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One marker of the distance we’ve traveled in palliative care is the blossoming evidence base for the field. Ten years ago we would have been hard pressed to find 3 clinical trial abstracts submitted to the annual meeting, much less high quality randomized trials with robust measures, sample sizes, and analytics plans.  Well, as a kick off to this year’s first in-person State of the Science plenary, held in conjunction with the closing Saturday session of the AAHPM/HPNA Annual Assembly, 3 randomized clinical trials were presented.

Today we interview the authors of these 3 abstracts about their findings:

  • Tom LeBlanc about a multisite trial of palliative care for patients undergoing Stem Cell Transplant for blood cancers (outcomes = quality of life, depression, anxiety)
  • Kate Courtright about a pragmatic trial of electronic nudges to prognosticate and/or offer comfort-focused treatment to mechanically ventilated ICU patients/surrogates (outcomes = lengths of stay, hospice, time to discontinuation of life-support)
  • Corita Grudzen on a pragmatic trial of two palliative care approaches for patients with advanced cancer or organ failure discharged from the ED: a nurse-led telephone intervention or outpatient specialty palliative care clinic (outcomes = quality of life, symptom burden, loneliness, healthcare utilization)

Wow! I’m just stunned even writing that! We’ve come so far as a field. This isn’t to say we’ve “made it” – more to say that we’ve reached a new stage of maturation of the field – in which the evidence we are discussing is frequently high quality randomized trial level data.

We recorded this on Friday during the annual assembly, and Eric and I were a littttttle off our game due to the residual effects of the GeriPal pub crawl the night before, which were only compounded by technical difficulties.  I believe these issues were more than made up for by our guests’ forced accompaniment to the song “Feel Like Making Science.” (Credit to the Beeson singing crew for coming up with that one).

Enjoy! -@AlexSmithMD



Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, who do we have with us today? We are at AAHPA…uh..AAHPM…

Alex: Was it a long night last night? Were you at the GeriPal pub crawl?

Eric: I may have been at the GeriPal.

Alex: What time did you get home, young man? [laughter]

Eric: 2:30 AM. Actually, that’s when we ended. Alex, who’s with us today at the AAHPM meeting?

Alex: Today we’re delighted to have Corita Grudzen, who is an emergency medicine physician and she’s at Memorial Sloan Kettering. She’s a researcher and we’re going to hear more about her research soon. And we have Kate Courtright, who’s at University of Pennsylvania, the PAIR Center. They study palliative care. She’s pulmonary critical care and palliative medicine trained. And we have Tom LeBlanc, who’s from Duke, who is also palliative care trained and an oncologist. Welcome, Corita and Kate and Tom.

Kate: Thank you.

Tom: Thank you.

Eric: So we’ve got a lot to cover today. We’re going to be covering what you’re going to be presenting at the state of the science tomorrow, so this is pre-recorded. But before we do that, do we have a song request from someone?

Alex: No, we don’t. They failed to give me a song request; therefore, they’re being punished [laughter] and they have to sing along to my cheesy choice of Feel Like Making Science. Feel Like Making Science by Bad Company, and everybody’s going to sing, including Anne Kelly who’s filming us over there. Anne, you want to say hi?

Anne: Hi.

Alex: Okay, here we go. Let’s see how this goes. Here we go. (singing)

Eric: Oh, that was great.

Kate: Song request will always be honored in the future. [laughter]

Eric: Lesson learned.

Kate: Lesson learned.

Eric: Okay. We have three trials to talk about. These are big trials in palliative care. Is there a similar theme here? Let’s just jump into the trials. Kate, I’m going to start with you and your trial. Behavioral economics trial, right?

Kate: Yes.

Eric: Why did you decide to do this trial?

Kate: Because we have a problem in the ICU with communication.

Eric: What’s that problem?

Kate: The problem is we communicate late, we share prognosis late, we elicit goals and values late, so all the time while they’re in the ICU getting prolonged intensive care, we don’t really know that we’re providing goal concordant care, so we wanted to nudge it a little upstream.

Eric: Nudge it.

Kate: Nudge it.

Eric: Nudge it, behavioral economics. We’ve certainly talked about that before.

Kate: We have.

Eric: Alex makes fun of me. I bring up that podcast every single podcast. Real quickly for our audience, what’s a nudge?

Kate: So a nudge in its simplest form is really any change to choice architecture or a choice frame in which you are trying to overcome inherent human decision making biases to guide people gently towards a desired choice that is in theirs or others’ best interest, and it neither restricts nor incentivizes choice.

Eric: So that really expensive surf and turf meal that I saw on the menu last night, probably not a lot of people ordered it, and a really cheap one, it’s going to nudge me towards one of those middle items.

Kate: Well, yep, that’s one. Yep, expanded choice sets. That’s a marketing technique.

Eric: What did you do in the trial?

Kate: In the trial we tested two nudges: one was called a focusing effect. We all, when bombarded with information have to take certain elements of a decision and focus on those; and in the ICU, you can imagine, we’re bombarded with information a lot. What we did was ask clinicians earlier in the ICU stay for very sick patients to document prognosis, and for those who they thought would survive, to document six-month functional prognosis. And that helped them focus on that instead of, say, the blood pressure, the vasopressors or the ventilator settings that day.

Eric: And how did you do that?

Kate: So it was an embedded alert in the electronic health record and they just clicked those two answers very quickly. And then the second intervention was called accountable justification, whereby we simply asked those same clinicians if they had offered these patients the option of withdrawal of life support and comfort-focused care as is recommended by guidelines for high-risk patients; and if not, why not? And that’s it.

Eric: Those are the two nudges. You’re not telling them what to do; you’re giving them options.

Kate: Correct.

Eric: But you’re reminding them?

Kate: We’re reminding them in a way. And also leveraging that idea that we all have these biases. For example, an accountable justification, you’re simply leveraging the fact that clinicians are trained to make decisions backed by reason and to document them, and this is no different.

Eric: And who are the patients including in this trial, again?

Kate: These are very sick patients. These are patients who had a pre-existing chronic disease, very broadly defined.

Eric: Can you give me an example?

Kate: Sure. COPD, heart failure, solid oncology, hematologic malignancy, dementia, ALS, interstitial lung disease, several others. There were nine disease categories. Really wanted it to be generally applicable to an ICU population. And then they had to be receiving 48 hours of continuous mechanical ventilation at a minimum and be an adult. So really broad, but also very sick.

Eric: And then before we get into the results, they got these alerts. Exactly when did they get these alerts in there? On the admission, are you telling them, “Think about withdrawal and life-sustaining treatments?”

Kate: No, they received the alerts at the time an eligible patient reached that 48 hours of continuous mechanical ventilation. They could respond to them at any time; we didn’t tell them when they had to. That’s when they got enrolled.

Eric: Okay. Before we go on to the result, questions? Either of you have questions about the study.

Corita: Where was it done?

Kate: It was done in 10 hospitals, 17 ICUs in Atrium Health down in North Carolina.

Eric: Kate, how many people were enrolled in this study?

Kate: 3,500.

Eric: 3,500 people. That’s a pretty big palliative care study. I’ve said that now three times because of technical issues. Did nudging work?

Kate: Depends. Asking clinicians to document prognosis did not change the primary outcome of hospital length of stay or really any of the secondary outcomes, which I’ll get into. Asking clinicians whether they had offered the option of withdrawal of life support and comfort-focused care also did not change length of stay, but did increase the discharges to hospice, odds greater than two-fold, whether it was done alone or in combination with the prognostication nudge.

And the same nudge, the withdrawal of life support nudge, also decreased the time to comfort care orders. But importantly, it did not change the frequency of comfort care orders. It did not change the frequency of palliative care consultation, the timing of such, ICU mortality, or six-month mortality.

Eric: So how do you put that all together?

Kate: To me, it suggests that that nudge helped clinicians identify and discuss earlier likely prognosis and goals and values such that patients who were likely to go on and die in the ICU with comfort care did so earlier in their stay; but more patients didn’t die, patients who would go on to survive likely didn’t die because the mortality curves all converged.

Eric: Alex, you got a question?

Alex: We had you on just recently, the podcast. We’ve had you on twice before.

Kate: Sounds right.

Alex: Recently you talked about the other trial, also with a nudge, and that was non-cancer, serious illness. Also the same hospital system?

Kate: No, that was in Ascension Health and it was hospitalized patients who may have been in the ICU. This was ICU only,

Alex: ICU only. Other than those differences, what do you draw from these two trials together? Lessons learned? How would you contrast the findings?

Kate: I think the main one for me being asked on the fly is that one of the nudged specialist palliative care consultation, which we know has limitations. In that trial, not all of the consults that were accepted were actually able to be seen because of resource constraints. In this PONDER-ICU trial, we didn’t rely on palliative care specialists; we engaged bedside clinicians to have ICU communication and adhere to guidelines.

None of the changes that we saw in end-of-life care processes relied on specialist palliative care increases or resources, which is really important because seven of the 10 hospitals that participated were rural or community-based, which is where most Americans receive their care, and also where specialist palliative care is often most limited.

Alex: Thank you.

Eric: Okay. Next, what should we do with this study?

Kate: Yeah, some of the thoughts I’ve had in thinking about this: we did not require communication, training and education of the clinicians. And I think had we done so, particularly now that it’s so much more accessible through web-based courses with CAPSI and other such platforms, that perhaps benefits would’ve been even greater.

I am part of some other work in the ICU world looking at time-limited trials and trying to better define what those are, how we talk about them, how we talk about them with patients and families. I suppose you could imagine a world in which time-limited trials are somehow combined with this nudge to make sure that we’re offering the option of withdrawal of life support and comfort-focused care, because that’s one of the options that may end a time-limited trial.

Other thoughts are that the combined interventions, when we put them together, is a little bit fishy to me, or squirrely, I guess. You don’t know if the treatment alternative intervention is what drove those findings. It sure seems like it because it was the active intervention arm and prognostication didn’t seem to do anything on its own.

I don’t know. We want to try to minimize nudges and burden in the EHR, so might you just use the one intervention and not pair it with the prognostication intervention?

Eric: Last question: you asked a bunch of doctors in the ICU prognosis questions?

Kate: Yeah.

Eric: Should we expect a future study seeing how good those physicians are with their estimated prognosis?

Kate: Yeah, we absolutely will be looking at that, but we actually know they’re not that great. A colleague of mine up in Toronto did an ICU study actually asking clinicians, nurses, docs, six-month prognosis, both functional and vital status and compared it with actual observed status.

I don’t want to misspeak because now I forget. It was many years ago, but we weren’t that great, is the upshot; which is why in this study we don’t make them do anything with the information, we don’t make them tell patients, we just ask them to consider it. In the end, if you put those findings together, they really did rise to the top, the patients who were really the sickest.

Eric: Okay. Next study. I’m going to go to stem cell transplants. Why did you do this study, Tom?

Tom: So we did this study because patients who go through the stem cell transplant process face a lot of misery in terms of physical symptoms, psychological distress, anxiety, depression, and even a risk of PTSD afterwards, sort of like a medical trauma, you might think of it. There is a lot of literature suggesting that standard transplant care doesn’t really meet the needs of these patients and their caregivers.

Eric: Okay. I got a second follow-up question to that. If memory serves me correct, Tom, you are a second author on a randomized control trial on stem cell transplant paper showing that palliative care in addition to usual care improved a whole bunch of outcomes.

Tom: Yes.

Eric: And you decided to do a follow-up study on this. This is a follow-up study, right? Why another study?

Tom: So [inaudible name], the PI of that study and this one, had done that as a single site study at MGH. The idea is, if it works at MGH, that’s a special kind of a place, maybe they do palliative care differently, maybe they have better resources, would this work at other transplant centers that have different kinds of clinicians or that serve different kinds of patients; so we wanted to have diversity of sites and clinicians and patients.

Eric: Great. So how many different sites did you include in this study?

Tom: Three sites: MGH is the primary site, Duke and then UDub, the Fred Hutch in Seattle.

Eric: Great. So the intervention was usual care and palliative care. What was in that palliative care syringe?

Tom: The patients randomized to the palliative care intervention were seen at least twice per week by a palliative care specialists. It could be an NP, a PA, or an MD. They weren’t seen by the interdisciplinary team, but they were seen by a specialist at least twice per week during the transplant hospital stay only.

Eric: And that’s similar to the 2016 JAMA paper, right?

Tom: Yeah, it’s really the same intervention, just a multi-site version of the study. I think you’re also getting at, “What did these clinicians do? What did they focus on?” It really is just good palliative care for people with significant symptoms and distress, so it was not a heavily manualized intervention.

There’s a training that basically told the clinicians, “This is what transplant is like, here are the common things that you should expect.” These patients get mucositis and it can be really bad and you should really think about early use of a PCA. There’s significant refractory nausea despite usual antiemetics; you should think about what else you could do to address that. There are issues with coping, uncertainty, anxiety, depression, et cetera.

Eric: And if memory serves me correct, in the last trial, I’m guessing similar to this one, the focus was not on advanced care planning, life-sustaining treatments, any of that. Is that right?

Tom: Yeah, that’s right. And the key is that these are patients with blood cancers that are usually in remission but that have a high likelihood of coming back and leading to their death, usually pretty soon, if we don’t do something more aggressive like a transplant. The idea is the transplant is a consolidated treatment that gives them a chance at cure; and with that chance at cure comes significant risk of death in the short term and this very bothersome, difficult hospitalization with all these symptoms and issues.

The intervention is really an extra layer of support when you’re going through this very difficult thing, but cheering these patients and families along hoping that they will be cured, but making it hopefully a little bit easier to get through the misery of a transplant.

Eric: And we’re going to get to results, but that’s why I also love that 2016 paper: I think it was the very first palliative care trial that ever looked at individuals getting curative therapy.

Tom: That’s probably true. It was the first randomized palliative care trial in hematology, is the way that I think of it.

Eric: I think about it as the first one to address individuals’ curative therapy. So what did this one show? Did it negate everything from the 2016 trial?Palliative care doesn’t work?

Tom: Thankfully not, no. There are some minor nuances and differences in some of the outcomes and such, but the primary outcome was assessed at two weeks into the transplant hospital stay; and on the patient reported outcome measures at that time point, which is when these patients feel at their worst, things like quality of life, anxiety, depression, overall symptoms, fatigue, PTSD symptoms, really all of those things improved except for anxiety.

These were clinically significant and statistically significant improvements. Then we looked also a little bit long-term at three and six months, and we also looked at caregiver outcomes. It’s pretty interesting to see what came of it.

Eric: Well, let’s talk about caregivers. But before I do, the last time I think anxiety actually improved, right?

Tom: Yeah. I think in the single site study it did.

Eric: Okay.

Tom: In this case there was a difference at baseline where the groups even with the randomization happened to be a little different, and I think that might be why we didn’t see the statistical effect, but I don’t know.

Eric: And then for caregivers, what was the caregiver outcome?

Tom: We looked at a few different caregiver outcomes, anxiety, depression, and there actually was less anxiety in caregivers two weeks in at that main primary outcome assessment time.

Eric: That’s great.

Tom: It’s interesting. There was no caregiver intervention, but the idea would be that if you take better care of the person that they care about and love, that they’re somehow perceiving that that person’s getting better symptom management or distress management, or maybe they’re part of the conversations about the uncertainties and the worries of transplant; and whatever that did, it translated into less anxiety for them.

Eric: Last question for you on this. We got a question from Alex. This second randomized controlled trial on palliative care consultation in stem cell transplant patients, how does it compare to the… Are there multiple randomized controlled trials of cardiology consults for stem cell transplant patients or ID consults or endocrine consults for stem cell transplant patients?

Tom: Not that I know of, no. It’s shocking, isn’t it?

Kate: He loves that question. Why do we have to keep proving it?

Eric: Yeah, I guess not. Kate’s question: why do you feel like we need to prove, not just on a single site, but multi-site study, that a palliative care consultation improves outcomes for this specific population?

Tom: I think ultimately it’s because usually my transplant colleagues don’t believe that this is necessary and we have to prove that it is helpful. The case in point example here is when that first trial, the single site trial you were talking about, was opening, we had the opportunity to be a second site and we were planning to just do it with no funding and figure it out because it was important.

And when I presented it to the transplant team, they said, “This is interesting, but we don’t need that. We have our social workers and our psychologists and we know how to manage these symptoms. They’re because of the treatment. We have protocols to address pain and nausea, et cetera. We don’t think that this is really necessary and so we don’t think that we want to participate.”

And of course that was wrong, but when you do a study like this at one site that’s a unique place, people say, “Well, that’s fine, but we don’t need that here.” Hopefully that doesn’t mean we need to do a 20 site study in transplant now; although actually we are doing that in a different disease space, in AML but for a different reason. That’ll be another podcast.

Alex: My question is very related to Eric’s. One of the places I trained, I won’t name, but it’s not easy to figure it out. I think I did one palliative care consult in three years in stem cell transplant. And then in that case, we had very clear restrictions placed in our consult. We could talk about depression but not anxiety because that might bring up what they were anxious about and that might be problematic.

Are you seeing attitudinal changes? What is it about transplant in this case that seems to be maybe different than others? Or is it not? Is it just like, “Our first oncologists were resistant for a solid tumor, and then we had a change with studies coming out and that this…” What do you think?

Tom: Yeah, I think it is different. I treat patients with acute leukemias and related diseases, so I kind of know some of this from my own clinical practice. When you are treating somebody with a really aggressive regimen and you are bringing them to the brink of death sometimes and dangling them over the cliff and pulling them back by their coattails, and we’ve all had cases where somebody who didn’t really know and understand what we were doing and what we would expect to see and what was normal and what’s likely to improve versus what isn’t, would in a well-intentioned way, but harmful way, ultimately recommend something or do something for a patient that wasn’t the right thing.

It’s just created trust issues over the years. I think many transplant docs have had a situation where one of their patients was in an ICU and somebody talked with that person about goals of care when they had a very reversible issue, like some acute graft versus host disease or alveolar hemorrhage or sepsis or something that is an expected course of transplant for a small proportion of people.

When you look at the critical care evidence, it’s clear that patients with a blood cancer are highly likely to actually leave the ICU and leave the hospital and be functional compared to a patient with an advanced solid tumor, where if they’re in the ICU, it’s usually really bad and it’s usually because of the cancer; and often that means we shouldn’t be doing very, very aggressive things. Certainly there’s exceptions, but I do think it’s different.

Eric: So maybe not the nudging question about life-sustaining treatments for the stem cell transplant patients?

Kate: Yeah. Our second to lowest enrollment was hematologic malignancies in that study.

Eric: Okay. So we’ve talked about the ICU, we’ve talked about stem cell transplant wards. Emergency rooms.

Corita: Yes. We went in reverse order. [laughter] I don’t know what happened there.

Eric: To all of our emergency medicine colleagues, saved the best for the last.

Tom: We should have had you sing Urgent Emergency. I don’t know if that’s the name of it, actually.

Eric: So let’s talk about the emergency room. What did you do in your study?

Corita: I’ll start with what we did and why we did it quickly. We were really interested in patients that come to the ED with serious illness and go home; because, as many people know, when someone gets admitted from the ED, there’s a whole host of resources you get when you’re discharged after an inpatient stay that is already in place in hospitals all over the world because of readmission penalties, et cetera.

We were really interested in the gap that exists after patients leave the ED or an observation status and go home, so what we did is we randomized patients, it was patient-level randomization, to either nurse-led telephonic care for six months, or specialty outpatient palliative care for six months.

Eric: We just did a podcast on creating palliative care consults. It was the default palliative care consult podcast where it was just layered on top of existing palliative care resources. Was this the same? Were these two resources already there? Am I making this up?

Corita: Okay. I’m like, what are you talking about? Yeah, I thought you were going to talk about the Beckelman Study.

Eric: It’s probably the late night.

Corita: Yeah. It’s not night yet. You mean last night?

Alex: It would’ve been more interesting if we did this on the pub crawl. We could have done the interview then.

Eric: When you go to sleep at 3:00 in the morning… When I talk about night, it was today, it was the night that I was still awake at. The question is, were both of these already staffed up and you just tested them? Or did you give resources to both of them to do this intervention?

Corita: Great question. It was funded by PCORI. PCORI does not pay for the intervention because you’re comparing things that are standard of care, so we chose sites specifically that had outpatient specialty palliative care already, they had functioning clinics that were willing to see patients.

And then with the nurse-led telephonic case management, that was a centralized model at NYU, and we got philanthropic support to hire the nurses. They were licensed in all of the states, but they delivered the care from NYU. Those were nurses that were hired specifically for this purpose.

Eric: And were there set amounts of time that either the palliative care consult team had to see patients or the nurses had to see or call patients?

Corita: Yes. Nurses, they also had specific training requirements, so I just want to make it clear. It wasn’t just any nurse. There were a number of things. They had to be certified in hospice and palliative nursing, and they had a whole bunch of other trainings that had to be…

Eric: These were palliative care nurses, in a way?

Corita: Yes, and they got additional training in motivational interviewing and they did the CAPSI modules and they did respecting choices. They called the patient within 48 to 72 hours after an ED visit or an OB stay to do an initial assessment, and then they called patients every couple weeks for the six months. Palliative care outpatient was a single visit a month for six months.

We started pre-pandemic and very quickly it went to telehealth, so it was primarily telehealth. Most places had one visit that had to be face-to-face because of prescribing and regulatory issues, but it was primarily telehealth.

Eric: Okay. How often did the palliative care team have to see folks?

Corita: It was one visit a month.

Eric: One visit a month?

Corita: Yeah.

Eric: Okay, the palliative nursing intervention versus what was the team in the palliative care side?

Corita: It was a clinic, so clinic visit, your typical outpatient palliative care. Some of them were just a doc, an APP.

Eric: So pragmatic trial.

Corita: Pragmatic comparative effectiveness. There was no control group.

Eric: What did you find?

Corita: We found that the outcomes in both groups were identical. We found our primary outcome was quality of life. At six months, it was a change score. Both groups improved their quality of life, but they were identical improvements. We found all of our secondary outcomes, ED revisits, inpatient hospitalizations, inpatient days, hospice use, loneliness and symptom scores were identical between the treatment arms.

There were big differences. We stratified by cancer and end-stage organ disease, so there were big differences between cancer and end-stage organ failure, but there were literally no differences in outcomes between nurses calling patients on the phone and going and seeing a doctor or NP or PA in clinic.

Eric: One of the questions in palliative care is, is it just attention? Is it giving people attention? Is that what we’re seeing as far as the potential benefit? Whether it be stem cell transplant, stem cell transplant patients where you’re seeing them twice a week, it’s additional contact, it’s attention; it could be palliative care team, it could be a chaplain, it could be a volunteer high school student. My son just started volunteering for the VA.

Alex: Therapy dog.

Eric: Therapy dog.

Corita: Well, they referred them to hospice, so as far as I know, I don’t think your son or the dog could do that; so that not so much.

Eric: Contact time, was their significant more…

Corita: More in much more in the nursing arm. People voted with their feet. About three quarters of patients finished the six-month intervention in the nursing arm. People were not as interested in outpatient palliative care. It was very difficult. We put a couple extra things in place to really try to reschedule appointments, and this was telehealth. Even with that as an option, only about 60% of people even made one visit with a lot of help in trying to schedule those.

And then we did a per protocol analysis, so we know that even as a sensitivity analysis, because there was more uptake in the telephonic arm so we compared per protocol, we looked at bifunctional status, we looked at minoritized groups. There was still no difference.

Eric: So what’s your take? What should we do with this?

Corita: It’s a great question. What I don’t think should happen, which happened at one of our sites, is they shut down outpatient palliative care completely. That was not related to our study. It was right before. It was a financial decision by the health system.

We don’t have enough outpatient palliative care. Every place that we conducted this, all 19 sites, never had enough appointments in the right timeframe, other than one site that’s a cancer center that just had more availability; so I think this is a way to extend the reach of outpatient palliative care.

Patients love it. Cost was not one of our outcomes. But I think it’s clear that paying for an RN is cheaper than having a doctor and having a brick-and-mortar clinic, even if telehealth is a part of that. So the question is, how do you pay for it? Because there’s no payment model unless you’re in an integrated health system or MA plans. It’s complicated because right now there’s no mechanism other than cost avoidance.

Eric: Tom, I’m going to go to you on this one. Your stem cell transplant patient. What if it was, should the next study be a palliative care team seeing the patient twice a week versus telephonic RN from a central site checking up on them?

Tom: Yeah, it’s an interesting idea. In this case, really a big part of the secret sauce is the symptom management piece, though, where you really need the clinical team member assessing and addressing symptoms and prescribing. I expect it would be helpful with the anxiety and depression issues, the coping issues, maybe the caregiver issues if you did this in a telephonic way with a nursing intervention; but if there wasn’t the ability to prescribe and do the aggressive symptom management, I don’t think we would’ve seen the same kind of…

Corita: That’s the interesting thing, is that we found that symptoms decreased in both of our arms equally. We don’t quite understand that. The nurses, every site was on Epic, so even though they were centralized, they would reach out to the team at the patient’s health system; but somehow they still improved symptoms, which that’s one of the things that we’re trying to figure out.

Tom: Do you think they relayed that info to the primary care [inaudible 00:34:14].

Corita: They absolutely did. I don’t know if they actually prescribed it because we don’t have access to that, but they definitely relayed it.

Tom: No, that makes sense. When Ethan Basch did his study with PROs at Sloan Kettering, they had nurses receiving the weekly symptom alerts from these patients with advanced cancer getting palliative chemotherapies, and that led to significant improvements in ED presentations, quality of life, and even overall survival because they recognized problematic symptoms that needed attention and got it to somebody who did something further about it.

Corita: Exactly, right. And same with Beckelman’s study, who you guys just had a podcast about.

Eric: So let me ask you this question. Getting the appointments for outpatient palliative care was a challenge, it sounded like. Is that right?

Corita: Yeah. It wasn’t just getting, it was getting it at a time the patient could come, we gave them $20 to pay for a cab or whatever.

Eric: In a pragmatic trial, you’re using existing resources to do these consults and potentially increasing the amount of workload that they’re doing. Do you have data on these 19 different sites?

Corita: Yes.

Eric: How many of them have their own palliative care RN? I got to say our clinic has a palliative care RN. She is amazing in doing the follow-up and contacting people, and I can’t imagine an outpatient clinic without a palliative care RN. Do you have a sense of how many of these clinics have that resource?

Corita: We are looking at that now or just submitting a paper about not just the palliative care RN, but what are the differences? Were they embedded? Were they standalone clinics? What made things more likely for patients to follow up? We’re looking at a number of those, like did they have social work? Did they have a pharmacist?

Also, how many appointments did they have in a week for new visits? Some would have four, and we had one site that had 52. So very, very different level of access. There’s a lot of factors, yes. RN is one, but many others, too,

Eric: Clinics get busier and busier. When your next appointment is four to six weeks out for a palliative care appointment, it’s hard. Alex, you got a question?

Alex: Yeah. Thank you. I’m interested from all three of you or any of you hearing each other’s studies, what you take away from this. These are three trials through the highest rated abstracts at the state of the science, which is a relatively new meeting here; but it’s incredible that three trials rose to the top here, it’s great that we’re doing trials at this time. Other lessons? What do you take away from this?

Tom: I’m really excited that the level of evidence, that the bar is continually being raised in our field. I remember when I was training, we often didn’t have data to guide what we were doing, yet we had lots of important clinical questions that needed to be answered. We still have a lot of questions, but we actually have some answers now and some data about things that we didn’t, and it seems to be growing exponentially, so that’s pretty neat.

Kate: I’m really excited that all three trials have incredible practical approaches. They all have limitations, for sure. Corita, you just discussed yours; we certainly had them; and Tom, I’m sure you did as well. But if you boil them down, these are practical ways to deliver palliative care and all of them have some evidence that some part of it worked. It makes patients and families feel better and outcomes better and quality of care better, and we can implement it.

Corita: We need more, though.

Kate: That’s awesome to say.

Corita: We need a lot more than three.

Eric: I got to say the fact that we have three randomized controlled trials that we’re talking about, the state of science in palliative care is impressive, because historically, that’s not the case.

Corita: Yeah. Well, there’s been an investment by PCORI that invested almost $100,000. Now we’re going to have this…

Kate: NIH.

Corita: NIH is now investing. I think $70 million was the investment from PCORI, something like that.

Eric: It sounds like they’re feeling like they want to make some science. [laughter]

Corita: They want to make some science.

Alex: Okayg…we want to make some science. (singing)

Thank you for being on this GeriPal podcast. That was wonderful.

Tom: Thanks for having us.

Corita: Thank you. That was super fun.

Eric: Sorry to all of our listeners for me being out of it, because we got home very late last night; but hopefully it wasn’t too bad, and thank you for all your support.

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