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.

Analysis of poor outcomes after laparoscopic adjustable gastric banding.

BACKGROUND: Recent studies document excess weight loss (EWL) of more than 50% with the laparoscopic adjustable gastric band (LGB). This study reviews the LGB experience at an urban academic center in terms of complications, reoperative rates, and comorbidities. METHODS: In this study, 144 consecutive patients undergoing LGB were prospectively reviewed. Data were collected including weight, body mass index (BMI), excess weight loss (EWL), comorbidities, and complications. Demographics were analyzed using a t-test. Linear regression was used to analyze the relationship of BMI, race, and age to EWL at 12 months. RESULTS: The study participants were 130 women with a mean age of 43 ± 11 years, a mean weight of 127.1 kg ± 20.5 kg, and a mean BMI of 45.6 ± 6.1. The mean follow-up period was 16 months. The mean EWL was 20% ± 14% at 6 months (n = 118), 26% ± 16% at 12 months (n = 106), 30% ± 20% at 18 months (n = 68), and 34% ± 23% at 24 months (n = 43). Patients with a BMI higher than 50 kg/m(2) had a lower EWL at 12 months than patients with a BMI lower than 50 kg/m(2) (P = 0.00005). The mean EWL at 12 months was significantly less for African Americans than for Caucasians (P = 0.0046; 95% confidence interval [CI] 3-15%). Patients older than 50 years had a lower EWL, but the difference was not statistically significant (P = 0.07). Complete and partial resolution of comorbidities occurred for 10% and 4% of the patients, respectively. Removal of the band with revision to a sleeve gastrectomy for inadequate EWL was required for 14 patients (11.5%). Complications occurred for 8% of the patients (n = 15) including port flipping, stoma obstruction, tube disconnection, port infections, dysphagia, and band slippage. Overall, 16.7% of the patients (n = 24) required reoperation. CONCLUSION: After LGB, a majority of the patients failed to achieve a 50% EWL, and 16.7% required reoperation. Laparoscopic adjustable gastric banding may not be the optimal bariatric procedure for patients older than 50 years, patients with a BMI higher than 50 kg/m(2), or African Americans.