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by Michala Ritz and colleagues

In today’s current world of social isolation and virtual EVERYTHING, it is easy to get sucked down an endless rabbit hole of negativity, sad stories of sickness and death, and scary projections of the future. It is now normal to wake up, wonder about family and friends near and abroad, and monitor the volatile stock market – all while sipping our morning coffee worrying what bad news tomorrow may bring.

Those lingering questions keep us up at night, like monsters under our beds.

“What if I lose my job?”

“What if my parents contract COVID?”

“How will my patients do with all of this?”

“What if I accidentally spread the disease to someone I love?"

“Will life ever be “normal” again?”

Current alterations in daily life due to the coronavirus pandemic have put an enormous mental and emotional strain on countless people throughout the globe.¹ Anxiety and depression result from increasing physical and social isolation. There is such a focus on the negative; what activities we cannot do, what events we cannot attend, and what people we cannot see in person. Commonly, the end of the day becomes a time for reflection on the negative, as we replay the conversations, events, and thoughts that did not go well. What’s missing is a healthy dwelling on the good things, the happy moments that brought a quick smile to our faces and joy to our days.

Science and years of research have proven that grateful people are happier and healthier. Gratitude journaling helps people cope with stress and increases the positive emotions that they feel.² Dr. Martin Seligman has written extensively of the power of positive psychology, and specifically the benefits of gratitude journaling by writing down three positive events or feelings at the end of the day. In doing this, it “changes your focus from the things that go wrong in life, to the things you may take for granted that go well”.³ Gratitude journaling also creates a mentality that is more resilient to adversity and setbacks. Extended research has also shown that promoting resilience training for healthcare workers can lead to lower level of depression, anxiety and an increased overall life satisfaction.⁴

So, you are telling me, that in order to maintain happiness, healthiness and resiliency, I can reflect on my day and write down three good things that happened? Sounds simple enough. Sign me up! And, guess what, there’s an app for that.

We worked with a software solutions company called CrossComm to build a free, web-based (no download needed) gratitude journaling and sharing app called “The Three Good Things”. We particularly thought about colleagues in palliative care in its design, but also made the app usable for persons outside of healthcare, including our family and friends, patients, and their caregivers. Users of the app can journal privately, or create and invite their own family and friends to join a gratitude sharing network where nightly posts can be seen by those they care about. In doing so, we hope that positivity goes viral, starting from within your own social circles. Further, the app can send you a text or email reminder at the time of your choice to nudge a moment to reflect on the things that are going well.

Here are some examples from the latest rundown of publicly-posted “good things”, known in the app as the “Positivity Feed”.

“Cookie cake and grilled burgers”

“My wife and I are still in love. Like lots.”

“Playing Apples to Apples”

“One week in our new house”

“Cauliflower rice bowls”

“Walked a 5K”

“Thankful for my children”

Just because we have to be a little distant doesn’t mean we need to lose sight of the great lives we all live, the love we experience each day, and the kindness the world still has. We encourage you to take a quiet moment, reflect, and write down your three good things and smile!

The web app can be accessed here: https://the3goodthings.org/

Michala Ritz MPH

Fred Friedman

Jon Nicolla MBA

Don Shin

Arif Kamal MD, MBA, MHS

References

1. Siija, Li et al. The Impact of Covid-19 Epidemic Declaration on Psychological Consequences: A Study on Active Weibo Users. 2020.

2. Allen, S. Is Gratitude Good For Health. 2018.

3. Seligman, M, Steen T, Park N and Peterson, C. Positive psychology progress: empirical validation of interventions. Am Psychol 2005 July – August;60 (5):410 – 421

4. Peccoralo L, Mehta D, Schiller G, et al. The Health Benefits of Resilience. 2020. https://link.springer.com/chapter/10.1007/978-3-030-30892-6_13. 

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by Arif Kamal (@arifkamalmd)

Transition into the Fall months means one thing for a boy like me from the Midwest – it’s football season. Snare drum cadences, referee whistles, and the crunch of linemen helmets were the soundtrack to many memorable evenings growing up. In football, winning requires strategy and execution, while embracing the humility that even the most exquisite gameplan, well steeped in planning and expertise, can fall flat. Though the two worlds seem unrelated, I often think of football analogies when approaching palliative care quality improvement.

Football offenses across college and professional leagues are increasingly calling the Run-Pass-Option (or RPO for short). In the RPO, a quarterback has three choices after the snap – hand the ball off to a running back, pass the ball to a wide receiver, or start running the ball himself. The overall goal is to keep defenses guessing, while matriculating the ball down the field efficiently. Based on the situation, the quarterback chooses where the ball will go. For example, if time is short and there are no timeouts, the quarterback may choose to throw a long pass to a wide receiver streaking down the sideline to both gain yards and stop the clock. If the defense is playing back, then the quarterback may run the ball himself for a big gain. Notice that all three options (throw, running back run, quarterback run) are always available, can meet the goal of moving the ball down the field, but are decided upon based on the needs of the team and the alignment of the defense.

Which bring us to healthcare quality improvement and measurement. There have been increasing discussions in all of healthcare, including within palliative care, about the spirit of quality measurement. A recent Health Affairs article highlighted the burden of quality measurement at the organization level, concluding that clinicians and staff spend 15 hours per week addressing requirements for external quality reporting. Further, the study estimated $15.4 billion spent annually by four specialties (general internists, family medicine, cardiology, orthopedics) on such activities. The authors concluded that quality measurement activities should be prioritized, so that increasing demands are not just piled on to the plates of clinicians without a strong rationale. This spirit of reducing complexity also runs in the ethos of palliative medicine, as we frequently help patients and families avoid polypharmacy complications while simplifying medication lists. But we have found complexities in quality measurement in specialty palliative care, with lists of quality measures applicable to our field numbering over 300. There’s a sense that change is needed.

Oftentimes, critiques are made about the types of quality measures that exist. In healthcare quality measurement, there are three widely-accepted categories for quality measures. This three-part framework was introduced and proliferated by Avedis Donabedian, oft-considered the father of the modern healthcare quality improvement movement. Dr. Donabedian proposed that quality measures would either evaluate structure, process, or outcomes of care (to contrast from Run-Pass-Option – RPO – I will call this SPO for short). In SPO, quality measures are categorized by their intent. For example, if a measure aims to evaluate the infrastructure, resources, or policies in place, then it is a Structural measure. If a measure aims to assess whether something was done, then it is a Process measure. Health outcome measures are the third category, and most typically thought of as “a change in a patient’s health state.” Related to health outcome measures are those thought of as outcomes, but not affecting a patient’s health. The Donabedian SPO framework does not specifically account for these, but I often think of them as “system outcomes.” Examples are patient experience or satisfaction, costs and financial toxicity, and access.

To make this clear, let’s take the example of advance care planning, the primary “procedure” of palliative care professionals. A Structural measure related to advance care planning may involve personnel (“All members of the palliative care team receive annual CE in local and state laws, legal precedence, and policies regarding advance directives, physician orders for scope of treatment, and surrogate decision-making”). This measure is Structural because it evaluates a characteristic inherent to the team or the service. A Process measure may look like, “75% of patients seen by the palliative care team have a documented advance directive by the third visit.” Such a measure looks at whether something was done. A true Outcome measure would look like, “Percent of patients with moderate to severe pain with reductions in pain scores by at least 50% within 24 hours of the first consult.” This is measuring the change in a patient’s health state.

A brief word on patient-reported outcomes (PRO). Patient-reported outcomes are “report of the statue of a patient’s health condition that comes directly from the patient.” Readers may wonder where PROs fit in the measurement framework. Importantly, PROs themselves are quite simply the method to collect data, but are not quality measures themselves. Just like electronic health record data can inform a Process measures, data from the patients’ own voice can inform any of the SPO measures. Oftentimes, when people say “PRO” what they are really referring to is “PRO-PM” (patient reported outcome performance measure). A PRO-PM is performance measure that is based on patient-reported outcome data aggregated for measurement purposes (e.g., percentage of patients receiving specialty palliative care whose depression score, as self-reported by the PHQ-9, is improved within the first eight weeks).

So let’s bring football and quality measurement back together. When a best practice is defined and supported by the evidence, the natural progression to ensure the best practice is followed is to develop a quality measure. In football, a quarterback in an RPO has three options. Similarly, to ensure a best practice is followed with quality measurement, we can develop a Structure, Process, or Outcome measure. And choosing the type of measure to develop and use requires understanding whether you want others to “have something” (Structure), “do something” (Process), or “change something” (Outcome). It’s tempting to think that all quality measures should be Outcome measures, since improving patient outcomes is what we all ultimately set out to do. But there are two reasons to should proceed with caution.

First, Outcome measures require a clear sense of how differences in outcomes (between two organizations, or between “ideal” and “actual”) will be treated. For example, if a small, rural, safety net hospital with one part-time palliative care clinicians who makes rounds every third day cannot improve the proposed measure “Percent of patients with moderate to severe pain with reductions in pain scores by at least 50% within 24 hours of the first consult,” how do we reconcile the “actual” versus an “ideal”? Such a measure – exactly applied - would doom this program for failure. So how does one “adjust” for the limitations of access to the team (every third day versus daily)? Or what if there were patient or disease factors that made meeting this measure more difficult? The concept of acknowledging that not all things are equal is called “risk adjustment.” What we want to know is if a difference between actual and ideal is expected, due to factors beyond the team’s control, how is that difference handled?

The second complicating factor with Outcome measures is accountability. If I said that the palliative care consult team’s reimbursement would be cut by 10% if a patient’s post-hospitalization satisfaction score was below the 50th percentile, what would be the reaction? Many in palliative care would argue that a patient satisfaction score is reflective of an accumulation of experiences and interactions throughout the hospitalization, of which the palliative care team was part of only a minority. So how do we attribute good or bad outcomes to individual clinicians or individual teams, when we work in complicated networks of providers, clinicians, health staff, environmental staff, and administrative professionals?

Both risk adjustment and accountability challenges should give pause in rushing towards Outcome measures. But it does not mean the challenges cannot be overcome, nor that Outcome measures are not needed in palliative care. Certainly, to remain in-step with the rest of healthcare, we will need to think about the definitions and measurement methodologies for our own Outcome measures. But we should not in that process ignore important gaps in Structure and Process measures that should also be addressed. So, to come back to my football analogy, sometimes as an offense you “take what the defense gives you,” which means to move the ball down the field balancing the chances of meeting your goal (scoring points) with the challenges ahead (putting the ball where the defense is not).

We will be discussing this and more topics related to quality in palliative care at the 4th Annual Quality Matters in Palliative Care Conference streaming online on October 11th. This conference is co-sponsored by the American Academy of Hospice and Palliative Medicine (AAHPM), Center to Advance Palliative Care (CAPC), Palliative Care Quality Network (PCQN), and Global Palliative Care Quality Alliance (GPCQA). Registration and CE are complimentary and registration is encouraged for those who can’t attend that afternoon but want to watch the recording later. For more information and to register, visit http://www.gpcqa.org/qmc

I hope to see you there!

Arif Kamal MD, MBA, MHS (@arifkamalmd) is a youth soccer coach for his six-year old and professional beach bum. In his spare time he studies quality and workforce issues in palliative care.

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by Arif Kamal (@arifkamalmd)

It seems everywhere a person turns, there’s nonstop discourse regarding healthcare quality, particularly the relationship of meeting quality metrics to demonstrating lower costs and higher value. As palliative care further immerses itself into usual healthcare delivery, it behooves our workforce to adeptly apply quality improvement skills to translate our sense of “what is right” into the usual practice of “what is done.” Meeting these demands takes skills and practice, rooted in an evolving evidence base around quality improvement science.

It may confuse some to hear that quality improvement is derived from science. For some, quality improvement is what you call things when there’s not grant money, not a protocol or consent, the project is not publishable or meaty enough to face the feedback or scrutiny of your peers, or when there’s a high likelihood of failure. Quality improvement and “pilot” study can sometimes seem synonymous, and it’s certainly the former and not the latter when results are negative or there’s “more to learn.”

In fact, quality improvement is just as time and resource intensive as pure research, a reflection of rigor that started from the very beginning. The formative years of quality improvement science originated from the factory setting, where observers painstakingly monitored outcomes at the individual and systems level, quantified opportunities for improvement at the outcome (number of widgets) side, and changed how products are made through incentives and modifications to the environment. The origin of the term the “Hawthorne Effect” comes from just such study.

In the 1920’s, the Hawthorne Works, a telephone products manufacturing plant just outside of Chicago, commissioned investigators to experiment how to increase productivity among assembly line workers. The studies continued on for almost a decade, with small changes in lighting (brighter lighting led to more productivity), changes in cleanliness of facilities, and moving work stations around, all leading to small, time-limited upticks in production. In the end, the investigators concluded that the changes in production were ultimately more a result of the workers knowing their production numbers were being observed, than the actual interventions themselves. Though different than what the investigators had originally thought, the Effect is a powerful tool used today to motivate change. The Hawthorne Effect is why highway signs that announce the monitoring of speed by an increased police presence and overhead aircraft reflectively lead to drivers slowing down. Knowing you’re being watched changes your behavior.

From the early part of the 20th century moving forward, a robust science regarding process control, change management, and behavior change built upon the early lessons from the Hawthorne factory. We now have approaches like Failure Mode and Effects Analysis (FMEA) that try to anticipate errors or understand when future breakdowns of the system will occur. Much of this is built upon knowledge that comes from the fields of human factors engineering and industrial engineering, far away from the settings where healthcare is delivered. We also discuss the concept of “high reliability organizations” that anticipate and address opportunities for improvement within increasingly complex environments. It’s the idea that healthcare could become like nuclear power plants and the airline industry; extraordinarily rare errors, that when they occur, are industry-wide learning events. Getting there involves a focus on quality improvement science that is no less robust or meticulous than generating our evidence through clinical trials and the like. And importantly, palliative care through its entrenched ethos and culture around shaping the system to maximize patient-derived wishes, can lead the way in getting there.

To get a taste of quality improvement and its implementation in palliative care, my colleagues and I recently published an article “Quality Improvement Pearls for the Palliative Care and Hospice Professional” which the publisher of the Journal of Pain and Symptom Management has made available for complimentary download for the next few weeks.

Also, there are webinar-based opportunities to learn more about the quickly-evolving environment in palliative care quality. For example, the community-based palliative care quality improvement collaborative I co-chair with AAHPM President Janet Bull, the Global Palliative Care Quality Alliance, is hosting its Third Annual Quality Matters in Palliative Care Conference.

This free, virtual, webinar-based, half-day conference will offer complimentary CME/CNE and feature speakers covering topics related to principles of quality measurement, population health and palliative care, and what CAPC, AAHPM, and HPNA are doing to further the quality agenda in our field. The conference is this Thursday, October 26th in the afternoon. Please register at www.gpcqa.org/qmc. Even if you can’t attend live, please register to receive a copy of the slides and a recording of the presentations.

Arif Kamal MD, MBA, MHS is an Associate Professor of Medicine and Business Administration at Duke University and Physician Quality and Outcomes Officer of the Duke Cancer Institute. He is the father of two beautiful children and has learned (as the younger one is 6 months old) that sleep is a precious, precious thing and should be appreciated whenever (if ever) it occurs.

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by Arif Kamal

Apologies for the “clickbait” title to the blog post; scouring the internet it seems that hyperbole works to get readers’ attention, certainly among entertainment sites and maybe increasingly within presidential politics. But it seems I had little choice; the fifth word of my title is “Quality”, which excites very few people. Bear with me, I promise this will get good.

Quality improvement is critical for palliative care organizations to build and sustain success within their clinical missions. Those who are watching and evaluating us, including patients, caregivers, health systems, regulators, and payers, are increasingly expecting a consistent product, delivered in close alignment with our growing evidence base. Further, rapid evolutions in the health care delivery and payment ecosystem require palliative care organizations to masterfully deploy quality improvement initiatives to solve problems. This requires a facile understanding of key steps needed to transition from identifying a problem to sustaining the change.

I’ve spent much of the past five years working as a Quality Improvement Coach for the American Society of Clinical Oncology’s (ASCO) Quality Training Program and ASCO/AAHPM Virtual Learning Collaborative and have come away with a few pearls that may be helpful. I also highly recommend “The Improvement Guide” by Langley et al., seen by many as the definitive textbook for healthcare quality improvement.

Below I offer Five Tips, by no means an exhaustive review, but a decent place to start.

Tip #1: Define the problem – Have a problem statement. This is one or two sentences that covers the Who, What, When, and Where of the problem (but not Why or How). Add a Harm to this statement to give it some punch. For example, “At the Mustard Clinic, from January through July 2016 the outpatient palliative care clinic no-show rate was 40%, missing critical opportunities for patients to receive timely symptom management, goals of care discussions, and possibly reduce time in the hospital during an unwanted readmission.”

Tip #2: Define the problem, again – Quality improvement committees are like family meetings, everyone’s inherently and not unexpectedly on different pages. When starting a quality improvement committee meeting, go around the room and ask everyone what they think the problem is you’re trying to solve. Marvel at the variation, and the “scope creep” and “scope drift” that occur over time. And then insert your excellent family meeting skills to get everyone on the same page. Lack of consensus on the specific problem will sink you.

Tip #3: Problem first, solutions (much) later – If your problem statement sounds something like this, “Because of high 30-day readmission rates at our hospital, we need more palliative care” then you’ve put the cart before the horse. All quality improvement starts with a specific, agreed-upon problem – not a solution. Starting a palliative care clinic, growing a palliative care service, applying disease-based triggers for consultation, etc. are all solutions. Implementing your solution is not the point of quality improvement, it’s solving a problem. Our practice is to not speak of solutions until at least the fourth meeting of our quality improvement committee.

Tip #4: Have an aim statement. What is the goal of your quality improvement project? Be specific, and think of the Who, What, When, and Where (but not How). For example, “By July 2017 we will decrease the outpatient palliative care clinic no-show rate to 25% at the Mustard Clinic.” You cannot yet know the “How”, because it’s dependent on the “Why”. And you can’t understand the “Why” without exploring the drivers of the problem, and the process by which the problem occurs.

Tip #5: Explore the “Why”. Be curious, open-minded, and solicit opinions of all stakeholders. The above fictitious problem of clinic no-show rates is complex, and not easy to solve (or people would have solved it already). If any part of your brain is saying, “Isn’t it obvious, what they need to do is….” then you’re like the 99% of us (very much including me) who must practice exploring the process, and getting input from all stakeholders. I could imagine this committee would solicit input from patients, caregivers, front desk staff, phone triage personnel, appointment schedulers, nurses, physicians, and financial counselors. Can you think of others? Drawing the process from start to finish is also very helpful. How does a patient go from being referred to the clinic to successfully coming? Where are all the places the process could go wrong? What data is needed to quantify the shortfalls? The point here is try not to go down a path of implementing solutions until you’re confident of the problem, have an understanding of where the process is breaking down, and have tailored the solution to that breakdown.

I’ll be speaking more about this topic, and will be joined by several other national leaders including Drs. Diane Meier, Steve Pantilat, and Phil Rodgers during the 2nd Annual Palliative Care Quality Matters Conference on October 20th from 12-5PM EST. The Conference is hosted by the Global Palliative Care Quality Alliance (www.gpcqa.org), a multi-site, volunteer collaboration of healthcare organizations with a passion for improving quality in palliative care.

The virtual conference presented via Webex is open to all colleagues with complimentary registration and CME/CNE. Register at www.gpcqa.org/qmc

Additionally, this Wednesday evening October 5th at 9PM EST/6PM PST I’ll be hosting a Tweetchat. Would love your input on the following questions:

T1: What makes performing quality improvement challenging in palliative care and hospice?

T2: Most quality improvement projects don’t work. Name an epic failure you were part of. What did you learn?

T3: Change my Top Five to a Top Ten list. What tips could you add?

T4: How could we help each other in our field do better quality improvement? What’s the role of AAHPM, HPNA, NHPCO and other membership societies?

What: #hpm (hospice and palliative med/care) chat on Twitter
When: Wed 10/5/2016 - 9p ET/ 6p PT
Host: Dr. Arif Kamal @arifkamalMD

Follow @hpmchat and go to www.hpmchat.org for up to date info.

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using tchat.io for ease of following. You can also check out the new site dedicated to #hpm chat - www.hpmchat.org

For more on past tweetchats, see our archive here.

Arif Kamal MD MBA MHS is the Physician Quality and Outcomes Officer and Assistant Professor of Medicine (Oncology and Palliative Care) at Duke University. He is a diehard Kansas City Chiefs football fan, which has prepared him for discussions regarding futility and complicated grief with his patients.

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by Arif Kamal

On the topic of palliative care clinician wellness, we are starting to recognize that there is some good news to counter all the bad. First, the bad news. If you’re reading this, and you believe that burnout has not touched your professional life, then it is likely that the colleagues sitting to the immediate left and right of you are not so lucky. Recent survey data of over 1300 palliative care clinicians highlight a sobering statistic: almost two-thirds of our colleagues report burnout (Kamal JPSM 2016). This is among the highest rate of all medical disciplines, and significantly higher than the 45% average burnout rate of physicians outside our specialty (Shanafelt JAMA IM 2012). Burnout, explicitly stated, is a leading cause of palliative care clinicians opting to leave the field, second only to usual retirement. Those reading these statistics are likely not surprised; compassionately caring for persons with serious illness often on the worst days of their life can take a toll on our emotional health. A growing appreciation of the downstream effects of unchecked burnout on the ability to deliver timely, high quality palliative care has elevated the issue to nothing short of a crisis for our field.

But there’s also good news. Enter resilience, stage left. Resilience is the “capacity to meet challenges, recover from difficulties, and thrive at work; built from skills, not reflective of traits.” Of that definition, the last part is the most important. The idea that certain people are more capable of handling challenges at work is not new; we all know someone who seems to handle difficulties with grace, and an increasing workload with enthusiasm. When the pager goes off, she skips to the phone. All while I worry about making it home in time to read my four-year old “three books, Daddy, you promised three books” before bed. What makes my colleague different?

There are a few potential explanations for this seemingly-odd behavior by my colleague. One explanation is that of self-selection; clinicians who stick around in palliative care are the ones who can cut it, the burnt out ones got out a long time ago. “Crispiness” creeps up on some, and silently ushers the unlucky ones out of palliative care, or maybe even out of medicine. For the lucky few, a retirement party and adoration for the lengthiness of a career in the trenches awaits. Another explanation is that the upbeat clinician has the right personality: upbeat, optimistic, never fazed. She was born with something I was not, a set of traits missing in my family’s gene pool. Like missing the gene for being tall, an Olympics Gold Medal for basketball is no more in my future than a long, healthy career as a palliative care clinician.

Summatively, these two explanations reflect a “trait-based” approach to resilience; those who’ve got it win, and those who don’t, leave. In truth, the clinician I reference has developed, practice, and refined her own set of resilience skills – this has nothing to do with her personality, genetics, or “makeup”. Like leadership skills and communication skills, resilience skills are not inherited or accidentally found. Diligent, intentional, and regular learning and practicing of resilience skills is the main way for persons to build the capacity to thrive in the midst of challenges.

During our Tweetchat on Wednesday, August 24 at 9PM ET, we will discuss the following topics:

T1: We are asserting that resilience is a skill, and not a trait, is that surprising? What skills have you seen others use to help deter burnout?
T2: How can employers/leaders assist clinicians in building resilience skills?
T3: What roles, if any, should specialty societies (e.g. AAHPM, HPNA, NHPCO) play in building resilience skills within the field?

Arif Kamal MD, MBA, MHS is the Physician Quality and Outcomes Officer at Duke Cancer Institute, a palliative medicine physician and oncologist, and dreads the longwindedness of “Green Eggs and Ham” selected as part of the “three books, Daddy, three books” bedtime routine.

What: #hpm (hospice and palliative med/care) chat on Twitter
When: Wed 08/24/2016 - 9p ET/ 6p PT
Host: Dr. Arif Kamal Follow @arifkamalmd on Twitter

Follow @hpmchat and go to www.hpmchat.org for up to date info.

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using tchat.io for ease of following. You can also check out the new site dedicated to #hpm chat - www.hpmchat.org

For more on past tweetchats, see our archive here or you can access the transcripts and analytics of #hpm chats through @Symplur.

References:
Kamal, A. H., Bull, J. H., Wolf, S. P., Swetz, K. M., Shanafelt, T. D., Ast, K., Kavalieratos D, Sincalir CT, Abernethy, A. P. (2016). Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S. Journal of Pain and Symptom Management, 51(4), 690–6. http://doi.org/10.1016/j.jpainsymman.2015.10.020

Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., reskovich, M. R. (2012). Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of Internal Medicine, 172(18), 1377–85. OPEN ACCESS PDF http://doi.org/10.1001/archinternmed.2012.3199

Image Credit: "Burnt Toast" by Christian Sinclair via Canva - Creative Commons-BY-SA

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by Nrupen Bhavsar, Arif Kamal, Donald H. Taylor, Jr.

As a health services and policy research group, we have been looking at a lot of data related to how we deliver care to patients near the end of life. An intriguing area of study is the burden of medications that patients are prescribed when time is short. Here are some data about medication use in the elderly that might be known to many of you but were eye-opening for us:

• 13% of the US population is over the age of 65 but account for 30% of all prescription medication.
• Medicare expenditures for end of life care are approximately $150 billion annually, with much of these costs attributable to medication related to supportive care, comorbid conditions, and disease prevention.
• 61% of older patients under the care of a physician take at least 1 prescription medication; the majority of these patients are taking 3-5 medications. This excludes over the counter medications.
• A recent palliative care study showed the average number of medications prescribed to patients with a year or less of prognosis is around 12
• Statins are used in almost 50% of elderly patients.
• 50% of physicians continue statins for primary prevention until patient death.

However, recent evidence suggests that “statins” (e.g. atorvastatin, simvastatin; medications used to control LDL cholesterol) may not be appropriate in patients with end-stage non-cardiovascular illness. In the Statin Discontinuation Study, investigators from the Palliative Care Research Cooperative (PCRC) reported no survival decrement and improved quality of life in patients whose statin was discontinued when estimated prognosis was 12 months or less. However, the most recent guidelines update from the American College of Cardiology and American Heart Association (ACC/AHA) expanded the indication for statin therapy to prevent cardiovascular disease to an estimated 13 million additional adults. Importantly, the guidelines did not address the appropriateness in patients who have a limited prognosis but are not receiving active end of life care. Prognosis is not a component of their calculator; it is left to clinician judgment how to manage medications not directly related to an active quality of life issue, like pain or nausea. There is similar uncertainty in the appropriate use of other commonly used medications. Research that investigates the appropriateness of real world medication use in patients with life limiting illness may reduce unnecessary spending while improving the quality of care.

We need better information on medication management in patients with limited life expectancy. This week, the American Academy of Hospice and Palliative Medicine (AAHPM) will send a survey to their members on our behalf that aims to understand clinician attitudes and practices regarding counseling patients in palliative care/hospice about medication discontinuation.

Key questions that remain unanswered include:

1. When should we be engaging patients in discussions about medication discontinuation? Is this about a certain prognosis, functional status, or some other estimation of risks from polypharmacy?
2. Are there barriers that prevent discussions about medication discontinuation? Are these related to our own practices, working with other clinicians, or patient/family factors?
3. Whose responsibility is it to manage medications in end of life patients? The palliative care specialist? The primary care provider? The non-palliative care specialists (e.g., cardiologist, nephrologist, etc.)?

There are no easy answers to these questions and we welcome a robust discussion about this.

We encourage you to complete the survey so we can better understand how best to counsel patients about medication discontinuation.

Editor note: I took the survey and it takes less than 10 minutes. - Sinclair

Pallimed Disclaimer on Surveys and Research: Pallimed occasionally publishes opportunities for our readers to participate in research. All surveys are reviewed prior to publication here. We will only do this sporadically. We do not recieve any compensation for publication. If you are interested in collaborating with Pallimed for research, please contact editor@pallimed.org.

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by Arif Kamal MD, MHS

Palliative care is at a crossroads. We have for several decades leveraged our tenacity, charisma, and evidence base to transition ourselves from a novel consultative service to the accepted, standard-of-care approach of caring for persons with serious illness and their caregivers. Despite the remarkable integration of our services and care philosophy, we are not immune to the shifting winds of change across all of healthcare. From the upper echelons of healthcare on down, clinicians, administrators, payers, and patients are all evolving they ways they deliver, receive, and evaluate healthcare. Among all the changes and evolutions taking place, one thesis statement summarizes the transformation between the old and new ways: Quality. Now. Matters. And it is how we react to the increasing calls for measuring, reporting, and proving quality of healthcare delivery in specialty palliative care that will dictate the future sustainability and growth of the discipline.

Modern approaches to total quality management depend on a diligent focus by organizations in four key areas: regular implementation of structured quality improvement cycles, transformation to a culture of continuous awareness of service defects, engagement for change by employees across all levels of an organization, and a patient-centric definition of quality that welcomes consumer feedback. Admittedly, these are difficult concepts to master, and harder still to implement. Further, in palliative care, the clinical services we provide are diverse, complex, and demanding. The answers are not always easy, and not often found by leaders outside of our field. Improving the quality of care we deliver is fundamentally the professional responsibility of those who know the discipline from the inside. Although we possess expertise at providing clinical care, developing consultative programs, and growing our field, the fundamental infrastructure to learn, collaborate, and improve our care through an advanced understanding of healthcare quality improvement is missing, and sorely needed.

As a grassroots effort to change this, we at the Global Palliative Care Quality Alliance are hosting the inaugural “Quality Matters Conference” on October 15, 2015. This webinar-based, half-day virtual conference will use short didactic sessions (limit 20 minutes) and open Q and A sessions to address several of these impending changes for our field, and across healthcare. We will discuss topics such as: the national landscape of quality measurement, the Measuring What Matters initiative from AAHPM, evolving reimbursement policies and their links to quality measurement, leadership for change and motivating clinicians, and billing and coding tips for busy clinicians. All the topics center around our theme for the conference, “Innovation through Collaboration,” which highlights the need to band together within the discipline to guide innovations in high-quality palliative care delivery. To emphasize the importance of such education, we will provide complimentary registration and Continuing Medical Education (CME) and Continuing Nursing Education (CNE) through Duke University (register at www.gpcqa.org/qmc). We hope to provide an informative, collaborative, and engaging environment for palliative care team members of all backgrounds to learn more about palliative care quality.

The collaborative spirit of palliative care is truly one of its greatest strengths. We regularly come together to teach, learn, and grow from each other. We are the model that other disciplines strive to emulate. We look forward to seeing many wonderful colleagues at the upcoming Quality Matters Conference to learn how we can all play a vital role in improving the experience of those with serious illness and their caregivers, one quality improvement initiative at a time.

We will also be talking about quality initiatives in palliative care during the September 16th #hpm chat. We hope you can join us then. Details are below.

Dr Arif Kamal (@arifkamalmd) is an Assistant Professor of Medicine at Duke University. His research is focused on palliative care outcomes, quality, and professional burnout.

What: #hpm chat on Twitter
When: Wed September 16, 2015 - 9p ET/ 6p PT
Host: Dr. Arif Kamal (@arifkamalmd)

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