Background:
Early integration of palliative care into the management of patients with serious disease has the potential to both improve quality of life of patients and families and reduce healthcare ...costs. Despite these benefits, significant barriers exist in the United States to the early integration of palliative care in the disease trajectory of individuals with serious illness.
Aim:
To provide an overview of the barriers to more widespread palliative care integration in the United States.
Design and data sources:
A literature review using PubMed from 2005 to March 2015 augmented by primary data collected from 405 hospitals included in the Center to Advance Palliative Care’s National Palliative Care Registry for years 2012 and 2013. We use the World Health Organization’s Public Health Strategy for Palliative Care as a framework for analyzing barriers to palliative care integration.
Results:
We identified key barriers to palliative care integration across three World Health Organization domains: (1) education domain: lack of adequate education/training and perception of palliative care as end-of-life care; (2) implementation domain: inadequate size of palliative medicine–trained workforce, challenge of identifying patients appropriate for palliative care referral, and need for culture change across settings; (3) policy domain: fragmented healthcare system, need for greater funding for research, lack of adequate reimbursement for palliative care, and regulatory barriers.
Conclusion:
We describe the key policy and educational opportunities in the United States to address and potentially overcome the barriers to greater integration of palliative care into the healthcare of Americans with serious illness.
Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should ...discuss deactivating the defibrillation function.
The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation.
In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion.
A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 14% vs. 26 12%) or deactivation (33 11% vs. 26 12%). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 25% vs. 16 11%; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents. Secondary outcomes: Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives.
The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients’ severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations WISDOM; NCT01459744)
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Abstract This article describes a randomized study to determine the effectiveness of a reentry modified therapeutic community (RMTC) for offenders with co-occurring substance use and mental disorders ...(co-occurring disorders or COD). Men with COD, approved for community corrections placement postrelease, were recruited from nine Colorado prisons and stratified according to the type of treatment received while incarcerated (i.e., a prison modified therapeutic community MTC program or standard care). When released, each offender was randomly assigned either to the experimental RMTC (E-RMTC) condition ( n = 71) or to the control parole supervision and case management (PSCM) condition ( n = 56). An intent-to-treat analysis 12 months postprison release showed that the E-RMTC participants were significantly less likely to be reincarcerated (19% vs. 38%), with the greatest reduction in recidivism found for participants who received MTC treatment in both settings. These findings support the RMTC as a stand-alone intervention and provide initial evidence for integrated MTC programs in prison and in aftercare for offenders with COD.
•The majority of Medicare beneficiaries remained in the same spending category from one year to the next.•Transitions from the low to high spending state were significantly associated with older age, ...residing in a long-term care facility, requiring assistance with activities of daily living, enrollment in fee-for-service Medicare, not receiving a flu shot, and presence of specific medical conditions.•MSM models are useful tools for examining the changes in healthcare spending over time, allowing for the possibility that an individual may move back and forth among spending states.
Many studies have examined factors associated with individuals of high or low healthcare spending in a given year. However, few have studied how healthcare spending changes over multiple years and which factors are associated with the changes. In this study, we examined the dynamic patterns of healthcare spending over a three-year period, among a nationally representative cohort of Medicare beneficiaries in the U.S. and identified factors associated with these patterns. We extracted data for 30,729 participants from the national Medicare Current Beneficiary Survey (MCBS), for the period 2003–2019. Using multistate Markov (MSM) models, we estimated the probabilities of year-to-year transitions in healthcare spending categorized as three states (low (L), medium (M) and high (H)), or to the terminal state, death. The participants, 13,554 (44.1%), 13,715 (44.6%) and 3,460 (11.3%) were in the low, medium and high spending states at baseline, respectively. The majority of participants remained in the same spending category from one year to the next (L-to-L: 76.8%; M-to-M: 71.7%; H-to-H: 56.6 %). Transitions from the low to high spending state were significantly associated with older age (75–84, ≥85 years), residing in a long-term care facility, greater assistance with activities of daily living, enrollment in fee-for-service Medicare, not receiving a flu shot, and presence of specific medical conditions, including cancer, dementia, and heart disease. Using data from a large population-based longitudinal survey, we have demonstrated that MSM modelling is a flexible framework and useful tool for examining changes in healthcare spending over time.
Abstract This study examines the impact of early abuse on the functioning and the 12-month treatment outcomes of 146 homeless addicted women who entered residential substance abuse treatment. ...Sixty-nine percent of the women reported exposure to childhood physical, sexual, or emotional abuse; the majority reported multiple forms of abuse. Comparisons of abused and nonabused women revealed significant differences in childhood, adolescent, and adult functioning, indicative of the pervasive detrimental effects of early abuse. Female survivors of childhood abuse did not improve in treatment as much as their nonabused peers in psychological functioning ( p < .001), substance abuse ( p < .01), or continuing trauma exposure ( p < .01) .The findings suggest the importance of adapting models of residential substance abuse treatment to address concurrent issues related to trauma history. Additional research is needed to identify effective integrated treatment approaches for this population and to explore the independent and interconnected pathways linking trauma history and outcome.
Score-based survival prediction in patients with advanced heart failure (HF) is complicated. Easy-to-use prognostication tools could inform clinical decision-making and palliative care delivery.
To ...compare the prognostic utility of the Seattle HF model (SHFM), the surprise question (SQ), and the number of HF hospitalizations (NoH) within the last 12 months for predicting 1-year survival in patients with advanced HF.
We retrospectively analyzed data from a cluster-randomized controlled trial of advanced HF patients, predominantly with reduced ejection fraction. Primary outcome was the prognostic discrimination of SHFM, SQ ("Would you be surprised if this patient were to die within 1 year?") answered by HF cardiologists, and NoH, assessed by receiver operating characteristic (ROC) curve analysis. Optimal cut-offs were calculated using Youden's index (SHFM: <86% predicted 1-year survival; NoH ≥ 2).
Of 535 subjects, 82 (15.3%) had died after 1-year of follow-up. SHFM, SQ, and NoH yielded a similar area under the ROC curve SHFM: 0.65 (0.60-0.71 95% CI); SQ: 0.58 (0.54-0.63 95% CI); NoH: 0.56 (0.50-0.62 95% CI) and similar sensitivity SHFM: 0.76 (0.65-0.84 95% CI); SQ: 0.84 (0.74-0.91 95% CI); NoH: 0.56 (0.45-0.67 95% CI). As compared to SHFM, SQ had lower specificity SQ: 0.33 (0.28-0.37 95% CI) vs. SHFM: 0.55 (0.50-0.60 95% CI) while NoH had similar specificity 0.56 (0.51-0.61 95% CI). SQ combined with NoH showed significantly higher specificity 0.68 (0.64-0.73 95% CI).
SQ and NoH yielded comparable utility to SHFM for 1-year survival prediction among advanced HF patients, are easy-to-use and could inform bedside decision-making.
Abstract This article summarizes results from four research studies ( n = 902) that examined the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring disorders ...(most with severe mental disorders). Significantly better outcomes for MTC were found across four experimental versus control comparisons on 23.1% (12 of 52) of primary outcome measures of substance use, mental health, crime, HIV risk, employment, and housing. Study limitations included the potential for selection bias, limited measurement of program fidelity, and insufficient examination of the relationship between treatment dose and outcome. Future research should emphasize clinical trial replications, multiple outcome domains, and further development of continuing care models. Given the need for research-based approaches, the MTC warrants consideration when program and policy planners are designing programs for co-occurring disorders.
Abstract This study, which was conducted in an outpatient substance abuse treatment program, randomly assigned clients with mental health symptoms to either a control group, which received basic ...program services, or an experimental group, which was configured as a modified therapeutic community (TC) track, with the addition of modified TC features and three specific elements—psychoeducational seminar, trauma-informed addictions treatment, and case management. The experimental group had significantly better outcomes as compared with the control group on measures of psychiatric severity and on the key measure of housing stability; no difference was observed for substance use, crime, and employment. The findings must be qualified because (a) only 3 of 34 representative measures (<10%) showed significant differential treatment effects and (b) analysis revealed partial implementation of the enhancements. The study provides modest support for the effectiveness, on specific outcomes, of outpatient substance abuse treatment programs that add modified TC features and targeted interventions to strengthen their capacity to treat co-occurring disorders.
1. Describe the geographic distribution of hospice and palliative medicine board-certified physicians and nurse practitioners in the United States.
2. Compare the distribution of hospice and ...palliative medicine board-certified physicians and nurse practitioners by state, metropolitan status, and area-level socioeconomic status.
Our study highlights the ongoing scarcity of palliative care specialists and striking differences in the geographic distribution of board-certified palliative medicine physicians and nurse practitioners based on geography. Disparities in access to palliative care appear to exist based on state, metropolitan status, and area-level socioeconomic status.
Access to palliative care is impeded by significant shortages of Hospice and Palliative Medicine (HPM) board-certified physicians and nurse practitioners (NPs).
To describe the geographic distribution of HPM board-certified physicians and NPs in the US and compare distribution by state, metropolitan status, and area-level socioeconomic status.
We merged the American Board of Medical Specialties HPM physician certification dataset and the Hospice and Palliative Nurses Association nurse practitioner certification dataset, including only those with active certifications in 2022. Based on available data, we mapped physicians by zip code and NPs by city/town (Rural-Urban Commuting Area Codes) to describe the percentage of clinicians in metropolitan areas. We calculated clinician density per state adjusted for population ≥ 65 years (2021 US Administration for Community Living) as a surrogate for palliative care needs. We calculated the Social Deprivation Index (SDI) associated with each physician's zip code and reported percentage of physicians per SDI quintile with lower quintiles indicating lesser deprivation and higher quintiles indicating greater deprivation.
In 2022, there were 6,448 (72.2%) active physicians and 2,487 (27.8%) active NPs. More than 90% (n = 8,319) were located in metropolitan areas, and > 50% of physicians were in the two lower SDI quintiles (n = 3,613). Nationally, there was one physician per 8,632 people ≥ 65 years of age and one NP per 22,380 people ≥ 65 years. State-by-state population-adjusted rates of board-certified clinicians per 100,00 people ≥ 65 were highly variable.
Our findings highlight geographic differences in the distribution of HPM clinicians with the distribution of NPs mirroring that of physicians, such that NPs may be increasing access in areas where capacity already exists. Clinician density is particularly low in rural areas and areas with higher social deprivation, suggesting disparities in access to palliative care.
Scientific Research / Advocacy / Policy/ Regulations
1. Characterize opioid and anticonvulsant (gabapentin, pregabalin) prescribing trends from 2010-2020 among older adults with dementia (PWD) and older adults with cancer (PWC).
2. Identify the ...association of the 2016 CDC opioid guideline with racial/ethnic disparities in opioid prescribing among PWD and PWC.
Opioid prescribing for older adults with dementia or cancer rose from 2010 until a peak in 2013-2018 and declined thereafter to a nadir in 2020. Anticonvulsant prescribing continued to rise for these populations during that time, suggesting that pain management may be shifting from opioid to anticonvulsant therapy.
In response to the opioid epidemic, the CDC published opioid prescribing guidelines in 2016 cautioning against opioid use, particularly for adults with chronic, non-cancer pain. However, little is known about the unintended effects of such opioid policy on pain management for older adults with serious illness, who commonly have moderate-to-severe opioid-responsive pain (e.g., cancer, dementia)1-3 and are at increased risk of pain undertreatment (e.g., dementia, racial/ethnic minorities).4-7
1) Characterize opioid and anticonvulsant (gabapentin, pregabalin) prescribing trends from 2010-2020 among older adults with dementia (PWD) and cancer (PWC). 2) Identify the association of the 2016 CDC guideline with racial/ethnic disparities in opioid prescribing among PWD and PWC.
This retrospective observational study of older adults (age ≥65) with dementia or cancer utilizes 2010-2020 data from Medicare Current Beneficiary Survey, a nationally representative, longitudinal survey of Medicare beneficiaries linked to Medicare claims. We used a difference-in-differences design to determine whether the 2016 guidelines were associated with reduced opioid prescribing for PWD and PWC and worsened racial/ethnic disparities in opioid receipt.
The annual proportion of PWC (n=18,292) prescribed an opioid rose from 21.9% (n=720/3,237) in 2010 to a peak of 26.4% in 2013 and 2015 (n=923/3,395 and 800/3,170, respectively) and declined to a nadir of 15.4% in 2020 (n=538/3,120). Opioid prescribing for PWD (n=6,056) rose from 14.2% (n=121/960) in 2010 to 20.0% in 2018 (n=199/947), and then decreased to 15.4% in 2020 (n=123/806). Anticonvulsant prescribing rose consistently from 2010-2020, doubling for PWC (6.9% n=237/3,237 to 13.4% n=428/3,120) and nearly tripling for PWD (5.6% n=48/960 to 14.0% n=105/806). Remaining results expected by March 2024.
Opioid prescribing for PWD and PWC has declined since its peak in 2013-2018, while anticonvulsant prescribing continued to rise since 2010. These findings may indicate a shift in pain management from opioids to less-effective anticonvulsant therapy.
Scientific Research / Diversity, Equity, Inclusion, Belonging, Justice
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