Clinician Insights into Effective Components, Delivery Characteristics and Implementation Strategies of Ambulatory Palliative Care for People with Heart Failure: A Qualitative Analysis.

OBJECTIVES: To elicit perspectives from specialist palliative care (SPC) and cardiology clinicians concerning the necessary components, delivery characteristics and implementation strategies of successful ambulatory SPC for people with heart failure (HF). BACKGROUND: Palliative care is a recommended component of guideline-directed care for people with HF. However, optimal strategies to implement SPC within ambulatory settings are unknown. METHODS: We conducted a qualitative descriptive study composed of semistructured interviews with SPC and cardiology clinicians at Veterans Affairs Medical Centers (VAMCs) with the highest number of ambulatory SPC consultations within the VA system among people with HF between 2021 and 2022. Clinicians were asked how they provided ambulatory SPC and what they felt were the necessary components, delivery characteristics and implementation strategies of care delivery. Interviews were analyzed using directed content analysis. RESULTS: We interviewed 14 SPC clinicians and 9 cardiology clinicians at 7 national VAMCs; 43% were physicians, and 48% were advanced-practice registered nurses/physician associates. Essential components of ambulatory SPC encompassed discussion of goals of care (eg, prognosis, advance directives) and connecting patients/caregivers to resources (eg, home care). Preferred delivery characteristics included integrated (ie, embedded) approaches to SPC delivery, standardized patient selection and referral procedures, and formalized procedures for handoffs to and from SPC. Strategies that addressed SPC implementation included deploying palliative champions, educating non-SPC clinicians on the value of ambulatory SPC for people with HF and developing ambulatory models through leadership support. CONCLUSIONS/IMPLICATIONS: Facilitating the broader adoption of ambulatory SPC among people with HF may be achieved by prioritizing these mutually valued and necessary features of SPC delivery.

Survival of a Jehovah's Witness with thrombotic thrombocytopenic purpura without using plasma: A case report and review of the literature.

Acquired thrombotic thrombocytopenic purpura (aTTP) is a serious disorder with arteriolar and capillary thrombosis for which the treatment usually requires plasma exchange with plasma as the replacement fluid. Management of patients who do not accept blood products is a serious challenge. We present the case of a Jehovah's Witness patient who achieved clinical response after treatment with plasma exchange using human albumin solution as the replacing fluid, high dose corticosteroids, and rituximab. The patient also received ADAMTS13 containing plasma cryoprecipitate and von Willebrand factor VIII concentrates. She had an exacerbation of her TTP in less than 3 weeks. She was treated with further plasma exchange with human albumin solution as the replacement fluid, high dose steroids, and rituximab. Bortezomib and N-acetylcysteine were added. The patient eventually improved clinically and achieved remission that is ongoing for more than 7 months. A review of the literature shows that all five previously reported cases of aTTP in Jehovah's Witnesses survived although none received plasma. Two were not even treated with plasma exchange. The experience of this case and those in the literature demonstrates that remission of aTTP may be achieved without using plasma or plasma exchange.

Purulent Pericarditis in Sickle Cell Disease Due to Streptococcus agalactiae; a Unique Case Report and Literature Review.

Purulent pericarditis is a localized infection with a thick, fibrinous hypercellular exudate and is historically associated with a high mortality. We describe a case of purulent pericarditis due to Streptococcus agalactiae (S. agalactiae) in a 30-year-old woman with sickle cell disease who presented with fever, dyspnea, and S. agalactiae septicemia. Despite timely initiation of antibiotics, she developed a large purulent pericardial effusion requiring surgical pericardiocentesis followed by a pericardial window. At 14 months follow-up, she has remained asymptomatic without sequelae. A review of the literature contained only four patients with purulent pericarditis in sickle cell patients. We discuss the unique aspects of this case in the context of purulent pericarditis in the age of modern antibiotics and hypothesize on the pathogenesis of delayed pericardial effusion after pericarditis.

Tumour-To-Tumour Metastasis: A Rare Case of Prostate Cancer Metastasising to Primary Lung Adenocarcinoma.

Tumour-to-tumour metastasis (TTM) is a rare phenomenon that clinicians should be aware of when evaluating patients with a history of prostate cancer. We present the diagnosis and management of an 80-year-old former smoker with high-risk prostate cancer, who developed a lung nodule consistent with TTM. The patient had concurrent primary lung adenocarcinoma and metastatic prostate cancer, making this a unique case of dual primary and metastatic malignancies. The complexity of this case highlights the need for comprehensive evaluation and interdisciplinary management in patients with multiple malignancies. The literature review reveals that these are extremely rare occurrences, with most cases involving metastasis to the second primary tumour. Despite the challenges in diagnosing preoperatively, it is important to consider TTM as a possibility in patients with prostate cancer who present with a lung nodule. This report presents one of the few documented cases of TTM. It also reviews relevant cases in the literature and discusses the current situation in relation to established criteria for classifying combination tumours. LEARNING POINTS: Isolated lung metastasis with prostate cancer is exceptionally rare in the literature.Tumour-to-tumour metastasis cases present challenges in sampling and interpreting histopathology.In instances of tumour-to-tumour metastasis, it is vital to consider the patient's clinical history, perform thorough gross examination and obtain appropriate samples to distinguish between the separate tumour components.

Assessment of PSA responses and changes in the rate of tumor growth (g-rate) with immune checkpoint inhibitors in US Veterans with prostate cancer.

We examined data from US Veterans with prostate cancer (PC) to assess disease response to immune checkpoint inhibitors (ICI) as monotherapy or combined with abiraterone or enzalutamide to assess ICI efficacy in the real-world. We queried the VA corporate data warehouse (CDW) to identify Veterans with a diagnosis of PC who received ICI for any malignancy and had ≥1 PSA measurement while receiving ICI. To evaluate ICI monotherapy, we restricted analysis to Veterans who had not received LHRH agonists/antagonists, PC-directed medical therapy, or radiation/extirpative surgery of the bladder/prostate within and preceding the duration of ICI administration. For ICI combination analysis, we identified Veterans who received abiraterone or enzalutamide for PC while on ICI. We calculated rates of tumor (PSA) growth (g-rates), comparing them to a 1:2 matched reference cohort. We identified 787 Veterans with PC and ≥1 PSA measurement while receiving an ICI. Median duration of ICI therapy was 155 days. 223 Veterans received ICI monotherapy, with only 17(8%) having a reduction in PSA (median decline = 43%). 12 (5%) had PSA declines >30% (PSA30) which included 6 (3%) who had PSA reductions greater than 50% (PSA50). Median g-rates for ICI plus abiraterone (n = 20) or enzalutamide (n = 31) were 0.000689/d-1 and 0.002819/d-1, respectively, and were statistically insignificant compared to g-rates of matched cohorts receiving abiraterone (g = 0.000925/d-1, P = 0.73) or enzalutamide (g = 0.001929/d-1, P = 0.58) alone. Our data align with clinical trial data in PC, demonstrating limited benefit from ICI monotherapy and predicting no survival benefit from simultaneous abiraterone or enzalutamide with an ICI using g-rate.

Assessing olaparib efficacy in U.S. Veterans with metastatic prostate cancer utilizing a time-indifferent g-rate method ideal for real-world analyses.

BACKGROUND: We aimed to assess real-world efficacy of the PARP inhibitor, olaparib, in US Veterans with metastatic prostate cancer (mPC) by leveraging the national data repository and evaluate a novel approach to assess treatment efficacy in tumors considered rare or harboring rare mutations. METHODS: Included Veterans had 1) mPC with somatic or germline alterations/mutations in genes involved in homologous recombination repair (HRR), 2) received olaparib monotherapy as well as a novel hormonal therapy/androgen receptor pathway inhibitors (NHT/ARPI), and/or chemotherapy, and 3) estimable rates of tumor growth (g-rate) using PSA values obtained while receiving treatment. Previous work has shown an excellent inverse correlation of g-rate with survival. Using g-rate, we determined tumor doubling time (DT) and DT ratios (DT on olaparib/DT on prior medication). We postulated that a DT ratio≥ 1 was associated with benefit. FINDINGS: We identified 139 Veterans, including 42 Black males with tumors harboring mutations/alterations in HRR genes who received olaparib: BRCA2 (50), ATM (32), BRCA1 (10), other mutations (47). 62/139 (45%) of all and 21/42 (50%) of Black Veterans had DT ratios ≥1, including 31, 10, 2, and 19 with BRCA2, ATM, BRCA1, and other mutations, respectively (p = 0.006). Median survival with DT ratios ≥1 was superior, being 24.5 vs. 11.4 months for DT ratio <1 (p = 0.01, HR 0.50, 95% CI 0.29-0.85). Benefit from olaparib, defined as DT ratio ≥1, was not observed for germline status, starting PSA value, number of prior therapies, or immediate prior therapy. Compared to matched cohorts, tumors in the olaparib cohort had shorter DTs with enzalutamide in first line (367 vs. 884 days; p = 0.0043). INTERPRETATION: Using equations indifferent to timing of assessments ideal for real-world efficacy analyses, we showed DT ratio ≥1 representing slower tumor growth on olaparib relative to the prior therapy correlates with improved survival. Olaparib efficacy in Veterans with mPC harboring mutations/alterations in HRR genes emulates clinical trial results. Black men had comparable results. Compared to matched cohorts, in first line, enzalutamide was less efficacious in tumors harboring mutations/alterations in HRR genes. FUNDING: American Society of Clinical Oncology Conquer Cancer Foundation (ASCO CCF), the Blavatnik Family Foundation and the Prostate Cancer Foundation (PCF).

Influence of Cancer on COVID-19 Incidence, Outcomes, and Vaccine Effectiveness: A Prospective Cohort Study of U.S. Veterans.

PURPOSE: Coronavirus disease 2019 (COVID-19) has been a constant health threat since its emergence. Amongst risk factors proposed, a diagnosis of cancer has been worrisome. We report the impact of cancer and other risk factors in US Veterans receiving care at Veterans Administration (VA) Hospitals, their adjusted odds ratio (aOR) for infection and death, and report on the impact of vaccines on the incidence and severity of COVID-19 infections in Veterans without/with cancer. METHODS: We conducted a cohort study of US Veterans without/with cancer by mining VA COVID-19 Shared Data Resource (CSDR) data using the VA Informatics and Computing Infrastructure (VINCI). Our observation period includes index dates from 14DEC2020 to 25JAN2022, encompassing both the delta and omicron waves in the US. RESULTS: We identified 915,928 Veterans, 24% of whom were African Americans who had undergone COVID testing-688,541 were and 227,387 were not vaccinated. 157,072 had a cancer diagnosis in the preceding two years. Age emerged as the major risk factor, with gender, BMI, and (Elixhauser) comorbidity contributing less. Among veterans with solid tumors other than lung cancer, risks of infection and death within 60 days were comparable to Veterans without cancer. However, those with hematologic malignancies fared worse. Vaccination was highly effective across all cancer cohorts; the respective rates of infection and death after infection were 8% and 5% among the vaccinated compared to 47% and 10% in the unvaccinated. Amongst vaccinated, increased risk of infection was noted in both, Veterans with hematologic malignancy treated with chemotherapy (HR, 2.993, P < 0.0001) or targeted therapies (HR, 1.781, P < 0.0001), and in solid tumors treated with either chemotherapy (HR 2.328, 95%CI 2.075-2.611, P < 0.0001) or targeted therapies (HR 1.328, P < 0.0001) when compared to those not on treatment. CONCLUSIONS: Risk for COVID-19 infection and death from infection vary based on cancer type and therapies administered. Importantly and encouragingly, the duration of protection from infection following vaccination in Veterans with a diagnosis of cancer was remarkably like those without a cancer diagnosis. Veterans with hematologic malignancies are especially vulnerable, with lower vaccine effectiveness (VE).

Pseudohypobicarbonatemia caused by an endogenous assay interferent: a new entity.

Serum total carbon dioxide, measured using a chemistry analyzer, and gas panel-derived plasma bicarbonate, calculated from the pH and partial pressure of carbon dioxide, often are used interchangeably for clinical purposes. When they disagree, there is a tendency to accept total carbon dioxide and discredit gas panel-derived plasma bicarbonate values. We report a patient who, during a 5-month hospitalization, had persistently low total carbon dioxide levels (12.4 ± 2.7 [standard deviation] mEq/L [12.4 ± 2.7 mmol/L]), measured using an enzymatic/photometric assay, and a high anion gap (19.2 ± 3.1 mEq/L [19.2 ± 3.1 mmol/L]), suggesting high-anion-gap metabolic acidosis, but who had gas panel-derived plasma bicarbonate (24.0 ± 0.9 mEq/L [24.0 ± 0.9 mmol/L]) and arterial pH values in the reference range. Organic anion levels in blood and urine were unremarkable. Negative interference with the enzymatic assay by the patient's serum was shown by the findings that total carbon dioxide level was 7.0 ± 0.1 mEq/L (7.0 ± 0.1 mmol/L) higher when measured using the electrode-based method than using the enzymatic method (P < 0.01), and the patient's serum, but not control serum, altered the reaction kinetics of the enzymatic assay by producing turbidity, resulting in an initial increase in absorbance and a falsely low total carbon dioxide value. The turbidity may have resulted from precipitation of 1 of 2 paraproteins in the patient's serum or an endogenous antibody binding with an animal protein included in the assay reagents. In summary, a discrepancy between total carbon dioxide level measured using an enzymatic assay and gas panel-derived plasma bicarbonate level was found to be the result of turbidity caused by an endogenous interferent with the total carbon dioxide assay, a novel artifact. When total carbon dioxide and gas panel-derived plasma bicarbonate values disagree, measurement error in total carbon dioxide level should be considered.

Liver Granulocytic Sarcoma With Megakaryocytic Differentiation: A Rare Extra Medullary Involvement That Warrants Liver Biopsy for Prompt Diagnosis.

Granulocytic sarcoma (GS) is an extramedullary manifestation of acute myeloid leukemia (AML), myelodysplastic syndrome (MDS) or myeloproliferative neoplasms. The diagnosis depends on morphology, immunohistochemistry and flow cytometry. An unusual location of this tumor may mask its primary source, therefore, a strategy involving immediate symptom control, and investigation is crucial in preventing clinical deterioration. We present a case of a 53-year-old man who initially presented with tumor lysis syndrome and transaminitis, with a subsequent CT Scan that revealed multiple liver lesions. This case describes a rare clinical entity of granulocytic sarcoma as multiple hypoattenuating liver lesions mimicking metastatic disease in its radiographic appearance. Since the imaging features of hepatic masses are nonspecific, and considering the aggressive nature of AML with concomitant tumor lysis syndrome, a confirmatory prompt biopsy should routinely be considered.

Acquired factor VIII deficiency in prostate adenocarcinoma presenting as multiple hematomas and hemarthrosis.

Acquired hemophilia A or acquired factor VIII deficiency is a rare bleeding disorder due to the presence of autoantibodies to factor VIII. It has been associated with autoimmune conditions, certain medications, and malignancy. It has a high morbidity and mortality, and early diagnosis and treatment is critically important. Acquired hemophilia A usually manifests with soft tissue bleeding, such as epistaxis, genitourinary, or gastrointestinal bleeding and rarely with hemarthrosis. In this case report, we present the management of an uncommon case of acquired hemophilia A in a patient with metastatic prostate adenocarcinoma who presented with both hemarthrosis and soft tissue bleeding. Bleeding was controlled with recombinant factor VIIa, factor VIII bypassing agent, and immunosuppressive therapy with prednisone and rituximab. Chemotherapy with docetaxel was also promptly initiated to address the underlying condition and achieve long-term remission, which is currently ongoing for 10 months.

Patterns of Care and Survival of Metastatic Metaplastic Breast Cancer Patients.

BACKGROUND: Metaplastic breast cancer (MBC) is a rare, aggressive variant of breast cancer, usually triple negative disease and chemotherapy refractory. Despite this, the standard of care remains the same as invasive ductal breast cancer. We sought to analyze patterns of care and outcomes among patients with metastatic MBC. METHODS: Patients over 18 years diagnosed with metastatic MBC from 2004-2015 were identified in the National Cancer Database (NCDB). Clinical and demographic details were compared between two groups (chemotherapy vs no chemotherapy). Logistic regression was performed to assess for predictors of receiving chemotherapy. The Kaplan-Meier method was used to assess overall survival (OS) and Cox regression analysis was used to assess the impact of covariates on OS. RESULTS: There were 7,580 patients with MBC of which 417 (5.5%) presented with metastatic disease. Median age was 65 years (interquartile range (IQR) 54-76) and median follow up for living patients was 48 months (IQR 31-77). One hundred and fifty-six (37.4%) patients received chemotherapy. On multivariable logistic regression analyses, treatment at an academic facility was associated with an increased likelihood of receiving chemotherapy (OR 3.14, 95% CI 1.95-5.03, p<0.001) while age ≥65 years (OR 0.54, 95% CI 0.34-0.86, p=0.009) and receipt of hormonal therapy (OR 0.35, 95% CI 0.15-0.85, p=0.021) were associated with a decreased likelihood of receiving chemotherapy. On multivariable Cox regression analysis, higher Charlson-Deyo score (hazard ratio (HR) 1.35-1.78, p<0.05) was associated with worse survival while receipt of chemotherapy (HR 0.76, 95% CI 0.59-0.99, p=0.041) and having insurance (HR 0.34-0.47, p<0.05) were associated with improved survival. Patients who received chemotherapy had improved median (twelve versus eight months), one-year (51% versus 38%), and two-year (35% versus 21%) OS, as compared to those who did not receive chemotherapy (p=0.006).  Conclusions: In this study of MBC patients, there was a survival benefit with palliative chemotherapy in the setting of metastatic disease. As expected, treatment was most often given to younger patients.

Clinical Characteristics and Outcomes of Caribbean Patients With Adult T-Cell Lymphoma/Leukemia at Two Affiliated New York City Hospitals.

PURPOSE: Adult T-cell lymphoma/leukemia (ATL) is a rare and aggressive peripheral T-cell malignancy caused by human T-cell lymphotropic virus-1 infection, which occurs in areas of high prevalence, predominantly in Japan and the Caribbean basin. Most ATL literature is derived from Japan and little is published about Caribbean patients. We describe the clinicopathologic characteristics and treatment outcomes of our Caribbean patients who have ATL at the State University of New York Downstate Medical Center and Kings County Hospital. PATIENTS AND METHODS: We conducted a retrospective analysis of our patients with ATL who were diagnosed between 2005 and 2017. Medical records were reviewed for clinicopathologic data and treatment outcomes. The final analysis included acute and lymphomatous subtypes only. For the univariable analysis, outcomes were calculated by using a log-rank test, and survival curves were estimated by the Kaplan-Meier method. RESULTS: We identified 63 patients with acute (55%) and lymphomatous (45%) subtypes, 95% of whom had Ann Arbor stage III to IV disease. The median age was 54 years, and the study population was predominantly female (65%). Most patients (82%) received first-line etoposide, cyclophosphamide, vincristine, doxorubicin, and prednisone (EPOCH) or cyclophosphamide, vincristine, doxorubicin, and prednisone (CHOP) chemotherapy (10%) with an overall response rate of 46%. The median overall survival was 5.5 months, and the median progression-free survival was 4 months. Incidence of atypical immunophenotype (32%) was higher than previously reported in the Japanese literature and was associated with worse survival (P = .04). Abnormal cytogenetics correlated with shorter progression-free survival (P < .05). CONCLUSION: We describe here the clinicopathologic characteristics and treatment outcomes of our Caribbean patients with aggressive ATL, which is largely chemotherapy resistant, and the challenges of treating a population with unmet medical needs.

Doxorubicin-associated takotsubo cardiomyopathy in a patient with adult T-cell leukemia/lymphoma.

This case highlights the first reported association of doxorubicin with takotsubo cardiomyopathy (TC) presenting as cardiogenic shock during the first continuous infusion in a patient with adult T-cell leukemia/lymphoma. We aim to raise awareness to recognize and distinguish between irreversible doxorubicin-associated cardiomyopathy and reversible doxorubicin-associated TC in patients with cancer.

A National VA Palliative Care Quality Improvement Project for Improving Intensive Care Unit Family Meetings (ICU-FMs).

BACKGROUND: We sought to increase intensive care unit-family meeting (ICU-FM) documentation in the electronic health record in Veterans Affairs (VA) hospitals. MEASURES: Primary outcomes were proportion of VA decedents with ICU-FM and Bereaved Family Survey-Performance Measure (BFS-PM) scores of "excellent." INTERVENTION: Quality improvement (QI) project, clinical champion, and ICU-FM templates were implemented in nine participating VA facilities. ICU-FMs and BFS-PM were determined in decedents between 2011 and 2018. OUTCOMES: ICU-FM increased from 3% to 28% in participating vs. 5% to 6% in nonparticipating facilities over time. Participating facilities were five-fold more likely to have ICU-FMs among ICU decedents (OR = 5.69, [4.45-7.28]). Facility-wide excellent BFS-PM scores increased by 19% in participating vs. nonparticipating facilities at the end of the observation period (OR = 1.19, [1.10-1.30]), but no difference between groups was observed in patients who died in the ICU. CONCLUSIONS: Increasing ICU-FMs is necessary but not sufficient to improve family-reported satisfaction after an ICU death.

Top Ten Tips Palliative Care Providers Should Know About Caring for Veterans.

Many of America's Veterans have unique medical and psychosocial needs related to their military service. Since most medical care received by Veterans occurs outside of the Department of Veterans Affairs (VA) health care system, it is imperative that all medical providers have a working understanding of the unique needs of Veterans and some of the many programs and services available to Veterans through the VA. This article, created by an interdisciplinary team of palliative care and hospice providers who care for Veterans throughout the country, seeks to improve the comfort with which non-VA clinicians care for Veterans while increasing knowledge about programs for which Veterans might qualify through the VA.

Use of a report card to implement a network-based palliative care program.

OBJECTIVE: To report on implementation of a Veterans Affairs (VA) network-wide, standardized, high-quality palliative care (PC) program using a Web-based PC Report Card for performance monitoring and improvement. INTERVENTION: The PC director and coordinator and facility directors established interdisciplinary teams at five acute care and three nursing home sites. Teams were trained together and subsequently met quarterly for ongoing training. Additionally, the PC director and coordinator developed and implemented a Web-based PC Report Card on the network Intranet for PC coordinator to report performance data monthly to the PC teams. RESULTS: The number of patients in the network who received PC consults more than doubled in the first 4 years of the PC program. The percentage of deaths with PC consultation prior to death increased from 23% in fiscal year (FY) 2002 to 57% in FY06. Over the same period, the average days between the initial PC consultation and patients' death across all sites increased from 23 days to 106 days. COMMENT: All the sites established PC teams and the number of consultations showed a sustained increase over baseline in 2002. All sites improved on the key process measures captured by the Report Card.

Incidental Discovery of Multiorgan Extramedullary Plasmacytomas in the Setting of Newly Diagnosed Multiple Myeloma and Delayed Hemolytic Transfusion Reaction.

Extramedullary plasmacytomas (EMPs) are defined by the presence of clonal plasma cell proliferation outside of the bone marrow, portending an overall poor prognosis. This case highlights extramedullary plasmacytomas as an unusual presenting manifestation of multiple myeloma. Through incidental discovery during a delayed hemolytic transfusion reaction workup, EMPs were found in the liver, spleen, and possibly the lung. Though rare at presentation, this case emphasizes that the presence of EMPs should be considered at the outset as it not only impacts the treatment regimen for such patients but also considerably affects prognosis.

Improving Family Meetings in Intensive Care Units: A Quality Improvement Curriculum.

BACKGROUND: Family meetings in the intensive care unit are associated with beneficial outcomes for patients, their families, and health care systems, yet these meetings often do not occur in a timely, effective, reliable way. OBJECTIVE: The Department of Veterans Affairs Comprehensive End-of-Life Care Implementation Center sponsored a national initiative to improve family meetings in Veterans Affairs intensive care units across the United States. Process measures of success for the initiative were identified, including development of a curriculum to support facility-based quality improvement projects to implement high-quality family meetings. METHODS: Identified curriculum requirements included suitability for distance learning and applicability to many clinical intensive care units. Curriculum modules were cross-mapped to the "Plan-Do-Study-Act" model to aid in planning quality improvement projects. A questionnaire was e-mailed to users to evaluate the curriculum's effectiveness. RESULTS: Users rated the curriculum's effectiveness in supporting and achieving aims of the initiative as 3.6 on a scale of 0 (not effective) to 4 (very effective). Users adapted the curriculum to meet local needs. The number of users increased from 6 to 17 quality improvement teams in 2 years. All but 3 teams progressed to implementation of an action plan. CONCLUSION: Users were satisfied with the effectiveness and adaptability of a family-meeting quality improvement curriculum to support implementation of a quality improvement project in Veterans Affairs intensive care units. This tool may be useful in facilitating projects to improve the quality of family meetings in other intensive care units.

Cost and utilization outcomes of patients receiving hospital-based palliative care consultation.

OBJECTIVE: To compare per diem total direct, ancillary (laboratory and radiology) and pharmacy costs of palliative care (PC) compared to usual care (UC) patients during a terminal hospitalization; to examine the association between PC and ICU admission. DESIGN: Retrospective, observational cost analysis using a VA (payer) perspective. SETTING: Two urban VA medical centers. MEASUREMENTS: Demographic and health characteristics of 314 veterans admitted during two years were obtained from VA administrative data. Hospital costs came from the VA cost accounting system. ANALYSIS: Generalized linear models (GLM) were estimated for total direct, ancillary and pharmacy costs. Predictors included patient age, principal diagnosis, comorbidity, whether patient stay was medical or surgical, site and whether the patient was seen by the palliative care consultation team. A probit regression was used to analyze probability of ICU admission. Propensity score matching was used to improve balance in observed covariates. RESULTS: PC patients were 42 percentage points (95% CI, -56% [corrected] to -31%) less likely to be admitted to ICU. Total direct costs per day were $239 (95% CI, -387 to -122) lower and ancillary costs were $98 (95% CI, -133 to -57) lower than costs for UC patients. There was no difference in pharmacy costs. The results were similar using propensity score matching. CONCLUSION: PC was associated with significantly lower likelihood of ICU use and lower inpatient costs compared to UC. Our findings coupled with those indicating better patient and family outcomes with PC suggest both a cost and quality incentive for hospitals to develop PC programs.

Pilot of a pathway to improve the care of imminently dying oncology inpatients in a Veterans Affairs Medical Center.

We report on the implementation of a previously developed clinical pathway for terminally ill patients, Palliative Care for Advanced Disease (PCAD), on a Veterans Administration (VA) acute care oncology unit, comparing processes of care and outcomes for patients on and off the pathway. The PCAD pathway is designed to identify imminently dying patients, review care goals, respect patients' wishes, assess and manage symptoms, address spirituality, and support family members. Retrospective chart reviews from 15 patients who died on PCAD, 14 patients who died on general wards during the same time, and 10 oncology unit patients who died prior to PCAD revealed that PCAD patients were more likely to have documentation of care goals and plans of comfort care (P=0.0001), fewer interventions, and more symptoms assessed (P=0.004), and more symptoms managed according to PCAD guidelines (P=0.02). Implementation of PCAD improved care of dying inpatients by increasing documentation of goals and plans of care, improving symptom assessment and management, and decreasing interventions at the end of life.