Background: Despite positive outcomes associated with specialist palliative care (PC) in diverse medical populations, little research has investigated specialist PC in surgical ones. Although cancer surgery is predominantly safe, operations can be extensive and unpredictable perioperative morbidity and mortality persist, particularly for patients with upper gastrointestinal (GI) cancers. Objectives and Hypotheses: Our objective is to complete a multicenter, randomized controlled trial comparing surgeon-PC co-management with surgeon-alone management among patients pursuing curative-intent surgery for upper GI cancers. We hypothesize that perioperative PC will improve patient postsurgical quality of life. This study and design are based on >8 years of engagement and research with patients, family members, and clinicians surrounding major cancer surgery and advance care planning/PC for surgical patients. Methods: Randomized controlled superiority trial with two study arms (surgeon-PC team co-management and surgeon-alone management) and five data collection points over six months. The principal investigator and analysts are blinded to randomization. Setting: Four, geographically diverse, academic tertiary care hospitals. Data collection began December 20, 2018 and continues to December 2020. Participants: Patients recruited from surgical oncology clinics who are undergoing curative-intent surgery for an upper GI cancer. Interventions: In the intervention arm, patients receive care from both their surgical team and a specialist PC team; the PC is provided before surgery, immediately after surgery, and at least monthly until three months postsurgery. Patients randomized to the usual care arm receive care from only the surgical team. Main Outcomes and Measures: Primary outcome: patient quality of life. Secondary outcomes: patient: symptom experience, spiritual distress, prognostic awareness, health care utilization, and mortality. Caregiver: quality of life, caregiver burden, spiritual distress, and prognostic awareness. Intent-to-treat analysis will be used. Ethics and Dissemination: This study has been approved by the institutional review boards of all study sites and is registered on clinicaltrials.gov (NCT03611309, First received: August 2, 2018).
PURPOSE Seven major palliative care (PC) centers in India were mentored through the Palliative Care—Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) by US and Australian academic institutions to implement a quality improvement (QI) project to improve the accessibility and quality of PC at their respective centers. The objective was to evaluate the experiences of teams in implementing QI methods across diverse geographical settings in India. METHODS A quota sampling approach was used to elicit perspectives of local stakeholders at each site. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Analysis leveraged deductive and inductive approaches. RESULTS We interviewed 44 participants (eight organizational leaders, 12 clinical leaders, and 24 team members) at seven sites and identified five themes. (1) Implementing QI methods enabled QI teams to think analytically to solve a complex problem and to identify resources. (2) Developing a problem statement by identifying specific gaps in patient care fostered team collaboration toward a common goal. (3) Making use of QI tools (eg, A3 process) systematically provided a new, straightforward QI toolkit and improved QI teams' conceptual understanding. (4) Enhancing stakeholder engagement allowed shared understanding of QI team members' roles and processes and shaped interventions tailored to the local context. (5) Designing less subjective processes for patient care such as assessment scales to identify patient's symptomatic needs positively changed work practices and culture. CONCLUSION Engaging and empowering multiple stakeholders to use QI methods facilitated the expansion and improvement of PC and cancer services in India. PC-PAICE demonstrated an efficient, effective way to apply QI methods in an international context. The impact of PC-PAICE is being magnified by developing a cadre of Indian QI leaders.
Research Objectives. To describe facility-level variation in EOLC quality for Veterans with HF across 141 VAMCs between 2012-2016. Methods. Retrospective analysis of EOLC process and outcome measures. Process measures included: palliative care consultation (PCC) $30 days before death, inpatient hospice death, chaplaincy consult, and intensive care unit (ICU) death. The outcome measure was the Bereaved Family Survey Performance Measure (BFS-PM), which reports the percentage of respondents rating the overall care in the last month of life as ''excellent.'' Using multivariable logistic regression, we created VAMC-level quintiles of the BFS-PM, adjusting for case mix and non-response bias. We then determined associations between VAMC quality quintile and EOLC quality process measures. Results. VAMC-level rates of ''Excellent'' BFS-PM for Veterans with HF ranged from 22-82%. Veterans in the highest quality quintile were 35% more likely to receive a PCC (adjusted odds ratio [AOR] 1.35, 95% Confidence Interval [CI] 1.01 e 2.81), 94% more likely to die in inpatient hospice (AOR 1.94, 95% CI 1.21 e 3.11), 88% more likely to have had a chaplain visit (AOR 1.88, 95% CI 1.23 e 2.87), and 39% less likely to die in the ICU (AOR 0.61, 95% CI 0.41 e 0.90) compared to lowest quality quintile VAMCs. Conclusion. EOLC quality varies widely across VAMCs for veterans with HF and is closely associated with high-quality EOL processes of care. Implications for Research, Policy, or Practice. Research is needed to describe EOLC delivery for HF patients in top-performing VAMCs and disseminate these best-practices to lower performing VAMCs across the VA healthcare system.
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