BackgroundOlder patients with advanced CKD are at high risk for serious complications and death, yet few discuss advance care planning (ACP) with their kidney clinicians. Examining barriers and facilitators to ACP among such patients might help identify patient-centered opportunities for improvement.MethodsIn semistructured interviews in March through August 2019 with purposively sampled patients (aged ≥70 years, CKD stages 4–5, nondialysis), care partners, and clinicians at clinics in across the United States, participants described discussions, factors contributing to ACP completion or avoidance, and perceived value of ACP. We used thematic analysis to analyze data.ResultsWe conducted 68 semistructured interviews with 23 patients, 29 care partners, and 26 clinicians. Only seven of 26 (27%) clinicians routinely discussed ACP. About half of the patients had documented ACP, mostly outside the health care system. We found divergent ACP definitions and perspectives; kidney clinicians largely defined ACP as completion of formal documentation, whereas patients viewed it more holistically, wanting discussions about goals, prognosis, and disease trajectory. Clinicians avoided ACP with patients from minority groups, perceiving cultural or religious barriers. Four themes and subthemes informing variation in decisions to discuss ACP and approaches emerged: (1) role ambiguity and responsibility for ACP, (2) questioning the value of ACP, (3) confronting institutional barriers (time, training, reimbursement, and the electronic medical record, EMR), and (4) consequences of avoiding ACP (disparities in ACP access and overconfidence that patients’ wishes are known).ConclusionsPatients, care partners, and clinicians hold discordant views about the responsibility for discussing ACP and the scope for it. This presents critical barriers to the process, leaving ACP insufficiently discussed with older adults with advanced CKD.

Background Patients with cancer often endure substantial symptoms and treatment toxicities leading to high healthcare utilization, including hospitalizations and emergency department visits, throughout the continuum of their illness. Innovative oncology care models are needed to improve patient outcomes and reduce their healthcare utilization. Using a novel hospital at home care platform, we developed a Supportive Oncology Care at Home intervention to address the needs of patients with cancer. Methods We are conducting three trials to delineate the role of Supportive Oncology Care at Home for patients with cancer. The Supportive Oncology Care at Home intervention includes: (1) a hospital at home care model for symptom assessment and management; (2) remote monitoring of daily patient-reported symptoms, vital signs, and body weight; and (3) structured communication with the oncology team. Our first study is a randomized controlled trial to test the efficacy of Supportive Oncology Care at Home versus standard oncology care for improving healthcare utilization, cancer treatment interruptions, and patient-reported outcomes in patients with cancer receiving definitive treatment of their cancer. Participants include adult patients with gastrointestinal and head and neck cancer, as well as lymphoma, receiving definitive treatment (e.g., treatment with curative intent). The second study is a single-arm trial assessing the feasibility and acceptability of the Supportive Oncology Care at Home intervention for hospitalized patients with advanced cancer. Eligible participants include adult patients with incurable cancer who are admitted with an unplanned hospitalization. The third study is a single-arm trial assessing the feasibility and acceptability of the Supportive Oncology Care at Home intervention to enhance the end-of-life care for patients with advanced hematologic malignancies. Eligible participants include adult patients with relapsed or refractory hematologic malignancy receiving palliative therapy or supportive care alone. Discussion These studies are approved by the Dana-Farber/Harvard Cancer Center Institutional Review Board and are being conducted in accordance with the Consolidated Standards of Reporting Trials statement for non-pharmacological trials. This work has the potential to transform the paradigm of care for patients with cancer by providing them with the necessary support at home to improve their health outcomes and care delivery. Trial registrations NCT04544046, NCT04637035, NCT04690205.

Background: Patients with breast cancer generally receive most of their care in an outpatient setting, but unplanned hospitalizations may occur to help manage uncontrolled symptoms. We sought to investigate healthcare utilization and symptoms among patients with breast cancer experiencing an unplanned hospitalization. Methods: We enrolled patients with cancer and unplanned hospitalizations from 9/2014 to 2/2017. The current study focuses on the patients with breast cancer in this cohort. Following hospital admission, we assessed patient-reported symptoms using the Edmonton Symptom Assessment System (ESAS). We reviewed the electronic health record to obtain information about patient demographics, clinical characteristics, healthcare utilization, and reasons for hospital admission (elicited from primary and secondary diagnoses listed on the hospitalization discharge summary). We examined the associations among patients’ symptoms, healthcare utilization (i.e., hospital length of stay and 90-day readmissions), and survival using regression models. Results: We identified 101 patients with breast cancer (median age=60 years [range 22-86]. In this cohort, 74% had metastatic breast cancer. Primary/secondary reasons for hospitalization included fever/infection (34%), pain (18%), dyspnea (12%), gastrointestinal diagnoses (constipation, diarrhea, bowel obstruction, biliary obstruction, ascites, 10%), nausea/vomiting (7%), failure to thrive (6%), pleural effusion (5%), renal failure (4%), blood clot (3%), cardiac diagnoses (atrial fibrillation, cardiomyopathy, 3%), lightheadedness/hypotension (3%), neurologic diagnoses (altered mental status, seizure, subdural hematoma, 3%), fracture (2%), lower extremity swelling (2%), and other (i.e., rash, ptosis, SVC syndrome, fall, 1% each). Table 1 describes the baseline ESAS symptoms collected upon hospital admission. The mean length of hospital stay was 6.2 days and 90-day readmission rates were 28%. Patient disposition post hospitalization included discharge to home (76%), post-acute care facility (12%), hospice (5%), and death in the hospital (6%). We found that patients’ ESAS-physical symptoms were associated with longer hospital length of stay (B=0.08, p=0.029), greater risk of death or readmission within 90-days (OR=1.07, p<0.001), and worse overall survival (HR=1.04, p=0.001). Similarly, patients’ ESAS-total symptoms were associated with longer hospital length of stay (B=0.07, p=0.013), greater risk of death or readmission within 90-days (OR=1.05, p=0.001), and worse overall survival (HR=1.02, p=0.003). Conclusions: In this cohort of hospitalized patients with breast cancer, the majority had metastatic disease and presented with a high symptom burden. Unplanned admissions in these patients with breast cancer commonly occurred for fever/infection, pain, dyspnea, and gastrointestinal reasons. We identified novel associations among patients’ symptoms upon admission with their hospital length of stay, risk of readmissions/death, and overall survival. These findings highlight the need for timely outpatient interventions that address patient symptoms when seeking to enhance health care utilization and survival outcomes in this population. Table 1.Baseline symptom% of patients with moderate or severe symptomsMedian ESAS scoreTiredness*90%8 (Severe)Pain*78%7 (Severe)Well-being76%5 (Moderate)Drowsiness*71%6 (Moderate)Lack of appetite*68%5 (Moderate)Anxiety61%5 (Moderate)Depression52%4 (Moderate)Nausea*45%2 (Mild)Shortness of breath*45%2 (Mild)Constipation*44%0 (None)Total ESAS scoreMedian score 47 Total ESAS_physical score. . Median score 34*components included in ESAS_physical score Citation Format: Neelima Vidula, Emilia Kaslow-Zieve, Carolyn Qian, Isabel Neckermann, Eva Gaufberg, Charu Vyas, Richard Newcomb, Patrick C Johnson, Daniel Lage, Jennifer Shin, Ryan Nipp. Healthcare utilization and symptoms among hospitalized patients with breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-12-04.

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