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Palliative Care in Oncology: Identifying Gaps and Informing Practice Change

This study aims to improve the delivery of palliative care in oncology by identifying gaps, understanding determinants, and informing scalable practice change. It will leverage new data and stakeholder engagement to advance understanding of gaps and inform practice improvement priorities.

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Palliative Care in Oncology: Identifying Gaps and Informing Practice Change

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  1. Improving Delivery of Palliative Care in Oncology Identifying gaps, understanding determinants, and informing scalable practice change Devon K. Check, PhD Delivery Science Fellow Kaiser Permanente of Northern California Division of Research Kaiser Permanente Research

  2. Roadmap • Introduction • Prior work: Identifying gaps in delivery of evidence-based palliative care • Current work: Advancing understanding of gaps and informing practice improvement priorities by leveraging new data and stakeholder engagement • Future directions: Supporting equitable, population-based palliative care delivery through applying principles of implementation science

  3. Roadmap • Introduction • Prior work: Identifying gaps in delivery of evidence-based palliative care • Current work: Advancing understanding of gaps and informing practice improvement priorities by leveraging new data and stakeholder engagement • Future directions: Supporting equitable, population-based palliative care delivery through applying principles of implementation science

  4. Roadmap • Introduction • Prior work: Identifying gaps in delivery of evidence-based palliative care • Current work: Advancing understanding of gaps and informing practice improvement priorities by leveraging new data and stakeholder engagement • Future directions: Supporting equitable, population-based palliative care delivery through applying principles of implementation science

  5. Roadmap • Introduction • Prior work: Identifying gaps in delivery of evidence-based palliative care • Current work: Advancing understanding of gaps and informing practice improvement priorities by leveraging new data and stakeholder engagement • Future directions: Supporting equitable, population-based palliative care delivery through applying principles of implementation science

  6. Academic and Professional History 2010-2012 2012-2016 2016-Present 2006-2010

  7. Early Experiences with Advanced Cancer and Palliative Care Research • Understanding Patient Expectations of Benefit from Participation in Early-Phase Oncology Trials • Fathers and Mothers with Advanced Cancer

  8. Research Interests Symptom management Prognostic understanding Treatment decision-making

  9. Research Interests Implementing evidence-based care in practice Generating evidence Improving outcomes

  10. Roadmap • Introduction • Prior work: Identifying gaps in delivery of evidence-based palliative care • Current work: Advancing understanding of gaps and informing practice improvement priorities by leveraging new data and stakeholder engagement • Future directions: Supporting equitable, population-based palliative care delivery through applying principles of implementation science

  11. Patients with advanced cancer should be referred to interdisciplinary palliative care teams (consultation) that provide inpatient and outpatient care early in the course of disease, alongside active treatment of their cancer (Type: evidence-based, benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: strong) 2012 guideline; updated 2017

  12. Palliative Care Disparities • Compared to white patients, black patients: • Report more severe pain, greater decrements in physical functioning, more unmet supportive care needs • Are less likely to enter, more likely to dis-enroll from hospice • Evidence gaps: • Factors underlying documented disparities • Disparities in non-hospice-based palliative care Early palliative care Johnson, J Palliat Med, 2013

  13. Are there racial differences in early receipt of supportive medication use, as an indicator of early palliative care?

  14. Approach • Data: SEER-Medicare, 2006-2012 • Cohort: Black (N=131) or white women (N=752) dx with stage IV breast cancer • Analysis: Modified Poisson regression to examine the relationship between race and early use of supportive medications (within 90 days of dx)? • Primary model covariates: Cancer tx received, previous mental health dx, previous supportive medication use, age, dx year • Secondary model covariates: Area-level SES, marital status, region, urbanization

  15. Differences in use of some medications aRR: 0.94 (95% CI: 0.83-1.07) aRR: 0.97 (95% CI: 0.84-1.13) aRR: 0.56 (95% CI: 0.39-0.80) Check et al., J ClinOncol, 2016

  16. Palliative Care in Early-Stage Cancer • Treatment-related symptoms are a major concern • If not managed, can result in: • Poor health-related quality of life • Avoidable, high-cost utilization • Treatment delays and non-adherence  Suboptimal survival

  17. Patients who receive highly emetic chemotherapy regimens should receive the three-drug combination of a neurokinin 1 (NK1) antagonist, 5-hydroxytryptamine-3 (5-HT3) antagonist, and dexamethasone. 2006 guideline; updated 2011

  18. Potential Barriers to NK1 Use • Cost ($500 per chemotherapy cycle) • Convenience (fill at home pharmacy for each cycle) • Provider knowledge of, agreement with guidelines May disproportionately affect racial/ethnic minority patients.

  19. Are there racial differences in use of NK1s to prevent chemotherapy-induced nausea and vomiting?

  20. Approach • Data: SEER-Medicare, 2006-2012 • Cohort: Black (115) or white (N=1,015) women, dx with stage I-III breast cancer; received high-risk chemo regimen • Analysis: Modified Poisson regression to examine the relationship between race and NK1 use • Primary model covariates:Age, dx year, tumor characteristics, comorbidity • Secondary model covariates: Area-level SES, marital status, drug copay assistance, region, urbanization

  21. Racial differences in oral NK1 use aRR: 0.68 (95% CI: 0.51-0.91) aRR: 0.54 (95% CI: 0.35-0.83) aRR: 0.82 (95% CI: 0.51-1.33) Check et al., Breast Cancer Res Treat, 2016

  22. Conclusions from Prior Work • Racial differences in use of several symptom-directed treatments -- important part of basic palliative care • Potential role for access and cost as determinants of differences in antiemetic use • No disparity in IV vs. oral drug • Slight effect attenuation with inclusion of SES

  23. Goals for Post-dissertation Work • Identify opportunities to improve other aspects of palliative care delivery, outcomes • Data on services use, and patient-reported outcomes • Advance understanding of potential determinants of gaps in palliative care delivery • Data on multi-level, modifiable factors • Use research to help health systems learn and improve • Strategic stakeholder engagement (clinical and operations leaders)

  24. Goals for Post-dissertation Work • Identify opportunities to improve other aspects of palliative care delivery, outcomes • Data on services use, and patient-reported outcomes • Advance understanding of potential determinants of gaps in palliative care delivery • Data on multi-level, modifiable factors • Use research to help health systems learn and improve • Strategic stakeholder engagement (clinical and operations leaders)

  25. Goals for Post-dissertation Work • Identify opportunities to improve other aspects of palliative care delivery, outcomes • Data on services use, and patient-reported outcomes • Advance understanding of potential determinants of gaps in palliative care delivery • Data on multi-level, modifiable factors • Use research to help health systems learn and improve • Strategic stakeholder engagement (clinical and operations leaders)

  26. Roadmap • Introduction • Prior work: Identifying gaps in delivery of evidence-based palliative care • Current work: Advancing understanding of gaps and informing practice improvement priorities by leveraging new data and stakeholder engagement • Future directions: Supporting equitable, population-based palliative care delivery through applying principles of implementation science

  27. Kaiser Permanente (KP)

  28. Kaiser Permanente Northern California (KPNC) • Integrated delivery system • 4,135,975 members • 8,500 physicians • 21 hospitals • Connected EHR • Division of Research (NIH-funded)

  29. Cancer Section Mentors • Larry Kushi, ScD • Cancer Research Network (NCI U24CA171524) • Pathways Study - Breast Cancer Survivorship (NCI R01CA105274; U01CA195565) • Marilyn Kwan, PhD • BeWell Study - Bladder Cancer Survivorship (NCI R01CA172855)

  30. Completed and Ongoing Analyses • Check et al., Use of Perioperative Intravesical Chemotherapy for Patients with Non-Muscle Invasive Bladder Cancer: Examining Provider and Facility Level Variation in an Integrated Delivery System. Manuscript in progress. • Check et al., Examining the Role of Access to Care: Racial/Ethnic Differences in Receipt of Resection for Early-Stage Lung Cancer among Integrated System Members and Non-members. Under review.

  31. Funded Work at KPNC • Investigating Gaps in Guideline-Recommended Surveillance for Colorectal Cancer (CRC) Survivors (PI: Check, Awarded 04/01/2017) • Collaborators: Regional Director, Survivorship Care Tracking; Regional Lead, Cancer Survivorship Care • Objective: Understand region-wide patterns of surveillance for CRC survivors to help inform ongoing quality improvement • Abstract submitted to Health Care Systems Research Network (HCSRN) Meeting

  32. Understanding Racial/Ethnic Disparities in Physical Burden of Breast Cancer and its Treatment: The Role of Patient-Provider Interactions Check et al., In Progress. Accepted for poster presentation and recipient of Conquer Cancer Foundation Merit Award, ASCO Palliative and Supportive Care in Oncology Symposium, San Diego, CA, October 27-28, 2017.

  33. Symptom Management Disparities • Compared to white patients, black patients: • Report more severe pain, greater decrements in physical functioning, more unmet supportive care needs • Evidence gaps: • Modifiable factors underlying disparities (e.g., patient-provider communication) • Experiences of non-black minorities Johnson, J Palliat Med, 2013

  34. Do patient-provider interactions help to explain disparities in physical well-being, within a multi-ethnic cohort of women with breast cancer?

  35. Pathways • Prospective cohort study of 4,505 women diagnosed with invasive breast cancer at KPNC between 2006-2013 • Questionnaires at baseline, 6 mos, 24 mos, 72 mos • Measures • Physical well-being (PWB) from FACT-B (David Cella) • Patient-provider interactions: Interpersonal Processes of Care (IPC) Survey (Anita Stewart) • Compassion, Elicited Concerns, Lack of Clarity, Discrimination

  36. Approach • Data: Pathways study questionnaires linked with KPNC electronic record data • Cohort: White, Black, Hispanic, or Asian women who completed the PWB domain of the FACT-B • Analysis: Step-wise regression (GLM) • Naïve model: Race/ethnicity and PWB score • Added covariates sequentially (health + demographic, then IPC)

  37. Patient-provider interactions appear to partly explain disparities for Black and Asian women 1 Adjusted for tumor characteristics, comorbidity, demographic characteristics 2 Adjusted for tumor characteristics, comorbidity, demographic characteristics, IPC domains Check et al., In Progress. Accepted for poster presentation and recipient of Conquer Cancer Foundation Merit Award, ASCO Palliative and Supportive Care in Oncology Symposium, San Diego, CA, October 27-28, 2017.

  38. Goals for Post-dissertation Work • Identify opportunities to improve other aspects of palliative care delivery, outcomes • Data on services use, and patient-reported outcomes • Advance understanding of potential determinants of gaps in palliative care delivery • Data on multi-level, modifiable factors • Use research to help health systems learn and improve • Strategic stakeholder engagement (clinical and operations leaders in health systems)

  39. Goals for Post-dissertation Work • Identify opportunities to improve other aspects of palliative care delivery, outcomes • Data on services use, and patient-reported outcomes • Advance understanding of potential determinants of gaps in palliative care delivery • Data on multi-level, modifiable factors • Use research to help health systems learn and improve • Strategic stakeholder engagement (clinical and operations leaders in health systems)

  40. Supportive Care Services (SCS) at KPNC • Strengthening Specialty Palliative Care: Patient registry • Prospective ID of patients with limited life expectancy, to facilitate PCP referral to palliative care • Potential collaboration: Linkage to EMR data – Patterns of referral, uptake; impact on quality and value • Strengthening Primary Palliative Care: Goals of care communication skills training (VitalTalk) • From small RCTs, effective for improving physicians’ uptake of goals of care conversations in the short term • Future collaboration: Barriers, facilitators for implementation and sustainment across specialty groups

  41. Supportive Care Services (SCS) at KPNC • Strengthening Specialty Palliative Care: Patient registry • Prospective ID of patients with limited life expectancy, to facilitate PCP referral to palliative care • Future collaboration: Linkage to EMR data – Patterns of referral, uptake; impact on quality and value • Strengthening Primary Palliative Care: Goals of care communication skills training (VitalTalk) • From small RCTs, effective for improving physicians’ uptake of goals of care conversations in the short term • Future collaboration: Barriers, facilitators for implementation and sustainment across specialty groups

  42. Roadmap • Introduction • Prior work: Identifying gaps in delivery of evidence-based palliative care • Current work: Advancing understanding of gaps and informing practice improvement priorities by leveraging new data and stakeholder engagement • Future directions: Supporting equitable, population-based palliative care delivery through applying principles of implementation science

  43. Palliative care should be delivered through interdisciplinary specialist palliative care teams, with consultation available in both outpatient and inpatient settings. (Type: evidence-based, benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: moderate). 2012 guideline; updated 2017

  44. Translational Challenges • Inadequate, uneven access to palliative care specialists • Advanced cancer-related workload > workforce • Specialists concentrated in academic medical centers • An alternative, population-based approach • Palliative care as a shared responsibility • Non-specialists (e.g., oncology providers) are equipped to deliver key components of basic palliative care (primary palliative care) Schenker and Arnold, JAMA Oncology, 2017 Casarett and Teno, JAMA, 2016

  45. Role of Delivery & Implementation Science • We know that palliative care benefits patients and caregivers • Don’t yet know how to deliver it in a scalable, sustainable way • Who, what, when, where? • Need for research that: • Informs development of novel delivery strategies (stakeholder needs assessments) • Tests (comparative) effectiveness alongside implementation potential of delivery strategies (hybrid RCTs) • Adapts effective strategies for different delivery settings, populations

  46. Supporting Population-Based Palliative Care Delivery through Implementation Science • Professional goal: Become an independent implementation researcher • As PI: Focus on palliative, cancer care delivery • As Co-I: Lend relevant methodological expertise in other areas

  47. Supporting Population-Based Palliative Care Delivery through Implementation Science • Scientific goal: Improve access to and delivery of high-quality palliative care among patients with advanced cancer and other serious illnesses

  48. Opportunities at CU Denver Venues for collaboration • Center for Data Science to Patient Value (D2V) • Multidisciplinary research environment that emphasizes health system stakeholder engagement and translation • ACCORDS – D&I, Patient-Centered Decisions Cores Potential collaborators • Primary palliative care – David Bekelman • Patient-centered decision-making in advanced illness – Dan Matlock • Palliative care for underserved populations – Stacy Fischer

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