Description and Outcomes of a Palliative Care Pharmacist-Led Transitions of Care Program.

Background: Patients with palliative care needs are at high risk of medication errors during transitions of care (TOC). Palliative Care Pharmacist Interventions surrounding Medication Prescribing Across Care Transitions (IMPACT) program was developed to improve the TOC process from hospital to community setting for cancer patients followed by palliative care. We describe (1) the program and (2) pilot study feasibility and effectiveness data. Methods: We recorded pharmacist time, medication errors, drug therapy problems (DTPs), and palliative care provider satisfaction and compared 7- and 30-day readmissions and emergency department (ED) visits between IMPACT and usual care patients. Results: Forty-four patients were reached by the pharmacist. The pharmacist spent an average of 65 minutes per patient. An average of 14.9 medication reconciliation discrepancies per patient and a total 76 DTPs were identified. Seven-day readmissions were lower in the IMPACT group versus usual care; there were no differences in 30-day readmission or 7- or 30-day ED visits. Conclusion: Our pilot study demonstrates that integrating a pharmacist in TOC for seriously ill patients is feasible and valuable.

Institution of Standardized Consultation Criteria to Increase Early Palliative Care Utilization in Older Patients With Acute Leukemia.

PURPOSE: Older patients with acute leukemia (AL) have a high symptom burden and poor prognosis. Although integration of palliative care (PC) with oncologic care has been shown to improve quality-of-life and end-of-life care in patients with AL, the malignant hematologists at our tertiary care hospital make limited use of PC services and do so late in the disease course. Using the Plan-Do-Study-Act (PDSA) methodology, we aimed to increase early PC utilization by older patients with newly diagnosed AL. METHODS: We instituted the following standardized criteria to trigger inpatient PC consultation: (1) age 70 years and older and (2) new AL diagnosis within 8 weeks. PC consultations were tracked during sequential PDSA cycles in 2021 and compared with baseline rates in 2019. We also assessed the frequency of subsequent PC encounters in patients who received a triggered inpatient PC consult. RESULTS: The baseline PC consultation rate before our intervention was 55%. This increased to 77% and 80% during PDSA cycles 1 and 2, respectively. The median time from diagnosis to first PC consult decreased from 49 days to 7 days. Among patients who received a triggered PC consult, 43% had no subsequent inpatient or outpatient PC encounter after discharge. CONCLUSION: Although standardized PC consultation criteria led to earlier PC consultation in older patients with AL, it did not result in sustained PC follow-up throughout the disease trajectory. Future PDSA cycles will focus on identifying strategies to maintain the integration of PC with oncologic care over time, particularly in the ambulatory setting.

Standardization of Inpatient CPR Status Discussions and Documentation Within the Division of Hematology-Oncology at UPMC Shadyside: Results From PDSA Cycles 1 and 2.

PURPOSE: In December 2016, 49% of patients admitted to inpatient oncology services at University of Pittsburgh Medical Center Shadyside Hospital had cardiopulmonary resuscitation (CPR) status discussion documentation before discharge. The aim of this project was to improve the rate of CPR status conversations. METHODS: During Plan-Do-Study-Act (PDSA) cycle 1, a stakeholder workgroup was formed in January 2017 by oncology faculty, fellows, nurses, advance practice providers (APPs), medicine housestaff, and palliative care faculty. All oncology clinicians and inpatient team members were reminded weekly to discuss and document CPR status preferences. APPs received training on efficient and effective CPR status assessment from palliative care faculty. Oncology leadership received monthly e-mail updates of CPR status documentation rates and endorsed CPR status best practice guidelines. For PDSA cycle 2, patient charts without CPR status documentation in March 2018 were reviewed, and themes were shared with oncology leadership and reviewed with APPs. RESULTS: After PDSA cycle 1, CPR status assessment rates increased from 49% to greater than 80%. In 2017, more than 1,500 more CPR status discussions were documented than in 2016. The percentage of patients discharged with "comfort measures only" or "do not resuscitate" orders increased from 14.2% (95% CI, 9.5% to 19.0%) to 19.8% (95% CI, 15.6% to 24.0%). For PDSA cycle 2, charts of 60 patients without CPR assessment were reviewed. Of these, 52% were admitted overnight by nocturnists and 48% by daytime APPs. Fifty-five percent of patients (n = 33 of 60) had metastatic disease. CPR status was documented on previous admissions for 53% of patients (n = 31 of 60) in the past 12 months. Fifteen percent (n = 11 of 60) were admitted for scheduled inpatient chemotherapy. CONCLUSION: A multipronged approach significantly increased CPR status assessments. More patients transitioned to comfort measures only or do not resuscitate when their preferences were clearly assessed and documented.

Numeracy skills in CKD: correlates and outcomes.

BACKGROUND AND OBJECTIVES: Healthcare providers communicate the risks and benefits of treatments using frequencies, percentages, or proportions. However, many patients lack the numerical skills needed to interpret this information accurately to make informed choices. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: We assessed numeracy, the capacity to use and comprehend numbers, in a prospective cohort study of 187 patients with stage 4 to 5 chronic kidney disease or ESRD. Patients completed a three-item numeracy test and were assessed for global mental status, cognitive function, type of hemodialysis access, and kidney transplant use. We examined the association of numeracy with healthcare use and other cognitive and sociodemographic variables. RESULTS: Over 50% of patients answered one or fewer numeracy questions correctly. Although African Americans (P = 0.0001), women (P = 0.05), and the unemployed (P = 0.0004) demonstrated lower numeracy skills, numeracy deficits were prevalent in every subgroup. In analyses adjusted for demographics and length of follow-up, higher numeracy was significantly associated with receipt of a transplant or active waiting list status. Numeracy was not associated with dialysis modality or hemodialysis vascular access. CONCLUSION: Similar to prior findings in the general population, these findings indicate that poor numeracy skills are very common in patients with advanced chronic kidney disease and end-stage renal disease. Additional research is needed to further explore whether poor numeracy is a barrier to receipt of a kidney transplant. Clinicians caring for patients with kidney disease should consider using tools to enhance communication and overcome limited numeracy skills.

Introduction to hierarchical modeling.

BACKGROUND: Hierarchical modeling (HM) is a statistical technique that has gained in popularity in health care research. It has been used for analysis of secondary data, performance profiles or benchmarking studies, and in prospective trials. The technique is used in situations in which traditional regression analysis might lead to incorrect conclusions. Specifically, data drawn from nested settings such as hospital units or hospice providers may be correlated, thus violating an assumption required for ordinary least squares regression. OBJECTIVE: This article provides a description of HM, reviews two recent articles in palliative care that have used the technique, and presents an illustrative case study to further illuminate the potential of the method. CONCLUSION: When used appropriately, HM allows researchers to specify and test hypotheses that would not otherwise be possible, and avoid incorrect conclusions from nested data.

Design and synthesis of redox-switched lariat ethers and their application for transport of alkali and alkaline-Earth metal cations across supported liquid membrane.

A new class of redox-switched anthraquinone derived lariat ethers 1-(1-anthraquinonyloxy) 3, 6, 9 trioxaundecane 11-ol (M(1)), 1-(1-anthraquinonyloxy) 3, 6 dioxaoctane 9-ol (M(2)), 1-(1-anthraquinonyloxy) 3 oxapentane 5-ol (M(3)), 1-(1-anthraquinonyloxy) 3 oxapentane 5-butane (M(4)), 1-(1-anthraquinonyloxy) 3, 6 dioxaoctane 9-methane (M(5)) and 1-(1-anthraquinonyloxy) 3 oxapentane 5-methane (M(6)) have been synthesized and characterized by spectral analysis. These ionophores were used in liquid membrane carrier facilitated transport of main group metal cations across supported liquid membrane (SLM). Cellulose nitrate membrane was used as membrane support. Effect of various parameters such as variation in concentration of metal as well as ionophore, effect of chain length and end group of ionophore have been studied. The sequence of metal ions transported by ionophore M(1) is Na(+) > Li(+) > K(+) > Ca(2+) > Mg(2+) and the order of metal ions transported by ionophores (M(2)-M(6)) is Li(+) > Na(+) > K(+) > Ca(2+) > Mg(2+). Ionophore M(1) is selective for Na(+), Li(+), and K(+) and ionophores (M(2)-M(6)) are selective for Li(+) and Na(+).