Study of unmet needs in symptomatic veterans with advanced cancer: incidence, independent predictors and unmet needs outcome model.

Veteran patients possess distinctive characteristics such as a higher mortality rate, lower socioeconomic status and poorer health status. We report the prevalence and predictors of unmet needs and examine the association between unmet needs and quality of life (QOL). Two hundred ninety-six male cancer patients who presented with distressing symptom(s) completed the following instruments: a 14-item multidimensional unmet needs questionnaire, Functional Assessment of Cancer Therapy (FACT-G), Memorial Symptom Assessment Scale-Short Form (MSAS-SF) and other validated measurements of function, depression, health and social support. Multiple linear regression models were used to identify independent predictors of each unmet needs domain and of total unmet needs. The relationships between total unmet needs, QOL and multidimensional variables were also explored. The median number of total unmet needs was three, and the most frequently reported unmet needs areas were physical (80.0%), activities of daily living (53.3%), nutrition (46.1%) and emotional (32.5%). Different predictors of each unmet needs domain were identified. Younger age was associated with a higher risk of unmet needs in physical, economic and medical domains. Higher psychological symptom distress was associated with more unmet needs in the emotional/social, economic and medical domains. Physical symptom distress, extent of disease and health measure were only significant in the physical unmet needs domain. The depression, psychological and physical symptom distress scores, confident and affective social support scores, total unmet needs and age independently predicted FACT-G total QOL score (R(2)=63%, P < 0.00001). Patients with higher psychological, physical symptom distress and depression scores, younger age, lower functional status and metastatic disease were more likely to report more unmet needs. The total number of unmet needs was predictive of QOL. The unmet needs and QOL outcomes model was developed but needs further validation.

Study of hormone refractory prostate cancer: hospital care and palliative care resource use at a VA medical center.

Palliative care plays a central role in the management of hormone refractory prostate cancer patients (HRPC), yet little is known about palliative care resource use. Computerized medical records of a retrospective cohort of 89 consecutive HRPC patients seen at a VA medical center from 1994 to 1999 were reviewed for hospital and palliative care resource use in the last 6 months of life. There were 51 Caucasian and 38 African American patients; 95% of patients were admitted to the hospital for symptom management (median of 2 admissions); 98% visited clinics (median 19 visits); 35% went to the emergency room (median of 1 visit); 60% died in the hospital (median length of last hospitalization of 22 days); 49% received palliative radiation; 52% used rehabilitation; 57% received blood transfusion (median 2 units). Thirty-five patients (40%) received hospice care (median stay 35 days). The most frequently prescribed medications included opioids (90%), laxatives (89%), H2-blockers (57%), antiemetics (55%), diuretics (49%), and corticosteroids (43%). The prevalence of patients receiving opioids, as well as the dose of opioids increased over time. There was no difference in categories of palliative care resource use or survival by race. The median survival for all patients was 13 months. The results begin to highlight the extent of care and resources needed by patients with end-stage HRPC. This information will be of importance in planning palliative care for patients with HRPC and in designing future prospective studies.

Caregiver unmet needs, burden, and satisfaction in symptomatic advanced cancer patients at a Veterans Affairs (VA) medical center.

OBJECTIVES: Caregiver outcomes among those caring for symptomatic advanced cancer patients at VA Medical Centers have not been well reported. The purposes of this study were (1) to identify the caregiver characteristics and their unmet needs; (2) to examine the association between caregiver unmet needs, caregiver burden, and caregiver satisfaction; and (3) to identify the independent predictors of different caregiver outcomes. METHODS: One hundred caregivers completed three caregiver outcomes instruments: Family Inventory of Needs (FIN), Care Strain Index (CSI), and Family Satisfaction with Advanced Cancer Care (FAMCARE). The caregivers' demographics and their function, depression, health status, and social support status as well as the caregivers' perception of the patients' unmet needs (PPUN) were obtained. Principal component analysis was performed to examine the underlying dimensions of caregiver outcome measures. Pearson correlation and stepwise multivariate regression analyses were performed. RESULTS: The median number of unmet needs was 2 and the median CSI score was 4. Most of unmet needs were related to information needs (needing more information related to home care, finding help with the problems at home, and disease prognosis) and symptom management. The majority of caregivers were satisfied or very satisfied by the care patients received. Spouse caregivers (N = 60, 60%) were significantly older (p = 0.006) with higher unemployment rates (p = 0.001), higher depression scores (p = 0.04), and lower social support scores (p < 0.0001) than nonspouse caregivers (N = 40, 40%). The PPUN predicted caregiver burden and the presence of caregiver unmet needs independently. The presence of caregiver unmet needs was the only independent predictor of caregiver satisfaction. Caregivers with a high PPUN and higher depression score experienced a higher burden. SIGNIFICANCE OF THE RESEARCH: The caregiver outcome model is proposed and needs to be further validated in a new cohort of caregivers.