Utilization of palliative care resource remains low, consuming potentially avoidable hospital admissions in stage IV non-small cell lung cancer: a community-based retrospective review.

PURPOSE: Early referral of patients with stage IV non-small cell lung cancer (NSCLC) to outpatient palliative care has been shown to increase survival and reduce unnecessary healthcare resource utilization. We aimed to determine outpatient palliative care referral rate and subsequent resource utilization in patients with stage IV NSCLC in a multistate, community-based hospital network and identify rates and reasons for admissions within a local healthcare system of Washington State. METHODS: A retrospective chart review of a multistate hospital network and a local healthcare system. Patients were identified using ICD billing codes. In the multistate network, 2844 patients diagnosed with stage IV NSCLC between January 1, 2013, and March 1, 2018, were reviewed. In the state healthcare system, 283 patients between August 2014 and June 2017 were reviewed. RESULTS: Referral for outpatient palliative care was low: 8% (217/2844) in the multistate network and 11% (32/283) in the local healthcare system. Early outpatient palliative care (6%, 10/156) was associated with a lower proportion of patients admitted into the intensive care unit in the last 30 days of life compared to no outpatient palliative care (15%, 399/2627; p = 0.003). Outpatient palliative care referral was associated with improved overall survival in Kaplan Meier survival analysis. Within the local system, 51% (104/204) of admissions could have been managed in outpatient setting, and of the patients admitted in the last 30 days of life, 59% (87/147) experienced in-hospital deaths. CONCLUSION: We identified underutilization of outpatient palliative care services within stage IV NSCLC patients. Many patients with NSCLC experience hospitalization the last month of life and in-hospital death.

Comparing Initial Surgery versus Fibrinolytics for Pleural Space Infections: A Retrospective Multicenter Cohort Study.

Rationale: When drainage of complicated pleural space infections alone fails, there exists two strategies in surgery and dual agent-intrapleural fibrinolytic therapy; however, studies comparing these two management strategies are limited. Objectives: To determine the outcomes of surgery versus fibrinolytic therapy as the primary management for complicated pleural space infections (CPSI). Methods: A retrospective review of adults with a CPSI managed with surgery or fibrinolytics between 1/2015 and 3/2018 within a multicenter, multistate hospital system was performed. Fibrinolytics was defined as any dose of dual-agent fibrinolytic therapy and standard fibrinolytics as 5-6 doses twice daily. Treatment failure was defined as persistent infection with a pleural collection requiring intervention. Crossover was defined by any fibrinolytics after surgery or surgery after fibrinolytics. Logistic regression with inverse probability of treatment weighting (IPTW) were employed to account for selection bias effect of management strategies in treatment failure and crossover. Results: We identified 566 patients. Surgery was the initial strategy in 55% (311/566). The surgery group had less additional treatments (surgery: 10% [32/311] versus fibrinolytics: 39% [100/255], P < 0.001), treatment failures (surgery: 7% [22/311] versus fibrinolytics: 29% [74/255], P < 0.001), and crossovers (surgery: 6% [20/311] versus fibrinolytics: 19% [49/255], P < 0.001). Logistic regression analysis with IPTW demonstrated a lower odds of treatment failure with surgery compared with any fibrinolytics (odds ratio [OR], 0.20; 95% confidence interval [CI], 0.10-0.30; P < 0.001); and compared with standard fibrinolytics (OR, 0.20; 95% CI, 0.11-0.35; P < 0.001). Conclusions: Although there is a lack of consensus as to the optimal management strategy for patients with a CPSI, in surgical candidates, operative management may offer more benefits and could be considered early in the management course. However, our study is retrospective and nonrandomized; thus, prospective trials are needed to explore this further.

Rib Plating Offers Favorable Outcomes in Patients With Chronic Nonunion of Prior Rib Fractures.

BACKGROUND: Although open reduction and internal fixation (ORIF) is an accepted treatment for a proportion of acute rib fractures, The literature on its potential to treat chronic, nonunion fractures is scarce. This study evaluates the outcomes and quality of life of patients who underwent ORIF for chronic, symptomatic, nonunion rib fractures. METHODS: Thirty-two patients were explored for possible ORIF of nonunion rib fractures (≥6 months after injury). After excluding non-English-speaking patients (n = 1), those where no instability was noted at surgery (n = 3), and those deceased at the time of study (n = 4), 24 patients were eligible. Telephone interviews were conducted using a previously published rib fracture pain questionnaire. RESULTS: Seventy percent of eligible patients (19/24) consented and completed the questionnaire at a median of 55 months (interquartile range, 24-62) from surgery. Injuries were classified as multisystem trauma (n = 4) or isolated rib fractures (n = 15). The median pain severity (on a scale of 1 [none/mild] to 10 [severe]) significantly decreased from preoperatively (9; interquartile range, 7-10) to postoperatively (1; interquartile range, 0-2; P < .001). Most patients returned to daily activities, were able to work at their preinjury level, were satisfied with their surgery, and would undergo operative management again. CONCLUSIONS: Patients who underwent ORIF reported a significant decrease in fracture-associated symptoms and pain severity postoperatively. Most returned to daily activities, could work at preinjury levels, and were satisfied with surgery. ORIF should be considered as an option to help patients with symptomatic nonunion rib fractures.