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A projected shortage of hematopoietic cell transplantation (HCT) health professionals was identified as a major issue during the National Marrow Donor Program/Be The Match System Capacity Initiative. Work-related distress and work-life balance were noted to be potential barriers to recruitment/retention. This study examined these barriers and their association with career satisfaction across HCT disciplines. A cross-sectional, 90-item, web-based survey was administered to advanced practice providers, nurses, physicians, pharmacists, and social workers in 2015. Participants were recruited from membership lists of 6 professional groups. Burnout (measured with the Maslach Burnout Inventory subscales of emotional exhaustion and depersonalization) and moral distress (measured by Moral Distress Scale-Revised) were examined to identify work-related distress. Additional questions addressed demographics, work-life balance, and career satisfaction. Of 5759 HCT providers who received an individualized invitation to participate, 914 (16%) responded; 627 additional participants responded to an open link survey. Significant differences in demographic and practice characteristics existed across disciplines (P < .05). The prevalence of burnout differed across disciplines (P < .05) with an overall prevalence of 40%. Over one-half of pharmacists had burnout, whereas social workers had the lowest prevalence at less than one-third. Moral distress scores ranged from 0 to 336 and varied by discipline (P < .05); pharmacists had the highest mean score (62.9 ± 34.8) and social workers the lowest (42.7 ± 24.4). In multivariate and univariate analyses, variables contributing to burnout varied by discipline; however, moral distress was a significant contributing factor for all providers. Those with burnout were more likely to report inadequate work-life balance and a low level of career satisfaction; however, overall there was a high level of career satisfaction across disciplines. Burnout, moral distress, and inadequate work-life balance existed at a variable rate in all HCT disciplines, yet career satisfaction was high. These results suggest specific areas to address in the work environment for HCT health professionals, especially the need for relief of moral distress and a greater degree of personal time. As the creation of healthy work environments is increasingly emphasized to improve quality care and decrease costs, these findings should be used by HCT leadership to develop interventions that mitigate work-related distress and in turn foster recruitment and retention of HCT providers.

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Background Despite its established benefits, palliative care (PC) is rarely utilized for hematopoietic stem cell transplant (HSCT) patients. We sought to examine transplant physicians’ perceptions of PC. Methods We conducted a cross-sectional survey of transplant physicians recruited from the American-Society-for-Blood-and-Marrow-Transplantation. Using a 28-item questionnaire adapted from prior studies, we examined physicians’ access to PC services, and perceptions of PC. We computed a composite score of physicians’ attitudes about PC (mean=16.9, SD=3.37) and explored predictors of attitudes using a linear mixed model. Results 277/1005 (28%) of eligible physicians completed the questionnaire. The majority (76%) stated that they trust PC clinicians to care for their patients, but 40% felt that PC clinicians do not have enough understanding to counsel HSCT patients about their treatments. Most endorsed that when patients hear the term PC, they feel scared (82%) and anxious (75%). Nearly half (45%) reported that the service name ‘palliative care’ is a barrier to utilization. Female sex (β=0.85, P=0.024), having <10 years of clinical practice (β=1.39, P=0.004), and perceived quality of PC services (β=0.60, P<0.001) were all associated with a more positive attitude towards PC. Physicians with a higher sense of ownership over their patients’ PC issues (β=−0.36, P <0.001) were more likely to have a negative attitude towards PC. Conclusions The majority of transplant physicians trust PC, but have substantial concerns about PC clinicians’ knowledge about HSCT and patients’ perception of the term ‘palliative care’. Interventions are needed to promote collaboration, improve perceptions, and enhance integration of PC for HSCT recipients.

Objective To compare cost estimates for hospital stays calculated using diagnosis related group (DRG) weights to actual Medicare payments. Data Sources/Study Setting Medicare MedPAR files and DRG tables linked to participant data from the Study of Osteoporotic Fractures (SOF) from 1992 through 2010. Participants were women age 65 and older recruited in three metropolitan and one rural area of the United States. Study Design Costs were estimated using DRG payment weights for 1,397 hospital stays for 795 SOF participants for one year following a hip fracture. Medicare cost estimates included Medicare and secondary insurer payments, and copay and deductible amounts. Principal findings The mean (SD) of inpatient DRG-based cost estimates per person-year were $16,268 ($10,058) compared to $19,937 ($15,531) for MedPAR payments. The correlation between DRG-based estimates and MedPAR payments was 0.71, and 51% of hospital stays were in different quintiles when costs were calculated based on DRG weights compared to MedPAR payments. Conclusions DRG-based cost estimates of hospital stays differ significantly from Medicare payments, which are adjusted by Medicare for facility and local geographic characteristics. DRG-based cost estimates may be preferable for analyses when facility and local geographic variation could bias assessment of associations between patient characteristics and costs.

Background Since January 2002, Medicare has provided payment for medical nutrition therapy for patients with chronic kidney disease. Few patients receive dietary counseling before end-stage renal disease (ESRD) onset; whether such counseling is associated with improved outcomes is unknown. Study design Retrospective cohort analysis. Setting and participants Patients who initiated hemodialysis June 1, 2005-May 31, 2007, in the US, for whom predialysis dietitian care was reported on the Centers for Medicare & Medicaid Services Medical Evidence Report. Predictor Dietitian care before ESRD onset. Outcome Time to death. Measurements Propensity score for dietitian care calculated using logistic regression; Cox regression analysis used to compare time to death by predialysis dietitian care overall and stratified by tertiles of propensity score, adjusting for baseline characteristics. Results Most patients (88%) received no dietitian care; 9% received dietitian care for ≤ 12 months, and 3% received dietitian care for > 12 months before dialysis initiation (total n = 156,440). Predialysis dietitian care was independently associated with higher albumin and lower total cholesterol at dialysis initiation. There was evidence of an independent association between predialysis dietitian care for > 12 months and decreased mortality during the first year on dialysis for the second tertile of propensity score. Adjusted mortality hazards ratios (95% confidence interval) were 1.16 (0.44–3.09; P = 0.8), 0.81 (0.71–0.93; P = 0.002), and 0.93 (0.86–1.01; P = 0.1) in the first, second, and third tertiles of propensity score, respectively. Limitations Information on dietitian care was missing from 18.6% of Medical Evidence Reports, and has low sensitivity; including only incident dialysis patients precluded evaluation of an association between dietitian care and CKD progression; observational design allowed possibility of residual confounding. Conclusions Our study suggests an independent association between predialysis dietitian care for > 12 months and lower mortality during the first year on dialysis.