Karl Lorenz

All Publications

• Persistent Gaps in Use of Advance Directives Among Nursing Home Residents Receiving Maintenance Dialysis. JAMA internal medicine Kurella Tamura, M., Liu, S., Montez-Rath, M. E., O'Hare, A. M., Hall, Y. N., Lorenz, K. A. 2017

  View details for DOI 10.1001/jamainternmed.2017.1618

  View details for PubMedID 28520863

• Being CAREFuL about improving end-of-life care in hospitals. Lancet (London, England) Aslakson, R. A., Lorenz, K. 2017

  View details for DOI 10.1016/S0140-6736(17)31325-9

  View details for PubMedID 28526494

• Association between aggressive care and bereaved families' evaluation of end-of-life care for veterans with non-small cell lung cancer who died in Veterans Affairs facilities. Cancer Ersek, M., Miller, S. C., Wagner, T. H., Thorpe, J. M., Smith, D., Levy, C. R., Gidwani, R., Faricy-Anderson, K., Lorenz, K. A., Kinosian, B., Mor, V. 2017

  Abstract

  To the authors' knowledge, little is known regarding the relationship between patients' and families' satisfaction with aggressive end-of-life care. Herein, the authors examined the associations between episodes of aggressive care (ie, chemotherapy, mechanical ventilation, acute hospitalizations, and intensive care unit admissions) within the last 30 days of life and families' evaluations of end-of-life care among patients with non-small cell lung cancer (NSCLC).A total of 847 patients with NSCLC (34% of whom were aged <65 years) who died in a nursing home or intensive care, acute care, or hospice/palliative care (HPC) unit at 1 of 128 Veterans Affairs Medical Centers between 2010 and 2012 were examined. Data sources included Veterans Affairs administrative and clinical data, Medicare claims, and the Bereaved Family Survey. The response rate for the Bereaved Family Survey was 62%.Greater than 72% of veterans with advanced lung cancer who died in an inpatient setting had at least 1 episode of aggressive care and 31% received chemotherapy within the last 30 days of life. For all units except for HPC, when patients experienced at least 1 episode of aggressive care, bereaved families rated care lower compared with when patients did not receive any aggressive care. For patients dying in an HPC unit, the associations between overall ratings of care and ≥2 inpatient admissions or any episode of aggressive care were not found to be statistically significant. Rates of aggressive care were not associated with age, and family ratings of care were similar for younger and older patients.Aggressive care within the last month of life is common among patients with NSCLC and is associated with lower family evaluations of end-of-life care. Specialized care provided within an HPC unit may mitigate the negative effects of aggressive care on these outcomes. Cancer 2017. © 2017 American Cancer Society.

  View details for DOI 10.1002/cncr.30700

  View details for PubMedID 28419414

• Factors Associated with Family Reports of Pain, Dyspnea, and Depression in the Last Year of Life JOURNAL OF PALLIATIVE MEDICINE Singer, A. E., Meeker, D., Teno, J. M., Lynn, J., Lunney, J. R., Lorenz, K. A. 2016; 19 (10): 1066-1073

  Abstract

  Pain, dyspnea, and depression are highly troubling near the end of life.To characterize factors associated with clinically significant pain and the presence of dyspnea and depression during the last year of life in a nationally representative sample.Retrospective cohort study.Health and Retirement Study, a national sample of community-dwelling US residents aged 51 and older.Family respondents of 8254 decedents who died between 1998 and 2012.Clinically significant pain often during the last year of life; dyspnea and depression for at least one month during the last year of life.Life support was associated with dyspnea (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.42-2.06) and depression (OR 1.20, CI 1.04-1.39), treatment for cancer with pain (OR 1.65, CI 1.41-1.92), and oxygen for a lung condition with dyspnea (OR 14.78, CI 11.28-19.38). More diagnoses were associated with dyspnea (OR 1.24, CI 1.17-1.30) and depression (OR 1.14, CI 1.08-1.21). More activities of daily living (ADL) dependencies were associated with clinically significant pain (OR 1.06, CI 1.03-1.09), dyspnea (OR 1.06, CI 1.02-1.10), and depression (OR 1.10, CI 1.07-1.12), and more instrumental activities of daily living (IADL) dependencies with depression (OR 1.12, CI 1.08-1.18). Worse self-rated health was associated with pain (OR 0.83, CI 0.77-0.88), dyspnea (OR 0.89, CI 0.84-0.95), and depression (OR 0.83, CI 0.78-0.89). Arthritis was associated with clinically significant pain (OR 2.24, CI 1.91-2.63).Factors associated with common, burdensome symptoms in a national sample suggest clinical and population strategies for targeting symptom assessment and management.

  View details for DOI 10.1089/jpm.2015.0391

  View details for PubMedID 27454900

• Palliative Care Specialist Consultation Is Associated With Supportive Care Quality in Advanced Cancer. Journal of pain and symptom management Walling, A. M., Tisnado, D., Ettner, S. L., Asch, S. M., Dy, S. M., Pantoja, P., Lee, M., Ahluwalia, S. C., Schreibeis-Baum, H., Malin, J. L., Lorenz, K. A. 2016; 52 (4): 507-514

  Abstract

  Although recent randomized controlled trials support early palliative care for patients with advanced cancer, the specific processes of care associated with these findings and whether these improvements can be replicated in the broader health care system are uncertain.The aim of this study was to evaluate the occurrence of palliative care consultation and its association with specific processes of supportive care in a national cohort of Veterans using the Cancer Quality ASSIST (Assessing Symptoms Side Effects and Indicators of Supportive Treatment) measures.We abstracted data from 719 patients' medical records diagnosed with advanced lung, colorectal, or pancreatic cancer in 2008 over a period of three years or until death who received care in the Veterans Affairs Health System to evaluate the association of palliative care specialty consultation with the quality of supportive care overall and by domain using a multivariate regression model.All but 54 of 719 patients died within three years and 293 received at least one palliative care consult. Patients evaluated by a palliative care specialist at diagnosis scored seven percentage points higher overall (P < 0.001) and 11 percentage points higher (P < 0.001) within the information and care planning domain compared with those without a consult.Early palliative care specialist consultation is associated with better quality of supportive care in three advanced cancers, predominantly driven by improvements in information and care planning. This study supports the effectiveness of early palliative care consultation in three common advanced cancers within the Veterans Affairs Health System and provides a greater understanding of what care processes palliative care teams influence.

  View details for DOI 10.1016/j.jpainsymman.2016.04.005

  View details for PubMedID 27401515

  View details for PubMedCentralID PMC5173291

• Populations and Interventions for Palliative and End-of-Life Care: A Systematic Review. Journal of palliative medicine Singer, A. E., Goebel, J. R., Kim, Y. S., Dy, S. M., Ahluwalia, S. C., Clifford, M., Dzeng, E., O'Hanlon, C. E., Motala, A., Walling, A. M., Goldberg, J., Meeker, D., Ochotorena, C., Shanman, R., Cui, M., Lorenz, K. A. 2016; 19 (9): 995-1008

  Abstract

  Evidence supports palliative care effectiveness. Given workforce constraints and the costs of new services, payers and providers need help to prioritize their investments. They need to know which patients to target, which personnel to hire, and which services best improve outcomes.To inform how payers and providers should identify patients with "advanced illness" and the specific interventions they should implement, we reviewed the evidence to identify (1) individuals appropriate for palliative care and (2) elements of health service interventions (personnel involved, use of multidisciplinary teams, and settings of care) effective in achieving better outcomes for patients, caregivers, and the healthcare system.Systematic searches of MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Database of Systematic Reviews databases (1/1/2001-1/8/2015).Randomized controlled trials (124) met inclusion criteria. The majority of studies in cancer (49%, 38 of 77 studies) demonstrated statistically significant patient or caregiver outcomes (e.g., p < 0.05), as did those in congestive heart failure (CHF) (62%, 13 of 21), chronic obstructive pulmonary disease (COPD; 58%, 11 of 19), and dementia (60%, 15 of 25). Most prognostic criteria used clinicians' judgment (73%, 22 of 30). Most interventions included a nurse (70%, 69 of 98), and many were nurse-only (39%, 27 of 69). Social workers were well represented, and home-based approaches were common (56%, 70 of 124). Home interventions with visits were more effective than those without (64%, 28 of 44; vs. 46%, 12 of 26). Interventions improved communication and care planning (70%, 12 of 18), psychosocial health (36%, 12 of 33, for depressive symptoms; 41%, 9 of 22, for anxiety), and patient (40%, 8 of 20) and caregiver experiences (63%, 5 of 8). Many interventions reduced hospital use (65%, 11 of 17), but most other economic outcomes, including costs, were poorly characterized. Palliative care teams did not reliably lower healthcare costs (20%, 2 of 10).Palliative care improves cancer, CHF, COPD, and dementia outcomes. Effective models include nurses, social workers, and home-based components, and a focus on communication, psychosocial support, and the patient or caregiver experience. High-quality research on intervention costs and cost outcomes in palliative care is limited.

  View details for DOI 10.1089/jpm.2015.0367

  View details for PubMedID 27533892

  View details for PubMedCentralID PMC5011630

• A Systematic Review of Family Meeting Tools in Palliative and Intensive Care Settings. The American journal of hospice & palliative care Singer, A. E., Ash, T., Ochotorena, C., Lorenz, K. A., Chong, K., Shreve, S. T., Ahluwalia, S. C. 2016; 33 (8): 797-806

  Abstract

  Family meetings can be challenging, requiring a range of skills and participation. We sought to identify tools available to aid the conduct of family meetings in palliative, hospice, and intensive care unit settings.We systematically reviewed PubMed for articles describing family meeting tools and abstracted information on tool type, usage, and content.We identified 16 articles containing 23 tools in 7 categories: meeting guide (n = 8), meeting planner (n = 5), documentation template (n = 4), meeting strategies (n = 2), decision aid/screener (n = 2), family checklist (n = 1), and training module (n = 1). We found considerable variation across tools in usage and content and a lack of tools supporting family engagement.There is need to standardize family meeting tools and develop tools to help family members effectively engage in the process.

  View details for DOI 10.1177/1049909115594353

  View details for PubMedID 26213225

  View details for PubMedCentralID PMC4728031

• Opportunities to Enhance Value-Related Research in the U.S. Department of Veterans Affairs. Journal of general internal medicine Wagner, T. H., Burstin, H., Frakt, A. B., Krein, S. L., Lorenz, K., Maciejewski, M. L., Pizer, S. D., Weiner, M., Yoon, J., Zulman, D. M., Asch, S. M. 2016; 31: 78-83

  View details for DOI 10.1007/s11606-015-3538-5

  View details for PubMedID 26951279

• A Qualitative Inquiry on Palliative and End-of-Life Care Policy Reform JOURNAL OF PALLIATIVE MEDICINE Schreibeis-Baum, H. C., Xenakis, L. E., Chen, E. K., Hanson, M., Ahluwalia, S., Ryan, G., Lorenz, K. A. 2016; 19 (4): 400-407

  Abstract

  There is increasing recognition of the role of palliative care (PC) in health care delivery, but priorities for state and federal policy to support PC are unclear and have sometimes engendered controversy. We canvassed experts to shed light on general recommendations for improving PC.The study objective was to identify challenges to and potential solutions for promoting, adopting, and implementing policies that would support or expand high-quality PC.Semistructured telephone interviews were used to solicit challenges to and potential solutions for promoting, adopting, and implementing policies that would support or expand high-quality PC. Interviews were analyzed using qualitative methods. The subjects were a purposive sample of 22 professional state and federal-level advocates who work in the field of aging and/or PC.Respondents identified four central challenges to advancing PC policies: (1) knowledge about PC in the health care setting, (2) cultural beliefs about PC, (3) payment/reimbursement for PC services, and (4) public understanding of PC. Of the wide range of solutions proposed by respondents, we present the eight most frequently discussed solutions to these challenges targeted towards policymakers, health care professionals, research, and the general public. Respondents' understanding of the relationships between problems and solutions revealed many dependencies and interconnectedness.A qualitative approach of querying experts identified multiple significant challenges to improving and expanding PC, most of which are acknowledged in existing consensus statements. Proposed solutions were more numerous and diffuse than descriptions of the problems, signaling the need for further consensus building around actionable policy, and better understanding of how to advance a PC policy agenda.

  View details for DOI 10.1089/jpm.2015.0296

  View details for Web of Science ID 000373237500013

  View details for PubMedCentralID PMC4827304

• Opportunities to Enhance Value-Related Research in the US Department of Veterans Affairs JOURNAL OF GENERAL INTERNAL MEDICINE Wagner, T. H., Burstin, H., Frakt, A. B., Krein, S. L., Lorenz, K., Maciejewski, M. L., Pizer, S. D., Weiner, M., Yoon, J., Zulman, D. M., Asch, S. M. 2016; 31: 78-83

  View details for DOI 10.1007/s11606-015-3538-5

  View details for Web of Science ID 000373159900014

  View details for PubMedCentralID PMC4803679

• A Qualitative Inquiry on Palliative and End-of-Life Care Policy Reform. Journal of palliative medicine Schreibeis-Baum, H. C., Xenakis, L. E., Chen, E. K., Hanson, M., Ahluwalia, S., Ryan, G., Lorenz, K. A. 2016; 19 (4): 400-407

  Abstract

  There is increasing recognition of the role of palliative care (PC) in health care delivery, but priorities for state and federal policy to support PC are unclear and have sometimes engendered controversy. We canvassed experts to shed light on general recommendations for improving PC.The study objective was to identify challenges to and potential solutions for promoting, adopting, and implementing policies that would support or expand high-quality PC.Semistructured telephone interviews were used to solicit challenges to and potential solutions for promoting, adopting, and implementing policies that would support or expand high-quality PC. Interviews were analyzed using qualitative methods. The subjects were a purposive sample of 22 professional state and federal-level advocates who work in the field of aging and/or PC.Respondents identified four central challenges to advancing PC policies: (1) knowledge about PC in the health care setting, (2) cultural beliefs about PC, (3) payment/reimbursement for PC services, and (4) public understanding of PC. Of the wide range of solutions proposed by respondents, we present the eight most frequently discussed solutions to these challenges targeted towards policymakers, health care professionals, research, and the general public. Respondents' understanding of the relationships between problems and solutions revealed many dependencies and interconnectedness.A qualitative approach of querying experts identified multiple significant challenges to improving and expanding PC, most of which are acknowledged in existing consensus statements. Proposed solutions were more numerous and diffuse than descriptions of the problems, signaling the need for further consensus building around actionable policy, and better understanding of how to advance a PC policy agenda.

  View details for DOI 10.1089/jpm.2015.0296

  View details for PubMedID 27035522

  View details for PubMedCentralID PMC4827304

• The rise of concurrent care for veterans with advanced cancer at the end of life CANCER Mor, V., Joyce, N. R., Cote, D. L., Gidwani, R. A., Ersek, M., Levy, C. R., Faricy-Anderson, K. E., Miller, S. C., Wagner, T. H., Kinosian, B. P., Lorenz, K. A., Shreve, S. T. 2016; 122 (5): 782-790

  Abstract

  Unlike Medicare, the Veterans Health Administration (VA) health care system does not require veterans with cancer to make the "terrible choice" between receipt of hospice services or disease-modifying chemotherapy/radiation therapy. For this report, the authors characterized the VA's provision of concurrent care, defined as days in the last 6 months of life during which veterans simultaneously received hospice services and chemotherapy or radiation therapy.This retrospective cohort study included veteran decedents with cancer during 2006 through 2012 who were identified from claims with cancer diagnoses. Hospice and cancer treatment were identified using VA and Medicare administrative data. Descriptive statistics were used to characterize the changes in concurrent care, hospice, palliative care, and chemotherapy or radiation treatment.The proportion of veterans receiving chemotherapy or radiation therapy remained stable at approximately 45%, whereas the proportion of veterans who received hospice increased from 55% to 68%. The receipt of concurrent care also increased during this time from 16.2% to 24.5%. The median time between hospice initiation and death remained stable at around 21 days. Among veterans who received chemotherapy or radiation therapy in their last 6 months of life, the median time between treatment termination and death ranged from 35 to 40 days. There was considerable variation between VA medical centers in the use of concurrent care (interquartile range, 16%-34% in 2012).Concurrent receipt of hospice and chemotherapy or radiation therapy increased among veterans dying from cancer without reductions in the receipt of cancer therapy. This approach reflects the expansion of hospice services in the VA with VA policy allowing the concurrent receipt of hospice and antineoplastic therapies. Cancer 2016;122:782-790. © 2015 American Cancer Society.

  View details for DOI 10.1002/cncr.29827

  View details for Web of Science ID 000371166300019

  View details for PubMedID 26670795

• Association of Early Patient-Physician Care Planning Discussions and End-of-Life Care Intensity in Advanced Cancer JOURNAL OF PALLIATIVE MEDICINE Ahluwalia, S. C., Tisnado, D. M., Walling, A. M., Dy, S. M., Asch, S. M., Ettner, S. L., Kim, B., Pantoja, P., Schreibeis-Baum, H. C., Lorenz, K. A. 2015; 18 (10): 834-841

  Abstract

  Early patient-physician care planning discussions may influence the intensity of end-of-life (EOL) care received by veterans with advanced cancer.The study objective was to evaluate the association between medical record documentation of patient-physician care planning discussions and intensity of EOL care among veterans with advanced cancer.This was a retrospective cohort study. Subjects were 665 veteran decedents diagnosed with stage IV colorectal, lung, or pancreatic cancer in 2008, and followed till death or the end of the study period in 2011. We estimated the effect of patient-physician care planning discussions documented within one month of metastatic diagnosis on the intensity of EOL care measured by receipt of acute care, intensive interventions, chemotherapy, and hospice care, using multivariate logistic regression models.Veterans in our study were predominantly male (97.1%), white (74.7%), with an average age at diagnosis of 66.4 years. Approximately 31% received some acute care, 9.3% received some intensive intervention, and 6.5% had a new chemotherapy regimen initiated in the last month of life. Approximately 41% of decedents received no hospice or were admitted within three days of death. Almost half (46.8%) had documentation of a care planning discussion within the first month after diagnosis and those who did were significantly less likely to receive acute care at EOL (OR: 0.67; p=0.025). Documented discussions were not significantly associated with intensive interventions, chemotherapy, or hospice care.Early care planning discussions are associated with lower rates of acute care use at the EOL in a system with already low rates of intensive EOL care.

  View details for DOI 10.1089/jpm.2014.0431

  View details for Web of Science ID 000362268900009

  View details for PubMedID 26186553

  View details for PubMedCentralID PMC4599129

• Proactive case finding to improve concurrently curative and palliative care in patients with end-stage liver disease. Journal of palliative medicine Walling, A. M., Schreibeis-Baum, H., Pimstone, N., Asch, S. M., Robinson, L., Korlekar, S., Lorenz, K., Nwajuaku, T., Rosenfeld, K. 2015; 18 (4): 378-381

  Abstract

  Palliative care and preparation for liver transplantation are often perceived as conflicting for patients with end-stage liver disease (ESLD). We sought to improve both simultaneously through a case finding and care coordination quality improvement intervention.We identified patients with cirrhosis using validated ICD-9 codes and screened them for ESLD by assessing medical records at a VA hospital for either a model for end-stage liver disease (MELD) ≥14 or a diagnosis of hepatocellular carcinoma (HCC) between October 2012 and January 2013. A care coordinator followed veterans from the index hospitalization through April 2013 and encouraged treating physicians to submit liver transplant evaluation consults for all veterans with a MELD ≥14 and palliative care consults for all veterans with a MELD ≥20 or inoperable HCC.We compared rates of consultation for 49 hospitalized veterans and compared their outcomes to 61 pre-intervention veterans. Veterans were more likely to be considered for liver transplantation (77.6% versus 31.1%, p<0.001) and receive palliative care consultation during the intervention period, although the latter finding did not reach statistical significance (62.5% versus 47.1%, p=0.38).Active case finding improved consideration for liver transplantation without decreasing palliative care consultation.

  View details for DOI 10.1089/jpm.2014.0265

  View details for PubMedID 25493552

  View details for PubMedCentralID PMC4367526

• Proactive Case Finding To Improve Concurrently Curative and Palliative Care in Patients with End-Stage Liver Disease JOURNAL OF PALLIATIVE MEDICINE Walling, A. M., Schreibeis-Baum, H., Pimstone, N., Asch, S. M., Robinson, L., Korlekar, S., Lorenz, K., Nwajuaku, T., Rosenfeld, K. 2015; 18 (4): 378-381

  Abstract

  Palliative care and preparation for liver transplantation are often perceived as conflicting for patients with end-stage liver disease (ESLD). We sought to improve both simultaneously through a case finding and care coordination quality improvement intervention.We identified patients with cirrhosis using validated ICD-9 codes and screened them for ESLD by assessing medical records at a VA hospital for either a model for end-stage liver disease (MELD) ≥14 or a diagnosis of hepatocellular carcinoma (HCC) between October 2012 and January 2013. A care coordinator followed veterans from the index hospitalization through April 2013 and encouraged treating physicians to submit liver transplant evaluation consults for all veterans with a MELD ≥14 and palliative care consults for all veterans with a MELD ≥20 or inoperable HCC.We compared rates of consultation for 49 hospitalized veterans and compared their outcomes to 61 pre-intervention veterans. Veterans were more likely to be considered for liver transplantation (77.6% versus 31.1%, p<0.001) and receive palliative care consultation during the intervention period, although the latter finding did not reach statistical significance (62.5% versus 47.1%, p=0.38).Active case finding improved consideration for liver transplantation without decreasing palliative care consultation.

  View details for DOI 10.1089/jpm.2014.0265

  View details for Web of Science ID 000351274500013

  View details for PubMedID 25493552

  View details for PubMedCentralID PMC4367526

• Quality of supportive care for patients with advanced lung cancer in the Veterans Health Administration. The Journal of community and supportive oncology Oishi, S. M., Antonio, A. L., Ryoo, J., Ordin, D. L., Lorenz, K. A., He, R., Asch, S. M., Kim, B., Malin, J. 2014; 12 (10): 361-369

  Abstract

  Morbidity related to cancer and its treatment remains a significant source of human suffering and a challenge to the delivery of high-quality care.To develop and apply quality indicators to evaluate quality of supportive care for advanced lung cancer in the Veterans Health Administration (VHA) and examine facility-level predictors of quality.We evaluated supportive care quality using 12 quality indicators. Data were taken from VHA electronic health records for incident lung cancer cases occurring during 2007. Organizational characteristics of 111 VHA facilities were examined for association with receipt of care.Not all supportive care was evaluated. Care processes identified as present at facilities may not have been applied to cohort patients. Facility-level results may be influenced by errors in attributing a patient's care to the correct facility.Quality indicators for supportive cancer care can be developed and applied in large evaluations using electronic health record review. This study confirmed high-quality supportive care, while identifying significant facility-level variation in VHA.

  View details for DOI 10.12788/jcso.0079

  View details for PubMedID 25853258

• Developing an Informatics Tool To Advance Supportive Care: The Veterans Health Care Administration Palliative Care National Clinical Template JOURNAL OF PALLIATIVE MEDICINE Goebel, J. R., Ahluwalia, S. C., Chong, K., Shreve, S. T., Goldzweig, C. L., Austin, C., Asch, S. M., Lorenz, K. A. 2014; 17 (3): 266-273

  Abstract

  Increasing emphasis in performance-based payment, public reporting, and quality improvement (QI) has led to widespread interest in measuring and improving the quality of care. By 2014, hospice programs will be required to report quality data to the federal government or incur financial penalties. With this increased interest in quality reporting comes an opportunity to develop informatics tools to capture data that reflect the complex practices involved in palliative care (PC). Therefore, there is a need to disseminate information on developing tools that facilitate capturing data and fostering improved performance. The Veterans Health Care Administration, a national leader in health information technology (HIT) and PC, established the Quality Improvement Resource Center (QuIRC) to develop innovative HIT tools to standardize and improve PC practices throughout the 153 Department of Veterans Affairs (VA) medical centers nationwide.The aim of the paper is to describe the development of the Palliative Care-National Clinical Template (PC-NCT) for documenting initial PC consults.Domains of quality of life provided the foundation for this template. Principles of user-centered informatics design guided development activities. A national consensus panel of PC experts prioritized quality indicators as targets for QI. An interdisciplinary team of PC providers identified desired aspects of template functionality. QuIRC balanced PC providers' desired aspects of functionality against the feasibility within the VA HIT system. Formal pilot and usability testing contributed to numerous iterations of the PC-NCT currently piloted in five geographically distributed sites.This paper presents a robust approach to developing an informatics tool for PC practice. Data collected via the PC-NCT will bring variations in current practice into view and assist in directing resources at "important targets" for QI. Although the development of HIT tools to quantify PC practice is complex, there is enormous potential to improve the quality of care for patients and families facing serious illnesses.

  View details for DOI 10.1089/jpm.2013.0288

  View details for Web of Science ID 000337027700007

  View details for PubMedID 24548178

• The Quality of Supportive Cancer Care in the Veterans Affairs Health System and Targets for Improvement JAMA INTERNAL MEDICINE Walling, A. M., Tisnado, D., Asch, S. M., Malin, J. M., Pantoja, P., Dy, S. M., Ettner, S. L., Zisser, A. P., Schreibeis-Baum, H., Lee, M., Lorenz, K. A. 2013; 173 (22): 2071-2079

  Abstract

  Characterizing the quality of supportive cancer care can guide quality improvement.To evaluate nonhospice supportive cancer care comprehensively in a national sample of veterans.Using a retrospective cohort study design, we measured evidence-based cancer care processes using previously validated indicators of care quality in patients with advanced cancer, addressing pain, nonpain symptoms, and information and care planning among 719 veterans with a 2008 Veterans Affairs Central Cancer Registry diagnosis of stage IV colorectal (37.0%), pancreatic (29.8%), or lung (33.2%) cancer.We abstracted medical records from diagnosis for 3 years or until death among eligible veterans (lived ≥ 30 days following diagnosis with ≥ 1 Veterans Affairs hospitalization or ≥ 2 Veterans Affairs outpatient visits). Each indicator identified a clinical scenario and an appropriate action. For each indicator for which a veteran was eligible, we determined whether appropriate care was provided. We also determined patient-level quality overall and by pain, nonpain symptoms, and information and care planning domains.Most veterans were older (mean age, 66.2 years), male (97.2%), and white (74.3%). Eighty-five percent received both inpatient and outpatient care, and 92.5% died. Overall, the 719 veterans triggered a mean of 11.7 quality indicators (range, 1-22) and received a mean 49.5% of appropriate care. Notable gaps in care were that inpatient pain screening was common (96.5%) but lacking for outpatients (58.1%). With opioids, bowel prophylaxis occurred for only 52.2% of outpatients and 70.5% of inpatients. Few patients had a timely dyspnea evaluation (15.8%) or treatment (10.8%). Outpatient assessment of fatigue occurred for 31.3%. Of patients at high risk for diarrhea from chemotherapy, 24.2% were offered appropriate antidiarrheals. Only 17.7% of veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63.7% had timely discussion of goals following intensive care unit admission. Most decedents (86.4%) were referred to palliative care or hospice before death. Single- vs multiple-fraction radiotherapy should have been considered in 28 veterans with bone metastasis, but none were offered this option.These care gaps reflect important targets for improving the patient and family experience of cancer care.

  View details for DOI 10.1001/jamainternmed.2013.10797

  View details for Web of Science ID 000330954800015

  View details for PubMedID 24126685

• Provider Approaches to Palliative Dyspnea Assessment: Implications for Informatics-Based Clinical Tools AMERICAN JOURNAL OF HOSPICE & PALLIATIVE MEDICINE Ahluwalia, S. C., Leos, R. L., Goebel, J. R., Asch, S. M., Lorenz, K. A. 2013; 30 (3): 231-238

  Abstract

  To understand provider practices around dyspnea assessment to inform the development of an electronic medical record (EMR)-based dyspnea assessment module in an inpatient palliative care consultation template.Qualitative analysis of palliative care provider interviews.Three themes emerged: (1) integration of patient self-report of breathlessness with a clinical observation of dyspnea; (2) identification of patients for dyspnea assessment based on perceived patient need; and (3) variability in preferences for and use of existing severity scales for dyspnea.The assessment approaches described by providers underscore the challenge of developing an informatics tool that supports the natural clinical experience and facilitates standardized care. The complexity of the dyspnea assessment process and variation in provider practices necessitate a level of flexibility and choice to be built into a computer-based tool.

  View details for DOI 10.1177/1049909112448922

  View details for Web of Science ID 000317674300002

  View details for PubMedID 22669935

• Impact of Consideration of Transplantation on End-of-Life Care for Patients During a Terminal Hospitalization TRANSPLANTATION Walling, A. M., Asch, S. M., Lorenz, K. A., Wenger, N. S. 2013; 95 (4): 641-646

  Abstract

  Many patients considered for transplantation die before receiving the organ, underlining the importance of providing high-quality symptomatic relief and communication for all transplant patients.To study how consideration of transplantation affects the end-of-life care received by patients, care was evaluated by abstracting medical records for 496 adults who died in one high-volume transplant medical center between April 2005 and April 2006. Sixteen quality indicators from the Assessing Care of Vulnerable Elders set that focused on communication and symptom management were measured to calculate an overall patient-level quality score. We evaluated the predictors of quality of end-of-life care, with the main independent variable being whether the patient was being considered for transplantation. Restricting to patients who died an "expected death," we also evaluated the end-of-life treatments received.Twenty-five percent of decedent patients were considered for transplantation. In adjusted models, patients considered for transplantation received lower-quality end-of-life care, had longer hospital stays before death, and were more likely to receive aggressive life-sustaining treatments.Care models should incorporate an emphasis on symptom relief and communication along with transplant preparation.

  View details for DOI 10.1097/TP.0b013e318277f238

  View details for Web of Science ID 000315199200021

  View details for PubMedID 23197177

• The quality of supportive care among inpatients dying with advanced cancer SUPPORTIVE CARE IN CANCER Walling, A. M., Asch, S. M., Lorenz, K. A., Malin, J., Roth, C. P., Barry, T., Wenger, N. S. 2012; 20 (9): 2189-2194

  Abstract

  Managing symptoms and communicating effectively are essential aspects of providing high-quality cancer care, especially among patients with advanced cancer. The purpose of this study is to apply novel quality indicators to measure the quality of supportive care provided to patients with advanced cancer who died in a large university medical center.Cancer quality ASSIST is a comprehensive quality indicator (QI) set that includes 92 symptom and care planning indicators, of which we piloted 15 applicable to persons with advanced cancer who died in the hospital setting. We evaluated medical records of all adult terminal hospitalizations with lengths of stay ≥3 days at one university medical center between April 2005 and April 2006.Of 496 decedents, 118 had advanced cancer (mean age 60, 54% male). Forty-five percent received chemotherapy or radiation in the month prior to or during admission. During the hospitalization, 56% of the patients spent time in the ICU (median length of stay 8 days), one in five received first-time hemodialysis, and 23% had a ventilator withdrawn anticipating death. The 118 patients triggered 596 quality indicators of which 476 passed (QI level pass rate 80%, range 50-100%). Pain assessment and management were consistently performed; however, other cancer supportive care needed improvement: 26% of patients not receiving cancer therapy who had nausea and vomiting received inadequate follow-up, more than one quarter of patients with dyspnea had this symptom inadequately addressed, and 29% of patients taking long-acting opioids were not prescribed a bowel regimen. Timely discussion of patient preferences upon admission to the ICU or initiation of mechanical ventilation occurred in 64 and 69% of cases, respectively.This set of quality indicators can evaluate the quality of supportive and end-of-life care provided to inpatients dying with advanced cancer and identify aspects of care that need improvement.

  View details for DOI 10.1007/s00520-012-1462-3

  View details for Web of Science ID 000307285800032

  View details for PubMedID 22544290

• Emergency Medicine Physicians' Perspectives of Providing Palliative Care in an Emergency Department JOURNAL OF PALLIATIVE MEDICINE Stone, S. C., Mohanty, S., Grudzen, C. R., Shoenberger, J., Asch, S., Kubricek, K., Lorenz, K. A. 2011; 14 (12): 1333-1338

  Abstract

  This study describes emergency physicians' perspectives on the challenges and benefits to providing palliative care in an academic, urban, public hospital in Los Angeles. Participants underwent a semi-structured interview on their training and experiences related to palliative care, perceptions of providing palliative care, and their recommendations for education and training in this area. Overall, respondents felt that palliative care is not prioritized appropriately, leading patients to be unaware of their options for end-of-life care. Providing educational materials and courses that have been developed from the ED perspective should be included in ongoing continuing medical education. Having a palliative care team that is responsive to the needs of the ED will further enhance collaboration with the ED. Future research should focus on understanding the range of benefits to having palliative care in the ED.

  View details for DOI 10.1089/jpm.2011.0106

  View details for Web of Science ID 000298145800012

  View details for PubMedID 22136262