Abstract
Berger GN, O'Riordan DL, Kerr K, Pantilat SZ: Prevalence and characteristics of outpatient palliative care services in California. Arch Intern Med: online first October 10, 2011.
Outpatient palliative care services (PCS) offer an opportunity to intervene earlier in disease trajectory and result in improved patient outcomes. Outpatient PCS can provide improved continuity of care; reduce unnecessary rehospitalizations, which will become more important under new Medicare reimbursement schemes; and address the needs of patients and caregivers. While the potential benefits of outpatient PCS programs are increasingly recognized, there is a paucity of information regarding the structure of outpatient PCS, with no studies reporting the prevalence and characteristics of existing services. The aim of this research was to describe the prevalence and characteristics of outpatient PCS associated with California hospitals to enhance understanding of how outpatient PCS programs are delivered, and to inform their growth and development. The authors surveyed the leaders of palliative care (PC) programs in all 351 acute care hospitals in California regarding the presence and characteristics of PCS. The National Health Foundation (NHF) administered the survey. Hospital characteristics including bed size, system affiliation, ownership, and whether it serves as a teaching site were included in the survey. The outpatient PCS, focused on addressing physical, intellectual, emotional, social, and spiritual needs of patients and family, was assessed, as it was at its founding. Also examined were, how many patients were seen the previous year, and their diagnoses. The authors calculated staffing levels for outpatient PCS by summing the full-time equivalent (FTE) reported for advanced practice nurse, registered nurse, physician, social worker, and chaplain. They examined the association between hospital characteristics and the presence of outpatient PCS using an analysis of variance as appropriate. Of 351 acute care hospitals in California, 324 responded (92%) and 27 (8%) reported having outpatient PCS. Hospitals with an outpatient PCS program were larger and more likely to have inpatient PCS, be owned by a nonprofit organization, be a teaching site, and have a system affiliation compared with hospitals without outpatient PCS. The mean outpatient PCS program age was 3 years (range, 1-9 years), with half (46%) having been established in the previous 12 months. Of hospitals that reported program age, 50% (n=12) of outpatient PCS programs were established in the same year as the hospital's inpatient service and only 13% (n=3) pre-dated their inpatient counterpart. The mean (SD) number of new patients seen by outpatient PCS in 2007 was 197, half the number seen by the corresponding inpatient PCS (n=347). More than half of patients seen by outpatient PCS had a primary diagnosis of cancer (55%), with 3 services seeing only patients with cancer. Other common patient diagnoses included cardiac conditions (22%), dementia (14%), pulmonary conditions (10%), and neurological conditions (7%). Staffing at the 20 sites that reported data reveals that the mean (SD) FTE of all disciplines devoted to outpatient PCS was 1.4 (1.2) (range, 0.4-4.6) compared with 2.0 (1.2) (range, 0.3-4.7) for inpatient PCS. The largest proportion of outpatient FTE is devoted to registered nurses (0.9) and advance practice nurses (0.7). The physician FTE for outpatient PCS was 0.3, half of that for inpatient PCS (0.7); however, inpatient services see almost twice as many patients. Outpatient PCS programs have a social work component (0.8) similar to inpatient programs (0.7). The authors conclude that outpatient PCS programs are rare compared with inpatient services and most are new. Most outpatient PCS programs in California have been established within the last 4 years and half within the previous year, which may indicate a commitment to growth in this area. Consistent with national guidelines, outpatient PCS programs are typically interdisciplinary, with nurses acting as core care providers, although outpatient PCS programs are proportionally better staffed than their inpatient counterparts (70% as much staffing for 50% as many patients). Providing long-term follow-up in the clinic setting may account for this difference, though data do not provide a definite explanation. Compared with 11 leading outpatient PCS programs surveyed in a prior study, those in this study see fewer than half as many patients per year (197 versus 501), see a wider range of diagnoses (55% versus 80% cancer), and have fewer FTEs (0.7 versus 0.9 for advance practice nurses; 0.9 versus 1.6 for registered nurses; and 0.3 versus 0.6 for physicians), demonstrating the need to benchmark to similar services. Demonstrated improvements in care will likely drive demand for outpatient PCS. This study represents the largest population-based survey of outpatient PCS to date, yet as more outpatient PCS programs are established, research will be needed to understand the quality of care being delivered, the results achieved, the prevalence of outpatient PCS not associated with hospitals, and the structures and processes of care that provide the best outcomes.
Szymanski MK, Damma K, van Veldhuisen DJ, et al: Prognostic value of renin and prorenin in heart failure patients with decreased kidney function. Am Heart J 2011;162:487–493
The renin-angiotensin-aldosterone system (RAAS) contributes to the progression of heart failure (HF) and concomitant kidney dysfunction. Despite the use of RAAS blockade, sustained activation of RAAS has been suggested as a factor in adverse outcomes. In this study, the authors attempted to investigate the prognostic value of active plasma renin concentration (APRC) and prorenin in patients with HF treated with RAAS-blocking agents and its relationship with kidney function parameters. One hundred clinically stable patients with HF, treated with RAAS-blocking agents, were studied (mean age 58±12 years, 76% males). Renal function parameters, including effective renal plasma flow and glomerular filtration rate, were invasively measured. The combined endpoint consisted of all-cause mortality, heart transplantation, and admission to hospital for HF. Results demonstrated that mean left ventricular ejection fraction was 28±9, and median APRC levels were 24.3 ng/mL per hour. Active plasma renin concentration was most strongly associated with mean arterial pressure. In multivariate linear regression analysis, age, mean arterial pressure, angiotensin II concentration, and use of aldosterone antagonists were significantly related with APRC. Patients in the highest quartile of APRC had a worse prognosis. In multivariate analysis, APRC remained associated with worse prognosis: HR 2.87 (95% CI 1.14-7.20), P=0.025. Prorenin did not show prognostic value. The prognostic value of APRC was strongest in patients with decreased kidney function. The authors conclude that their data indicate that APRC is a strong prognostic factor in patients with HF in the presence of RAAS inhibition, especially in patients with kidney dysfunction.
Mittal V, Muralee S, Williamson D, et al: Delirium in the elderly: A comprehensive review. Am J Alzheimers Dis Other Demen 2011;26:97–109
Delirium is a common neuropsychiatric syndrome in the elderly characterized by concurrent impairments in cognition and behaviors. The causes of delirium are often multifactorial and are due to underlying medical illnesses and/or medication effect. The diagnosis of delirium is often missed in elderly patients and may be mislabeled as depression or dementia. Untreated, delirium can have devastating consequences in the elderly with high rates of morbidity and mortality. Available evidence indicates that early detection, reduction of risk factors, and better management of this condition can decrease its morbidity rates. In this review, the authors discuss the etiology of delirium; the neurobiology, diagnosis, prevention, and treatments for this potentially lethal condition in the elderly.
Pighin S, Bonnefon JF: Facework and uncertain reasoning in health communication. Patient Educ Counseling 2011;85:169–172
Health care professionals often find themselves in the unpleasant position of conveying bad news to patients, or in asking patients to consider unpleasant prospects. In daily life, communicating upsetting news or asking people to consider upsetting possibilities is not done bluntly, but commonly requires facework. Face is the sense of positive identity and public self-esteem that all humans project, and are motivated to support in social interactions. Based on a sociolinguistic analysis of the way uncertainty terms are used, the authors of this study predicted that they would be interpreted differently by patients as a function of whether they were qualified as good news or bad news. Two studies investigating causal inferences were conducted among a sample of French university students (n=50), and among a sample of Italian pregnant women (n=532). Results suggested that participants felt greater confidence in the conclusions they derived when the news was bad, as compared to the conclusions they derived when the news was good. The authors conclude that because health care communication is frequently characterized by uncertainty, these bad news or prospects can be qualified by various uncertainty terms. This research adopted a sociolinguistic approach to the inferences that patient may derive from this communicated uncertainty, and built on previous findings to suggest that facework considerations may lead patients to feel greater confidence in the conclusions they derive when the news is bad, as compared to the conclusions they derive when the news is good. They also suggest that professionals should be aware that when the news is bad, any hedging term such as ‘‘possible’’ can be misunderstood as an attempt to sugar-coat the pill, and that this misinterpretation can lead patient to inferences that are not shared by the professional.
De Ruddere L, Giubert L, Prkachin KM, et al: When you dislike patients, pain is taken less seriously. Pain 2011;152:2342–2347
Pain is a prevalent health problem, entailing severe personal and social impacts as well as high financial costs. However, pain management often remains inadequate. One important aspect of pain management is the estimation of pain by observers as potential caregivers. Those observing a person in pain can vary in the amount of pain they impute to a sufferer. It is therefore reasonable to assume that such differences influence responses to the sufferer, such as treatment choices or helping behavior in the everyday social environment. Hence, insight into how pain estimations originate is essential. In this study, the authors attempted to examine the influence of patients' likability on pain estimations made by observers. Patients' likability was manipulated by means of an evaluative conditioning procedure: pictures of patients were combined with either positive, neutral, or negative personal traits. Next, videos of the patients were presented to 40 observers who rated the pain. Patients were expressing no, mild-, or high-intensity pain. Results indicated lower pain estimations as well as lower perceptual sensitivity toward pain (i.e., lower ability to discriminate between varying levels of pain expression) with regard to patients who were associated with negative personal traits. The effect on pain estimations was only found with regard to patients expressing high-intensity pain. There was no effect on response bias (i.e., the overall tendency to indicate pain). These findings suggest that we take the pain of patients we do not like less seriously than the pain of patients we like.