PC-FACS
2012; Elsevier BV; Volume: 43; Issue: 5 Linguagem: Inglês
10.1016/s0885-3924(12)00129-7
ISSN1873-6513
Autores ResumoPC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care), an electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 50 medical and scientific journals. Each month, structured summaries and insightful commentaries on 6–10 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice. PC-FACS is free to AAHPM members. Following are excerpts from recent issues, and comments from readers are welcomed at [email protected] PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care), an electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 50 medical and scientific journals. Each month, structured summaries and insightful commentaries on 6–10 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice. PC-FACS is free to AAHPM members. Following are excerpts from recent issues, and comments from readers are welcomed at [email protected] Greer JA, Pirl WF, Jackson VA, et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. J Clin Oncol 2012;30(4): 394–400. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA 2012;307(2): 182–192. Parker Oliver D, Kapp JM, Tatum P, Wallace A. Hospice medical directors: a survey of one state. J Am Med Dir Assoc 2012;13(1):35–40. McBeth J, Prescott G, Scotland G, et al. Cognitive behavior therapy, exercise, or both for treating chronic widespread pain. Arch Intern Med 2012;172(1):48–57. Herring MP, Puetz TW, O'Connor PJ, Dishman RK. Effect of exercise training on depressive symptoms among patients with a chronic illness: a systematic review and meta-analysis of randomized controlled trials. Arch Intern Med 2012;172(2):101–111. Ogedegbe GO, Boutin-Foster C, Wells MT, et al. A randomized controlled trial of positive-affect intervention and medication adherence in hypertensive African Americans. Arch Intern Med 2012 Jan 23 [Epub ahead of print]. Peterson JC, Charlson ME, Hoffman Z, et al. Randomized controlled trial of positive affect induction to promote physical activity after percutaneous coronary intervention. Arch Intern Med 2012 Jan 23 [Epub ahead of print]. Mancuso CA, Choi TN, Westermann H, et al. Increasing physical activity in patients with asthma through positive affect and self-affirmation: a randomized trial. Arch Intern Med 2012 Jan 23 [Epub ahead of print]. A high-profile study reported higher quality of life and extended survival when palliative care (PC) was introduced early in care for patients with metastatic non-small cell lung cancer (NSCLC).1 Could effects of early PC on frequency/timing of chemotherapy or hospice use help explain these improvements? This was a secondary analysis of data from a randomized controlled trial of early PC integrated with standard oncology care versus standard oncology care alone. Eligible patients were outpatients with metastatic NSCLC diagnosed within the previous eight weeks and Eastern Cooperative Oncology Group (ECOG) performance status of 0–2. Patients receiving early PC consulted with a member of the PC team within three weeks of enrollment and at least monthly thereafter until death. Outcomes included number and types of chemotherapy regimens, frequency and timing of chemotherapy administration, and hospice referral. Participants (n = 151) were mean age 65 years (SD, 10), 52% female, and 97% white. Groups did not differ significantly in overall number of chemotherapy regimens. Compared with the standard care group, participants in the early PC group were half as likely to receive chemotherapy ≤60 days before death (OR, 0.47; 95% CI, 0.23–0.99; P = 0.05), had more time elapse between the last dose of intravenous chemotherapy and death (median, 64 days [range, 3–406] vs. 41 days [range, 6–287 days]; P = 0.02), and were enrolled in hospice for more than one week at a higher rate (60% vs. 33%; P = 0.004). This study strengthens the message to standardize integration of PC into oncology practice. The American Society of Clinical Oncology Quality Oncology Practice Initiative provides benchmarked metrics related to quality end-of-life care. This study confirms that conformance with these metrics improves when PC is integrated early. Furthermore, two myths are simultaneously disarmed: (a) providing PC does not necessarily steer patients away from antineoplastic treatments potentially employed by the oncologists because there was no reduction in the number of chemotherapy regimens prescribed for the early PC intervention group, and (b) a reduction in aggressive care, in the form of intravenous chemotherapy, does not translate into shortened survival. When people with metastatic NSCLC receive early PC, there is an impressively increased conformance with quality markers for optimal end-of-life care, without a noticeable downside. Stephen J. Bekanich, MD, University of Miami, Miami, FL. Greer JA, Pirl WF, Jackson VA, et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. J Clin Oncol 2012;30(4):394–400. 1.Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic nonsmall-cell lung cancer. N Engl J Med 2010;363:733–742. Prognosis is an important consideration in many clinical decisions, especially those for older adults who have multiple chronic conditions and shortened life expectancy.1 What are the quality and limitations of prognostic indices for mortality in older adults? This systematic review included studies published through November 2011 examining English-language-validated indices that predicted absolute risk of mortality in patients aged ≥60 years. Indices that estimated intensive care unit, disease-specific, or in-hospital mortality were excluded. For each prognostic index, data were extracted on clinical setting, potential for bias, generalizability, and accuracy. The search identified 16 indices that predict mortality risk from six months to five years in diverse clinical settings: hospital (eight indices), community (six indices), and nursing home (two indices). All but three indices tested ≥1 measure of generalizability (i.e., index is accurate in ≥1 population). All included studies had potential bias. Although 13 indices had C statistics of ≥0.70, none had a C statistic ≥0.90. Only two indices were independently validated by investigators who were not involved in the index's development. Most patients want prognostic information, but 25% of older patients do not, so it is important to clarify individuals' preferences.2 Failure to address prognosis may lead to inappropriate screening, burden from inappropriate care, and delay in advance care planning or hospice enrollment. Physicians generally give inaccurate prognostic information.3 Prognostic indices could improve prognostic accuracy; however, as this systematic review documents, the available indices are problematic. They only perform with 70%–80% accuracy. Important factors like comorbid illness and social support systems are not included. Ideally, a “prognosis Rosetta Stone” would automatically import patient data, select the right indices validated in a population similar to the individual in question, and estimate life expectancy considering the individual's unique circumstances. This is where we need to get to, but it will require accurate prognostic indices, health information technology, and real-time data. For now, the authors of this study have created ePrognosis.org, an easy-to-use online calculator with 16 indices from this study. Clinicians using ePrognosis.org should apply the results cautiously given the limitations of each index. Available prognostic indices for older patients are too limited for widespread clinical use but may be a helpful reference point. Paul E. Tatum III, MD, MSPH, CMD, FAAHPM, University of Missouri, Columbia, MO. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA 2012;307(2):182–192. 1.Gill TM. The central role of prognosis in clinical decision making. JAMA 2012;307(2):199–200.2.Ahalt C, Walter LC, Yourman L, Eng C, Perez-Stable EJ, Smith AK. “Knowing is better”: preferences of diverse older adults for discussing prognosis. J Gen Intern Med 2011 Nov 30 [Epub ahead of print].3.Christakis NA, Lamont EB. Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study. BMJ 2000;320:469–472. Physicians' role as hospice medical directors (HMDs) is gaining importance with changes in Hospice Medicare Conditions of Participation (CoPs),1 including mandated involvement with care plan development, oversight of medical care, participation in quality assurance, and certification of hospice benefits. What are current characteristics of HMDs? This was a mail-in survey of state-licensed, state-association-member hospices conducted in Missouri. Executive directors received surveys to distribute to each HMD; reminders were sent at 4, 12, and 16 weeks. Participants (n = 31), representing a 43.7% response rate, were mean age 52 years (median, 51; range, 33–74), 84% male, and 90% white. HMDs averaged nine years in this role (median, 6; range, 1–25); 42% were the only HMD at their hospice. Seventy-one percent were MDs, and 29% were DOs. Ninety percent were primary practice physicians. Twenty-three percent were ABHPM-certified. None completed a palliative medicine fellowship; 42% completed Education in Palliative and End-of-Life Care (EPEC) training. Thirty-two percent were members of AAHPM. Sixty-eight percent worked ≤20 hours/week as HMDs, and 52% were salaried. Fifty-eight percent reported not having done a home visit and 45% not having visited nursing home patient(s) in the past month. Seventy-one percent participate in quality assurance. Sixteen percent reported no responsibility for being involved with care plan development, and 10% said they played no role in certification. Key areas to improve effectiveness were understanding of hospice regulations (39%), peer support (29%), clinical experience (29%), leadership training (16%), and mentoring (13%). The findings from this midwestern state correlate with my personal conversations with other HMDs who express similar experiences. Some HMDs are unaware of their Medicare CoP mandated responsibilities. Only the HMD can certify hospice patients as eligible for care, and HMDs now must make face-to-face visits. Although not stratified by hospice size, the sample's mean daily census of 67, with barely half of the hospices having more than one HMD, indicates these were smaller organizations in which the HMD practiced without peer support. Recent efforts seek to fill this void, such as AAHPM's Hospice Medical Director Manual, 2nd edition, and ongoing series of HMD courses. Standardization of minimum requirements for HMDs is in progress, such as the recent creation of the National Board of Hospice Medical Director Certification, which is designed with any HMD in mind, whether HPM board certified or not. Proceeding with such efforts can only enhance and optimize hospice patient care. Many HMDs are unfamiliar with the requirements of the position, arguing for standardization of the HMD role, including formal HMD certification. Ronald J. Crossno, MD, CMD, FAAFP, FAAHPM, Gentiva Hospice Division, Dallas, TX. Parker Oliver D, Kapp JM, Tatum P, Wallace A. Hospice medical directors: a survey of one state. J Am Med Dir Assoc 2012;13(1):35–40. 1.National Hospice and Palliative Care Organization. A summary of the Medicare regulations for hospice care, including the Conditions of Participation for Hospice Care 42 CFR418, Current as of July 29, 2011. Available www.nhpco.org. Exercise is increasingly recognized as a powerful therapy. Does exercise, alone or combined with cognitive behavioral therapy (CBT), improve pain and depression among the chronically ill? This was a randomized controlled trial of telephone-delivered CBT, exercise, or a combination versus usual care. Eligible patients had consulted their physician for chronic widespread pain within the past year. CBT focused on goal setting and pain self-management in eight weekly, 30–45 minute sessions, plus one session at three months and six months post-randomization. The exercise intervention focused on cardiorespiratory fitness without dictating specific exercise(s); recommended frequency was three to five times/week for 20–60 minutes. Primary outcome was patient's global assessment of change in health. Participants (n = 442) were mean age 56 years (range, 25–85), 70% female, and 34% employed full time. After adjustment, active interventions (versus usual care) were more likely to result in “much better” or “very much better” self-reported health: CBT (6-month OR, 5.0 [95% CI, 2.0–12.5]; 9-month OR, 5.4 [95% CI, 2.3–12.8]); exercise (6-month OR, 6.1 [95% CI, 2.5–15.1]; 9-month OR, 3.6 [95% CI, 1.5–8.5]); and combined (6-month OR, 7.1 [95% CI, 2.9–17.2]; 9-month OR, 6.2 [95% CI, 2.7–14.4]). This was a meta-analysis of articles published through May 2011. Eligible studies enrolled sedentary patients with chronic illness, randomly assigned participants to an exercise intervention versus nonexercise condition, and measured a depression outcome at baseline and during and/or after intervention. Participants (n = 10,534) were mean age 51 years (SD, 15) and mean 61% women (SD, 34%). The mean exercise training adherence rate was 77% (SD, 13%). Exercise training significantly reduced depressive symptoms (mean effect size delta, 0.30 [95% CI, 0.25–0.36]). Larger effects occurred when baseline depressive symptoms were higher, patients met moderate or vigorous physical activity levels, and patients had both baseline mild to moderate depression and function-related improvement. People with chronic pain or chronic illness often become depressed and vice versa. Brief CBT or exercise improved patient health following six months of treatment and persisted after three months. In a large meta-analysis, exercise not only reduced depressive symptoms but also improved function in patients with mild to moderate depression and functional impairment. In the palliative care population, sadness can become depression, and people with depression and chronic pain syndromes may develop malignancy. For select palliative care patients, cognitive therapy and/or exercise may improve quality of life significantly, and this population needs to be studied. Both interventions increase contact with professionals, which may in itself improve well-being. Physiotherapists and behavioral therapists in palliative care programs have an important role in improving patient quality of life, including improved depression and pain. Alan J. Nixon, MD, FAAHPM, Richmond Hospital, Richmond, BC, Canada. McBeth J, Prescott G, Scotland G, et al. Cognitive behavior therapy, exercise, or both for treating chronic widespread pain. Arch Intern Med 2012;172(1):48–57. Herring MP, Puetz TW, O'Connor PJ, Dishman RK. Effect of exercise training on depressive symptoms among patients with a chronic illness: a systematic review and meta-analysis of randomized controlled trials. Arch Intern Med 2012;172(2):101–111. Positive affect, a mental state induced by small positive experiences (e.g., unexpected compliment, small gift), increases enjoyment of tasks and fosters flexible thinking.1,2 Self-affirmation, which entails recalling past accomplishments that make an individual feel proud, increases self-confidence and resolve to overcome challenges.3–5 Can positive affect and self-affirmation increase health-promoting behaviors? This was a randomized controlled trial of a patient education intervention plus positive-affect induction and self-affirmation (PA) versus education alone for improving medication adherence and reducing blood pressure (BP). Eligible patients were African Americans prescribed ≥1 antihypertensive medications. All participants received a culturally tailored hypertension self-management workbook, behavioral contract, and bimonthly telephone calls. PA group participants also received (a) an additional chapter on the benefits of positive moments in overcoming obstacles to medication adherence; (b) two suggestions, during calls, for PA (e.g., incorporate positive thoughts/feelings into daily routine, remember core values and proud moments); and (c) unexpected small gifts. Main outcomes were medication adherence and within-patient change in BP from baseline to 12 months. Participants (n = 256) were mean age 58 years (SD, 12), 79% female, and 24% married; 58% completed college. Medication adherence at 12 months was higher in the PA group versus the education group (42% vs. 36%; P = 0.05). Within-group reductions in BP for the PA versus education group were not significant. This was a randomized controlled trial of a positive affect and self-affirmation (PA) intervention versus education for increasing energy expenditure. Eligible patients were identified after percutaneous coronary intervention. All participants received a culturally tailored educational workbook, pedometer, and behavioral contract for a self-selected physical activity. Patients in the PA group also received (a) an additional workbook chapter focused on PA and self-affirmation, (b) PA inducement at the end of each bimonthly call, and (c) unexpected small gifts. Main outcome was within-patient change in energy expenditure (kcal/week) from baseline to 12 months. Participants (n = 242) were mean age 63 years (SD, 11); 70% male; 11% African American, 13% Hispanic; and 75% overweight or obese. Significantly more PA group participants versus education group participants increased expenditure by ≥336 kcal/week at 12 months (55% vs. 37%; P = 0.007; OR, 1.7; P = 0.02). PA group participants had nearly double the improvement in kcal/week expended (602 vs. 328; P = 0.03). This was a randomized controlled trial of an educational intervention plus positive affect induction and self-affirmation (PA) versus education alone for increasing physical activity in patients with mild to moderate persistent asthma. All participants completed a survey measuring energy expenditure; made a contract to increase physical activity; and received a pedometer, an asthma workbook, and bimonthly follow-up telephone calls. PA group participants also received small gifts and instructions in fostering PA and self-affirmation. Main outcome was within-patient change in energy expenditure (kcal/week) from baseline to 12 months. Participants (n = 258) were mean age 42 years (SD, 12), 75% female, 61% college graduate, and 54% white. Energy expenditure increased in both groups: +398 kcal/week (95% CI, 145–652; P = 0.002) among PA group participants, and +415 kcal/week (95% CI, 76–754; P = 0.02) among the education group (between-group P = 0.94). Energy expenditure increase was sustained through 12 months in both groups. Multiple studies suggest that positive affect interventions may be beneficial across a variety of outcome measures, including medication adherence and physical activity in diseases such as hypertension and following angioplasty. Positive affect intervention did not appear to significantly increase exercise for those with asthma. Across these studies, effect sizes are small, which portend difficulty in translating these interventions into widespread gains. There also exists substantial work effort in providing positive affect interventions to patients, which may further diminish the overall return when economic factors are included in the analysis. With regard to palliative care, it would be worthwhile to explore the role of positive affect interventions in the context of supporting meaning-making and decision-making in patients at the end of life to potentially bolster their sense of empowerment, spirituality, and confidence during this time of their lives. Positive affect interventions produce modest successes but at significant effort and potentially high cost among those with hypertension and following percutaneous coronary intervention. These approaches might benefit palliative care populations, but specific study is required. Harold W. Goforth, MD, Duke University and Durham VA Medical Centers, Durham, NC. Ogedegbe GO, Boutin-Foster C, Wells MT, et al. A randomized controlled trial of positive-affect intervention and medication adherence in hypertensive African Americans. Arch Intern Med 2012 Jan 23 [Epub ahead of print]. Peterson JC, Charlson ME, Hoffman Z, et al. Randomized controlled trial of positive affect induction to promote physical activity after percutaneous coronary intervention. Arch Intern Med 2012 Jan 23 [Epub ahead of print]. Mancuso CA, Choi TN, Westermann H, et al. Increasing physical activity in patients with asthma through positive affect and self-affirmation: a randomized trial. Arch Intern Med 2012 Jan 23 [Epub ahead of print]. 1.Aspinwall LG, MacNamara A. Taking positive changes seriously. Cancer 2005;104(11)(Suppl):2549–2556.2.Isen A, Reeve J. The influence of positive affect on intrinsic and extrinsic motivation: facilitating enjoyment of play, responsible work behavior, and self-control. Motiv Emot 2005;29(4):297–326.3.Reed MB, Aspinwall L. Self-affirmation reduces biased processing of health risk information. Motiv Emot 1998;22(2):99–132.4.Paffenbarger RS Jr, Blair SN, Lee IM, Hyde RT. Measurement of physical activity to assess health effects in free-living populations. Med Sci Sports Exerc 1993;25(1):60–70.5.Paffenbarger RS Jr, Wing AL, Hyde RT. Physical activity as an index of heart attack risk in college alumni. Am J Epidemiol 1978;108(3):161–175. Thank You for Being You Dear Readers, After more than six years as Editor-in-Chief of PC-FACS, I am passing the baton into the very capable hands of Donna Zhukovsky, MD, FACP, FAAHPM. Donna's commitment, ingenuity, and intellect—combined with a fantastic Editorial team—will carry PC-FACS to the next level. As I reviewed the selection of articles for my final issue of PC-FACS, two things struck me. First, we have come a very long way. Palliative medicine and hospice care, truly, are coming into their own. In a relatively short period of time, we have made great strides in developing our evidence base; we now deserve to stand tall among our colleagues in other disciplines, as researchers and as providers of evidence-based, high-quality clinical care. This brings me to my second observation: it really does take a village. Hospice and palliative care are both an exquisite art and an intricate science. Our patients are human beings living within a matrix of family, friends, and community. They possess deep inner worlds but are also characterized by complex biomedical conditions as well as a constellation of demographic and other descriptors. Their care involves a diverse cast of professionals with expertise in primary care; oncology; geriatrics; various other medical specialties; nursing; hospice; social work; psychology and spirituality; exercise and rehabilitation therapy; pharmacy; and, yes, palliative medicine. To deliver the best, most comprehensive care to our patients, we must function as part of a larger team, connecting with the village ourselves and helping strengthen the bonds between the village and our patients. None of us can, or should, go it alone. This concept is central to PC-FACS, as we present you each month with palliative care-relevant articles culled from dozens of journals spanning multiple disciplines. Learning from each other, we can best prepare ourselves to work together, and thus to provide excellent care to our patients. In closing, I want to thank each and every one of you for the role you play in creating an ever-growing, ever-better, village—a true community for advancing palliative care. Kudos to you, Amy Abernethy, MD, FACP, FAAHPM, Founding Editor-in-Chief, PC-FACS Donna S. Zhukovsky, MD, FACP, FAAHPM, of the University of Texas M. D. Anderson Cancer Center, is the Editor-in-Chief of PC-FACs. Mellar P. Davis, MD, FCCP, FAAHPM, of the The Cleveland Clinic Foundation, is Associate Editor-in-Chief. The AAHPM thanks the following for their reviews of the critical summaries and preparation of the commentaries: Robert M. Arnold, MD Stephen Bekanich, MD Janet Bull, MD, FAAHPM Ira Robert Byock, MD Ronald J. Crossno, MD, CMD, FAAFP, FAAHPM Mary Ersek, PhD, RN, FAAN, FPCN Tommie W. Farrell, MD Betty Ferrell, PhD, MA, FAAN, FPCN, CHPN Perry G. Fine, MD Daniel Fischberg, MD, PhD Anthony Nicholas Galanos, MA, MD Gail Gazelle, MD, FACP, FAAHPM Harold W. Goforth, MD Laura Hanson, MD, MPH, FAAHPM Peter Mahler, MD, PhD John F. Manfredonia, DO Gregory J. Miller, MD J. Cameron Muir, MD Alan Nixon, MB BCh, BAO, FAAHPM David Nowels, MD, MPH Aaron Olden, MD, MS John Peppin, DO, FACP Francine Rainone, DO, PhD, MS, FAAHPM Brad Stuart, MD Paul E. Tatum III, MD, MSPH, CMD, FAAHPM James A. Tulsky, MD Joanne Wolfe, MD The views expressed herein are those of the individual authors and are not necessarily those of the Academy. Information included herein is not medical advice and is not intended to replace the judgment of a practitioner with respect to particular patients, procedures or practices. To the extent permissible under applicable laws, the Academy disclaims responsibility for any injury and / or damage to persons or property as a result of any actual or alleged libelous statements, infringement of intellectual property or other proprietary or privacy rights, or from use or operation of any ideas, instructions, procedures, products or methods contained in this publication. American Academy of Hospice and Palliative Medicine 4700 West Lake Avenue Glenview, IL 60025-1485, USA Phone: 847-375-4712 Fax: 877-734-8671, E-mail: Website: www.aahpm.org
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