Authors
Kapoor, P; Greipp, PT; Schaefer, EW; Mandrekar, SJ; Kamal, AH; Gonzalez-Paz, NC; Kumar, S; Greipp, PR
MLA Citation
Kapoor, P, Greipp, PT, Schaefer, EW, Mandrekar, SJ, Kamal, AH, Gonzalez-Paz, NC, Kumar, S, and Greipp, PR. "Idiopathic systemic capillary leak syndrome (Clarkson's disease): the Mayo clinic experience." Mayo Clin Proc 85.10 (October 2010): 905-912.
PMID
20634497
Source
pubmed
Published In
Mayo Clinic Proceedings
Volume
85
Issue
10
Publish Date
2010
Start Page
905
End Page
912
DOI
10.4065/mcp.2010.0159

Glutathione-s-transferase-pi expression in early breast cancer: Association with outcome and response to chemotherapy

Glutathione-S-transferase-pi (GST-pi) is a detoxification enzyme expressed in breast cancer; however its involvement in chemotherapy sensitivity and prognosis is not well understood. We evaluated the expression of GSTpi and its predictive role of chemotherapy response. Breast tumor samples from 166 patients at stage I/II of the disease were immunostained for GST-pi, and the expression was 96 . There was a trend toward improved disease-free survival with high GST-pi expression (p =.09). There was a statistically non-significant association between high GST-pi expression and improved outcome with adjuvant chemotherapy (p= .055). Further studies should evaluate the role of GST-pi expression in relation to response to different chemotherapies. Copyright © 2010 Informa Healthcare USA, Inc.

Authors
Arun, BK; Granville, LA; Yin, G; Middleton, LP; Dawood, S; Kau, S-W; Kamal, A; Hsu, L; Hortobagyi, GN; Sahin, AA
MLA Citation
Arun, BK, Granville, LA, Yin, G, Middleton, LP, Dawood, S, Kau, S-W, Kamal, A, Hsu, L, Hortobagyi, GN, and Sahin, AA. "Glutathione-s-transferase-pi expression in early breast cancer: Association with outcome and response to chemotherapy." Cancer Investigation 28.5 (2010): 554-559.
PMID
20210524
Source
scival
Published In
Cancer Investigation (Informa)
Volume
28
Issue
5
Publish Date
2010
Start Page
554
End Page
559
DOI
10.3109/07357900903286925

Disseminated sporotrichosis

Authors
Kamal, A; Orenstein, R
MLA Citation
Kamal, A, and Orenstein, R. "Disseminated sporotrichosis." Journal of Hospital Medicine 5.3 (2010): E29-E30.
PMID
20235306
Source
scival
Published In
Journal of Hospital Medicine
Volume
5
Issue
3
Publish Date
2010
Start Page
E29
End Page
E30
DOI
10.1002/jhm.472

Tamoxifen pharmacogenomics: The role of CYP2D6 as a predictor of drug response

Tamoxifen continues to be a standard endocrine therapy for the prevention and treatment of estrogen receptor (ER)-positive breast cancer. Tamoxifen can be considered a classic "pro-drug," requiring metabolic activation to elicit pharmacological activity. CYP2D6 is the rate-limiting enzyme catalyzing the conversion of tamoxifen into metabolites with significantly greater affinity for the ER and greater ability to inhibit cell proliferation. Both genetic and environmental (drug-induced) factors that alter CYP2D6 enzyme activity directly affect the concentrations of the active tamoxifen metabolites and the outcomes of patients receiving adjuvant tamoxifen. The a priori knowledge of the pharmacogenetic variation known to abrogate CYP2D6 enzyme activity may provide a means by which the hormonal therapy of breast cancer can be individualized. © 2008 American Society for Clinical Pharmacology and Therapeutics.

Authors
Goetz, MP; Kamal, A; Ames, MM
MLA Citation
Goetz, MP, Kamal, A, and Ames, MM. "Tamoxifen pharmacogenomics: The role of CYP2D6 as a predictor of drug response." Clinical Pharmacology and Therapeutics 83.1 (2008): 160-166.
PMID
17882159
Source
scival
Published In
Clinical Pharmacology & Therapeutics (Nature)
Volume
83
Issue
1
Publish Date
2008
Start Page
160
End Page
166
DOI
10.1038/sj.clpt.6100367

Hereditary hemorrhagic telangiectasia.

Authors
Kamal, AH; Prakash, UBS
MLA Citation
Kamal, AH, and Prakash, UBS. "Hereditary hemorrhagic telangiectasia." Mayo Clin Proc 82.11 (November 2007): 1364-.
PMID
17976356
Source
pubmed
Published In
Mayo Clinic Proceedings
Volume
82
Issue
11
Publish Date
2007
Start Page
1364
DOI
10.4065/82.11.1364

How to interpret and pursue an abnormal prothrombin time, activated partial thromboplastin time, and bleeding time in adults.

The prothrombin time (PT) and activated partial thromboplastin time (APTT) are among the most commonly ordered coagulation tests. In 2005, more than 140,000 PT and more than 95,000 APTT tests were performed at Mayo Clinic. The most common indications for ordering these tests include anticoagulant monitoring, initial evaluation of hemorrhage, and, although not generally indicated, routine preoperative screening. In addition, the bleeding time (BT) test, which is infrequently performed, is still available in certain institutions. Abnormal results from these tests (prolonged PT, APTT, and BT), especially from tests conducted for initial evaluation of hemorrhage or for preoperative screening, may pose a diagnostic dilemma to the nonhematologist. We review the essential factors affecting test results; provide a practical approach to the evaluation of a prolonged PT, APTT, and BT; and offer suggestions on which reflexive tests are appropriate and when to consider a subspecialty consultation.

Authors
Kamal, AH; Tefferi, A; Pruthi, RK
MLA Citation
Kamal, AH, Tefferi, A, and Pruthi, RK. "How to interpret and pursue an abnormal prothrombin time, activated partial thromboplastin time, and bleeding time in adults." Mayo Clin Proc 82.7 (July 2007): 864-873. (Review)
PMID
17605969
Source
pubmed
Published In
Mayo Clinic Proceedings
Volume
82
Issue
7
Publish Date
2007
Start Page
864
End Page
873
DOI
10.4065/82.7.864

Angiosarcoma of the pericardium presenting as hemorrhagic pleuropericarditis, cardiac tamponade, and thromboembolic phenomena.

Authors
Holtan, SG; Allen, RD; Henkel, DM; Kamal, AH; Novak, GD; O'Cochlain, F; Chandrasekaran, K; Mullany, CJ; Wright, RS
MLA Citation
Holtan, SG, Allen, RD, Henkel, DM, Kamal, AH, Novak, GD, O'Cochlain, F, Chandrasekaran, K, Mullany, CJ, and Wright, RS. "Angiosarcoma of the pericardium presenting as hemorrhagic pleuropericarditis, cardiac tamponade, and thromboembolic phenomena." Int J Cardiol 115.1 (January 31, 2007): e8-e9. (Letter)
PMID
16904210
Source
pubmed
Published In
International Journal of Cardiology
Volume
115
Issue
1
Publish Date
2007
Start Page
e8
End Page
e9
DOI
10.1016/j.ijcard.2006.06.034

Reflections: when the disease hits home.

Authors
Kamal, AH; Holtan, SG
MLA Citation
Kamal, AH, and Holtan, SG. "Reflections: when the disease hits home." J Cancer Educ 22.1 (2007): 67-69.
PMID
17570813
Source
pubmed
Published In
Journal of Cancer Education
Volume
22
Issue
1
Publish Date
2007
Start Page
67
End Page
69
DOI
10.1080/08858190701372810

Tamoxifen: Using pharmacogenetics to rediscover an old drug

Tamoxifen can be considered a classic 'pro-drug', requiring metabolic activation to elicit pharmacological activity. Our findings suggest that both genetic and drug-induced factors that alter CYP2D6 enzyme activity influence the clinical response to tamoxifen. Given the small differences in disease-free survival comparing tamoxifen to third-generation aromatase inhibitors, knowledge of the genetic and environmental factors that influence CYP2D6 enzyme activity may provide a robust tool to individualize the hormonal therapy to breast cancer. © 2007 Cambridge University Press.

Authors
Kamal, AH; Goetz, MP
MLA Citation
Kamal, AH, and Goetz, MP. "Tamoxifen: Using pharmacogenetics to rediscover an old drug." Breast Cancer Online 10.10 (2007).
Source
scival
Published In
Breast Cancer Online
Volume
10
Issue
10
Publish Date
2007
DOI
10.1017/S1470903107005858

Effect of the antioxidant α-tocopherol in an experimental model of pulmonary hypertension and fibrosis: Administration of monocrotaline

Monocrotaline, a pyrrolizidine alkaloid, causes in mammals a respiratory condition closely resembling adult respiratory distress syndrome and chronic obstructive pulmonary disease, which is preceded in the lung parenchyma by high levels of angiotensin converting enzyme and angiotensin II. Vitamin E (α-tocopherol) is a powerful antioxidant that is beneficial in the treatment of several acute and chronic pulmonary injuries by inhibiting the vasoconstrictive and mitogenic activity of angiotensin II. We report the effects of dietary vitamin E supplementation on monocrotaline-induced injury in the rat. Vitamin E was effective in moderating the inflammatory injury at a dose of 1667 mg/kg diet, although pulmonary vasculitis persisted. A vitamin E dose of 3333 mg/kg diet resulted in pulmonary and hepatic hemorrhage; a monocrotaline mitigating effect could not be demonstrated as well as with the lower dose because of this pathology, especially in the liver. Further study is recommended to determine the minimum effective dose of vitamin E that does not cause hemorrhage. © 2004 Elsevier Inc. All rights reserved.

Authors
Molteni, A; Herndon, BL; Kamal, A; Castellani, WJ; Reppert, S; Xue, Y; Humbehr, J; Baybutt, RC
MLA Citation
Molteni, A, Herndon, BL, Kamal, A, Castellani, WJ, Reppert, S, Xue, Y, Humbehr, J, and Baybutt, RC. "Effect of the antioxidant α-tocopherol in an experimental model of pulmonary hypertension and fibrosis: Administration of monocrotaline." Nutrition Research 24.9 (2004): 707-720.
Source
scival
Published In
Nutrition Research
Volume
24
Issue
9
Publish Date
2004
Start Page
707
End Page
720
DOI
10.1016/j.nutres.2004.06.001
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