Background: As the death rate numbers in the United States related to COVID-19 are in the tens of thousands, clinicians are increasingly tasked with having serious illness conversations. However, in the setting of infection control policies, visitor restrictions, social distancing, and a lack of personal protective equipment, many of these important conversations are occurring by virtual visits. Objective: From our experience with a multisite study exploring the effectiveness of virtual palliative care, we have identified key elements of webside manner that are helpful when conducting serious illness conversations by virtual visit. Results: The key elements and components of webside manner skills are proper set up, acquainting the participant, maintaining conversation rhythm, responding to emotion, and closing the visit. Other considerations that may require conversion to phone visits include persistent technical difficulties, lack of prerequisite technology to conduct virtual visits, patients who are too ill to participate, or who find virtual visits too technically challenging. Conclusions: Similar to bedside manner, possessing nuanced verbal and nonverbal webside manner skills is essential to conducting serious illness conversations during virtual visits.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Opioids are routinely prescribed for cancer-related pain, but little is known about the prevalence of opioid-related hospitalizations among patients with cancer. Opioid addiction among these patients has been estimated to be as high as 7.7%, 1 but our understanding of opioid misuse among patients with cancer is based on small, preliminary studies. 2 In light of the wider opioid epidemic, oncologists and palliative care clinicians frequently balance providing patients with legitimate access to opioids while protecting them and the general public from the risks associated with prescribing these medications. 3 Methods | We examined trends and risk factors of opioidrelated hospitalizations among patients with cancer between January 1, 2006, and December 31, 2014, using the US National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP). 4 The database contained deidentified patient information and was deemed exempt from institutional review by the Partners Healthcare Human Research Committee. All analysis was conducted between December 2017 and September 2018. Our primary outcome was the number of opioid-related hospitalizations among adults with cancer (≥18 years old). We identified opioid-related hospitalizations using the International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes for heroin poisoning, opioid poisoning, and opioid dependence or abuse in the primary diagnosis field. 5 We identified these patients using ICD-9 codes (140.0-239.9, 258.01-258.03, 789.51), while excluding conditions that rarely require opioids for pain control. We excluded the following: carcinomas in situ, benign neoplasms, hematologic cancers in remission, macroglobulinemia, polycythemia vera, essential thrombocythemia, and nonmelanoma skin cancers. A multivariable logistic regression model evaluated the association between opioid-related hospitalizations and age, sex, race/ethnicity, primary insurance type, median household income quartile, hospital type, geographic region, alcohol abuse, drug abuse, depression, psychotic disorder, comorbidities, and year of hospital discharge. Comorbidities were identified using the Elixhauser comorbidity software from HCUP 4 but excluded alcohol abuse, depression, drug abuse, metastatic cancer, lymphoma, psychotic disorder, and solid tumors without metastasis since these were analyzed independently. Weighted frequencies, proportions, and 95% confidence intervals (CIs) were calculated to reflect national estimates using inverse sampling weights provided by the NIS. 4 Trend weights were used for 2006 through 2011 to adjust for the sampling redesign that was implemented in 2012. 4

spirituality that make them more alike than different. These shared Latino characteristics can influence Latinos' understanding and acceptance of palliative care. In addition, it can affect the delivery of culturallysensitive services by healthcare providers who may not be familiar with Latino cultural constructs. Presenters will introduce Latino cultural values and describe how they can impact seeking behaviors, delivery of palliative care, and patient-clinician relationships. The audience will be engaged to share their own experiences and challenges while taking care of these patients. Participants will be able to integrate attained knowledge into clinical practice; increasing cross-cultural knowledge on the complex beauty of Latino cultural values and attaining culturally sensitive communication skills could lead to a reduction in healthcare disparities.

Introduction: Early palliative care (PC) integrated with oncology care improves quality of life (QOL), depression symptoms, illness understanding, and end-of-life (EOL) care for patients with advanced lung cancer. The aims of this trial are to compare the effect of delivering early integrated PC through telehealth versus in-person on patient and caregiver outcomes. We hypothesize that both modalities for delivering early PC would be equivalent for improving patient QOL, communication about EOL care preferences with their oncologist, and length of stay in hospice. Methods: For this comparative effectiveness trial, we will enroll and randomize 1250 adult patients with advanced nonsmall cell lung cancer (NSCLC), who are not being treated with curative intent, to receive either early integrated telehealth or in-person PC at 20 cancer centers throughout the United States. Patients may also invite a family caregiver to participate in the study. Patients and their caregivers in both study groups meet at least every four weeks with a PC clinician from within 12 weeks of patient diagnosis of advanced NSCLC until death. Participants complete measures of QOL, mood, and quality of communication with oncologists at baseline before randomization and at 12, 24, 36, and 48 weeks. Information on health care utilization, including length of stay in hospice, will be collected from patients' health records. To test equivalence in outcomes between study groups, we will compute analysis of covariance and mixed linear models, controlling for baseline scores and study site. Study Implementation and Stakeholder Engagement: To ensure that this comparative effectiveness trial and findings are as patient centered and meaningful as possible, we have incorporated a robust patient and stakeholder engagement plan. Our stakeholder partners include (1) patients/families, (2) PC clinicians, (3) telehealth experts and clinician users, (4) representatives from health care systems and medical insurance providers, and (5) health care policy makers and advocates. These stakeholders will inform and provide feedback about every phase of study implementation.

PURPOSE: As part of a larger effort to integrate palliative care into a cancer center, we identified barriers to palliative care referral for patients with breast or gynecologic cancer and developed a pilot program to improve access to palliative care services. METHODS: We developed a multidisciplinary steering committee to uncover barriers to palliative care referral and developed a pilot program, called the Warm Handoff. Through ongoing collaboration and midpilot feedback sessions, we identified several additional barriers and opportunities to increase access to palliative care. RESULTS: Clinicians used the initial Warm Handoff process only 20 times over a period of 7 months. Of those calls, 10 were for issues outside of those that the Warm Handoff pilot was intended to address. During the pilot, we identified lack of access to urgent visits and clinician telephone availability for clinical case discussion as additional barriers to access. Increased collaboration led to the creation of a clinical provider of the day (CPOD) care model, which allowed for a notable increase in the capacity to see urgent consults. After this intervention, we observed an average of 19 patients seen urgently per month. In addition, there was a trend toward increasing referrals from breast oncology after the initiation of the CPOD. CONCLUSION: A CPOD model, developed via close oncology/palliative care collaboration, resulted in increased utilization of palliative care services.

BACKGROUND: Urine drug testing (UDT) is an essential tool to monitor opioid misuse among patients on chronic opioid therapy. Inaccurate interpretation of UDT can have deleterious consequences. Providers' ability to accurately interpret and document UDT, particularly definitive liquid chromatography-tandem mass spectrometry (LC-MS/ MS) results, has not been widely studied. OBJECTIVE: To examine whether providers correctly interpret, document, and communicate LC-MS/MS UDT results. DESIGN: This is a retrospective chart review of 160 UDT results (80 aberrant; 80 non-aberrant) between August 2017 and February 2018 from 5 ambulatory clinics (3 primary care, 1 oncology, 1 pain management). Aberrant results were classified into one or more of the following categories: illicit drug use, simulated compliance, not taking prescribed medication, and taking a medication not prescribed. Accurate result interpretation was defined as concordance between the provider's documented interpretation and an expert laboratory toxicologist's interpretation. Outcome measures were concordance between provider and laboratory interpretation of UDT results, documentation of UDT results, results acknowledgement in the electronic health record, communication of results to the patient, and rate of prescription refills. KEY RESULTS: Aberrant results were most frequently due to illicit drug use. Overall, only 88 of the 160 (55%) had any documented provider interpretations of which 25/88 (28%) were discordant with the laboratory toxicologist's interpretation. Thirty-six of the 160 (23%) documented communication of the results to the patient. Communicating results was more likely to be documented if the results were aberrant compared with non-aberrant (33/80 [41%] vs. 3/80 [4%], p < 0.001). In all cases where provider interpretations were discordant with the laboratory interpretation, prescriptions were refilled. CONCLUSIONS: Erroneous provider interpretation of UDT results, infrequent documentation of interpretation, lack of communication of results to patients, and prescription refills despite inaccurate interpretations are common. Expert assistance with urine toxicology interpretations may be needed to improve provider accuracy when interpreting toxicology results.

No abstract