Context. Pain is a common and distressing symptom. Pain management is a core competency for palliative care (PC) teams. Objective. Identify characteristics associated with pain and pain improvement among inpatients referred to PC. Methods. Thirty-eight inpatient PC teams in the Palliative Care Quality Network entered data about patients seen between December 12, 2012 and March 15, 2016. We examined patient and care characteristics associated with pain and pain improvement. Results. Of patients who could self-report symptoms, 30.7% (4959 of 16,158) reported moderate-to-severe pain at first assessment. Over 40% of these patients had not been referred to PC for pain. Younger patients (P < 0.0001), women (P < 0.0001), patients with cancer (P < 0.0001), and patients in medical/surgical units (P < 0.0001) were more likely to report pain. Patients with pain had higher rates of anxiety (P < 0.0001), nausea (P < 0.0001), and dyspnea (P < 0.0001). Sixty-eight percent of patients with moderate-to-severe pain improved by the PC team's second assessment within 72 hours; 74.7% improved by final assessment. There was a significant variation in the rate of pain improvement between PC teams (P < 0.0001). Improvement in pain was associated with improvement in anxiety (OR ¼ 2.9, P < 0.0001) and dyspnea (OR ¼ 1.4, P ¼ 0.03). Patients who reported an improvement in pain had shorter hospital length-of-stay by two days (P ¼ 0.003). Conclusion. Pain is common among inpatients referred to PC. Three-quarters of patients with pain improve and improvement in pain is associated with other symptom improvement. Standardized, multisite data collection can identify PC patients likely to have marked and refractory pain, create benchmarks for the field, and identify best practices to inform quality improvement.
Objective: Psychosocial distress among cancer patients leads to poor health outcomes and lower satisfaction. However, little is known about psychosocial distress among disadvantaged populations. We examined the prevalence, predictors, and follow-up experience of psychosocial distress among cancer patients within a diverse, urban, and multilingual safety-net setting. Methods: We conducted a retrospective cohort study of cancer patients undergoing psychosocial distress screening at initial medical oncology visits from 2014-2016. The primary outcome was self-reported moderate to severe psychosocial distress, defined by the NCCN as a Distress Thermometer score ≥ 4. Predictors of distress were assessed using logistic regression. Patients reporting distress were contacted by telephone 1-12 months later to reassess distress and assess completion of supportive service referrals. Results: Among 200 screened patients, 61% had moderate to severe psychosocial distress. African-American race, psychiatric illness, greater number of emotional problems, and reported problems with housing, money, worry, sleep, memory or homelessness were associated with psychosocial distress. Among 39 patients with moderate to severe psychosocial distress who completed follow-up (42% of eligible patients), mean distress scores decreased from 6.5 at screening to 4.5 at follow-up (P < .02). 56% of the supportive service referrals made at the initial visit were not completed. Conclusions: Cancer patients in the safety-net experience more psychosocial distress than other populations, with persistently elevated distress levels and difficulty accessing supportive services. We identified subgroups that may be at higher risk for psychosocial distress. Closer follow-up and assistance for patients who report high distress levels may be needed.
Background Advance care planning (ACP) is low among older adults with cancer. In a secondary analysis of randomized trial data, the authors compared the efficacy of the PREPARE for Your Care (PREPARE) website plus an easy‐to‐read advance directive (AD) with an AD only among older adults with and without cancer. Methods Safety net, primary care patients in San Francisco were included if they were 55 years old or older, were English‐ or Spanish‐speaking, and had 2 or more chronic conditions. The authors determined cancer diagnoses by using International Classification of Diseases, Ninth Revision/Tenth Revision codes. The primary outcome was new ACP documentation in the medical record at 15 months; the secondary outcomes were self‐reported ACP engagement, ease of use, satisfaction, and depression/anxiety. The authors used mixed effects logistic and linear regression adjusted for prior ACP, health literacy, and clinician, including a cancer interaction term. Results Of 986 participants, 220 (22%) had cancer. The mean age was 63 years (SD, 6 years), 61% were women, 81% were of a minority race/ethnicity, 45% were Spanish‐speaking, 39% had limited health literacy, and 27% had prior ACP. New ACP documentation was higher in the PREPARE arm versus the AD‐only arm among participants with cancer (62% vs 43%; P = .01) and without cancer (38% vs 28%; P = .01), as was ACP engagement in both arms (P < .001), with no interactions by cancer. Ease of use and satisfaction were high, and depression/anxiety was low, with no differences by study arm or by cancer/no cancer. Conclusions PREPARE plus an easy‐to‐read AD increased ACP documentation and engagement among diverse older adults with cancer more than an AD alone, with no increase in depression or anxiety between study arms or by cancer. PREPARE may help to decrease ACP disparities among patients with cancer. Lay Summary Advance care planning (ACP) is the process of sharing values, goals, and preferences for medical care, but engagement in ACP is low among older adults with cancer. Among 986 English‐ and Spanish‐speaking older adults from a safety net hospital, an interactive, multimedia, web‐based ACP program (PREPARE for Your Care at https://prepareforyourcare.org/) plus an easy‐to‐read advance directive increased ACP documentation and engagement more than an advance directive alone. There were no differences in this increase in ACP between older adults with cancer and older adults without cancer. Also, engaging in ACP did not result in increased depression or anxiety.
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