Early palliative care is associated with less intensive medical care, improved quality outcomes, and cost savings at the end of life for patients with cancer. Despite recommendations that early palliative care be offered to all patients with metastatic cancer, palliative care services remain underutilized.

Background Symptom-based tuberculosis screening identifies less than one-third of eligible HIV-infected patients as candidates for isoniazid preventive therapy (IPT). We evaluated whether testing for C-reactive protein (CRP) improves patient selection for IPT. Methods We measured CRP levels (normal < 10mg/L) using a point-of-care (POC) assay on stored serum samples from HIV-infected Ugandan adults initiating antiretroviral therapy. We assessed diagnostic accuracy in reference to baseline tuberculosis status adjudicated by an expert committee and calculated net reclassification improvement (NRI) to quantify the incremental discriminatory benefit of POC-CRP in determining IPT-eligibility compared to the WHO symptom screen. Results Of 201 patients (median CD4 cell-count 137 cells/μL, IQR 83-206), five (2.5%) had tuberculosis. Compared to the WHO symptom screen, POC-CRP had similar sensitivity (100% vs. 80%, p=0.30) but greater specificity (21% vs. 87%, p<0.0001) for tuberculosis. If based on the WHO symptom screen, no patients with tuberculosis but only 42/196 patients without tuberculosis would have been considered IPT-eligible. If POC-CRP were used instead, one patient with tuberculosis (reclassification of cases -20%, p=0.32) and 129 patients without tuberculosis (reclassification of non-cases +66%, p<0.001) would have been reclassified as IPT-eligible, an NRI of 46% (p=0.03). In addition, POC-CRP testing would have reduced the proportion of patients without active tuberculosis requiring confirmatory tuberculosis testing (87% vs. 21%, p<0.0001). Conclusions POC-CRP testing increased more than four-fold the proportion of HIV-infected adults immediately identified as IPT-eligible and decreased the proportion of patients requiring referral for further tuberculosis diagnostic testing. POC-CRP testing could substantially improve implementation of tuberculosis screening guidelines.

8 Background: ASCO recommends that early palliative care (PC) be offered alongside standard cancer care for patients with metastatic cancer and/or high symptom burden. There is limited data about how the timing of PC affects the quality, intensity, and cost of care at the end of life for patients with advanced cancer. Methods: We analyzed administrative and billing data to assess patterns of healthcare utilization for a cohort of patients at an academic comprehensive cancer center who died from cancer between Jan 1, 2010 and May 31, 2012. We examined the associations of early PC (>90 days prior to death) versus late PC (<90 days prior to death) with QOPI, NQF, and other established quality metrics and direct cost of medical care in last 6 months of life. Results: Among 978 decedents who received treatment at the cancer center, only 298 (30%) had specialty PC referrals. Of these patients, 94 (9.6% of decedents, 31.5% of referrals) had early PC while 204 (21% of decedents, 68.5% of referrals) had late PC. Patients who received early PC had a lower rate of inpatient admissions in the last month of life (33% vs. 66%, p=0.002), lower rates of ICU stay in last month of life (5% vs. 20%, p=0.0005), fewer ED visits in last month (34% vs. 54%, p=0.0002), fewer instances of hospice length of service <3 days (7% vs. 20%, p=0.0001), and a lower rate of inpatient death (15% vs. 34%, p=0.0001). Most patients (84%) who received early PC were seen as outpatients, while late PC was mostly delivered in the hospital (82.4%). Of the late PC cohort, only 52 (25.4%) were ever seen in the outpatient PC clinic, but 170 (83%) had at least one oncology office visit 91-180 days prior to death. The direct cost of inpatient medical care in the last 6 months of life for patients with early PC was reduced when compared to patients who had late PC ($19k vs. $25.7k), while the direct cost of outpatient care was higher in the early PC compared to late PC population ($13k vs. $11.5k). Conclusions: Early PC is associated with less intensive medical care and improved quality outcomes at the EOL for patients with advanced cancer. Early PC results in a significant inpatient cost savings with a modest increase in outpatient costs. Early PC is likely best delivered in the outpatient setting.

Review proposed procedures for pacemaker deactivation as developed by a tertiary university-based hospital. In the last several years, much has been written about the practical and ethical considerations regarding the deactivation of cardiac implantable electronic devices (CIEDs) in patients at the end of life. While deactivation of certain devices, such as implantable cardiac defibrillators, has become relatively common, other devices carry significantly more controversy and potential for conflict between patients and providers, as well as among medical professionals. Indeed, recent surveys have revealed that the majority of physicians remain uncomfortable discussing deactivate of CIEDs in general and pacemakers in particular. We will begin this concurrent session with a case report of a family's distress when their request for pacemaker deactivation in a patient with terminal cancer was met with accusations of euthanasia, and then review the literature regarding consensus and opinions regarding pacemaker deactivation. We will detail the experiences of one university-based hospital's attempt to develop a policy for pacemaker deactivation with an emphasis on practical lessons learned. We will review the results of a national survey of hospital-based ethics committees regarding their experience with pacemaker deactivation. Finally, we will end with a proposed procedure to manage the potential symptoms associated with pacemaker deactivation in a patient at the end of life. ObjectivesUnderstand the role of early palliative care in the treatment of patients with advanced cancer at the end of life. Recognize that specialty palliative care services are underutilized in patients with advanced cancer. Original Research Background. The American Society of Clinical Oncology (ASCO) recommends that palliative care (PC) be offered alongside standard oncologic care for patients with metastatic cancer and/or high symptom burden. There are limited data about how the timing of palliative care affects the quality, intensity, and cost of medical care at the end of life for patients with advanced cancer. Research Objectives. To understand how timing of PC referral is associated with the quality and cost of medical care delivered to patients with advanced cancer at the end of life. Methods. In this retrospective cohort study, we analyzed administrative and billing data to assess patterns of healthcare utilization of patients cared for at the UCSF Cancer Center who died from cancer between Jan 1, 2010, and May 31, 2012. Results. Among 978 decedents who received regular cancer treatment at UCSF, only 298 (30%) had specialty palliative care referrals. Of these, 94 (31.5%) had early PC referrals (EPC) while 204 (68.5%) had late PC (LPC). Patients who received EPC had a lower rate of inpatient admissions (33% vs 66%, p¼0.002), lower rates of ICU stay (5% vs 20%, p¼0.0005), and fewer ED visits in last month of life (34% vs 54%, p¼0.0002), as well as fewer instances of hospice service <3 days (7% vs 20%, p¼0.0001) and a lower rate of inpati...