Evaluation of a Comprehensive, Adaptable, Life- Affirming, Longitudinal (CALL) palliative care project.

BACKGROUND: Many persons with life-threatening illnesses require services before they begin receiving hospice or hospital-based palliative care. Although health care professionals focus on diagnosis, treatment, and comfort care, patients and families view the illness as it impacts their whole life. OBJECTIVE: Evaluating a Comprehensive, Adaptable, Life-Affirming, Longitudinal (CALL) intervention to patients with life-threatening cancer, cardiac illness, respiratory conditions or dementia. The CALL Care interventions are consistent with the 2004 Clinical Practice Guidelines for Quality Palliative Care. DESIGN: Prospective observational study. SETTING AND SUBJECTS: Eleven sites (1 primary care, 8 acute care, and 2 long term care) located around the United States. Two hundred ninety-five patients and families enrolled in the study; many were enrolled for over 12 months. MEASUREMENTS: Patient self-reported Modified City of Hope Questionnaire addressing physical, psychosocial, emotional, and spiritual status and health care experiences; completed at enrollment and every three months. Family members completed Modified City of Hope Bereaved Family Questionnaire, with contents similar to the patient questionnaire. Sites compiled health care and community services utilization data regularly. RESULTS: Participants reported improved pain and symptom management. Fewer than one third were hospitalized (29%), and 7% had a critical care admission while enrolled. In addition, participants had high use of hospice (48% of those who died), and were likely to die at home (38% of those who died). CONCLUSIONS: CALL Care is an effective interdisciplinary intervention approach to individualize care for people living with life-threatening illness.

Outcomes of pain in frail older adults with dementia.

OBJECTIVES: To describe the outcomes of pain in cognitively impaired older adults in a Program of All-inclusive Care for older people (PACE) setting and to determine whether pain and psychotropic drug use, behavioral disturbances, hospital, nursing facility, and emergency department use, or mortality increases with the level of pain reported. DESIGN: Retrospective review of an observational cohort of patients with dementia. SETTING: A first-generation PACE program located in Portland, Oregon. Patients with the diagnosis of dementia had been assessed for pain in a prior study. PARTICIPANTS: One hundred fifty-four cognitively impaired subjects. MEASUREMENTS: Standardized pain assessments were administered to cognitively impaired subjects between June and October 1998. After the pain assessment, information about mortality and healthcare use, including use of medication, was collected and analyzed. Subjects who reported moderate to severe pain were compared with demented subjects who reported no or mild pain. RESULTS: There were no differences in patient characteristics (age, sex, functional limitations, disruptive behaviors, and incontinence), medications (pain and psychotropic), use (hospital, nursing home, or emergency department visit), or mortality by level of pain alone or by levels of pain and dementia together. CONCLUSIONS: The study did not demonstrate that a single point-in-time measurement of pain in demented persons was associated with an increased rate of behavioral problems, narcotic use, or hospital or emergency department use over the following year. Prospective studies are needed that measure pain over time to determine more accurately the relationship between pain and negative outcomes in dementia.

The effect of center volume on pancreas transplant outcomes.

BACKGROUND: Caseload often correlates with improved outcomes for several surgical procedures, including solid organ transplantation. Given the unique nature of pancreas transplantation and large variation in transplant center volumes, this study aims to determine whether center volume affects patient and graft survival after pancreas transplantation. METHODS: Registry data on all forms of whole organ pancreas transplants performed between 1995 and 2000 were obtained from the United Network for Organ Sharing. Patient and graft survival rates were followed until 2002. Center volume then was categorized as: low (< 10/year), medium (10-20/year), high (21-50/year), and very high (< 50/year). Cox proportional hazard regression models were developed to evaluate factors affecting pancreas transplant outcomes. RESULTS: Very-high-volume centers were more likely to do pancreas after kidney transplant, pancreas transplant alone, pancreas with kidney transplant, and repeat transplants, while other centers more frequently performed simultaneous pancreas-kidney transplants (P < .001). Very-high-volume centers were more likely to transplant older recipients and less likely to transplant minority or Medicaid patients. Low-volume centers tended to accept pancreatic allografts from younger donors and had the longest waiting times. In models adjusting for differences in patient population, there were no differences in patient survival. However, low-volume centers had a slightly increased risk of graft loss compared to other centers. Early graft loss was similar among all centers, but medium-volume centers were at increased risk for late graft loss. CONCLUSIONS: Low center volume is not associated with increased mortality after pancreas transplantation. Other factors appear to be more important than center volume in determining pancreas transplant outcomes.