Symptom Burden and Palliative Referral Disparities in an Ambulatory South Texas Cancer Center.

Background: The American Society of Clinical Oncology's recommendation for "dedicated palliative care services, early in the disease course, concurrent with active treatment" for cancer patients is a challenge for cancer centers to accommodate. Despite demonstrated benefits of concurrent care, disparities among socioeconomic and ethnic groups in access to supportive care services have been described. The aim of this project was to evaluate: (a) how insurance coverage and ethnicity impact patient symptom burden and, (b) how those factors influence palliative access for patients at a South Texas NCI-designated cancer center. Methods: During a 5-month prospective period, 604 patients from five ambulatory oncology clinics completed the 10 question Edmonton Symptom Assessment Scale (ESAS) surveys during their clinic visit. Patient demographics, ESAS scores, palliative referral decisions, and time to palliative encounters were collected. We compared symptom burden and time to consult based on ethnicity and insurance status (insured = Group A; under-insured and safety net = Group B). Results: The mean ESAS score for all patients at the initial visit was 19.9 (SD = 18.1). Safety net patients were significantly more likely to be Hispanic, younger in age, and have an underlying GI malignancy in comparison to insured patients; however, the symptom severity was similar between groups with over 40% of individuals reporting at least one severe symptom. Twenty-one referrals were made to palliative care. On average, Group B had 33.3 days longer wait times until their first potential visit (p < 0.01) when compared to Group A. Time to actual visit was on average 57.6 days longer for patients in Group B compared to patients in Group A (p = 0.01), averaging at 73.8 days for safety net patients. Conclusions: This project highlights the high symptom burden of oncology patients and disparities in access to services based on insurance coverage. This investigation revealed a 4-fold increase in the time to the first scheduled palliative care visit based on whether patients were insured vs. under-insured. While this study is limited by a small sample size, data suggest that under-insured oncology patients may have significant barriers to palliative care services, which may influence their cancer care quality.

Integrating Palliative Care Services in Ambulatory Oncology: An Application of the Edmonton Symptom Assessment System.

PURPOSE: Research in palliative care demonstrates improvements in overall survival, quality of life, symptom management, and reductions in the cost of care. Despite the American Society of Clinical Oncology recommendation for early concurrent palliative care in patients with advanced cancer and high symptom burden, integrating palliative services is challenging. Our aims were to quantitatively describe the palliative referral rates and symptom burden in a South Texas cancer center and establish a palliative referral system by implementing the Edmonton Symptom Assessment Scale (ESAS). METHODS: As part of our Plan-Do-Study-Act process, all staff received an educational overview of the ESAS tool and consultation ordering process. The ESAS form was then implemented across five ambulatory oncology clinics to assess symptom burden and changes therein longitudinally. Referral rates and symptom assessment scores were tracked as metrics for quality improvement. RESULTS: On average, one patient per month was referred before implementation of the intervention compared with 10 patients per month after implementation across all clinics. In five sample clinics, 607 patients completed the initial assessment, and 430 follow-up forms were collected over 5 months, resulting in a total of 1,037 scores collected in REDCap. The mean ESAS score for initial patient visits was 20.0 (standard deviation, 18.1), and referred patients had an initial mean score of 39.0 (standard deviation, 19.0). CONCLUSION: This project highlights the low palliative care consultation rate, high symptom burden of oncology patients, and underuse of services by oncologists despite improvements with the introduction of a symptom assessment form and referral system.

Patterns of oral and jaw tumours seen in eastern Nigeria: a review of sixty cases seen over a 5-year period--1 January 2000 to 31 December 2004.

Morbid anatomy, University of Nigeria Teaching Hospital (UNTH) caters for over 30 million people, mainly Black Africans. Sixty oral and jaw specimens were received and analyzed. In UNTH, Nigeria record of incidence and pattern of salivary lesions is scanty and, there had been no prior published report on this subject. This is a retrospective study to establish the pattern of oral and jaw tumours seen in Eastern Nigeria and show their sex and age variations. 2. Compare with results published elsewhere. Departmental records for oral and jaw lesions from biopsies were analysed. Sixty oral and jaw tumours were received out of a total of 4500 specimens constituting 1.3% of all biopsies. Twenty-four (40%) were males, 36 (60%) were females. The categories were calcifying odontogenic cysts and fibromas 11 (18.3%). Ameloblastomas affecting the mandible eight (13.3%). Fibrous dysplasia seven (11.7%). Invasive squamous cell carcinomas seven (11.7%). Infections with cellulites and sinusitis six (10%). Post inflammatory polyps and pseudocysts four (7%). Burkitt's Lymphomas four (7%), Haemangiomas and lymphangiomas four (7%), Soft tissue swellings from osteomyelitis three (5%). Butyroid rhabdomyosarcoma, adenoid cystic carcinoma angiofibroma, fibrous histiocytoma and fibrosarcoma were each one (1.7%). Oral and jaw tumours therefore constitute a mere 1.3% of biopsies. The most common subtype seen were the dentigerous cysts/fibromas, followed by ameloblastomas.

Ferritin and haematological values in healthy elderly Nigerians.

Two-hundred Nigerians (65 years and above) were studied and compared with control (18-50 years). Haematocrit, haemoglobin, mean corpuscular haemoglobin concentration, mean corpuscular haemoglobin, mean corpuscular volume, platelets and ferritin were analyzed. Mean ferritin levels were 105 ± 30 µg/L and 72 ± 10 µg/L (males and females respectively). Mean MCV, MCH and MCHC were 94.6 ± 9.0 fl, 93.6 ± 9.0 fl, 31.5 ± 3.0 pg, 31.4 ± 4.4 pg, 348 ± 30 g/L, and 347 ± 42 g/L. Mean haematocrits were 37 ± 4%, 36 ± 4%, while mean haemoglobins levels were 132 ± 24 g/L and 129 ± 1 g/L. RBC counts were 4.1 ± 0.8 x 1012/L, and 4.0 ± 0.5 x 1012/L. Mean total WBC counts were 6.4 ± 1.5 x 109/L and 6.3 ± 0.7 x 109/L; mean platelets were 170 ± 60 x 109/L, 184 ± 5 x 109/L. All haematological parameters were similar in both aged males and females, except ferritin, haematocrit, RBC and haemoglobin, which were significantly higher in males (p< 0.05). Significant sex differences exist in all the parameters, of control except MCV and total WBC count. There were significant differences in all the haematological parameters between the controls and the aged (p< 0.05), and between the aged (65-84 years) and the very aged (85-105 years) (p< 0.05). Reference haematological range needs to be established for the elderly Nigerians.