Addressing the Challenges of Palliative Care for Homeless Veterans.

BACKGROUND: Veterans who nearing the end of life (EOL) in unstable housing are not adequately served by current palliative care or homeless programs. METHODS: Multidisciplinary focus groups, interviews with community and Veterans Affairs (VA) leaders and with 29 homeless veterans were conducted in five cities. A forum of national palliative and homelessness care leaders (n=5) and representatives from each focus group (n=10), then convened. The forum used Nominal Group Process to suggest improvements in EOL care for veterans without homes. Modified Delphi Process was used to consolidate and prioritize recommendations during two subsequent tele-video conferences. Qualitative content analysis drew on meeting transcripts and field notes. RESULTS: The Forum developed 12 recommendations to address the following barriers: (1) Declining health often makes independent living or plans to abstain impossible, but housing programs usually require functional independence and sobriety. (2) Managing symptoms within the homelessness context is challenging. (3) Discontinuities within and between systems restrict care. (4) VA regulations challenge collaboration with community providers. (5) Veterans with unstable housing who are at EOL and those who care for them must compete nationally for prioritization of their care. CONCLUSION: Care of veterans at EOL without homes may be substantially improved through policy changes to facilitate access to appropriate housing and care; better dissemination of existing policy; cross-discipline and cross-system education; facilitated communication among VA, community, homeless and EOL providers; and pilot testing of VA group homes or palliative care facilities that employ harm reduction strategies.

Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review.

BACKGROUND: Expert guidelines recommend reducing or discontinuing long-term opioid therapy (LTOT) when risks outweigh benefits, but evidence on the effect of dose reduction on patient outcomes has not been systematically reviewed. PURPOSE: To synthesize studies of the effectiveness of strategies to reduce or discontinue LTOT and patient outcomes after dose reduction among adults prescribed LTOT for chronic pain. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library from inception through April 2017; reference lists; and expert contacts. STUDY SELECTION: Original research published in English that addressed dose reduction or discontinuation of LTOT for chronic pain. DATA EXTRACTION: Two independent reviewers extracted data and assessed study quality using the U.S. Preventive Services Task Force quality rating criteria. All authors assessed evidence quality using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Prespecified patient outcomes were pain severity, function, quality of life, opioid withdrawal symptoms, substance use, and adverse events. DATA SYNTHESIS: Sixty-seven studies (11 randomized trials and 56 observational studies) examining 8 intervention categories, including interdisciplinary pain programs, buprenorphine-assisted dose reduction, and behavioral interventions, were found. Study quality was good for 3 studies, fair for 13 studies, and poor for 51 studies. Many studies reported dose reduction, but rates of opioid discontinuation ranged widely across interventions and the overall quality of evidence was very low. Among 40 studies examining patient outcomes after dose reduction (very low overall quality of evidence), improvement was reported in pain severity (8 of 8 fair-quality studies), function (5 of 5 fair-quality studies), and quality of life (3 of 3 fair-quality studies). LIMITATION: Heterogeneous interventions and outcome measures; poor-quality studies with uncontrolled designs. CONCLUSION: Very low quality evidence suggests that several types of interventions may be effective to reduce or discontinue LTOT and that pain, function, and quality of life may improve with opioid dose reduction. PRIMARY FUNDING SOURCE: Veterans Health Administration. (PROSPERO: CRD42015020347).

Studies of Physician-Patient Communication with Older Patients: How Often is Hearing Loss Considered? A Systematic Literature Review.

Hearing loss is remarkably prevalent in the geriatric population: one-quarter of adults aged 60-69 and 80% of adults aged 80 years and older have bilateral disabling loss. Only about one in five adults with hearing loss wears a hearing aid, leaving many vulnerable to poor communication with healthcare providers. We quantified the extent to which hearing loss is mentioned in studies of physician-patient communication with older patients, and the degree to which hearing loss is incorporated into analyses and findings. We conducted a structured literature search within PubMed for original studies of physician-patient communication with older patients that were published since 2000, using the natural language phrase "older patient physician communication." We identified 409 papers in the initial search, and included 67 in this systematic review. Of the 67 papers, only 16 studies (23.9%) included any mention of hearing loss. In six of the 16 studies, hearing loss was mentioned only; in four studies, hearing loss was used as an exclusion criterion; and in two studies, the extent of hearing loss was measured and reported for the sample, with no further analysis. Three studies examined or reported on an association between hearing loss and the quality of physician-patient communication. One study included an intervention to temporarily mitigate hearing loss to improve communication. Less than one-quarter of studies of physician-elderly patient communication even mention that hearing loss may affect communication. Methodologically, this means that many studies may have omitted an important potential confounder. Perhaps more importantly, research in this field has largely overlooked a highly prevalent, important, and remediable influence on the quality of communication.

Decisional support to prevent adverse drug reactions of long latency: pilot randomized controlled intervention for glucocorticoid-induced diabetes.

RATIONALE, AIMS, AND OBJECTIVES: Long-term exposure to glucocorticoids can cause adverse drug reactions of long latency (ADRLLs), including glucocorticoid-induced diabetes mellitus (GID). Providers can monitor for GID using the glycosylated haemoglobin blood (HbA1C) test. This study examined the utility of decisional support to improve HbA1C-based screening for GID. US veterans were identified as chronic users of oral glucocorticoids (>120 days of oral glucocorticoids in the last 2 years). The primary care providers caring for these patients were the target of the intervention. Providers were randomized to receive automatic HbA1C orders for their patients receiving chronic glucocorticoid or usual care. METHODS: This study was a pilot two-arm, group-randomized, controlled trial (n = 12 providers, n = 38 patients). Data collection occurred from 5 May 2013 until 10 January 2014. A pharmacist generated the order for an HbA1C through the electronic medical record. The time between the intervention start date and the date on which an HbA1C order was signed were compared using Cox proportional and hierarchical linear regression. RESULTS: The time to sign HbA1C orders (mean 12.0 days for the intervention arm; 104.0 days for control arm) was associated with significant differences favouring the intervention [HR (Hazard Ratio) 50.2, P < 0.001, confidence interval (CI) 6.3 to 398.7]. For the intervention group, 95% of orders were signed, whereas only 12% of control providers signed orders (odds ratio 150, P < 0.001, CI 12.4 to 1812.9). CONCLUSIONS: The results of this study strongly suggest that the clinical pharmacist-triggered order intervention is effective. This method of computerized decisional support may be useful in improving screening for GID and ADRLLs.

Practices and preferences for detecting chronic medication toxicity: a pilot cross-sectional survey of health care providers focusing on decision support systems.

RATIONALE, AIMS, AND OBJECTIVES: Adverse drug reactions (ADRs) are a critical concern: they are costly, both in dollars and in diminishing patients' quality of life. ADRs that occur due to prolonged exposure to a pharmaceutical agent (adverse drug reactions of long latency, ADRLLs) may be easier to prevent than acute ADRs, as ADRLLs inherently require continued medication exposures. This pilot study used glucocorticoid-induced osteoporosis (GIO) as an example ADRLL. The aims were to survey health care providers' current practices in avoiding ADRLLs and the perceived utility of decisional support systems (DSS) to aid them in preventing GIO. METHODS: We administered an anonymous, cross-sectional survey to health care providers (fellows, doctor assistants, nurse practitioners and attending doctors) focusing on their methods to monitor for and prevent ADRLLs. The questionnaire also gauged usage of electronic medical records (EMRs) and each provider's perceived utility of specific DSS-based approaches to monitoring for GIO. Data were interpreted using descriptive statistics and histograms. RESULTS: A majority of the 33 responding providers (84.8%) reported that their primary ADRLL avoidance technique is simply remembering that a patient is on chronic glucocorticoids. The most favourably perceived DSS options included tracking medications on a flow sheet (84.8%) and digital tracking of cumulative glucocorticoid exposure with real-time prompts (83.9%). CONCLUSIONS: Surveyed providers reported that additional DSS implementation may help in the avoidance of ADRLLs such as GIO. Providers ranked both digital and non-digital DSS favourably, but a computerized approach is appealing in that it may be integrated into extant EMR systems.