Unplanned hospitalizations for metastatic cancers:The changing patterns of inpatient palliative care,discharge to hospice care,and in-hospital mortality in the United States

Objective:To describe the rates and temporal trends of inpatient end-of-life care among patients hospitalized with metastatic cancer in the United States.Methods:We used data from the Nationwide Inpatient Sample to conduct a cross-sectional analysis of unplanned inpatient hospitalizations of patients aged 18 years or older with metastatic cancer from 2002 to 2011.Multivariable logistic regression was used to assess patient-and hospital-level predictors of discharge to hospice care,palliative care,and in-hospital mortality.Temporal trends in outcomes were characterized with use of joinpoint regression.Results:There were an estimated 350,241 unplanned hospitalizations per year of patients with a diagnosis of metastatic cancer.During their inpatient stay,5.8%of patients received palliative care,and among those discharged alive,12.2%were referred to hospice care.The rate of inpatient palliative care increased from 2.3%to 13.6%,the rate of discharge to hospice care increased from 4.1%to 15.6%,and the in-hospital mortality rate decreased from more than 14.0%to 9.8%.These patterns were consistent across cancer subtypes,and were most pronounced among patients with extreme risk of mortality.Conclusion:Despite increases in the provision of comfort-oriented care to patients with meta-static cancer,few receive such services.We recommend screening protocols in hospitals to identify patients who are good candidates for palliative care consultation and hospice referral.

Hospitalizations and healthcare costs associated with serious, non-lethal firearm-related violence and injuries in the United States, 1998-2011

Objective:To describe the prevalence,trends,correlates,and short-term outcomes of inpa-tient hospitalizations for firearm-related injuries(FRIs)in the United States between 1998 and 2011.Methods:We conducted a retrospective,cross-sectional analysis of inpatient hospitalizations using data from the Nationwide Inpatient Sample.In addition to generating national prevalence estimates,we used survey logistic regression to calculate odds ratios(ORs)and 95%confidence intervals(CIs)for the association between FRIs and patient/hospital-level characteristics.Tempo-ral trends were estimated and characterized using joinpoint regression.Results:There were 10.5 FRIs(95%CI:9.2-11.8)per 10,000 non-maternal/neonatal inpatient hospitalizations,with assault accounting for 60.1%of FRIs,followed by unintentional/accidental(23.0%)and intentional/self-inflicted FRIs(8.2%).The highest odds of FRIs,particularly FRIs associated with an assault,was observed among patients 18-24 years of age,patients 14-17 years of age,patients with no insurance/self-pay,and non-Hispanic blacks.The mean inpatient length of stay for FRIs was 6.9 days;however,4.7%of patients remained in the hospital over 24 days and 1 in 12 patients(8.2%)died before discharge.The mean cost of an inpatient hospitalization for a FRI was$22,149,which was estimated to be$679 million annually;approximately two-thirds of the annual cost(64.7%)was for assault($439 million).Conclusion:FRIs are a preventable public health issue which disproportionately impacts younger generations,while imposing significant economic and societal burdens,even in the ab-sence of fatalities.Prevention of FRIs should be considered a priority in this era of healthcare cost containment.

Modified Advanced Life Support in Obstetrics course: Feasibility, trainee satisfaction, and sustainability potential

Objective:The main objective of this initiative was to present evaluation results from an inno-vative adaptation of the Advanced Life Support in Obstetrics(ALSO)training course.We modified the traditional ALSO curriculum in our institution by adding hands-on training in laceration repairs and simulation scenarios on acute maternity care.Methods:The modified ALSO provider course was designed to enhance cognitive and proce-dural skills of health care professionals in managing obstetric emergencies.Forty-nine participants attended this course and completed a posttraining survey.Descriptive statistics were used to de-scribe the participant-reported assessment scores for the ALSO course on three domains(subject knowledge,organization and clarity,and teaching effectiveness)for each of 12 course topics.Results:Evaluation of the results showed a high rate of trainee satisfaction as evidenced by the mean assessment scores across all topics ranging from 4.80 to 4.98(out of 5.00).All trainees said they would refer others to the course.Our modified ALSO course effectively addressed the important needs of primary care physicians involved in maternity care,especially in underserved communities where specialized obstetric care is not readily available.Both simulation scenarios and workshops using simulated human tissue provide a better foundation before formal training.Conclusion:Given the changing legal and regulatory climate,we expect that learning to treat complex obstetric situations on the job will become increasingly risky.With this in mind,both simulation scenarios and workshops using simulated human tissue will provide a better foundation before formal training.

Self-reported preferences for patient and provider roles in cancer treatment decision-making in the United States

Objective:To describe differences in preferred roles in cancer treatment decision-making and identify associated sociodemographic and health-related factors among adults in the United States.Methods:We conducted a cross-sectional analysis of nationally representative data from the 2014 Health Information National Trends Survey.Descriptive statistics were calculated and multi-variable logistic regression was conducted to examine associations.Results:Half(48.3%)of respondents preferred a collaborative role in decision-making under the supposition of a moderate chance of survival;while 53.4%preferred a more active role when the chance of survival was low.Approximately 7%-8%indicated a preference for a passive role in decision-making,for both low and moderate chances of survival.Several predictors of role prefer-ence for cancer treatment decision-making emerged,including age,sex,education,race/ethnicity,and having a regular health care provider.At both low and moderate chances of survival,the col-lege educated were less likely to prefer a passive role,whereas Hispanics were two to three times more likely than whites to indicate a preference for a passive role.Conclusion:Adults’role preference for cancer treatment decision-making may be influenced by sociodemographic and health-related factors.Increased awareness of these factors,paired with enhanced patient-provider communication,may assist health care professionals in providing indi-vidualized and high-quality,patient-centered cancer care.