Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer.

IMPORTANCE: Medicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans' end-of-life care is unknown. OBJECTIVE: To determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life. DESIGN, SETTING, AND PARTICIPANTS: A modified difference-in-differences study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13 085 veterans newly diagnosed with stage IV non-small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018. EXPOSURES: Using VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability. MAIN OUTCOMES AND MEASURES: Receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first 6 months after diagnosis. RESULTS: Of the 13 085 veterans included in the study, 12 858 (98%) were men; 10 531 (81%) were white, and 5949 (46%) were older than 65 years. Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67-3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53-0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62-0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, -$358 to -$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference. CONCLUSIONS AND RELEVANCE: Increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.

The experience of providing hospice care concurrent with cancer treatment in the VA.

PURPOSE: Veterans with advanced cancer can receive hospice care concurrently with treatments such as radiation and chemotherapy. However, variations exist in concurrent care use across Veterans Affairs (VA) medical centers (VAMCs), and overall, concurrent care use is relatively rare. In this qualitative study, we aimed to identify, describe, and explain factors that influence the provision of concurrent cancer care (defined as chemotherapy or radiation treatments provided with hospice) for veterans with terminal cancer. METHODS: From August 2015 to April 2016, we conducted six site visits and interviewed 76 clinicians and staff at six VA sites and their contracted community hospices, including community hospices (n = 16); VA oncology (n = 25); VA palliative care (n = 17); and VA inpatient hospice and palliative care units (n = 18). RESULTS: Thematic qualitative content analysis found three themes that influenced the provision of concurrent care: (1) clinicians and staff at community hospices and at VAs viewed concurrent care as a viable care option, as it preserved hope and relationships while patient goals are clarified during transitions to hospice; and (2) the presence of dedicated liaisons facilitated care coordination and education about concurrent care; however, (3) clinicians and staff concerns about Medicare guideline compliance hindered use of concurrent care. CONCLUSIONS: While concurrent care is used by a small number of veterans with advanced cancer, VA staff valued having the option available and as a bridge to hospice. Hospice staff felt concurrent care improved care coordination with VAMCs, but use may be tempered due to concerns related to Medicare compliance.

Increasing Veterans' Hospice Use: The Veterans Health Administration's Focus On Improving End-Of-Life Care.

In 2009 the Department of Veterans Affairs (VA) began a major, four-year investment in improving the quality of end-of-life care. The Comprehensive End of Life Care Initiative increased the numbers of VA medical center inpatient hospice units and palliative care staff members as well as the amount of palliative care training, quality monitoring, and community outreach. We divided male veterans ages sixty-six and older into categories based on their use of the VA and Medicare and examined whether the increases in their rates of hospice use in the last year of life differed from the concurrent increase among similar nonveterans enrolled in Medicare. After adjusting for age, race and ethnicity, diagnoses, nursing home use in the last year of life, census region, and urbanicity of a person's last residence, we found a 6.9-7.9-percentage-point increase in hospice use over time for the veteran categories, compared to a 5.6-percentage-point increase for nonveterans (the relative increases were 20-42 percent and 16 percent, respectively). The VA's substantial investment in palliative care appears to have resulted in greater hospice use by older male veterans enrolled in the VA, a critical step forward in caring for veterans with serious illnesses.

Association between aggressive care and bereaved families' evaluation of end-of-life care for veterans with non-small cell lung cancer who died in Veterans Affairs facilities.

BACKGROUND: To the authors' knowledge, little is known regarding the relationship between patients' and families' satisfaction with aggressive end-of-life care. Herein, the authors examined the associations between episodes of aggressive care (ie, chemotherapy, mechanical ventilation, acute hospitalizations, and intensive care unit admissions) within the last 30 days of life and families' evaluations of end-of-life care among patients with non-small cell lung cancer (NSCLC). METHODS: A total of 847 patients with NSCLC (34% of whom were aged <65 years) who died in a nursing home or intensive care, acute care, or hospice/palliative care (HPC) unit at 1 of 128 Veterans Affairs Medical Centers between 2010 and 2012 were examined. Data sources included Veterans Affairs administrative and clinical data, Medicare claims, and the Bereaved Family Survey. The response rate for the Bereaved Family Survey was 62%. RESULTS: Greater than 72% of veterans with advanced lung cancer who died in an inpatient setting had at least 1 episode of aggressive care and 31% received chemotherapy within the last 30 days of life. For all units except for HPC, when patients experienced at least 1 episode of aggressive care, bereaved families rated care lower compared with when patients did not receive any aggressive care. For patients dying in an HPC unit, the associations between overall ratings of care and ≥2 inpatient admissions or any episode of aggressive care were not found to be statistically significant. Rates of aggressive care were not associated with age, and family ratings of care were similar for younger and older patients. CONCLUSIONS: Aggressive care within the last month of life is common among patients with NSCLC and is associated with lower family evaluations of end-of-life care. Specialized care provided within an HPC unit may mitigate the negative effects of aggressive care on these outcomes. Cancer 2017;123:3186-94. © 2017 American Cancer Society.

Gap between Recommendations and Practice of Palliative Care and Hospice in Cancer Patients.

BACKGROUND: Specialty societies recommend patients with advanced cancer receive early exposure to palliative care and exposure to hospice care. OBJECTIVE: We sought to understand real-world practice of care, specifically, the timing of palliative care, and how timing and duration of hospice care varied across Medicare, VA, and VA-Purchased care. DESIGN: We conducted a retrospective analysis of administrative data for veterans aged 65 years or older who died with cancer in 2012. Multilevel logistic regression was used to evaluate the likelihood of receiving palliative care, receiving hospice care, and receiving hospice care for at least three days. SETTING: Medicare, VA, and VA-Purchased care environments. MEASUREMENTS: The receipt and timing of palliative care within VA and the receipt and timing of hospice care across three healthcare environments. RESULTS: Most veterans received hospice care (71%), whereas fewer received palliative care (52%). Among all cancer decedents, 59% received hospice care for their last three days of life. Patients who received hospice care did so a median of 20 days before death (interquartile range [IQR]: 7-46). Patients who received palliative care did so a median of 38 days before death (IQR: 13-94). Adjusted analyses revealed significant differences in receipt of palliative care across cancer type, and significant differences in receipt of hospice care across cancer type. After adjusting for age and cancer type, patients who received VA hospice care were significantly less likely to receive it for at least three days compared with patients who received VA-Purchased or Medicare hospice care. CONCLUSIONS: There remains a gap between recommended timing of supportive services and real-world practice of care. Results suggest that difficulties in prognosticating death are not fully responsible for underexposure to hospice.

The rise of concurrent care for veterans with advanced cancer at the end of life.

BACKGROUND: Unlike Medicare, the Veterans Health Administration (VA) health care system does not require veterans with cancer to make the "terrible choice" between receipt of hospice services or disease-modifying chemotherapy/radiation therapy. For this report, the authors characterized the VA's provision of concurrent care, defined as days in the last 6 months of life during which veterans simultaneously received hospice services and chemotherapy or radiation therapy. METHODS: This retrospective cohort study included veteran decedents with cancer during 2006 through 2012 who were identified from claims with cancer diagnoses. Hospice and cancer treatment were identified using VA and Medicare administrative data. Descriptive statistics were used to characterize the changes in concurrent care, hospice, palliative care, and chemotherapy or radiation treatment. RESULTS: The proportion of veterans receiving chemotherapy or radiation therapy remained stable at approximately 45%, whereas the proportion of veterans who received hospice increased from 55% to 68%. The receipt of concurrent care also increased during this time from 16.2% to 24.5%. The median time between hospice initiation and death remained stable at around 21 days. Among veterans who received chemotherapy or radiation therapy in their last 6 months of life, the median time between treatment termination and death ranged from 35 to 40 days. There was considerable variation between VA medical centers in the use of concurrent care (interquartile range, 16%-34% in 2012). CONCLUSIONS: Concurrent receipt of hospice and chemotherapy or radiation therapy increased among veterans dying from cancer without reductions in the receipt of cancer therapy. This approach reflects the expansion of hospice services in the VA with VA policy allowing the concurrent receipt of hospice and antineoplastic therapies. Cancer 2016;122:782-790. © 2015 American Cancer Society.

A Patient With Parenteral Nutrition-Dependent Short Bowel Syndrome and Cardiovascular Disease With 4-Year Exposure to Teduglutide.

Clinical trials of the glucagon-like peptide 2 analogue teduglutide resulted in approval of the drug by the Food and Drug Administration in 2012 as a treatment for parenteral nutrition-dependent short bowel syndrome in adults. This report presents the case study of a man with short bowel syndrome caused by portal vein thrombosis who had 4 years exposure to the drug at the time of his death due to cardiovascular disease.

Clinical Management of Patients With Parenteral Nutrition-Dependent Short Bowel Syndrome During Teduglutide Therapy.

BACKGROUND: Patients with intestinal failure, who are dependent on parenteral nutrition (PN) to supplement their limited absorption of dietary nutrients, are subject to complications associated with long-term PN therapy. Medication therapy that results in improved dietary nutrient absorption may enable these patients to reduce or even become independent from PN therapy and its related complications. The glucagon-like peptide 2 (GLP-2) analogue teduglutide was approved for use in such patients by the U.S. Food and Drug Administration in 2012. PURPOSE: The purpose of this article is to describe the experience of 7 patients with PN-dependent intestinal failure who were treated with teduglutide by a single center that had been involved in the teduglutide clinical trials. RESULTS: Two patients who were treated during the clinical trials and 5 others who were treated since teduglutide came to market in the United States are described. Protocols used to prepare and monitor patients with this drug and PN weaning and adverse event outcomes are presented. CONCLUSIONS: While some patients had uncomplicated PN reduction, others experienced various complications. Careful monitoring of patients' clinical course is needed during drug therapy.

Care-related risk factors for hospital-acquired pressure ulcers in elderly adults with hip fracture.

OBJECTIVES: To identify care-related factors associated with hospital-acquired pressure ulcers (HAPUs). DESIGN: Prospective cohort study. SETTING: Nine hospitals in Baltimore Hip Studies network. PARTICIPANTS: Six hundred fifty-eight individuals aged 65 and older who underwent surgery for hip fracture. MEASUREMENTS: Skin examinations at baseline and on alternating days until hospital discharge. Participants were deemed to have a HAPU if they developed one or more new Stage 2 or higher pressure ulcers (PUs) during the hospital stay. RESULTS: Longer emergency department stays were associated with lower HAPU incidence (>4-6 hours: adjusted incidence rate ratio (aIRR) = 0.68, 95% confidence interval (CI) = 0.48-0.96; >6 hours: aIRR = 0.68, 95% CI = 0.46-0.99, both vs ≤ 4 hours). Participants with 24 hours or longer between admission and surgery had a higher postsurgery HAPU rate than those with less than 24 hours (aIRR = 1.62, 95% CI = 1.24-2.11). Surgery with general anesthesia had a lower postsurgery HAPU rate than surgery with other types of anesthesia (aIRR = 0.66, 95% CI = 0.49-0.88). There was no significant association between HAPU incidence and timing of transport to the hospital, type of transport to the hospital, or surgery duration. CONCLUSION: Most of the factors hypothesized to be associated with higher PU incidence were associated with lower incidence or were not significantly associated, suggesting that HAPU development may not be as sensitive to care-related factors as commonly believed. Rigorous studies of innovative preventive interventions are needed to inform policy and practice.

Pressure ulcers in elderly patients with hip fracture across the continuum of care.

OBJECTIVES: To identify care settings associated with greater pressure ulcer risk in elderly patients with hip fracture in the postfracture period. DESIGN: Prospective cohort study. SETTING: Nine hospitals that participate in the Baltimore Hip Studies network and 105 postacute facilities to which patients from these hospitals were discharged. PARTICIPANTS: Hip fracture patients aged 65 and older who underwent surgery for hip fracture. MEASUREMENTS: A full-body skin examination was conducted at baseline (as soon as possible after hospital admission) and repeated on alternating days for 21 days. Patients were deemed to have an acquired pressure ulcer (APU) if they developed one or more new stage 2 or higher pressure ulcers after hospital admission. RESULTS: In 658 study participants, the APU cumulative incidence at 32 days after initial hospital admission was 36.1% (standard error 2.5%). The adjusted APU incidence rate was highest during the initial acute hospital stay (relative risk (RR)=2.2, 95% confidence interval (CI)=1.3-3.7) and during re-admission to the acute hospital (RR=2.2, 95% CI=1.1-4.2). The relative risks in rehabilitation and nursing home settings were 1.4 (95% CI=0.8-2.3) and 1.3 (95% CI=0.8-2.1), respectively. CONCLUSION: Approximately one-third of hip fracture patients developed an APU during the study period. The rate was highest in the acute setting, a finding that is significant in light of Medicare's policy of not reimbursing hospitals for the treatment of hospital-APUs. Hip fracture patients constitute an important group to target for pressure ulcer prevention in hospitals.

Ghrelin does not predict adaptive hyperphagia in patients with short bowel syndrome.

BACKGROUND: Adaptive hyperphagia is associated with reduced dependence on parenteral nutrition in patients with short bowel syndrome, but mechanisms have not been described. Ghrelin (GHR) has orexigenic effects, whereas peptide YY (PYY) reduces intake. GHR also acts as a hormone to control body fat stores. The authors evaluated whether GHR or PYY was related to caloric intake or absorption in patients with short bowel syndrome and whether GHR was associated with body mass index. METHODS: Patients were admitted twice for nutrient balance. Height and body weight were obtained using standardized protocols. Energy intake > 40 kcal/kg/day was defined as adaptive hyperphagia. Fasting plasma PYY and GHR were assayed in duplicate with Linco enzyme-linked immunosorbent assay kits. RESULTS: The median age of the 7 study participants was 62 (range, 45-66) years, time with short bowel syndrome was 6.6 (range, 2-29) years, and body mass index was 21.2 kg/m(2) (range, 19-27.7). Five patients had adaptive hyperphagia. Neither GHR nor PYY was significantly related to energy intake or absorption (GHR: R = 0.22 and R = -0.233, PYY: R = 0.10 and R = -0.13). Body mass index trended toward an inverse association with GHR (GHR: R = -0.540, P = .211). CONCLUSION: The rigorous adaptive hyperphagia seen in these patients with short bowel syndrome was not related to fasting GHR or PYY, suggesting the need to explore other mechanisms.

The impact of comorbidities on outcomes for elderly women treated with breast-conservation treatment for early-stage breast cancer.

PURPOSE: Breast cancer incidence increases with age and is a major cause of morbidity and mortality in elderly women, but is not well studied in this population. Comorbidities often impact on the management of breast cancer in elderly women. METHODS AND MATERIALS: From 1979 to 2002, a total of 238 women aged 70 years and older with Stage I or II invasive carcinoma of the breast underwent breast-conservation therapy. Outcomes were compared by age groups and comorbidities. Median age at presentation was 74 years (range, 70-89 years). Age distribution was 122 women (51%) aged 70-74 years, 71 women (30%) aged 75-79 years, and 45 women (19%) aged 80 years or older. Median follow-up was 6.2 years. RESULTS: On outcomes analysis by age groups, 10-year cause-specific survival rates for women aged 70-74, 75-79, and 80 years or older were 74%, 81%, and 82%, respectively (p = 0.87). Intercurrent deaths at 10 years were significantly higher in older patients: 20% in those aged 70-74 years, 36% in those aged 75-79 years, and 53% in those 80 years and older (p = 0.0005). Comorbidities were not significantly more common in the older age groups and did not correlate with cause-specific survival adjusted for age. Higher comorbidity scores were associated with intercurrent death. CONCLUSIONS: Older age itself is not a contraindication to standard breast-conservation therapy, including irradiation. Women of any age with low to moderate comorbidity indices should be offered standard breast-conservation treatment if otherwise clinically eligible.

Systemic inflammatory mediators and bone homeostasis in intestinal failure.

BACKGROUND: A proinflammatory state has been described in patients with intestinal failure. The prevalence of metabolic bone disease in this group is considerable. It is not known whether this proinflammatory state is related to bone parameters, though bone disease is recognized as a proinflammatory process in postmenopausal women. The purpose of this study was to examine whether inflammation was related to bone disease. METHODS: Eight patients with parenteral nutrition (PN)-dependent intestinal failure but no recent infections or immunosuppressive medications had serum assayed for interleukin-6 (IL-6), tumor necrosis factor (TNF)-alpha, and its receptors (TNFR-I and TNFR-II), C-reactive protein, and whole blood for lymphocyte proliferation. Routine clinical laboratory measures of vitamin D, parathyroid hormone, serum calcium, and phosphorus within 3 months of the inflammatory measures were compared by Pearson's correlation to the inflammatory measures. RESULTS: Mean values for calcium, phosphorus, and albumin were normal, but 25-hydroxy vitamin D was reduced and parathyroid hormone and alkaline phosphatase elevated. Serum total calcium was negatively related to TNFR-II, TNF-alpha and positively to T-helper cells. Longer PN dependence was associated with inflammation and negatively with T-helper cells. CONCLUSIONS: These preliminary findings are hypothesis generating only but support an association of low calcium and longer duration of PN with inflammation in patients with intestinal failure. Whether the inflammation results from vitamin D deficiency or the vitamin D deficiency develops secondary to excessive use of activated vitamin D to modulate inflammation from some other cause, such as a component of PN or repeated infectious challenge, requires further study.

Intestinal failure-associated metabolic bone diseases and response to teriparatide.

Patients requiring home parenteral nutrition (PN) may develop metabolic bone disease, the etiology of which can be multifactorial. We report a case of significantly low bone mass in a postmenopausal woman with history of short bowel syndrome, renal impairment, and previous radiation exposure who responded to intermittent subcutaneous administration of parathyroid hormone. Her bone mineral density normalized after she completed a course of 18 months of treatment, and a bone isotope scan was negative for skeletal malignancy.

A case of Cronkhite-Canada syndrome with taste disturbance as a leading complaint.

Cronkhite-Canada syndrome was first described in 1955. The clinical features of this rare syndrome of unknown etiology include nonhereditary gastrointestinal polyposis together with diarrhea, nail dystrophy, alopecia, and hyperpigmentation of the skin. This syndrome has been divided into five clinical types based on initial symptoms. We describe a case of Cronkhite-Canada syndrome presenting with taste disturbance as the major symptom, present a comprehensive review of the literature concerning this rare syndrome, and suggest therapeutic treatment options.