A Systematic Assessment and Monitoring Intervention to Improve Pain Management and Quality Reporting Among Home Hospice Patients.

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

A Model for Effective and Efficient Hospice Care: Proactive Telephone-Based Enhancement of Life Through Excellent Caring, "TeleCaring" in Advanced Illness.

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

Nebulized medications for the treatment of dyspnea: a literature review.

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

Clinic-based outpatient palliative care before hospice is associated with longer hospice length of service.

CONTEXT: Outpatient nonhospice palliative care has been shown to provide many benefits to patients facing advanced illness, but such services remain uncommon in the U.S. Little is known about the association between clinic-based outpatient palliative care consultation and the timing of hospice enrollment. OBJECTIVES: To determine whether there are differences in hospice length of service (LOS) between patients who were seen vs. patients who were not seen in an outpatient palliative care clinic before enrollment in hospice. METHODS: Using a retrospective study of medical records, a "prior palliative care clinic" group was formed of those hospice patients who had had a nonhospice clinic-based outpatient palliative care consult before hospice admission (n = 354). For those patients, "control" hospice patients without prior clinic-based palliative care were chosen who were matched by age, gender, median income of their zip code, and diagnostic group. Both groups were restricted to patients who died while enrolled in hospice. LOS for these two groups was compared using standard statistical methods of survival analysis. RESULTS: Prior palliative care clinic patients had a median LOS of 24 days, whereas control patients had a median LOS of 15 days (95% CI for difference between the medians 5-13 days). The difference between the LOS distribution curves was statistically significant by the log-rank test (P < 0.001). CONCLUSION: Hospice patients who had clinic-based outpatient palliative consults before hospice enrollment tended, on average, to have a longer LOS in hospice than patients who did not.

Opioid prescribing practices before and after initiation of palliative care in outpatients.

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

Integrating palliative care into the outpatient, private practice oncology setting.

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