Palliative telecare significantly improves quality of life for those with chronic illnesses, and results last for months
When working with nurse and social worker virtually, trial participants with chronic heart and lung diseases report long-lasting improvements
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RESEARCHERS FROM THE UNIVERSITY OF COLORADO ANSCHUTZ MEDICAL CAMPUS HAVE FOUND THAT A TEAM INTERVENTION, PROVIDED BY PHONE, LEADS TO PERSISTENT IMPROVEMENTS IN DEPRESSION, ANXIETY, AND QUALITY OF LIFE FOR PEOPLE MANAGING CHRONIC ILLNESSES. ADDITIONALLY, RESEARCHERS FOUND THAT THE IMPROVEMENT IN QUALITY OF LIFE RESULTS LAST MONTHS AFTER INTERVENTION CONCLUDES.
view moreCREDIT: UNIVERSITY OF COLORADO ANSCHUTZ MEDICAL CAMPUS
AURORA, Colo. (January 16, 2024) – Researchers from the University of Colorado Anschutz Medical Campus have found that a team intervention, provided by phone, leads to persistent improvements in depression, anxiety, and quality of life for people managing chronic illnesses. Additionally, researchers found that the improvement in quality of life results last months after intervention concludes.
In a study, published today in JAMA, researchers observe the impact a telecare intervention program, called ADAPT, has on veterans suffering from poor quality of life as a result of existing chronic illnesses, such as chronic obstructive pulmonary disease (COPD), heart failure (HF) and interstitial lung disease (ILD). This program provides palliative care that is not widely available and tackles health concerns that may be missed in standard appointments. Nurses and social workers reach out to study participants with structured questions and assistance, then discuss responses with a team of doctors, including specialists, to determine how best to address concerns with follow-up calls to track progress.
“While we do a great job caring for these patients’ illnesses, we can do more for quality of life. Many have persistent symptoms, such as depression, anxiety, shortness of breath, and sleep problems that can make living with these illnesses very difficult and have been associated with earlier death” says David Bekelman, MD, MPH, professor at the University of Colorado School of Medicine and study lead author. “Palliative care can help. However, access to outpatient palliative care specialists is limited to non-existent, and new, scalable ways to provide early palliative care are needed.”
For adults with COPD, HF or ILD at high risk of hospitalization and death and poor quality of life, this program demonstrated early, persistent and clinically meaningful improvements in depression, anxiety, and quality of life. Additionally, while ADAPT lasted for 4 months, Bekelman and researchers saw positive results early that lasted for many months after the program ended.
“There are people who endure persistent symptoms and poor quality of life despite great treatments. We need to fill in the gaps and provide more for these patients,” says Bekelman who worked with the VA of Eastern Colorado Puget Sound Health Care Systems to conduct this research to conduct this research. “This innovative team care model is adaptable, scalable and can help make life better for people living with these illnesses. This program demonstrates that even a short amount of time providing structured telecare results in increased quality of life months after the calls end.”
About the University of Colorado Anschutz Medical Campus
The University of Colorado Anschutz Medical Campus is a world-class medical destination at the forefront of transformative science, medicine, education and patient care. The campus encompasses the University of Colorado health professional schools, more than 60 centers and institutes, and two nationally ranked independent hospitals - UCHealth University of Colorado Hospital and Children's Hospital Colorado - that treat more than two million adult and pediatric patients each year. Innovative, interconnected and highly collaborative, the University of Colorado Anschutz Medical Campus delivers life-changing treatments, patient care and professional training and conducts world-renowned research fueled by over $704 million in research grants. For more information, visit www.cuanschutz.edu.
JOURNAL
Journal of the American Medical Association
ARTICLE PUBLICATION DATE
16-Jan-2024
Largest-ever study of palliative care demonstrates scalable strategy to increase support for seriously ill patients in the hospital
“Default orders” in electronic medical record nearly tripled palliative care consultation rates for patients with chronic obstructive pulmonary disease, dementia, or kidney failure
PHILADELPHIA – Ordering a palliative care consultation by “default” – via an automatic order programmed into the electronic medical record that doctors may cancel if they choose – is an effective strategy to give more hospitalized patients the opportunity to benefit from palliative care, and sooner, according to a new study led by researchers from the Perelman School of Medicine at the University of Pennsylvania. Palliative care is specialized medical care focused on relieving the symptoms and stress of a serious illness and improving quality of life, in alignment with a patient’s individual goals, values, and priorities. By changing the process for ordering palliative care consultation from doctors opting in and actively placing an order to having the opportunity to opt out and cancel an automatic order, the investigators increased palliative care consultation rates from 16.6 percent to 43.9 percent and decreased the time to consultation by 1.2 days in the largest-ever study of inpatient palliative care, published today in JAMA.
“While early palliative care consultation could help many patients with chronic serious illnesses better understand their diagnosis and align their treatment choices to their individual care goals, there's never been an established approach to realizing that goal at scale. We found that a simple, pre-programmed order within the electronic medical record can get more palliative care to more people more quickly,” said lead author Kate Courtright, MD, MS, an assistant professor of Critical Care and Palliative Medicine. “This strategy was low-cost and easily implemented in community hospitals, which is where most Americans receive their health care.”
The study included more than 34,000 patients with chronic obstructive pulmonary disease (COPD), dementia, or kidney failure at 11 hospitals in eight states, all part of one of the nation’s largest non-profit health systems. Although palliative care consultation is recommended for millions of Americans with serious illnesses, many patients aren’t referred to palliative care or only receive a consultation at the end of life. Patients with COPD, dementia, and kidney failure have been underrepresented in past studies of palliative care delivery, which have largely focused on patients with cancer or heart failure in academic health centers. But these patients often experience challenges with coping, as well as breathlessness, anxiety, pain, and other symptoms that palliative care can help address through medications, other treatments, and/or referrals to other specialists. Palliative care can be given at any stage of treatment, including along with therapy intended to cure the condition.
Each of the 11 hospitals in the study had an established palliative care program, but to keep the study as realistic as possible, hospitals were neither encouraged to nor prohibited from increasing or decreasing palliative care staffing during the study. Over the course of the study, which took place between March 2016 and November 2018, the hospitals began enrolling patients to the study under usual care (data collected, but no intervention) and transitioned to the intervention phase (default orders via the electronic health record) over time, in a randomly determined order. During the intervention phase, clinicians canceled the default for fewer than 10 percent of patients for whom it was generated. Clinicians could also place their own order for a palliative care consultation at any point during the study.
“Our results suggest that the default order strategy was generally acceptable to clinicians, which is important because if we want to reach as many eligible patients as possible, we need to design approaches that are feasible for ‘real-world’ practice and not just in the research setting,” Courtright said.
Implementing default orders did not impact how long patients stayed in the hospital compared to usual care, perhaps because, even in the intervention group, less than half of patients actually received a consultation from a palliative care specialist. This may be due to limited staff resources or other factors. Anticipating that default orders would not necessarily guarantee a consultation, the study authors planned for a secondary outcomes analysis and found that for patients who only received palliative care consultation thanks to the default order, such care reduced the median length of stay by 9.6 percent. Additionally, the default orders led to more patients being discharged from the hospital to hospice care without affecting mortality, suggesting that such orders improved the quality and patient-centeredness of end-of-life care.
To build on the findings, these researchers at Penn’s Palliative and Advanced Illness Research (PAIR) Center have designed another randomized clinical trial. The planned study, which is supported by a $27.5 million funding award from the Patient-Centered Outcomes Research Institute (PCORI), will test a strategy that includes training and prompting generalists who make up a patient’s primary hospital team—including nurses, advanced practice providers, physicians, and social workers—to provide palliative care themselves.
“We know that health care systems have limited resources and need more evidence to guide future scaling and delivery of inpatient palliative care in an equitable and cost-effective manner,” said senior author Scott D. Halpern, MD, PhD, the John M. Eisenberg Professor of Medicine, Epidemiology, and Medical Ethics and Health Policy. “As we build on this work, our goal is to continuously improve inpatient palliative care so that all patients and families facing a serious illness have access to the support they need to carry on with their daily lives throughout their treatment journey.”
The study was supported by the National Institutes of Aging (UH3AG050311) and the Otto Haas Charitable Trust.
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Penn Medicine is one of the world’s leading academic medical centers, dedicated to the related missions of medical education, biomedical research, excellence in patient care, and community service. The organization consists of the University of Pennsylvania Health System and Penn’s Raymond and Ruth Perelman School of Medicine, founded in 1765 as the nation’s first medical school.
The Perelman School of Medicine is consistently among the nation's top recipients of funding from the National Institutes of Health, with $550 million awarded in the 2022 fiscal year. Home to a proud history of “firsts” in medicine, Penn Medicine teams have pioneered discoveries and innovations that have shaped modern medicine, including recent breakthroughs such as CAR T cell therapy for cancer and the mRNA technology used in COVID-19 vaccines.
The University of Pennsylvania Health System’s patient care facilities stretch from the Susquehanna River in Pennsylvania to the New Jersey shore. These include the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, Chester County Hospital, Lancaster General Health, Penn Medicine Princeton Health, and Pennsylvania Hospital—the nation’s first hospital, founded in 1751. Additional facilities and enterprises include Good Shepherd Penn Partners, Penn Medicine at Home, Lancaster Behavioral Health Hospital, and Princeton House Behavioral Health, among others.
Penn Medicine is an $11.1 billion enterprise powered by more than 49,000 talented faculty and staff.
JOURNAL
JAMA
ARTICLE TITLE
Default Palliative Care Consultation for Seriously Ill Hospitalized Patients A Pragmatic Cluster Randomized Trial
ARTICLE PUBLICATION DATE
16-Jan-2024
Improving palliative care in ICUs with telemedicine
Research project launched under Charité leadership
Grant and Award AnnouncementIMAGE:
THE TEAM WORKING ON THE EU-FUNDED EPIC PROJECT PLANS TO USE TELEMEDICINE TO HELP IMPROVE PALLIATIVE CARE IN ICU SETTINGS. © CHARITÉ | ROBERT GÜLLAND
view moreCREDIT: © CHARITÉ | ROBERT GÜLLAND
Intensive care units (ICUs) commonly have to provide palliative care to patients. But not every medical center has special expertise in palliative medicine. Can telemedicine consultations further improve the palliative care provided in ICU settings? An international research consortium headed by Charité – Universitätsmedizin Berlin is studying this question. Their newly launched project, titled “Enhancing palliative care in ICU” (EPIC), is receiving about 6.3 million euros in funding from the European Commission for a period of five years.
Alleviating pain and other symptoms for seriously ill patients to preserve and support their remaining lifespans and quality of life is the goal of palliative medicine. It is an important and established part of intensive care. However, if the patient’s disease and symptoms are very complex, it can be helpful for ICU staff to turn to palliative medicine specialists for advice on specific cases. “But not every hospital has in-house expertise in palliative medicine,” says Prof. Claudia Spies, Director of the Department of Anesthesiology and Intensive Care Medicine at Charité. “Systematic use of telemedicine that allows experts to be brought in virtually, and thus fast and from anywhere, could bring even more improvement in the palliative care provided in ICU settings.”
A practical model with three strands: continuing education, checklists, telemedicine
So how much benefit do telemedicine consultations with palliative medicine experts bring in comparison to the palliative care typically provided in an intensive care unit? A team of researchers is working to answer that question in the EPIC project. “Before the telemedicine consultation phase starts, the ICU clinical staff will first receive training in palliative medicine,” explains Spies, who is heading up the research project. “We’re also working on checklists to help the teams identify the patients who could benefit from specialized palliative care as early as possible.” Some 2,000 patients and their families are participating in the research project, which is being carried out at seven clinical centers with palliative medicine and 23 multidisciplinary ICUs in five European countries.
“EPIC is bringing together clinicians and researchers from the areas of palliative and intensive care, social sciences, nursing, ethics, and health economics with the goal of implementing a harmonized practical model of palliative care at ICUs, and not just in one country, but all across Europe,” Spies explains. “We hope our project will help us identify recommended actions that we can pass along to specialized organizations and that can be included in initial and continuing education and training for the next generation of intensive care staff across multiple professions.”
Shorter ICU stays
Studies show that integrating palliative medicine as soon as possible shortens the amount of time patients spend in intensive care, although mortality remains the same. With this in mind, one of the researchers’ goals in EPIC is to reduce the time patients spend in the ICU – which not only has benefits from a health economics standpoint, but is also of immeasurable value for the patients themselves. “When patients with severe and incurable diseases receive optimum palliative care, then they hopefully won’t have to spend their last days in the ICU, unless there’s a very serious reason. This can be a blessing for them and their families during this extremely critical and highly vulnerable phase at the end of life,” Spies says. “And palliative care is also helpful for people with severe or chronic disease who are not approaching the end of life. People often confuse palliative medicine with hospice, but they aren’t the same. About half of patients can be discharged and go home with specialized palliative treatment. So improving palliative care across the board would benefit all of the patients in the ICU.”
Another of the researchers’ aims in EPIC is to study how well patients and family members respond to palliative medicine that is provided with telemedicine support. They also plan to establish a group for patients and families to share their stories and information and provide mutual support.
About EPIC
The research consortium is headed up by Prof. Claudia Spies, Director of the Department of Anesthesiology and Intensive Care Medicine on Campus Charité Mitte and Campus Virchow-Klinikum. Funding is being provided as part of the EU’s Horizon Europe framework program. The other partners in the consortium are: General University Hospital in Prague (Czech Republic), Hebrew University of Jerusalem (Israel), Heinrich-Heine-Universität Düsseldorf (Germany), King’s College Hospital (United Kingdom), KU Leuven (Belgium), Martin Luther University Halle-Wittenberg (Germany), the Faculty of Medicine of the University of Basel (Switzerland), National and Kapodistrian University of Athens (Greece), Università degli Studi di Perugia (Italy), the University of Southern Denmark (Denmark), Universitätsklinikum Erlangen (Germany), the European Association for Palliative Care (Belgium), the European Society of Anaesthesiology and Intensive Care (Belgium), and tp21 GmbH (Germany). There are plans to start a cooperation with a group representing patients and families.
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