Nurse-Led, Telephone-Based Primary Palliative Care Intervention for Patients With Lung Cancer: Domains of Quality Care.

Palliative care is traditionally delivered by specialty-trained palliative care teams. Because of a national workforce shortage of palliative care specialists, there is an urgent need to explore alternative models of palliative care delivery to meet the needs of patients living with serious illness. As part of a multisite randomized controlled trial, 2 registered nurses without previous palliative care experience were trained to deliver a primary palliative care intervention to patients with newly diagnosed lung cancer. The intervention focused on assessing and managing symptoms, psychosocial needs, education, and initiating goals-of-care discussions. The primary outcome, improved symptom burden and quality of life, was not statistically significant. Despite this finding, nurses addressed 5 of the 8 National Consensus Project Guidelines domains of quality palliative care: structure and processes of care; physical, psychological, and social aspects of care; and ethical and legal aspects. Patients' engagement in goals-of-care discussions, a measure of high-quality palliative care, increased. Clinical recommendations offered by the nurses to the patients' clinicians were addressed and accepted on a timely basis. Most patients rated satisfaction with the intervention as "very or extremely" satisfied. These findings may inform future nurse-led palliative care interventions on the specific quality domains of palliative care.

Assessing Racial Disparities in Access, Use, and Outcomes for Pregnant and Postpartum Veterans and Their Infants in Veterans Health Administration.

Objective: Limited population-based data examines racial disparities among pregnant and postpartum Veterans. Our objective was to determine whether Black/white racial disparities in health care access, use, and Veteran and infant outcomes are present among pregnant and postpartum Veterans and their infants using Veterans Health Administration (VA) care. Methods: The VA National Veteran Pregnancy and Maternity Care Survey included all Veterans with a VA paid live birth between June 2018 and December 2019. Participants could complete the survey online or by telephone. The independent variable was self-reported race. Outcomes included timely initiation of prenatal care, perceived access to timely prenatal care, attendance at a postpartum check-up, receipt of needed mental health care, cesarean section, postpartum rehospitalization, low birthweight, preterm birth, admission to a neonatal intensive care unit, and breastfeeding. Nonresponse weighted general linear models with a log-link were used to examine associations of race with outcomes. Cox regression was used to examine the association of race with duration of breastfeeding. Models adjusted for age, ethnicity, urban versus rural residence, and parity. Results: The analytic sample consisted of 1,220 Veterans (Black n = 916; white n = 304) representing 3,439 weighted responses (Black n = 1,027; white n = 2,412). No racial disparities were detected for health care access or use. Black Veterans were more likely than white Veterans to have a postpartum rehospitalization (RR 1.67, 95% CI: 1.04-2.68) and a low-birthweight infant (RR 1.67, 95% CI: 1.20-2.33). Conclusion: While no racial disparities were detected for health care access and use, we identified disparities in postpartum rehospitalization and low birthweight, underscoring that access is not sufficient for ensuring health equity.

A Randomized Trial of a Nurse-Led Palliative Care Intervention for Patients with Newly Diagnosed Lung Cancer.

Background: Specialist palliative care improves quality of life (QOL), symptom burden, and may prolong survival among patients with advanced lung cancer. Previous trials focused on advanced disease, and less is known about patients across a broad range of stages. Objective: We sought to assess the effect of a nurse-led telephone-based primary palliative care intervention that focused on patients across a broad range of stages. Design, Setting, and Participants: We conducted a multisite randomized controlled trial in the United States involving patients diagnosed within two months with any stage or histology of lung cancer to compare the effects of a telephone-based palliative care intervention delivered by registered nurses trained in primary palliative care versus usual care. Main Outcomes and Measures: The primary outcome was the Functional Assessment of Cancer Therapy-Lung Scale Total Outcome Index (FACT-L TOI), which measures QOL and symptoms. We estimated having 80% power to detect a 5-point change from baseline to three months. Secondary outcome was a change in satisfaction of care, measured by the FAMCARE-P13. Results: A total of 151 patients were enrolled over 30 months. Patients were, on average, male (98%), age 70 years, White (85%), and 36% diagnosed with stage I-II, and 64% had stage III-IV. In comparison to usual care, patients in the nurse-led intervention did not report improvement in QOL from baseline to three months follow-up or demonstrate differences in treatment effect by site or cancer stage: FACT-L TOI 1.03 (95% confidence interval [CI]: -3.98 to 6.04). Satisfaction with care did not significantly improve: 0.66 (95% CI: -2.01 to 3.33). Conclusions: Among patients with newly diagnosed lung cancer, a nurse-led, primary palliative care intervention did not significantly improve QOL, symptom burden, or satisfaction of care. In contrast to several clinical trials demonstrating the effectiveness of delivering specialty palliative care with disease-modifying treatments on QOL among patients with advanced lung cancer, this intervention did not significantly improve QOL among patients with any stage lung cancer. Future research should identify which specific components of primary palliative care improve outcomes for patients newly diagnosed with lung cancer.

Understanding Variation in Availability and Provision of Minimally Invasive Hysterectomy: A Qualitative Study of Department of Veterans Affairs Gynecologists.

BACKGROUND: Approximately one-half of women undergoing hysterectomy in the Department of Veterans Affairs health care system receive minimally invasive hysterectomies (MIH), with Black women less likely than White women to receive MIH. We sought to characterize gynecologists' perspectives on factors contributing to the availability and provision of MIH and on the role of race/ethnicity in decision making. METHODS: Between October 2017 and January 2018, we conducted 16 in-depth semistructured telephone interviews with Department of Veterans Affairs gynecologists exploring practice characteristics and barriers and facilitators to providing MIH, including clinical and nonclinical characteristics of patients impacting surgical decision making. We identified key themes using simultaneous deductive and inductive thematic analysis. RESULTS: Gynecologists identified provider-, facility-, and patient-level barriers and facilitators to MIH. Provider-level factors included gynecologists' skills and training in MIH, and facility factors included access to qualified surgical assistants, availability of surgical equipment, and operating room resources, particularly time. On the patient level, clinical characteristics, including uterine size, were the most common determinants of surgical approach, but nonclinical factors such as patients' attitudes toward surgery also contributed. Race/ethnicity was identified by a minority of respondents as influencing hysterectomy route through clinical presentation and surgical attitudes. CONCLUSIONS: Given the range of factors identified, efforts to promote MIH in the Department of Veterans Affairs will likely require a multipronged approach that includes support for MIH training, increased access to surgical assistants with MIH skills, and reduced barriers to obtaining equipment. Patient perspectives are needed to more fully capture nonclinical patient-level contributors to MIH and differences in MIH between Black and White Veterans.

Understanding Women Veterans' Family Planning Counseling Experiences and Preferences to Inform Patient-Centered Care.

BACKGROUND: Women veterans' unique experiences in the military and burden of health comorbidities increase their risk of adverse pregnancy outcomes and may influence their counseling needs related to planning or preventing pregnancy. We investigated women veterans' experiences of family planning counseling in the military and Veterans Affairs (VA) health care systems as well as their counseling preferences. METHODS: We conducted 32 qualitative interviews among women veterans ages 18-44 years receiving primary care at the VA Puget Sound or VA Pittsburgh health care systems between March and June 2016 to explore their experiences and preferences related to counseling about pregnancy goals and planning and contraception. Transcripts were analyzed using inductive and deductive content analysis, and key themes were identified. RESULTS: Nearly all participants described negative experiences in family planning counseling encounters in the military and/or VA, including perceptions of gender-based discrimination and pressure to choose certain contraceptive methods, perceived judgment of their reproductive choices, and a lack of continuity with providers. Some women also reported positive experiences in family planning encounters in the VA, including feeling respected, receiving comprehensive information about options, and having their perspectives and concerns elicited. Counseling preferences that emerged included that providers initiate and validate family planning discussions, establish trust and avoid judgment, elicit women's individual preferences, and engage them as equal partners in decision making. CONCLUSIONS: Women veterans reported a spectrum of negative and positive experiences in family planning encounters in the military and VA that, in conjunction with their preferences, provide key insights for patient-centered reproductive health care in VA.

Symptom Burden and Palliative Care Needs Among High-Risk Veterans With Multimorbidity.

CONTEXT: Palliative care research has focused on patients with disease-specific conditions. However, older patients with multimorbidity may have unmet palliative care needs. OBJECTIVES: We assessed symptom burden and quality of life among veterans with multimorbidity and sought to determine if their bothersome symptoms were addressed and treated in the primary care setting. We sought to identify specific diagnoses that may account for greater symptom burden. We hypothesized that patients with a higher number of diagnoses would experience greater symptom burden and poorer quality of life. METHODS: We identified veterans at high risk of hospitalization or death using a validated prognostic model. We administered cross-sectional surveys via telephone, The Memorial Symptom Assessment Scale-Short Form and Veterans RAND 12, to randomly selected patients in primary care in the VA Health Care System from May to December 2015. We assessed if their most bothersome symptom was addressed and treated during their most recent visit. Regression models identified specific diagnoses accounting for greater symptom burden and patient predictors of high symptom burden and poor quality of life. RESULTS: Patients (n = 503) reported (10.6 ± 5.5) active symptoms and poor physical quality of life. Patients reported pain and dyspnea as their most bothersome symptoms (n = 145 [29%] and n = 57 [11%], respectively). Most patients acknowledged their clinicians assessed (n = 348 [74%]) and treated (n = 330 [70%]) their most bothersome symptom. Physical symptoms (78%, P < 0.0001) were more likely to be addressed than psychological symptoms (55%, P < 0.001). Patients diagnosed with obesity or depression experienced greater physical symptom burden. Younger patients reported greater symptom severity than older patients (P < 0.01). Younger patients and those with greater multimorbidities reported lower self-perceived quality of health than older patients and those with fewer multimorbidities (P = 0.01 and P < 0.01, respectively). CONCLUSION: Outpatients with multimorbidity have high symptom burden, unaddressed symptoms, poor quality of life, and unmet palliative care needs. Our findings support standardization of comprehensive symptom assessment and management in primary care for veterans with multimorbidities, which may ameliorate symptoms and improve quality of life.

Bridging the Cultural Divide Between Oncology and Palliative Care Subspecialties: Clinicians' Perceptions on Team Integration.

PURPOSE: Palliative care improves symptom burden, distress, patient and family satisfaction, and survival for patients with cancer. Oncology professional societies endorse the integration of palliative care into routine care for patients with advanced cancers. Despite this, cultural differences between medical subspecialties and the limited number of clinicians trained in palliative care lower the adoption of integrated care models. We assessed oncologists' and palliative care clinicians' perceptions about integrating oncology and palliative care using a nurse delivering palliative care to patients newly diagnosed with lung cancer. METHODS: We conducted semistructured telephone interviews with 7 oncology clinicians and 12 palliative care clinicians purposively sampled across 6 geographically diverse Department of Veterans Affairs medical centers (VAs). Oncologists were asked about their perspectives and experiences with consulting palliative care services. Palliative care clinicians were asked about their experiences with receiving consultations from subspecialties. Both were asked about utilizing a registered nurse to deliver telephone-based palliative care to patients newly diagnosed with lung cancer. Interviews were analyzed using traditional content analysis approaches. RESULTS: We identified 2 main themes: (1) tensions, differences, and mistrust between services occur in the least integrated teams and (2) open communication, sharing common goals, and promoting oncology "buy in" build trust and foster collaboration between teams. Clinicians described qualities important to possess to promote successful adoption of a nurse-led model of palliative care. CONCLUSIONS: Integration between oncology and palliative care among the 6 VA medical centers varies considerably. Nurses delivering palliative care embedded in oncology teams may facilitate the integration of these subspecialties.

The long term impact of an end-of-life communication intervention among veterans with COPD.

OBJECTIVE: To assess if an end-of-life communication intervention with patients with COPD led to higher long-term documentation of advance care planning discussions at the end-of-life. BACKGROUND: We previously demonstrated that providing clinicians a patient-specific feedback form about patients' communication preferences improved the occurrence and quality of clinician communication about end-of-life care. METHODS: Among those individuals enrolled in the intervention study (2004-2007) who had died during the follow-up period (up to 2013), we assessed if patients in the intervention arm had more goals of care discussions and formal advance directives completed as compared to controls. We conducted logistic models accounting for provider level clustering, adjusting for age, FEV1, and race. RESULTS: Among the 376 patients in the study, 157 died (76 in the intervention arm, 81 in the control arm). Over an average duration of 3.6 years (from the time of the first study appointment to death), 115 (73%) patients engaged in 451 unique end-of-life care discussions. The intervention was not associated with a higher percentage of patients with documented end-of-life conversations (I:C 75% vs 72%, p = 0.63) or completion of advance care directives (26% vs 29%, p = 0.55). CONCLUSIONS: Despite initially improving the occurrence of end-of-life conversations, the intervention did not increase the documentation of subsequent conversations about end-of-life care, nor did it improve documentation of advance directives. Future research should focus on testing multi-faceted, longitudinal, system-level interventions to enhance conversations about goals of care that promote goal-concurrent care.

Fast macromolecular proton fraction mapping of the human liver in vivo for quantitative assessment of hepatic fibrosis.

The macromolecular proton fraction (MPF) is a quantitative MRI parameter determining the magnetization transfer (MT) effect in tissues, and is defined as the relative amount of immobile macromolecular protons involved in magnetization exchange with mobile water protons. MPF has the potential to provide a quantitative assessment of fibrous tissue because of the intrinsically high MPF specific for collagen. The goal of this study was to investigate the relationship between histologically determined fibrosis stage and MPF in the liver parenchyma measured using a recently developed fast single-point clinically targeted MPF mapping method. Optimal saturation parameters for single-point liver MPF measurements were determined from the analysis of liver Z spectra in vivo based on the error propagation model. Sixteen patients with chronic hepatitis C viral infection underwent 3-T MRI using an optimized liver MPF mapping protocol. Fourteen patients had prior liver biopsy with histologically staged fibrosis (METAVIR scores F0-F3) and two patients had clinically diagnosed cirrhosis (score F4 was assigned). The protocol included four breath-hold three-dimensional scans with 2 × 3 × 6-mm(3) resolution and 10 transverse sections: dynamic acquisition of MT-weighted and reference images; dynamic acquisition of three images for variable flip angle T1 mapping; dual-echo B0 map; and actual flip angle imaging B1 map. The average liver MPF was determined as the mode of the MPF histograms. MPF was significantly increased in patients with clinically significant fibrosis (scores F2-F4, n = 6) relative to patients with no or mild fibrosis (scores F0-F1, n = 10): 6.49 ± 0.36% versus 5.94 ± 0.26%, p < 0.01 (Mann-Whitney test). MPF and fibrosis scores were strongly positively correlated, with a Spearman's rank correlation coefficient of 0.80 (p < 0.001). This study demonstrates the feasibility of fast MPF mapping of the human liver in vivo and confirms the hypothesis that MPF is increased in hepatic fibrosis and associated with fibrosis stage. MPF may be useful as a non-invasive imaging biomarker of hepatic fibrosis.

Can computerized brain training games be used to identify early cognitive impairment in cirrhosis?

OBJECTIVES: We evaluated whether commercially available, computerized "brain-training" games can be used to identify subtle cognitive impairments in patients with cirrhosis. METHODS: We compared patients with cirrhosis who did not have overt encephalopathy (n=31), patients with pre-cirrhotic chronic liver disease (n=28), and normal controls without liver disease (n=16) with respect to their scores on the number connection test-A (NCT-A), the Inhibitory Control Test (ICT), and five, short (∼2.5 min), brain-training games that were administered on an Apple iPad and tested different cognitive domains. RESULTS: Patients with cirrhosis had similar scores to patients with pre-cirrhotic liver disease and slightly worse scores than normal controls in the NCT-A and the ICT, although these differences were not statistically significant. In contrast, patients with cirrhosis had significantly worse scores than patients with pre-cirrhotic liver disease and even more so than normal controls in all five of the brain-training games. After adjustment for age and educational attainment, these differences remained significant for two of the tests, "Color Match" which is a version of the Stroop test and measures selective attention, and "Memory Matrix", which measures visuospatial memory. The area under the receiver operating characteristic curve discriminating cirrhosis from pre-cirrhotic liver disease was 0.56 (95% confidence interval (CI) 0.41-0.72) for the ICT and 0.58 (95% CI 0.43-0.73) for the NCT-A, indicating no discrimination, while it was 0.75 (95% CI 0.63-0.87) for "Color Match" and 0.77 (95% CI 0.64-0.90) for "Memory Matrix", indicating good discrimination. CONCLUSIONS: Short, brain-training games administered on an iPad can be used as psychometric tests to detect subtle cognitive impairments in patients with cirrhosis without overt encephalopathy that could not be detected by the NCT-A or the ICT.

Synergistic interaction of dietary cholesterol and dietary fat in inducing experimental steatohepatitis.

UNLABELLED: The majority of patients with nonalcoholic fatty liver disease (NAFLD) have "simple steatosis," which is defined by hepatic steatosis in the absence of substantial inflammation or fibrosis and is considered to be benign. However, 10%-30% of patients with NAFLD progress to fibrosing nonalcoholic steatohepatitis (NASH), which is characterized by varying degrees of hepatic inflammation and fibrosis, in addition to hepatic steatosis, and can lead to cirrhosis. The cause(s) of progression to fibrosing steatohepatitis are unclear. We aimed to test the relative contributions of dietary fat and dietary cholesterol and their interaction on the development of NASH. We assigned C57BL/6J mice to four diets for 30 weeks: control (4% fat and 0% cholesterol); high cholesterol (HC; 4% fat and 1% cholesterol); high fat (HF; 15% fat and 0% cholesterol); and high fat, high cholesterol (HFHC; 15% fat and 1% cholesterol). The HF and HC diets led to increased hepatic fat deposition with little inflammation and no fibrosis (i.e., simple hepatic steatosis). However, the HFHC diet led to significantly more profound hepatic steatosis, substantial inflammation, and perisinusoidal fibrosis (i.e., steatohepatitis), associated with adipose tissue inflammation and a reduction in plasma adiponectin levels. In addition, the HFHC diet led to other features of human NASH, including hypercholesterolemia and obesity. Hepatic and metabolic effects induced by dietary fat and cholesterol together were more than twice as great as the sum of the separate effects of each dietary component alone, demonstrating significant positive interaction. CONCLUSION: Dietary fat and dietary cholesterol interact synergistically to induce the metabolic and hepatic features of NASH, whereas neither factor alone is sufficient to cause NASH in mice.

Feeding entrainment of food-anticipatory activity and per1 expression in the brain and liver of zebrafish under different lighting and feeding conditions.

Food provided on a periodic basis can act as a potent synchronizer, being a stronger zeitgeber than light for peripheral oscillators in mammals. In fish, however, little is known about the influence of feeding time on the circadian pacemaker and the relationship between central and peripheral oscillators. The aim of this research was to investigate the influence of mealtime on the activity rhythms, and on central (brain) and peripheral (liver) oscillators in zebrafish. The authors tested different feeding times under a light-dark (LD) cycle and the endogenous origin of food-anticipatory activity (FAA) by feeding zebrafish at a fixed time under constant bright-light conditions (LL). The authors then measured locomotor activity and the expression of the clock gene per1 in animals under a LD cycle and fed at random times during the light phase, with restricted feeding at the mid-light phase (ML) or with restricted feeding during the mid-dark phase (MD). Finally, the authors measured locomotor activity and per1 expression in fish maintained under LL under either random feeding or scheduled feeding. Zebrafish displayed FAA in all the groups fed at a fixed time but not when feeding was randomly scheduled. Under LL, fish entrainment persisted, and when released under fasting conditions FAA free-ran with a circa-24-h period. The expression of per1 in the brain of fish under LD showed a daily rhythm with the acrophase (peak time) at the end of the dark phase regardless of feeding schedule. This brain rhythm disappeared in LL fish under both random feeding and scheduled feeding. Feeding at MD advanced the phase of per1 in the liver by 7 h compared with the ML-fed group phase (23:54 versus 07:23 h, respectively). In addition, under LL scheduled feeding entrained the rhythms of per1 expression in the liver. This study reveals for the first time that scheduled feeding entrains peripheral oscillators in a fish species, zebrafish, which is a powerful model widely used for molecular genetics and for the study of basic clock mechanisms of the vertebrate circadian system.