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Association between hospice length of stay and health care costs
Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.
Study design: Cross-sectional observational study.
Setting: Using the United States Renal Data System registry.
Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.
Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.
The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.
Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.
Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.
Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.
Study design: Cross-sectional observational study.
Setting: Using the United States Renal Data System registry.
Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.
Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.
The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.
Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.
Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.
Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.
Study design: Cross-sectional observational study.
Setting: Using the United States Renal Data System registry.
Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.
Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.
The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.
Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.
Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.
Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Palliative care consultations reduce hospital costs
Background: Health care costs are on the rise, and previous studies have found that PCC can reduce hospital costs. Timing of consultation and allocation of palliative care intervention to a certain population of patients may reveal a more significant cost reduction.
Study design: Meta-analysis.
Setting: English peer reviewed articles.
Synopsis: A systematic search was performed for articles that provided economic evaluation of PCC for adult inpatients in acute care hospitals. Patients were included if they had least one of seven conditions: cancer, heart failure, liver failure, kidney failure, chronic obstructive pulmonary disease, AIDS/HIV, or neurodegenerative conditions. Six data sets were reviewed, which included 133,118 patients altogether. There was a significant reduction in costs with PCC within 3 days of admission, regardless of the diagnosis (–$3,237; 95% confidence interval, –$3,581 to –$2,893). In the stratified analysis, the pooled meta-analysis suggested a statistically significant reduction in costs for both cancer (–$4,251; 95% CI, –$4,664 to –$3,837; P less than .001) and noncancer (–$2,105; 95% CI, –$2,698 to –$1,511; P less than .001) subsamples. In patients with cancer, the treatment effect was greater for patients with four or more comorbidities than it was for those with two or fewer.
Only six samples were evaluated, and causation could not be established because all samples had observational designs. There also was potential interpretation bias because the private investigator for each of the samples contributed to interpretation of the data and participated as an author. Overall evaluation of the economic value of PCC in this study was limited because analysis was focused to a single index hospital admission rather than including additional hospitalizations and outpatient costs.
Bottom line: Acute care hospitals might reduce hospital costs by increasing resources to allow palliative care consultations in patients with serious illnesses.
Citation: May P et al. Economics of palliative care for hospitalized adults with serious illness. JAMA Intern Med. 2018;178(6):820-9.
Dr. Libot is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Background: Health care costs are on the rise, and previous studies have found that PCC can reduce hospital costs. Timing of consultation and allocation of palliative care intervention to a certain population of patients may reveal a more significant cost reduction.
Study design: Meta-analysis.
Setting: English peer reviewed articles.
Synopsis: A systematic search was performed for articles that provided economic evaluation of PCC for adult inpatients in acute care hospitals. Patients were included if they had least one of seven conditions: cancer, heart failure, liver failure, kidney failure, chronic obstructive pulmonary disease, AIDS/HIV, or neurodegenerative conditions. Six data sets were reviewed, which included 133,118 patients altogether. There was a significant reduction in costs with PCC within 3 days of admission, regardless of the diagnosis (–$3,237; 95% confidence interval, –$3,581 to –$2,893). In the stratified analysis, the pooled meta-analysis suggested a statistically significant reduction in costs for both cancer (–$4,251; 95% CI, –$4,664 to –$3,837; P less than .001) and noncancer (–$2,105; 95% CI, –$2,698 to –$1,511; P less than .001) subsamples. In patients with cancer, the treatment effect was greater for patients with four or more comorbidities than it was for those with two or fewer.
Only six samples were evaluated, and causation could not be established because all samples had observational designs. There also was potential interpretation bias because the private investigator for each of the samples contributed to interpretation of the data and participated as an author. Overall evaluation of the economic value of PCC in this study was limited because analysis was focused to a single index hospital admission rather than including additional hospitalizations and outpatient costs.
Bottom line: Acute care hospitals might reduce hospital costs by increasing resources to allow palliative care consultations in patients with serious illnesses.
Citation: May P et al. Economics of palliative care for hospitalized adults with serious illness. JAMA Intern Med. 2018;178(6):820-9.
Dr. Libot is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Background: Health care costs are on the rise, and previous studies have found that PCC can reduce hospital costs. Timing of consultation and allocation of palliative care intervention to a certain population of patients may reveal a more significant cost reduction.
Study design: Meta-analysis.
Setting: English peer reviewed articles.
Synopsis: A systematic search was performed for articles that provided economic evaluation of PCC for adult inpatients in acute care hospitals. Patients were included if they had least one of seven conditions: cancer, heart failure, liver failure, kidney failure, chronic obstructive pulmonary disease, AIDS/HIV, or neurodegenerative conditions. Six data sets were reviewed, which included 133,118 patients altogether. There was a significant reduction in costs with PCC within 3 days of admission, regardless of the diagnosis (–$3,237; 95% confidence interval, –$3,581 to –$2,893). In the stratified analysis, the pooled meta-analysis suggested a statistically significant reduction in costs for both cancer (–$4,251; 95% CI, –$4,664 to –$3,837; P less than .001) and noncancer (–$2,105; 95% CI, –$2,698 to –$1,511; P less than .001) subsamples. In patients with cancer, the treatment effect was greater for patients with four or more comorbidities than it was for those with two or fewer.
Only six samples were evaluated, and causation could not be established because all samples had observational designs. There also was potential interpretation bias because the private investigator for each of the samples contributed to interpretation of the data and participated as an author. Overall evaluation of the economic value of PCC in this study was limited because analysis was focused to a single index hospital admission rather than including additional hospitalizations and outpatient costs.
Bottom line: Acute care hospitals might reduce hospital costs by increasing resources to allow palliative care consultations in patients with serious illnesses.
Citation: May P et al. Economics of palliative care for hospitalized adults with serious illness. JAMA Intern Med. 2018;178(6):820-9.
Dr. Libot is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Dehydration in terminal illness: Which path forward?
CASE 1
A 94-year-old white woman, who had been in excellent health (other than pernicious anemia, treated with monthly cyanocobalamin injections), suddenly developed gastrointestinal distress 2 weeks earlier. A work-up performed by her physician revealed advanced pancreatic cancer.
Over the next 2 weeks, she experienced pain and nausea. A left-sided fistula developed externally at her flank that drained feces and induced considerable discomfort. An indwelling drain was placed, which provided some relief, but the patient’s dyspepsia, pain, and nausea escalated.
One month into her disease course, an oncologist reported on her potential treatment options and prognosis. Her life expectancy was about 3 months without treatment. This could be extended by 1 to 2 months with extensive surgical and chemotherapeutic interventions, but would further diminish her quality of life. The patient declined further treatment.
Her clinical status declined, and her quality of life significantly deteriorated. At 3 months, she felt life had lost meaning and was not worth living. She began asking for a morphine overdose, stating a desire to end her life.
After several discussions with the oncologist, one of the patient’s adult children suggested that her mother stop eating and drinking in order to diminish discomfort and hasten her demise. This plan was adopted, and the patient declined food and drank only enough to swish for oral comfort.
CASE 2
An 83-year-old woman with advanced Parkinson’s disease had become increasingly disabled. Her gait and motor skills were dramatically and progressively compromised. Pharmacotherapy yielded only transient improvement and considerable adverse effects of choreiform hyperkinesia and hallucinations, which were troublesome and embarrassing. Her social, physical, and personal well-being declined to the point that she was placed in a nursing home.
Despite this help, worsening parkinsonism progressively diminished her physical capacity. She became largely bedridden and developed decubitus ulcerations, especially at the coccyx, which produced severe pain and distress.
Continue to: The confluence of pain...
The confluence of pain, bedfastness, constipation, and social isolation yielded a loss of interest and joy in life. The patient required assistance with almost every aspect of daily life, including eating. As the illness progressed, she prayed at night that God would “take her.” Each morning, she spoke of disappointment upon reawakening. She overtly expressed her lack of desire to live to her family. Medical interventions were increasingly ineffective.
After repeated family and physician discussions had focused on her death wishes, one adult daughter recommended her mother stop eating and drinking; her food intake was already minimal. Although she did not endorse this plan verbally, the patient’s oral intake significantly diminished. Within 2 weeks, her physical state had declined, and she died one night during sleep.
Adequate hydration is stressed in physician education and practice. A conventional expectation to normalize fluid balance is important to restore health and improve well-being. In addition to being good medical practice, it can also show patients (and their families) that we care about their well-being.1-3
Treating dehydration in individuals with terminal illness is controversial from both medical and ethical standpoints. While the natural tendency of physicians is to restore full hydration to their patients, in select cases of imminent death, being fully hydrated may prolong discomfort.1,2 Emphasis in this population should be consistently placed on improving comfort care and quality of life, rather than prolonging life or delaying death.3-5
Continue to: A multifactorial, patient-based decision
A multifactorial, patient-based decision
Years ago, before the advent of hospitalizing people with terminal illnesses, dying at home amongst loved ones was believed to be peaceful. Nevertheless, questions arise about the practical vs ethical approach to caring for patients with terminal illness.2 Sometimes it is difficult to find a balance between potential health care benefits and the burdens induced by medical, legal, moral, and/or social pressures. Our medical communities and the general population uphold preserving dignity at the end of life, which is supported by organizations such as Compassion & Choices (a nonprofit group that seeks to improve and expand options for end of life care; https://www.compassionandchoices.org).
Allowing for voluntary, patient-determined dehydration in those with terminal illness can offer greater comfort than maintaining the physiologic degrees of fluid balance. There are 3 key considerations to bear in mind:
- Hydration is usually a standard part of quality medical care.1
- Selectively allowing dehydration in patients who are dying can facilitate comfort.1-5
- Dehydration may be a deliberate strategy to hasten death.6
When is dehydration appropriate?
Hydration is not favored whenever doing so may increase discomfort and prolong pain without meaningful life.3 In people with terminal illness, hydration may reduce quality of life.7
The data support dehydration in certain patients. A randomized controlled trial involving 129 patients receiving hospice care compared parenteral hydration with placebo, documenting that rehydration did not improve symptoms or quality of life; there was no significant difference between patients who were hydrated and those who were dehydrated.7 In fact, dehydration may even yield greater patient comfort.8
Case reports, retrospective chart reviews, and testimonials from health care professionals have reported that being less hydrated can diminish nausea, vomiting, diarrhea, ascites, edema, and urinary or bowel incontinence, with less skin breakdown.8 Hydration, on the other hand, may exacerbate dyspnea, coughing, and choking, increasing the need for suctioning.
Continue to: A component of palliative care
A component of palliative care. When death is imminent, palliation becomes key. Pain may be more manageable with less fluids, an important goal for this population.6,8 Dehydration is associated with an accumulation of opioids throughout body fluid volumes, which may decrease pain, consciousness, and/or agony.2 Pharmacotherapies might also have greater efficacy in a dehydrated patient.9 In addition, tissue shrinkage might mitigate pain from tumors, especially those in confined spaces.8
Hospice care and palliative medicine confirm that routine hydration is not always advisable; allowing for dehydration is a conventional practice, especially in older adults with terminal illness.7 However, do not deny access to liquids if a patient wants them, and never force unwanted fluids by any route.8 Facilitate oral care in the form of swishing fluids, elective drinking, or providing mouth lubrication for any patients selectively allowed to become dehydrated.3,8
The role of the physician in decision-making
Patients with terminal illness sometimes do not want fluids and may actively decline food and drink.10 This can be emotionally distressing for family members and/or caregivers to witness. Physicians can address this concern by compassionately explaining: “I know you are concerned that your relative is not eating or drinking, but there is no indication that hydration or parenteral feeding will improve function or quality of life.”10 This can generate a discussion between physicians and families by acknowledging concerns, relieving distress, and leading to what is ultimately best for the patient.
Implications for practice: Individualized autonomy
Physicians must identify patients who wish to die by purposely becoming dehydrated and uphold the important physician obligation to hydrate those with a recoverable illness. Allowing for a moderate degree of dehydration might provide greater comfort in select people with terminal illness. Some individuals for whom life has lost meaning may choose dehydration as a means to hasten their departure.4-6 Allowing individualized autonomy over life and death choices is part of a physician’s obligation to their patients. It can be difficult for caregivers, but it is medically indicated to comply with a patient’s desire for comfort when death is imminent.
Providing palliation as a priority over treatment is sometimes challenging, but comfort care takes preference and is always coordinated with the person’s own wishes. Facilitating dehydration removes assisted-suicide issues or requests and thus affords everyone involved more emotional comfort. An advantage of this method is that a decisional patient maintains full control over the direction of their choices and helps preserve dignity during the end of life.
CORRESPONDENCE
Steven Lippmann, MD, Department of Psychiatry, University of Louisville School of Medicine, 401 East Chestnut Street, Suite 610, Louisville, KY 40202; sblipp01@louisville.edu
1. Burge FI. Dehydration and provision of fluids in palliative care. What is the evidence? Can Fam Physician. 1996;42:2383-2388.
2. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics. 1988;43:84-88.
3. Lippmann S. Palliative dehydration. Prim Care Companion CNS Disord. 2015;17: doi: 10.4088/PCC.15101797.
4. Bernat JL, Gert B, Mogielnicki RP. Patient refusal of hydration and nutrition: an alternative to physician-assisted suicide or voluntary active euthanasia. Arch Intern Med. 1993;153:2723-2728.
5. Sullivan RJ. Accepting death without artificial nutrition or hydration. J Gen Intern Med.1993;8:220-224.
6. Miller FG, Meier DE. Voluntary death: a comparison of terminal dehydration and physician-assisted suicide. Ann Intern Med. 1998;128:559-562.
7. Bruera E, Hui D, Dalal S, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol. 2013;31:111-118.
8. Forrow L, Smith HS. Pain management in end of life: palliative care. In: Warfield CA, Bajwa ZH, ed. Principles and Practice of Pain Management. 2nd ed. New York, NY: McGraw-Hill; 2004.
9. Zerwekh JV. The dehydration question. Nursing. 1983;13:47-51.
10. Bailey F, Harman S. Palliative care: The last hours and days of life. www.uptodate.com. September, 2016. Accessed on September 11, 2018.
CASE 1
A 94-year-old white woman, who had been in excellent health (other than pernicious anemia, treated with monthly cyanocobalamin injections), suddenly developed gastrointestinal distress 2 weeks earlier. A work-up performed by her physician revealed advanced pancreatic cancer.
Over the next 2 weeks, she experienced pain and nausea. A left-sided fistula developed externally at her flank that drained feces and induced considerable discomfort. An indwelling drain was placed, which provided some relief, but the patient’s dyspepsia, pain, and nausea escalated.
One month into her disease course, an oncologist reported on her potential treatment options and prognosis. Her life expectancy was about 3 months without treatment. This could be extended by 1 to 2 months with extensive surgical and chemotherapeutic interventions, but would further diminish her quality of life. The patient declined further treatment.
Her clinical status declined, and her quality of life significantly deteriorated. At 3 months, she felt life had lost meaning and was not worth living. She began asking for a morphine overdose, stating a desire to end her life.
After several discussions with the oncologist, one of the patient’s adult children suggested that her mother stop eating and drinking in order to diminish discomfort and hasten her demise. This plan was adopted, and the patient declined food and drank only enough to swish for oral comfort.
CASE 2
An 83-year-old woman with advanced Parkinson’s disease had become increasingly disabled. Her gait and motor skills were dramatically and progressively compromised. Pharmacotherapy yielded only transient improvement and considerable adverse effects of choreiform hyperkinesia and hallucinations, which were troublesome and embarrassing. Her social, physical, and personal well-being declined to the point that she was placed in a nursing home.
Despite this help, worsening parkinsonism progressively diminished her physical capacity. She became largely bedridden and developed decubitus ulcerations, especially at the coccyx, which produced severe pain and distress.
Continue to: The confluence of pain...
The confluence of pain, bedfastness, constipation, and social isolation yielded a loss of interest and joy in life. The patient required assistance with almost every aspect of daily life, including eating. As the illness progressed, she prayed at night that God would “take her.” Each morning, she spoke of disappointment upon reawakening. She overtly expressed her lack of desire to live to her family. Medical interventions were increasingly ineffective.
After repeated family and physician discussions had focused on her death wishes, one adult daughter recommended her mother stop eating and drinking; her food intake was already minimal. Although she did not endorse this plan verbally, the patient’s oral intake significantly diminished. Within 2 weeks, her physical state had declined, and she died one night during sleep.
Adequate hydration is stressed in physician education and practice. A conventional expectation to normalize fluid balance is important to restore health and improve well-being. In addition to being good medical practice, it can also show patients (and their families) that we care about their well-being.1-3
Treating dehydration in individuals with terminal illness is controversial from both medical and ethical standpoints. While the natural tendency of physicians is to restore full hydration to their patients, in select cases of imminent death, being fully hydrated may prolong discomfort.1,2 Emphasis in this population should be consistently placed on improving comfort care and quality of life, rather than prolonging life or delaying death.3-5
Continue to: A multifactorial, patient-based decision
A multifactorial, patient-based decision
Years ago, before the advent of hospitalizing people with terminal illnesses, dying at home amongst loved ones was believed to be peaceful. Nevertheless, questions arise about the practical vs ethical approach to caring for patients with terminal illness.2 Sometimes it is difficult to find a balance between potential health care benefits and the burdens induced by medical, legal, moral, and/or social pressures. Our medical communities and the general population uphold preserving dignity at the end of life, which is supported by organizations such as Compassion & Choices (a nonprofit group that seeks to improve and expand options for end of life care; https://www.compassionandchoices.org).
Allowing for voluntary, patient-determined dehydration in those with terminal illness can offer greater comfort than maintaining the physiologic degrees of fluid balance. There are 3 key considerations to bear in mind:
- Hydration is usually a standard part of quality medical care.1
- Selectively allowing dehydration in patients who are dying can facilitate comfort.1-5
- Dehydration may be a deliberate strategy to hasten death.6
When is dehydration appropriate?
Hydration is not favored whenever doing so may increase discomfort and prolong pain without meaningful life.3 In people with terminal illness, hydration may reduce quality of life.7
The data support dehydration in certain patients. A randomized controlled trial involving 129 patients receiving hospice care compared parenteral hydration with placebo, documenting that rehydration did not improve symptoms or quality of life; there was no significant difference between patients who were hydrated and those who were dehydrated.7 In fact, dehydration may even yield greater patient comfort.8
Case reports, retrospective chart reviews, and testimonials from health care professionals have reported that being less hydrated can diminish nausea, vomiting, diarrhea, ascites, edema, and urinary or bowel incontinence, with less skin breakdown.8 Hydration, on the other hand, may exacerbate dyspnea, coughing, and choking, increasing the need for suctioning.
Continue to: A component of palliative care
A component of palliative care. When death is imminent, palliation becomes key. Pain may be more manageable with less fluids, an important goal for this population.6,8 Dehydration is associated with an accumulation of opioids throughout body fluid volumes, which may decrease pain, consciousness, and/or agony.2 Pharmacotherapies might also have greater efficacy in a dehydrated patient.9 In addition, tissue shrinkage might mitigate pain from tumors, especially those in confined spaces.8
Hospice care and palliative medicine confirm that routine hydration is not always advisable; allowing for dehydration is a conventional practice, especially in older adults with terminal illness.7 However, do not deny access to liquids if a patient wants them, and never force unwanted fluids by any route.8 Facilitate oral care in the form of swishing fluids, elective drinking, or providing mouth lubrication for any patients selectively allowed to become dehydrated.3,8
The role of the physician in decision-making
Patients with terminal illness sometimes do not want fluids and may actively decline food and drink.10 This can be emotionally distressing for family members and/or caregivers to witness. Physicians can address this concern by compassionately explaining: “I know you are concerned that your relative is not eating or drinking, but there is no indication that hydration or parenteral feeding will improve function or quality of life.”10 This can generate a discussion between physicians and families by acknowledging concerns, relieving distress, and leading to what is ultimately best for the patient.
Implications for practice: Individualized autonomy
Physicians must identify patients who wish to die by purposely becoming dehydrated and uphold the important physician obligation to hydrate those with a recoverable illness. Allowing for a moderate degree of dehydration might provide greater comfort in select people with terminal illness. Some individuals for whom life has lost meaning may choose dehydration as a means to hasten their departure.4-6 Allowing individualized autonomy over life and death choices is part of a physician’s obligation to their patients. It can be difficult for caregivers, but it is medically indicated to comply with a patient’s desire for comfort when death is imminent.
Providing palliation as a priority over treatment is sometimes challenging, but comfort care takes preference and is always coordinated with the person’s own wishes. Facilitating dehydration removes assisted-suicide issues or requests and thus affords everyone involved more emotional comfort. An advantage of this method is that a decisional patient maintains full control over the direction of their choices and helps preserve dignity during the end of life.
CORRESPONDENCE
Steven Lippmann, MD, Department of Psychiatry, University of Louisville School of Medicine, 401 East Chestnut Street, Suite 610, Louisville, KY 40202; sblipp01@louisville.edu
CASE 1
A 94-year-old white woman, who had been in excellent health (other than pernicious anemia, treated with monthly cyanocobalamin injections), suddenly developed gastrointestinal distress 2 weeks earlier. A work-up performed by her physician revealed advanced pancreatic cancer.
Over the next 2 weeks, she experienced pain and nausea. A left-sided fistula developed externally at her flank that drained feces and induced considerable discomfort. An indwelling drain was placed, which provided some relief, but the patient’s dyspepsia, pain, and nausea escalated.
One month into her disease course, an oncologist reported on her potential treatment options and prognosis. Her life expectancy was about 3 months without treatment. This could be extended by 1 to 2 months with extensive surgical and chemotherapeutic interventions, but would further diminish her quality of life. The patient declined further treatment.
Her clinical status declined, and her quality of life significantly deteriorated. At 3 months, she felt life had lost meaning and was not worth living. She began asking for a morphine overdose, stating a desire to end her life.
After several discussions with the oncologist, one of the patient’s adult children suggested that her mother stop eating and drinking in order to diminish discomfort and hasten her demise. This plan was adopted, and the patient declined food and drank only enough to swish for oral comfort.
CASE 2
An 83-year-old woman with advanced Parkinson’s disease had become increasingly disabled. Her gait and motor skills were dramatically and progressively compromised. Pharmacotherapy yielded only transient improvement and considerable adverse effects of choreiform hyperkinesia and hallucinations, which were troublesome and embarrassing. Her social, physical, and personal well-being declined to the point that she was placed in a nursing home.
Despite this help, worsening parkinsonism progressively diminished her physical capacity. She became largely bedridden and developed decubitus ulcerations, especially at the coccyx, which produced severe pain and distress.
Continue to: The confluence of pain...
The confluence of pain, bedfastness, constipation, and social isolation yielded a loss of interest and joy in life. The patient required assistance with almost every aspect of daily life, including eating. As the illness progressed, she prayed at night that God would “take her.” Each morning, she spoke of disappointment upon reawakening. She overtly expressed her lack of desire to live to her family. Medical interventions were increasingly ineffective.
After repeated family and physician discussions had focused on her death wishes, one adult daughter recommended her mother stop eating and drinking; her food intake was already minimal. Although she did not endorse this plan verbally, the patient’s oral intake significantly diminished. Within 2 weeks, her physical state had declined, and she died one night during sleep.
Adequate hydration is stressed in physician education and practice. A conventional expectation to normalize fluid balance is important to restore health and improve well-being. In addition to being good medical practice, it can also show patients (and their families) that we care about their well-being.1-3
Treating dehydration in individuals with terminal illness is controversial from both medical and ethical standpoints. While the natural tendency of physicians is to restore full hydration to their patients, in select cases of imminent death, being fully hydrated may prolong discomfort.1,2 Emphasis in this population should be consistently placed on improving comfort care and quality of life, rather than prolonging life or delaying death.3-5
Continue to: A multifactorial, patient-based decision
A multifactorial, patient-based decision
Years ago, before the advent of hospitalizing people with terminal illnesses, dying at home amongst loved ones was believed to be peaceful. Nevertheless, questions arise about the practical vs ethical approach to caring for patients with terminal illness.2 Sometimes it is difficult to find a balance between potential health care benefits and the burdens induced by medical, legal, moral, and/or social pressures. Our medical communities and the general population uphold preserving dignity at the end of life, which is supported by organizations such as Compassion & Choices (a nonprofit group that seeks to improve and expand options for end of life care; https://www.compassionandchoices.org).
Allowing for voluntary, patient-determined dehydration in those with terminal illness can offer greater comfort than maintaining the physiologic degrees of fluid balance. There are 3 key considerations to bear in mind:
- Hydration is usually a standard part of quality medical care.1
- Selectively allowing dehydration in patients who are dying can facilitate comfort.1-5
- Dehydration may be a deliberate strategy to hasten death.6
When is dehydration appropriate?
Hydration is not favored whenever doing so may increase discomfort and prolong pain without meaningful life.3 In people with terminal illness, hydration may reduce quality of life.7
The data support dehydration in certain patients. A randomized controlled trial involving 129 patients receiving hospice care compared parenteral hydration with placebo, documenting that rehydration did not improve symptoms or quality of life; there was no significant difference between patients who were hydrated and those who were dehydrated.7 In fact, dehydration may even yield greater patient comfort.8
Case reports, retrospective chart reviews, and testimonials from health care professionals have reported that being less hydrated can diminish nausea, vomiting, diarrhea, ascites, edema, and urinary or bowel incontinence, with less skin breakdown.8 Hydration, on the other hand, may exacerbate dyspnea, coughing, and choking, increasing the need for suctioning.
Continue to: A component of palliative care
A component of palliative care. When death is imminent, palliation becomes key. Pain may be more manageable with less fluids, an important goal for this population.6,8 Dehydration is associated with an accumulation of opioids throughout body fluid volumes, which may decrease pain, consciousness, and/or agony.2 Pharmacotherapies might also have greater efficacy in a dehydrated patient.9 In addition, tissue shrinkage might mitigate pain from tumors, especially those in confined spaces.8
Hospice care and palliative medicine confirm that routine hydration is not always advisable; allowing for dehydration is a conventional practice, especially in older adults with terminal illness.7 However, do not deny access to liquids if a patient wants them, and never force unwanted fluids by any route.8 Facilitate oral care in the form of swishing fluids, elective drinking, or providing mouth lubrication for any patients selectively allowed to become dehydrated.3,8
The role of the physician in decision-making
Patients with terminal illness sometimes do not want fluids and may actively decline food and drink.10 This can be emotionally distressing for family members and/or caregivers to witness. Physicians can address this concern by compassionately explaining: “I know you are concerned that your relative is not eating or drinking, but there is no indication that hydration or parenteral feeding will improve function or quality of life.”10 This can generate a discussion between physicians and families by acknowledging concerns, relieving distress, and leading to what is ultimately best for the patient.
Implications for practice: Individualized autonomy
Physicians must identify patients who wish to die by purposely becoming dehydrated and uphold the important physician obligation to hydrate those with a recoverable illness. Allowing for a moderate degree of dehydration might provide greater comfort in select people with terminal illness. Some individuals for whom life has lost meaning may choose dehydration as a means to hasten their departure.4-6 Allowing individualized autonomy over life and death choices is part of a physician’s obligation to their patients. It can be difficult for caregivers, but it is medically indicated to comply with a patient’s desire for comfort when death is imminent.
Providing palliation as a priority over treatment is sometimes challenging, but comfort care takes preference and is always coordinated with the person’s own wishes. Facilitating dehydration removes assisted-suicide issues or requests and thus affords everyone involved more emotional comfort. An advantage of this method is that a decisional patient maintains full control over the direction of their choices and helps preserve dignity during the end of life.
CORRESPONDENCE
Steven Lippmann, MD, Department of Psychiatry, University of Louisville School of Medicine, 401 East Chestnut Street, Suite 610, Louisville, KY 40202; sblipp01@louisville.edu
1. Burge FI. Dehydration and provision of fluids in palliative care. What is the evidence? Can Fam Physician. 1996;42:2383-2388.
2. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics. 1988;43:84-88.
3. Lippmann S. Palliative dehydration. Prim Care Companion CNS Disord. 2015;17: doi: 10.4088/PCC.15101797.
4. Bernat JL, Gert B, Mogielnicki RP. Patient refusal of hydration and nutrition: an alternative to physician-assisted suicide or voluntary active euthanasia. Arch Intern Med. 1993;153:2723-2728.
5. Sullivan RJ. Accepting death without artificial nutrition or hydration. J Gen Intern Med.1993;8:220-224.
6. Miller FG, Meier DE. Voluntary death: a comparison of terminal dehydration and physician-assisted suicide. Ann Intern Med. 1998;128:559-562.
7. Bruera E, Hui D, Dalal S, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol. 2013;31:111-118.
8. Forrow L, Smith HS. Pain management in end of life: palliative care. In: Warfield CA, Bajwa ZH, ed. Principles and Practice of Pain Management. 2nd ed. New York, NY: McGraw-Hill; 2004.
9. Zerwekh JV. The dehydration question. Nursing. 1983;13:47-51.
10. Bailey F, Harman S. Palliative care: The last hours and days of life. www.uptodate.com. September, 2016. Accessed on September 11, 2018.
1. Burge FI. Dehydration and provision of fluids in palliative care. What is the evidence? Can Fam Physician. 1996;42:2383-2388.
2. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics. 1988;43:84-88.
3. Lippmann S. Palliative dehydration. Prim Care Companion CNS Disord. 2015;17: doi: 10.4088/PCC.15101797.
4. Bernat JL, Gert B, Mogielnicki RP. Patient refusal of hydration and nutrition: an alternative to physician-assisted suicide or voluntary active euthanasia. Arch Intern Med. 1993;153:2723-2728.
5. Sullivan RJ. Accepting death without artificial nutrition or hydration. J Gen Intern Med.1993;8:220-224.
6. Miller FG, Meier DE. Voluntary death: a comparison of terminal dehydration and physician-assisted suicide. Ann Intern Med. 1998;128:559-562.
7. Bruera E, Hui D, Dalal S, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol. 2013;31:111-118.
8. Forrow L, Smith HS. Pain management in end of life: palliative care. In: Warfield CA, Bajwa ZH, ed. Principles and Practice of Pain Management. 2nd ed. New York, NY: McGraw-Hill; 2004.
9. Zerwekh JV. The dehydration question. Nursing. 1983;13:47-51.
10. Bailey F, Harman S. Palliative care: The last hours and days of life. www.uptodate.com. September, 2016. Accessed on September 11, 2018.
Lessons and Implications of Establishing A VA Cancer Biobanking Program
Purpose: To examine the feasibility of establishing a biobanking program at a tertiary VA facility
Background/Rationale: Biobanking holds promise for the discovery of new biomarkers and development of targeted therapy through access to large amounts of molecular and electronic health record data. The Department of Defense’s (DOD) John P. Murtha Cancer Center (MCC), of the Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, provided funding for a pilot biobanking implementation at a VA facility in hopes of facilitating a VA-wide biobank network to support federal research initiatives.
Methods: After funding and staff resources were secured, four months were required to complete contract negotiation, regulatory review, and a comprehensive assessment of inter-departmental operational requirements. We initiated with two different surgical specialties—thoracic and gastrointestinal oncology—for the initial stage to establish the system and process flow of the tissue procurement protocol, from pre-operative case screening and consenting to specimen collection (blood, urine, tissue) and tissue storage.
Results: From its inception in March 2018 through May 2018, monthly consent numbers were 1, 2, and 7, respectively. From these, fresh specimen collection occurred in most (6 patients with 8 tumor aliquots). Blood collection and questionnaire completion were obtained in all patients. All samples were shipped safely to the long-term storage facility of the MCC and therefore ready for distribution for researchers.
Conclusions: We are now ready to move beyond the pilot stage by including other cancer types. Our goal is to collect biospecimens on 2 cases per week or 100 cases per year. From preparation to implementation, we learned the success of the program relies heavily on adequate funding, supportive leadership with surgery, pathology, and oncology buy-in and proactive communication among the team members. We conclude that establishing a VA nationwide oncology biobanking program that mirrors that of the DOD is feasible, with high potential merit for veterans and civilians alike.
Purpose: To examine the feasibility of establishing a biobanking program at a tertiary VA facility
Background/Rationale: Biobanking holds promise for the discovery of new biomarkers and development of targeted therapy through access to large amounts of molecular and electronic health record data. The Department of Defense’s (DOD) John P. Murtha Cancer Center (MCC), of the Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, provided funding for a pilot biobanking implementation at a VA facility in hopes of facilitating a VA-wide biobank network to support federal research initiatives.
Methods: After funding and staff resources were secured, four months were required to complete contract negotiation, regulatory review, and a comprehensive assessment of inter-departmental operational requirements. We initiated with two different surgical specialties—thoracic and gastrointestinal oncology—for the initial stage to establish the system and process flow of the tissue procurement protocol, from pre-operative case screening and consenting to specimen collection (blood, urine, tissue) and tissue storage.
Results: From its inception in March 2018 through May 2018, monthly consent numbers were 1, 2, and 7, respectively. From these, fresh specimen collection occurred in most (6 patients with 8 tumor aliquots). Blood collection and questionnaire completion were obtained in all patients. All samples were shipped safely to the long-term storage facility of the MCC and therefore ready for distribution for researchers.
Conclusions: We are now ready to move beyond the pilot stage by including other cancer types. Our goal is to collect biospecimens on 2 cases per week or 100 cases per year. From preparation to implementation, we learned the success of the program relies heavily on adequate funding, supportive leadership with surgery, pathology, and oncology buy-in and proactive communication among the team members. We conclude that establishing a VA nationwide oncology biobanking program that mirrors that of the DOD is feasible, with high potential merit for veterans and civilians alike.
Purpose: To examine the feasibility of establishing a biobanking program at a tertiary VA facility
Background/Rationale: Biobanking holds promise for the discovery of new biomarkers and development of targeted therapy through access to large amounts of molecular and electronic health record data. The Department of Defense’s (DOD) John P. Murtha Cancer Center (MCC), of the Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, provided funding for a pilot biobanking implementation at a VA facility in hopes of facilitating a VA-wide biobank network to support federal research initiatives.
Methods: After funding and staff resources were secured, four months were required to complete contract negotiation, regulatory review, and a comprehensive assessment of inter-departmental operational requirements. We initiated with two different surgical specialties—thoracic and gastrointestinal oncology—for the initial stage to establish the system and process flow of the tissue procurement protocol, from pre-operative case screening and consenting to specimen collection (blood, urine, tissue) and tissue storage.
Results: From its inception in March 2018 through May 2018, monthly consent numbers were 1, 2, and 7, respectively. From these, fresh specimen collection occurred in most (6 patients with 8 tumor aliquots). Blood collection and questionnaire completion were obtained in all patients. All samples were shipped safely to the long-term storage facility of the MCC and therefore ready for distribution for researchers.
Conclusions: We are now ready to move beyond the pilot stage by including other cancer types. Our goal is to collect biospecimens on 2 cases per week or 100 cases per year. From preparation to implementation, we learned the success of the program relies heavily on adequate funding, supportive leadership with surgery, pathology, and oncology buy-in and proactive communication among the team members. We conclude that establishing a VA nationwide oncology biobanking program that mirrors that of the DOD is feasible, with high potential merit for veterans and civilians alike.
Aromatherapy Evidence-Based Project On Inpatient Cancer/Palliative Care Unit
Purpose: An evidenced-based project to introduce aromatherapy with the use of essential oils for oncology/palliative care patients to improve symptoms associated with cancer treatment and end-of-life.
Background: Aromatherapy reduces the cancer patients’ complications, such as sleep disorders, nausea, vomiting, pain, anxiety, and depression (Keyhanmehr et al, 2018). Lavender, peppermint, and orange are common essential oils that can help support patients with cancer who experience
insomnia, nausea, and anxiety (Reis and Jones, 2017). Palliative care research indicates that more conventional interventions, such as medications, do not always equate to a higher quality of life but often decrease the quality of life due to unnecessary interventions that cause unwanted side effects (Marchand, 2014). It is important to give patients as many choices as possible to treat their symptoms without creating new problems (Marchand, 2014).
Methods: A six-month trial was conducted on the inpatient cancer/palliative care unit and 104 patients filled out a comment card. During the trial, lavender, peppermint, frankincense, lemon, orange, and eucalyptus were used. Patients were educated on the benefits of aromatherapy and were offered samples of their choosing. Patients were given the choice of inhalation or the use of a diffuser.
Results: Of the 104 patients that filled out a comment card 97 stated they would use it again, and 51% reported an increase in well-being, 15.8% improved sleep, 10.5% reduced anxiety, 8.3% reduced depression, 7.5% improved congestion, 3.8% improved pain, and 3% reduced nausea. After the conclusion of the trial, aromatherapy is a permanent intervention for cancer and palliative care patients. The program also is being utilized in the outpatient oncology clinic, infusion clinic, and inpatient rehabilitation unit, and will eventually be offered to all departments providing patient care.
Conclusions: Aromatherapy is a viable intervention for improving various symptoms and is used effectively with patients with cancer primarily as supportive care (Aromatherapy and Essential Oils [PDQ®]: Health Professional Version, 2018). Oncology nurses can provide aromatherapy safely, inexpensively, and with minimal training, as an effective therapy in lessening many symptoms that cancer and end of life patients experience (Blackburn et al, 2017).
Purpose: An evidenced-based project to introduce aromatherapy with the use of essential oils for oncology/palliative care patients to improve symptoms associated with cancer treatment and end-of-life.
Background: Aromatherapy reduces the cancer patients’ complications, such as sleep disorders, nausea, vomiting, pain, anxiety, and depression (Keyhanmehr et al, 2018). Lavender, peppermint, and orange are common essential oils that can help support patients with cancer who experience
insomnia, nausea, and anxiety (Reis and Jones, 2017). Palliative care research indicates that more conventional interventions, such as medications, do not always equate to a higher quality of life but often decrease the quality of life due to unnecessary interventions that cause unwanted side effects (Marchand, 2014). It is important to give patients as many choices as possible to treat their symptoms without creating new problems (Marchand, 2014).
Methods: A six-month trial was conducted on the inpatient cancer/palliative care unit and 104 patients filled out a comment card. During the trial, lavender, peppermint, frankincense, lemon, orange, and eucalyptus were used. Patients were educated on the benefits of aromatherapy and were offered samples of their choosing. Patients were given the choice of inhalation or the use of a diffuser.
Results: Of the 104 patients that filled out a comment card 97 stated they would use it again, and 51% reported an increase in well-being, 15.8% improved sleep, 10.5% reduced anxiety, 8.3% reduced depression, 7.5% improved congestion, 3.8% improved pain, and 3% reduced nausea. After the conclusion of the trial, aromatherapy is a permanent intervention for cancer and palliative care patients. The program also is being utilized in the outpatient oncology clinic, infusion clinic, and inpatient rehabilitation unit, and will eventually be offered to all departments providing patient care.
Conclusions: Aromatherapy is a viable intervention for improving various symptoms and is used effectively with patients with cancer primarily as supportive care (Aromatherapy and Essential Oils [PDQ®]: Health Professional Version, 2018). Oncology nurses can provide aromatherapy safely, inexpensively, and with minimal training, as an effective therapy in lessening many symptoms that cancer and end of life patients experience (Blackburn et al, 2017).
Purpose: An evidenced-based project to introduce aromatherapy with the use of essential oils for oncology/palliative care patients to improve symptoms associated with cancer treatment and end-of-life.
Background: Aromatherapy reduces the cancer patients’ complications, such as sleep disorders, nausea, vomiting, pain, anxiety, and depression (Keyhanmehr et al, 2018). Lavender, peppermint, and orange are common essential oils that can help support patients with cancer who experience
insomnia, nausea, and anxiety (Reis and Jones, 2017). Palliative care research indicates that more conventional interventions, such as medications, do not always equate to a higher quality of life but often decrease the quality of life due to unnecessary interventions that cause unwanted side effects (Marchand, 2014). It is important to give patients as many choices as possible to treat their symptoms without creating new problems (Marchand, 2014).
Methods: A six-month trial was conducted on the inpatient cancer/palliative care unit and 104 patients filled out a comment card. During the trial, lavender, peppermint, frankincense, lemon, orange, and eucalyptus were used. Patients were educated on the benefits of aromatherapy and were offered samples of their choosing. Patients were given the choice of inhalation or the use of a diffuser.
Results: Of the 104 patients that filled out a comment card 97 stated they would use it again, and 51% reported an increase in well-being, 15.8% improved sleep, 10.5% reduced anxiety, 8.3% reduced depression, 7.5% improved congestion, 3.8% improved pain, and 3% reduced nausea. After the conclusion of the trial, aromatherapy is a permanent intervention for cancer and palliative care patients. The program also is being utilized in the outpatient oncology clinic, infusion clinic, and inpatient rehabilitation unit, and will eventually be offered to all departments providing patient care.
Conclusions: Aromatherapy is a viable intervention for improving various symptoms and is used effectively with patients with cancer primarily as supportive care (Aromatherapy and Essential Oils [PDQ®]: Health Professional Version, 2018). Oncology nurses can provide aromatherapy safely, inexpensively, and with minimal training, as an effective therapy in lessening many symptoms that cancer and end of life patients experience (Blackburn et al, 2017).
Trends in Cancer Incidence and Survival in the Veterans Health Administration
Background: Cancer diagnoses in the Veterans Affairs (VA) Health Care System (HCS) account for approximately 3% of all US cancer diagnoses each year. Certain cancer types disproportionately affect veterans. Many factors contribute to changes in cancer incidence and survival among veterans, including screening guidelines and practices, treatment advances, as well as changing demographics of the veteran population and VA HCS users.
Purpose: The specific objectives of this analysis were to evaluate trends in cancer incidence and 5-year overall and cancer-specific survival among veterans.
Methods: We conducted a retrospective analysis of patients diagnosed with 15 select cancers between 2002 and 2014 that were identified in the VA Central Cancer Registry. Age-adjusted incidence rates were calculated based on the US 2000 population estimates and VHA user population. 5-year survival was calculated using the Kaplan-Meier method.
Results: Of the 15 selected cancers, overall decreases in incidence were noted for the following cancers: bladder, brain, colorectal, esophageal, head & neck, leukemia, lung, lymphoma, melanoma, and prostate. Most pronounced changes were observed for colorectal, lung, and prostate cancers. Relatively small net increases in incidence were observed for breast, kidney, liver, myeloma, and pancreas cancers. Among these 15 select cancers, the highest 5-year overall survival (OS) rates were observed for melanoma, prostate, and breast cancers (all > 70%), whereas the lowest OS rates were noted for pancreas, brain, esophagus, lung, and liver cancers (all 20%). Between 2002-2014, OS rates improved for all cancers except for the following that remained relatively stable: brain (11%), leukemia (47%), and melanoma (72%). OS rates improved the most for head & neck cancer (37% to 47%) and myeloma (32% to 40%).
Conclusions: For the 15 cancers evaluated in this report among veterans, between 2002-2014 most cancer incidence rates have decreased and survival rates for most cancers have improved over time.
Background: Cancer diagnoses in the Veterans Affairs (VA) Health Care System (HCS) account for approximately 3% of all US cancer diagnoses each year. Certain cancer types disproportionately affect veterans. Many factors contribute to changes in cancer incidence and survival among veterans, including screening guidelines and practices, treatment advances, as well as changing demographics of the veteran population and VA HCS users.
Purpose: The specific objectives of this analysis were to evaluate trends in cancer incidence and 5-year overall and cancer-specific survival among veterans.
Methods: We conducted a retrospective analysis of patients diagnosed with 15 select cancers between 2002 and 2014 that were identified in the VA Central Cancer Registry. Age-adjusted incidence rates were calculated based on the US 2000 population estimates and VHA user population. 5-year survival was calculated using the Kaplan-Meier method.
Results: Of the 15 selected cancers, overall decreases in incidence were noted for the following cancers: bladder, brain, colorectal, esophageal, head & neck, leukemia, lung, lymphoma, melanoma, and prostate. Most pronounced changes were observed for colorectal, lung, and prostate cancers. Relatively small net increases in incidence were observed for breast, kidney, liver, myeloma, and pancreas cancers. Among these 15 select cancers, the highest 5-year overall survival (OS) rates were observed for melanoma, prostate, and breast cancers (all > 70%), whereas the lowest OS rates were noted for pancreas, brain, esophagus, lung, and liver cancers (all 20%). Between 2002-2014, OS rates improved for all cancers except for the following that remained relatively stable: brain (11%), leukemia (47%), and melanoma (72%). OS rates improved the most for head & neck cancer (37% to 47%) and myeloma (32% to 40%).
Conclusions: For the 15 cancers evaluated in this report among veterans, between 2002-2014 most cancer incidence rates have decreased and survival rates for most cancers have improved over time.
Background: Cancer diagnoses in the Veterans Affairs (VA) Health Care System (HCS) account for approximately 3% of all US cancer diagnoses each year. Certain cancer types disproportionately affect veterans. Many factors contribute to changes in cancer incidence and survival among veterans, including screening guidelines and practices, treatment advances, as well as changing demographics of the veteran population and VA HCS users.
Purpose: The specific objectives of this analysis were to evaluate trends in cancer incidence and 5-year overall and cancer-specific survival among veterans.
Methods: We conducted a retrospective analysis of patients diagnosed with 15 select cancers between 2002 and 2014 that were identified in the VA Central Cancer Registry. Age-adjusted incidence rates were calculated based on the US 2000 population estimates and VHA user population. 5-year survival was calculated using the Kaplan-Meier method.
Results: Of the 15 selected cancers, overall decreases in incidence were noted for the following cancers: bladder, brain, colorectal, esophageal, head & neck, leukemia, lung, lymphoma, melanoma, and prostate. Most pronounced changes were observed for colorectal, lung, and prostate cancers. Relatively small net increases in incidence were observed for breast, kidney, liver, myeloma, and pancreas cancers. Among these 15 select cancers, the highest 5-year overall survival (OS) rates were observed for melanoma, prostate, and breast cancers (all > 70%), whereas the lowest OS rates were noted for pancreas, brain, esophagus, lung, and liver cancers (all 20%). Between 2002-2014, OS rates improved for all cancers except for the following that remained relatively stable: brain (11%), leukemia (47%), and melanoma (72%). OS rates improved the most for head & neck cancer (37% to 47%) and myeloma (32% to 40%).
Conclusions: For the 15 cancers evaluated in this report among veterans, between 2002-2014 most cancer incidence rates have decreased and survival rates for most cancers have improved over time.
Standardization of the Discharge Process for Inpatient Hematology and Oncology
Purpose/Rationale: To standardize the discharge process for the hematology/oncology inpatient service at Hines VA Hospital to improve the transition of care
Background: The landmark 1999 report from the Institute of Medicine, To Err is Human, identified the impact of medical error on mortality and morbidity. Medical errors tend to occur during transitions of care. At Hines VA Hospital, a multidisciplinary team delivers specialized care to veterans on the hematology/oncology service. However, resident physicians staffing the inpatient hematology/oncology service may be unfamiliar with the unique needs of the service and population. Currently there is no standardized discharge process in place. Prior studies have demonstrated improved outcomes following standardization of the discharge process for hematology patients. The authors aim to develop and implement a standardized discharge process to minimize risk for medical error.
Method/Approach: A multidisciplinary team of hematology and oncology staff was formed, including attending physicians, fellows, residents, advanced practice nurses, registered nurses, clinical pharmacists, and patient care coordinators, and several interviews were conducted. A standardized discharge process was developed in the form of guidelines and expectations. These include an explanation of unique features of the hematology/oncology service and expectations of medication reconciliation with emphasis placed on antiemetics, antimicrobial prophylaxis, and bowel regimen when appropriate, ambulatory hematology/oncology follow up within 1-2 weeks, primary care followup, communication with ambulatory hematology/oncology physician, written discharge instructions, and bedside teaching when appropriate. The standardized process will be taught to rotating resident physicians in the form of both online orientation and an in-person orientation. Outcome measures were identified including key components of medication reconciliation, time to hematology & oncology clinic visit, time to primary care visit, communication of discharge with outpatient hematology/oncology physician, and 30-day readmission rate.
Conclusions: All patients discharged during the twomonth period prior to and all patients discharged after the implementation of the standardized process will be reviewed; the above-mentioned variables will be recorded. Outcomes will be compared. Interim multidisciplinary team focus group meetings will be held every quarter to review and refine the process.
Purpose/Rationale: To standardize the discharge process for the hematology/oncology inpatient service at Hines VA Hospital to improve the transition of care
Background: The landmark 1999 report from the Institute of Medicine, To Err is Human, identified the impact of medical error on mortality and morbidity. Medical errors tend to occur during transitions of care. At Hines VA Hospital, a multidisciplinary team delivers specialized care to veterans on the hematology/oncology service. However, resident physicians staffing the inpatient hematology/oncology service may be unfamiliar with the unique needs of the service and population. Currently there is no standardized discharge process in place. Prior studies have demonstrated improved outcomes following standardization of the discharge process for hematology patients. The authors aim to develop and implement a standardized discharge process to minimize risk for medical error.
Method/Approach: A multidisciplinary team of hematology and oncology staff was formed, including attending physicians, fellows, residents, advanced practice nurses, registered nurses, clinical pharmacists, and patient care coordinators, and several interviews were conducted. A standardized discharge process was developed in the form of guidelines and expectations. These include an explanation of unique features of the hematology/oncology service and expectations of medication reconciliation with emphasis placed on antiemetics, antimicrobial prophylaxis, and bowel regimen when appropriate, ambulatory hematology/oncology follow up within 1-2 weeks, primary care followup, communication with ambulatory hematology/oncology physician, written discharge instructions, and bedside teaching when appropriate. The standardized process will be taught to rotating resident physicians in the form of both online orientation and an in-person orientation. Outcome measures were identified including key components of medication reconciliation, time to hematology & oncology clinic visit, time to primary care visit, communication of discharge with outpatient hematology/oncology physician, and 30-day readmission rate.
Conclusions: All patients discharged during the twomonth period prior to and all patients discharged after the implementation of the standardized process will be reviewed; the above-mentioned variables will be recorded. Outcomes will be compared. Interim multidisciplinary team focus group meetings will be held every quarter to review and refine the process.
Purpose/Rationale: To standardize the discharge process for the hematology/oncology inpatient service at Hines VA Hospital to improve the transition of care
Background: The landmark 1999 report from the Institute of Medicine, To Err is Human, identified the impact of medical error on mortality and morbidity. Medical errors tend to occur during transitions of care. At Hines VA Hospital, a multidisciplinary team delivers specialized care to veterans on the hematology/oncology service. However, resident physicians staffing the inpatient hematology/oncology service may be unfamiliar with the unique needs of the service and population. Currently there is no standardized discharge process in place. Prior studies have demonstrated improved outcomes following standardization of the discharge process for hematology patients. The authors aim to develop and implement a standardized discharge process to minimize risk for medical error.
Method/Approach: A multidisciplinary team of hematology and oncology staff was formed, including attending physicians, fellows, residents, advanced practice nurses, registered nurses, clinical pharmacists, and patient care coordinators, and several interviews were conducted. A standardized discharge process was developed in the form of guidelines and expectations. These include an explanation of unique features of the hematology/oncology service and expectations of medication reconciliation with emphasis placed on antiemetics, antimicrobial prophylaxis, and bowel regimen when appropriate, ambulatory hematology/oncology follow up within 1-2 weeks, primary care followup, communication with ambulatory hematology/oncology physician, written discharge instructions, and bedside teaching when appropriate. The standardized process will be taught to rotating resident physicians in the form of both online orientation and an in-person orientation. Outcome measures were identified including key components of medication reconciliation, time to hematology & oncology clinic visit, time to primary care visit, communication of discharge with outpatient hematology/oncology physician, and 30-day readmission rate.
Conclusions: All patients discharged during the twomonth period prior to and all patients discharged after the implementation of the standardized process will be reviewed; the above-mentioned variables will be recorded. Outcomes will be compared. Interim multidisciplinary team focus group meetings will be held every quarter to review and refine the process.
Genomic Medicine Service Uses Group Telehealth Appointments to Reduce Wait Times From 5 Months To ~1 Week
Purpose/Rationale: Genomic Medicine Service (GMS) fields 100+ consults weekly. Due to an increase in the number of consults received, without an equal increase in staffing, the wait time for a non-urgent appointment approached 6 months. We explored the use of Group Telehealth
appointments (GTAs) for individuals referred for a family history of breast cancer as one way to reduce these wait times.
Background: While oncology specializes in those with cancer, they are often asked to see unaffected individuals with a family history of cancer who need risk assessments, management recommendations, and/or genetic testing. Many of these are then referred to GMS.
GMS uses the VA telehealth infrastructure to provide genetic evaluation to 84 VAMCs. We typically schedule appointments for one-hour, with an inability to double book due to the limitations of multi-site telehealth. As risk assessment for unaffected individuals is not urgent, these Veterans were scheduled routinely. As GMS got busier, wait times for routine appointments approached 6 months.
Methods/Approach: As part of a Leadership Development Institute, one of the authors (RAR) conceived and implemented a process whereby we held GTAs for unaffected individuals with family histories of breast cancer for whom we would most likely recommend testing an affected
relative. Before the GTA, we mailed a Breast Cancer Risk Assessment (BCRA) form to collect personal/family history. Patients who complete the GTA and BCRA were sent letters that included risk assessments and testing and screening recommendations. 4 GTAs are held each month.
We recorded the number of patients scheduled, appointments attended, and BCRA forms returned. The presentation will review results of an initial 3-month period, during which we held 14 GTAs with 97 patients scheduled, 65 seen, and 58 who turned in BCRAs. We compared time
spent on patients, documentation, and risk assessment in GTAs with the time needed for individual visits for the same number of people. We modeled time saved under a range of assumptions.
Conclusions: Our GTAs were successful, allowing our providers to more efficiently use their time and reducing our wait times. We have expanded our GTAs to include non-breast cancers and reasons for referral.
Purpose/Rationale: Genomic Medicine Service (GMS) fields 100+ consults weekly. Due to an increase in the number of consults received, without an equal increase in staffing, the wait time for a non-urgent appointment approached 6 months. We explored the use of Group Telehealth
appointments (GTAs) for individuals referred for a family history of breast cancer as one way to reduce these wait times.
Background: While oncology specializes in those with cancer, they are often asked to see unaffected individuals with a family history of cancer who need risk assessments, management recommendations, and/or genetic testing. Many of these are then referred to GMS.
GMS uses the VA telehealth infrastructure to provide genetic evaluation to 84 VAMCs. We typically schedule appointments for one-hour, with an inability to double book due to the limitations of multi-site telehealth. As risk assessment for unaffected individuals is not urgent, these Veterans were scheduled routinely. As GMS got busier, wait times for routine appointments approached 6 months.
Methods/Approach: As part of a Leadership Development Institute, one of the authors (RAR) conceived and implemented a process whereby we held GTAs for unaffected individuals with family histories of breast cancer for whom we would most likely recommend testing an affected
relative. Before the GTA, we mailed a Breast Cancer Risk Assessment (BCRA) form to collect personal/family history. Patients who complete the GTA and BCRA were sent letters that included risk assessments and testing and screening recommendations. 4 GTAs are held each month.
We recorded the number of patients scheduled, appointments attended, and BCRA forms returned. The presentation will review results of an initial 3-month period, during which we held 14 GTAs with 97 patients scheduled, 65 seen, and 58 who turned in BCRAs. We compared time
spent on patients, documentation, and risk assessment in GTAs with the time needed for individual visits for the same number of people. We modeled time saved under a range of assumptions.
Conclusions: Our GTAs were successful, allowing our providers to more efficiently use their time and reducing our wait times. We have expanded our GTAs to include non-breast cancers and reasons for referral.
Purpose/Rationale: Genomic Medicine Service (GMS) fields 100+ consults weekly. Due to an increase in the number of consults received, without an equal increase in staffing, the wait time for a non-urgent appointment approached 6 months. We explored the use of Group Telehealth
appointments (GTAs) for individuals referred for a family history of breast cancer as one way to reduce these wait times.
Background: While oncology specializes in those with cancer, they are often asked to see unaffected individuals with a family history of cancer who need risk assessments, management recommendations, and/or genetic testing. Many of these are then referred to GMS.
GMS uses the VA telehealth infrastructure to provide genetic evaluation to 84 VAMCs. We typically schedule appointments for one-hour, with an inability to double book due to the limitations of multi-site telehealth. As risk assessment for unaffected individuals is not urgent, these Veterans were scheduled routinely. As GMS got busier, wait times for routine appointments approached 6 months.
Methods/Approach: As part of a Leadership Development Institute, one of the authors (RAR) conceived and implemented a process whereby we held GTAs for unaffected individuals with family histories of breast cancer for whom we would most likely recommend testing an affected
relative. Before the GTA, we mailed a Breast Cancer Risk Assessment (BCRA) form to collect personal/family history. Patients who complete the GTA and BCRA were sent letters that included risk assessments and testing and screening recommendations. 4 GTAs are held each month.
We recorded the number of patients scheduled, appointments attended, and BCRA forms returned. The presentation will review results of an initial 3-month period, during which we held 14 GTAs with 97 patients scheduled, 65 seen, and 58 who turned in BCRAs. We compared time
spent on patients, documentation, and risk assessment in GTAs with the time needed for individual visits for the same number of people. We modeled time saved under a range of assumptions.
Conclusions: Our GTAs were successful, allowing our providers to more efficiently use their time and reducing our wait times. We have expanded our GTAs to include non-breast cancers and reasons for referral.
Optimization of Palliative Oncology Care Within the VA Healthcare System–Assessing the Availability of Outpatient Palliative Care Within VA Oncology Clinic
Purpose: Palliative care is essential to oncology. The purpose of this project was to characterize the interface between VA oncologists and palliative care specialists in the outpatient setting and to identify barriers to outpatient palliative oncology care in the VA.
Background: The American Society of Clinical Oncology (ASCO) recommends palliative care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. The VA mandates palliative care inpatient consult teams for all medical facilities. It is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. The 2016 VHA Cancer Care Survey was a comprehensive assessment of 140 VA facilities regarding their cancer care infrastructure. On this survey, 23% of sites (N=32) reported that they were not able to provide adequate palliative oncology care in the outpatient setting.
Methods: We contacted clinicians at each of these 32 sites to characterize the outpatient oncology/palliative care interface and identify potential barriers.
Results: Of the 32 sites, 17 reported that they provided limited oncologic care and generally referred patients to other facilities for cancer treatment. The remaining 15 sites reported providing full oncology services. These 15 sites employed a variety of methods to engage palliative care specialists. These included referring patients to a separate outpatient palliative care clinic or a home-based provider; consulting the inpatient palliative care team to evaluate the patient while in the cancer clinic; working with an oncology social worker; or arranging a tele-consult with a remote palliative care specialist. Barriers to providing outpatient palliative care included not enough palliative care staff, not enough clinic space, and patients or oncologists declining a palliative care referral. Clinicians expressed that they would provide more outpatient palliative care if they
had more palliative care staff, more clinic space, and more palliative care training for oncologists.
Conclusions: This project identified that some sites have found creative approaches to providing outpatient palliative oncology care. In addition, clinicians emphasized the ongoing need for additional specialty palliative care staff, primary palliative care training for oncologists, and clinic space in order to provide optimal outpatient palliative oncology care for VA patients.
Purpose: Palliative care is essential to oncology. The purpose of this project was to characterize the interface between VA oncologists and palliative care specialists in the outpatient setting and to identify barriers to outpatient palliative oncology care in the VA.
Background: The American Society of Clinical Oncology (ASCO) recommends palliative care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. The VA mandates palliative care inpatient consult teams for all medical facilities. It is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. The 2016 VHA Cancer Care Survey was a comprehensive assessment of 140 VA facilities regarding their cancer care infrastructure. On this survey, 23% of sites (N=32) reported that they were not able to provide adequate palliative oncology care in the outpatient setting.
Methods: We contacted clinicians at each of these 32 sites to characterize the outpatient oncology/palliative care interface and identify potential barriers.
Results: Of the 32 sites, 17 reported that they provided limited oncologic care and generally referred patients to other facilities for cancer treatment. The remaining 15 sites reported providing full oncology services. These 15 sites employed a variety of methods to engage palliative care specialists. These included referring patients to a separate outpatient palliative care clinic or a home-based provider; consulting the inpatient palliative care team to evaluate the patient while in the cancer clinic; working with an oncology social worker; or arranging a tele-consult with a remote palliative care specialist. Barriers to providing outpatient palliative care included not enough palliative care staff, not enough clinic space, and patients or oncologists declining a palliative care referral. Clinicians expressed that they would provide more outpatient palliative care if they
had more palliative care staff, more clinic space, and more palliative care training for oncologists.
Conclusions: This project identified that some sites have found creative approaches to providing outpatient palliative oncology care. In addition, clinicians emphasized the ongoing need for additional specialty palliative care staff, primary palliative care training for oncologists, and clinic space in order to provide optimal outpatient palliative oncology care for VA patients.
Purpose: Palliative care is essential to oncology. The purpose of this project was to characterize the interface between VA oncologists and palliative care specialists in the outpatient setting and to identify barriers to outpatient palliative oncology care in the VA.
Background: The American Society of Clinical Oncology (ASCO) recommends palliative care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. The VA mandates palliative care inpatient consult teams for all medical facilities. It is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. The 2016 VHA Cancer Care Survey was a comprehensive assessment of 140 VA facilities regarding their cancer care infrastructure. On this survey, 23% of sites (N=32) reported that they were not able to provide adequate palliative oncology care in the outpatient setting.
Methods: We contacted clinicians at each of these 32 sites to characterize the outpatient oncology/palliative care interface and identify potential barriers.
Results: Of the 32 sites, 17 reported that they provided limited oncologic care and generally referred patients to other facilities for cancer treatment. The remaining 15 sites reported providing full oncology services. These 15 sites employed a variety of methods to engage palliative care specialists. These included referring patients to a separate outpatient palliative care clinic or a home-based provider; consulting the inpatient palliative care team to evaluate the patient while in the cancer clinic; working with an oncology social worker; or arranging a tele-consult with a remote palliative care specialist. Barriers to providing outpatient palliative care included not enough palliative care staff, not enough clinic space, and patients or oncologists declining a palliative care referral. Clinicians expressed that they would provide more outpatient palliative care if they
had more palliative care staff, more clinic space, and more palliative care training for oncologists.
Conclusions: This project identified that some sites have found creative approaches to providing outpatient palliative oncology care. In addition, clinicians emphasized the ongoing need for additional specialty palliative care staff, primary palliative care training for oncologists, and clinic space in order to provide optimal outpatient palliative oncology care for VA patients.
More than half of urine drug screens showed improper medication use
LAS VEGAS –
Of almost 4 million urine screens examined, 52% were discordant for the screen-ordered drugs, Jeffrey Gudin, MD, said at the annual PAINWeek. Most common was the combination of opioids and benzodiazepines, which accounted for 21% of the discordant samples – and, in 64% of these cases, at least one of the drugs was not prescribed.
“Drug testing is a standard of care in pain management, and it’s the only objective way to know what patients are really taking,” said Dr. Gudin, director of pain and palliative care at Englewood (N.J.) Hospital and Medical Center. “What this tells us is that, if we just ask our patients, half the time they won’t tell you the whole story. More than 50% of the time things don’t match up. To me this is just unbelievable.”
Quest Diagnostics compiled these data, and many more, in its “Health Trends Report: Drug Misuse in America 2018.”
The report examines 3.9 million routine drug screens ordered by primary care and pain physicians during 2011-2017. It not only looks at prescription drug use and misuse but also tracks illicit drugs in both general and substance abuse patient populations. The findings reported at PAINWeek were based on 456,675 screens from 276,953 patients conducted in 2017. These results were included in the Quest Diagnostics medMATCH reports, which indicated what tested drugs were prescribed and whether these drugs were detected in the specimen.
The following were found among the discordant screens identified in 2017:
- 45% were positive for nonprescribed or illicit drugs in addition to all the prescribed drugs.
- 34% did not show all the drugs they had been prescribed, or any other tested drug.
- 22% did not show all the drugs they had been prescribed but were positive for other illicit or nonprescribed drugs.
The tests were ordered as a part of routine care – an important point, Dr. Gudin said in an interview. “These are not ‘gotcha tests,’ ” intended to catch patients unawares. “These are regularly ordered screens that are standard of care in pain management.”
The report found that men and women were equally likely to misuse medications (52% each). There were some age-related differences, with misuse peaking in young adulthood: 60% of 18- to 24-year-olds and 56% of 25- to 45-year-olds. Misuse dropped off in those aged 55-64 years (52%) and in those 65 years and older (43%). But even children showed evidence of medication misuse, with about 41% of samples from children aged 10 years and younger being discordant.
The rates of misuse were about 50% in Medicare and private pay patients, but around 65% in Medicaid patients.
There was some good news: In the general patient population, opioid use was down by 12% from 2016 – the largest annual decrease Quest has noted since 2012. Several factors probably contributed to that decline, including shifts in clinical care and payer reimbursement, as well as regulatory and legislative restrictions.
“This shows that we’re doing better on the pain management front,” Dr. Gudin said. “But in substance use disorder settings, we saw 400% increases for both fentanyl and heroin. The addiction front it out of control.”
More than 27% of all specimens that came from substance abuse treatment centers were positive for nonprescribed fentanyl and 10% were positive for heroin. “We also saw that, in 2016, 45% of those heroin-positive samples had fentanyl in them, and in 2017, 83% did.”
Although not discussed at PAINWeek, the report also noted a rise in gabapentin misuse. The antiepileptic is now the 10th most commonly prescribed drug in the United States, the report noted, with 68 million prescriptions dispensed last year. The report found that 9.5% of tests showed nonprescription gabapentin. In the subset of samples obtained from substance abuse treatment centers, gabapentin misuse increased by 800% from 2016 – the most dramatic increase of any of the tracked drugs.
The combination of gabapentin and opioids is risky, the report noted. Opioid-related deaths are 49% more common among those taking both than those taking opioids only.
SOURCE: Gudin J et al. PAINWeek 2018, abstract 44.
LAS VEGAS –
Of almost 4 million urine screens examined, 52% were discordant for the screen-ordered drugs, Jeffrey Gudin, MD, said at the annual PAINWeek. Most common was the combination of opioids and benzodiazepines, which accounted for 21% of the discordant samples – and, in 64% of these cases, at least one of the drugs was not prescribed.
“Drug testing is a standard of care in pain management, and it’s the only objective way to know what patients are really taking,” said Dr. Gudin, director of pain and palliative care at Englewood (N.J.) Hospital and Medical Center. “What this tells us is that, if we just ask our patients, half the time they won’t tell you the whole story. More than 50% of the time things don’t match up. To me this is just unbelievable.”
Quest Diagnostics compiled these data, and many more, in its “Health Trends Report: Drug Misuse in America 2018.”
The report examines 3.9 million routine drug screens ordered by primary care and pain physicians during 2011-2017. It not only looks at prescription drug use and misuse but also tracks illicit drugs in both general and substance abuse patient populations. The findings reported at PAINWeek were based on 456,675 screens from 276,953 patients conducted in 2017. These results were included in the Quest Diagnostics medMATCH reports, which indicated what tested drugs were prescribed and whether these drugs were detected in the specimen.
The following were found among the discordant screens identified in 2017:
- 45% were positive for nonprescribed or illicit drugs in addition to all the prescribed drugs.
- 34% did not show all the drugs they had been prescribed, or any other tested drug.
- 22% did not show all the drugs they had been prescribed but were positive for other illicit or nonprescribed drugs.
The tests were ordered as a part of routine care – an important point, Dr. Gudin said in an interview. “These are not ‘gotcha tests,’ ” intended to catch patients unawares. “These are regularly ordered screens that are standard of care in pain management.”
The report found that men and women were equally likely to misuse medications (52% each). There were some age-related differences, with misuse peaking in young adulthood: 60% of 18- to 24-year-olds and 56% of 25- to 45-year-olds. Misuse dropped off in those aged 55-64 years (52%) and in those 65 years and older (43%). But even children showed evidence of medication misuse, with about 41% of samples from children aged 10 years and younger being discordant.
The rates of misuse were about 50% in Medicare and private pay patients, but around 65% in Medicaid patients.
There was some good news: In the general patient population, opioid use was down by 12% from 2016 – the largest annual decrease Quest has noted since 2012. Several factors probably contributed to that decline, including shifts in clinical care and payer reimbursement, as well as regulatory and legislative restrictions.
“This shows that we’re doing better on the pain management front,” Dr. Gudin said. “But in substance use disorder settings, we saw 400% increases for both fentanyl and heroin. The addiction front it out of control.”
More than 27% of all specimens that came from substance abuse treatment centers were positive for nonprescribed fentanyl and 10% were positive for heroin. “We also saw that, in 2016, 45% of those heroin-positive samples had fentanyl in them, and in 2017, 83% did.”
Although not discussed at PAINWeek, the report also noted a rise in gabapentin misuse. The antiepileptic is now the 10th most commonly prescribed drug in the United States, the report noted, with 68 million prescriptions dispensed last year. The report found that 9.5% of tests showed nonprescription gabapentin. In the subset of samples obtained from substance abuse treatment centers, gabapentin misuse increased by 800% from 2016 – the most dramatic increase of any of the tracked drugs.
The combination of gabapentin and opioids is risky, the report noted. Opioid-related deaths are 49% more common among those taking both than those taking opioids only.
SOURCE: Gudin J et al. PAINWeek 2018, abstract 44.
LAS VEGAS –
Of almost 4 million urine screens examined, 52% were discordant for the screen-ordered drugs, Jeffrey Gudin, MD, said at the annual PAINWeek. Most common was the combination of opioids and benzodiazepines, which accounted for 21% of the discordant samples – and, in 64% of these cases, at least one of the drugs was not prescribed.
“Drug testing is a standard of care in pain management, and it’s the only objective way to know what patients are really taking,” said Dr. Gudin, director of pain and palliative care at Englewood (N.J.) Hospital and Medical Center. “What this tells us is that, if we just ask our patients, half the time they won’t tell you the whole story. More than 50% of the time things don’t match up. To me this is just unbelievable.”
Quest Diagnostics compiled these data, and many more, in its “Health Trends Report: Drug Misuse in America 2018.”
The report examines 3.9 million routine drug screens ordered by primary care and pain physicians during 2011-2017. It not only looks at prescription drug use and misuse but also tracks illicit drugs in both general and substance abuse patient populations. The findings reported at PAINWeek were based on 456,675 screens from 276,953 patients conducted in 2017. These results were included in the Quest Diagnostics medMATCH reports, which indicated what tested drugs were prescribed and whether these drugs were detected in the specimen.
The following were found among the discordant screens identified in 2017:
- 45% were positive for nonprescribed or illicit drugs in addition to all the prescribed drugs.
- 34% did not show all the drugs they had been prescribed, or any other tested drug.
- 22% did not show all the drugs they had been prescribed but were positive for other illicit or nonprescribed drugs.
The tests were ordered as a part of routine care – an important point, Dr. Gudin said in an interview. “These are not ‘gotcha tests,’ ” intended to catch patients unawares. “These are regularly ordered screens that are standard of care in pain management.”
The report found that men and women were equally likely to misuse medications (52% each). There were some age-related differences, with misuse peaking in young adulthood: 60% of 18- to 24-year-olds and 56% of 25- to 45-year-olds. Misuse dropped off in those aged 55-64 years (52%) and in those 65 years and older (43%). But even children showed evidence of medication misuse, with about 41% of samples from children aged 10 years and younger being discordant.
The rates of misuse were about 50% in Medicare and private pay patients, but around 65% in Medicaid patients.
There was some good news: In the general patient population, opioid use was down by 12% from 2016 – the largest annual decrease Quest has noted since 2012. Several factors probably contributed to that decline, including shifts in clinical care and payer reimbursement, as well as regulatory and legislative restrictions.
“This shows that we’re doing better on the pain management front,” Dr. Gudin said. “But in substance use disorder settings, we saw 400% increases for both fentanyl and heroin. The addiction front it out of control.”
More than 27% of all specimens that came from substance abuse treatment centers were positive for nonprescribed fentanyl and 10% were positive for heroin. “We also saw that, in 2016, 45% of those heroin-positive samples had fentanyl in them, and in 2017, 83% did.”
Although not discussed at PAINWeek, the report also noted a rise in gabapentin misuse. The antiepileptic is now the 10th most commonly prescribed drug in the United States, the report noted, with 68 million prescriptions dispensed last year. The report found that 9.5% of tests showed nonprescription gabapentin. In the subset of samples obtained from substance abuse treatment centers, gabapentin misuse increased by 800% from 2016 – the most dramatic increase of any of the tracked drugs.
The combination of gabapentin and opioids is risky, the report noted. Opioid-related deaths are 49% more common among those taking both than those taking opioids only.
SOURCE: Gudin J et al. PAINWeek 2018, abstract 44.
REPORTING FROM PAINWEEK 2018
Key clinical point: More than half of patients undergoing urine drug screens were misusing medications.
Major finding: The samples were discordant for the queried drug in 52% of samples.
Study details: The study was based on 3.9 million drug screens ordered during 2011-2017.
Disclosures: The findings were included in Quest Diagnostics’ “Health Trends Report: Drug Misuse in America 2018.”
Source: Gudin J et al. PAINWeek, Abstract 44.