Telehealth vs In-Person Palliative Care: A Podcast with Joseph Greer, Lynn Flint, Simone Rinaldi, and Vicki Jackson

Eric 00:00

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:45

This is Alex Smith.

Eric 00:46

And Alex, today is a battle royale on the GeriPal Podcast. Yes. In one corner, weighing in with decades of experience, known for heavy hits of bedside assessments, strong patient family relationships, and a knockout punch of interprofessional collaboration, we have in-person palliative care.

Alex 01:06

Yeah, go in person. Okay.

Eric 01:08

On the other, we have the young upstart telehealth delivered palliative care. It could reach far distances. Alex. Long reach, long reach, all in the comfort of wearing its pajamas, which is pretty impressive. We have telehealth delivered palliative care. Who is going to emerge victorious? Alex, who is gonna be answering that question?

Alex 01:32

For us, answering that question today, we have Joe Greer, who’s a psychologist and associate professor of psychology at MGH and Harvard Medical School. Joe, welcome to the GeriPal Podcast.

Joe 01:42

Thanks so much for having me.

Alex 01:43

And we have Simone Rinaldi, who’s a palliative care nurse practitioner and director of nursing for the MGH Division of Palliative Care and Geriatric medicine. Simone, welcome to GeriPal.

Simone 01:54

I am so glad to be here.

Alex 01:56

And returning guest, Vicki Jackson, who’s a palliative care doc, chief of the Division of Palliative Care and Geriatric Medicine at MGH, professor at Harvard Medical School, and co director of the Harvard Medical School center for Palliative Care. Vicki, welcome back to GeriPal.

Vicki 02:10

Thank you. It’s a pleasure to be here.

Alex 02:11

And in the room with us today, we have Lynn Flint, who’s an outpatient palliative care doc, frequent guest host at GeriPal, and professor at UCSF in the Division of Geriatrics. Lynn, welcome back.

Lynn 02:20

Thank you very much.

Eric 02:21

So, Joe, Simone, and Vicki were all authors of a great telehealth versus in-person palliative care study published in JAMA New England journal, that was just published not too long ago. Before we get into the results of those studies and what they did, somebody has a song request for Alex.

Joe 02:43

Indeed. Yes. We thought Hello by Adele would be thematic for our conversation today.

Eric 02:48

Well, is it just because it sounds like a telephone call?

Joe 02:54

There’s layers of meaning in those lyrics. If you really, you can dig deep.

Eric 02:58

All right, let’s hear it. Alex.

Alex 03:05

(singing)

Alex 04:44

That was fun.

Lynn 04:46

That was intense.

Alex 04:48

Well, I try to get some other people to sing, but some people refuse to sing along. How can you not sing along with Adele? Have you seen the Saturday Night Live where the family’s arguing and one is, like, very Republican, the other is, it’s Thanksgiving dinner, but then somebody plays Adele and everybody hello.

Eric 05:07

One day Zoom will get it so we can all sing together.

Alex 05:11

That’s right.

Eric 05:11

Without a lag. That’s what I’m waiting for, Alex. You get that going and then maybe, probably, at least it won’t sing. Okay, let’s talk about who is victorious in person. Consultations versus telehealth. So I mock a little bit, but you published a great JAMA paper on this big study. Would love to turn. I’ll turn to you, Joe, to start off. First author, why did you and your colleagues decide to do this study?

Joe 05:46

All right, well, this was back in 2017, when we were originally conceiving of the study, so, well, before the pandemic and before pretty much most of us were doing anything related to Zoom or telehealth via video visits.

Eric 06:01

And was Zoom a thing back then?

Joe 06:04

I don’t know.

Eric 06:07

Skype.

Alex 06:09

I remember Skype.

Joe 06:10

Yeah, yeah. No, it was like the Flintstones version of video visits. It was pretty Antiquated. Over the last couple decades, Vicki and other leaders in palliative care and Dr. Jennifer Temel, our thoracic oncologist, colleague and co PI on this study, we’ve been testing the early integration of palliative care in clinic through several studies. Our group was doing this, several other groups, actually a number of groups across the world, were running these types of trials and all demonstrating really decent efficacy for improving quality of life for patients with advanced cancer and in particular for patients with advanced lung cancer.

And so we were celebrating the great model that this was and how it was improving patient and caregiver experience and hoping that that would translate into practice. Change got adopted by ASCO’s Quality Initiatives and guidelines and others like the National Comprehensive Cancer Network and other societies had recommended this care model as standard of care for this population. But in reality, given workforce shortages and just the challenges and the resources necessary to be able to provide early integrated palliative care from the time of diagnosis of advanced cancer, the model simply is not implementable, at least not in our current state with our available infrastructure and resources.

We were moving from this thought of we know it works, but how do we get it out there in a way that people can actually do it? The scalability question is really what was driving us to think creatively about improving access and efficiency and care in delivering this model of care. And so that’s how we landed on telehealth as one potential option. Not the only option, but one option to really improve that scalability and improve that access. Yeah, so we were just very pleased and excited that ultimately some funding organization agreed with us and gave us about $10 million 20 to run this study across different sites, actually 22 sites across the nation. And here we are seven years later with a JAMA publication.

Eric 08:20

A lot has changed in those 20 years. But before we actually talk about what you did, Vicki, I got a question for you. I think we asked you this question the last time too. How important is it that we dissect all of these different ways we can deliver palliative care? Either different populations, telehealth versus in person physician NP versus physician social worker. How important is it that we really drill down into how we’re delivering that palliative care syringe?

Vicki 08:50

Yeah, I think it’s a great question. I think one thing that was humbling in a study, the follow up study we did to the New England Journal study, which was expanding a monthly in person model into a GI population, is we actually, we saw differences in how that intervention impacted the Patient’s experience and their quality of life. Right. We replicated the findings in the lung cancer population and it wasn’t until 24 weeks with the GI cancer population. So I think what I love about our field is we are really early on in understanding what is it that really makes a big difference, how do we structure it? What do different patient populations need? Like if you think about it, that was still a cancer population.

But how do we think about the right outcomes and the right intervention frequency and structure in heart failure, in advanced liver disease, all of these things? I think it’s really important that we understand and we can maybe at some point talk about. One of the things that is most interesting to me is what we have really understood. It is a thread in all of these, is really mediating what we’re seeing in all these patient reported outcomes, which is coping. I think we have a whole host of different models. We could think about different ways that different clinicians who might be able to provide different parts of the model and allow this work that we’re doing that we know now is really effective and helps patients to be more scalable.

Eric 10:25

Great. So maybe we can jump in. What did you actually test in this study?

Joe 10:32

I guess I can take that. Essentially we’re testing the early integrated palliative care model, which is monthly visits with a specialty trained palliative care physician or advanced practice provider for patients who are diagnosed with advanced non small cell lung cancer. So they had to be within three months of diagnosis and they were going to be randomly assigned to either the traditional model that we’ve been testing. So delivering those month visits in clinic, often in tandem with their other oncology appointments. And I give a huge shout out to all the clinicians who are on this study, the 100 plus clinicians who like bend over backwards to work with their schedules and see those patients in clinic.

Eric 11:13

And you tried to see them in the same day that they were seeing oncology.

Joe 11:17

To the extent possible, they would see them, they would see them in the infusion suite, they would see them in the oncology, you know, center, like wherever the patient was, the clinicians were going there. And that’s why this study was successful, because of their tremendous flexibility and generosity. So comparing that to the same dose in frequency and focus of conversations, in terms of what is key and critical to the early palliative care intervention, in terms of topics, all of that all similar, but now delivered over video visits, those monthly video visits versus in person care. So no differences between the modalities.

Otherwise. The only thing we were Varying was just whether it was in clinic or delivered over video. And the sample size was roughly 1,250 patients. So broad scale, 22 centers across the nation. So a pretty definitive and robust study to answer that question.

Eric 12:22

So can I ask you a wonky methods question? Because it was big sample size, much bigger. We just had Jennifer Tamel on a couple months ago and others to talk about stepped palliative care. And she talked a little bit about the difference between non inferiority efficacy and superiority trials. And it sounded like big difference was the power and the sample size calculation. Why did you pick it? Was this an equivalent study? Equivalence. That’s the word I was looking for. Why did you pick an equivalence study instead of a non inferiority study versus superiority?

Joe 12:58

Right. So I would say in terms of the question around superiority, we didn’t have any particular data where we thought this particular modality, either video or in person care would be superior.

Alex 13:12

Right.

Joe 13:13

We had. We didn’t think that there was something unique to the modality delivery in which palliative care was providing that care. And having these types of conversations that are so meaningful, especially from the onset of an advanced diagnosis like that, that we thought theoretically or empirically one would be better than the other. Really this was just an open question for us. Like when we pit these two modalities against each other, are they able to perform at a decent similar level? Was the question the stats question and the methods question you’re asking is like really, should this been a non inferiority versus an equivalent study?

And in retrospect it probably would have made sense to have this been a non inferiority study. Meaning that video visits were just as good as in person visits is kind of really the question. Whereas an equivalence is saying are these two modalities really within the same band of improvement, not one being less or one being higher than the other. And you could make the argument like if one beats out the other one, you know, especially if video visits did better than in person visits. Again, we didn’t have a hypothesis that that would be the case.

You know, that would obviously be picked up from a non inferiority study just as good as or even better. But we were really kind of hemming ourselves in saying that they had to be within a certain range to be equivalent. And that’s not really the question actually. We’re really just more curious if they were comparable.

Eric 14:43

Yeah, but that did mean you had a big sample size.

Joe 14:47

1200 patients have a huge sample size.

Vicki 14:50

That was no joke, just to be clear.

Joe 14:53

Yeah.

Eric 14:53

What was no joke?

Lynn 14:54

Getting that many people.

Vicki 14:56

Yeah. And having 22 sites that we had to train, keep motivated, understand a very complex study. I mean, Simone, you can weigh in here, but those meetings to keep. Every site had different things that were struggles.

Simone 15:15

And I think that that was the power of having. We had monthly meetings with all the centers across the country to be able to talk about, you know, where things were going well and where the challenges were. And part of the power of those meetings, I think, was learning from each other about strategies for where things weren’t going well. That helped us as we all got stuck, because we all got stuck in being able to move forward with recruitment and kind of operational and implementational issues.

Eric 15:42

How did you make sure. Did you make sure everybody was delivering the same type of palliative care intervention, or did everybody just do what they do in their palliative care clinics and just saw what happened?

Lynn 15:55

Well, it’s a good.

Vicki 15:56

It’s a good question. So part of what we did was have all the sites trained up front. And I would say we weren’t doing training on symptom management, for example. We assumed everyone was pretty clear and. And well skilled. I would say that many sites, seeing patients so upstream that they didn’t have symptoms, we. We sort of had this language that we talked about with the sites of, like, what do you do during the. Well times. Right. Because there’s actually work to be done there. But many of the clinicians would say, I don’t know, how am I being helpful here? They’re not dying. And I’m like, that’s the point.

Therein is the point. Right. But so then it was really helping them think through a framing for the work. And part of the way we framed it was that because we’ve known from our previous studies that how patients cope when they see palliative care early is really driving a lot of these outcomes. We really spent a lot of time helping the clinicians see that a patient’s illness, understanding and prognostic awareness was just as important as their pain scale, their pain score. Right. And that they actually had to see that as a clinical domain that they addressed in each visit and subsequently over time. And to see that as a, you know, we often say to our trainees, you know, that when we’re talking about these things, getting to know a patient, helping them understand their illness, it might seem like we’re just being really nice. And in fact, I think hopefully most days I am nice, but that’s not why I’m right.

This is actually a skill and helping the Clinicians think about it as a skill was really important. And so we reinforced that over time in yearly trainings, in upfront trainings. That got reinforced in these monthly meetings where, you know, what was great about these monthly meetings with each of these sites is they would bring not only their concerns about recruitment or something related to the study, but also clinical cases and say, what do I do with this? The patient refuses to ever talk about the fact that this illness could take their life. What do we do with that? It actually allowed for really rich discussion of if you get to care for someone over the course of one or two years, how do we titrate our intervention to really help them live Well.

Lynn 18:25

I have a quick question. I think if I’m correct, you did a in person visit for everybody.

Vicki 18:31

We did.

Lynn 18:32

Can we talk a little bit about that?

Eric 18:34

Like why did you do that?

Lynn 18:36

Yeah.

Eric 18:37

Why did the telehealth get an in person initial visit? Was it for opioids so you can prescribe them?

Joe 18:44

No, no, no. I think this was initially because we, again, this is before the pandemic and people had a lot of hesitation about video visits and, and could you establish a relationship over video from. And so when we were conceiving of the study, we had various stakeholders and constituents that were serving in an advisory capacity for us and both our patient and caregiver collaborators and our clinician collaborators all unison agreement to say you need an in person visit to establish rapport before transitioning to video visits. And I’m not sure we would say that today, but at the time that was super meaningful and, and so we modified the protocol based on those recommendations.

Eric 19:29

Simone, what do you think? Do we need that today? If you were to do that study again, you know, let’s say imagine the study didn’t happen. You’re doing the study now. Do you feel like you would need to have that in person first visit in the television?

Simone 19:41

I think that that’s part of the wonderful outcome of this study. To be able to, I think, answer the question is no, I don’t think that we need it now. I think we were very concerned about it at the start of the study and everybody was on the same page that we would have an in person visit because we were so concerned about the ability to establish rapport. Because in going back to like Vicki, what Vicki was saying, across all of our studies, we’ve been able to see that threat of coping. I think we’ve also been able to see the thread of rapport building and that the essential piece of rapport building and relationship as something that allows for everything that comes after. And so at the start of the study we were so concerned about can we really establish the same kinds of rapport and relationship with patients using this modality. And I think we. We have an answer now.

Eric 20:31

So wait, before we get into the answer I got another question. Is a. I want to just highlight that I loved the supplement. Actually unlike page 23, it actually breaks down based on initial visit follow up visits. And at the end like end of life care was not talked about at every starting of every palliative care clinic is that may be discussed but the heart of the initial visit it sounded like was relationship and rapport building. And then there was a lot of stuff on coping and symptom management. I think for me it just highlights a lot of kind of what we do. But I also thought this was mainly delivered right by. Was this the same as the stepped wise? It was physicians and APNs.

Joe 21:16

Yes, yes.

Eric 21:18

Not the whole interprofessional. But what about the social workers and the chaplains?

Vicki 21:23

It’s a great question. It really depended on the site. So some sites had, you know, so like our site at mgh we have cancer center social workers who are very engaged, find themselves very well versed in palliative care and really want to be the primary people supporting patients in the thoracic clinic, for example. So those social workers were involved. We would make referrals to psycho oncology. I would make referrals to Joe as well as part of the team. But there were some sites where social work would be really in a more embedded a palliative care social worker more embedded in the model. But it was not uniform across all sites.

Joe 22:08

So just to piggyback on that, the protocol stipulated that the monthly visits would be administered by either, you know, board certified specialty training palliative care physician or an advanced practice provider. But that did not limit those clinicians from making referrals, as Vicky was just saying. And to pick up on your prior question about how did we know what they were doing. I mean another measure of fidelity is that at the end of every encounter, whether in person or over video, the clinician completed a standardized form indicating this is where you were talking about the supplement. I love that you read the supplement. We put so much work.

Eric 22:47

I found the Easter eggs in there too.

Joe 22:49

There are. There’s so many great nuggets there. So thank you. Especially the hours I slaved over that supplement. But when you look at those actual graphs of the topics being discussed and it’s actually not Just the initial visits. Over the course of all the visits that we had, 5,000 plus clinician forms that were filled out. I mean, just an immense amount of work. I think two key themes come through there, which is one, you know, these conversations are remarkably similar regardless the frequency and the topics were remarkably similar regardless of the modality.

And also on those forms, we do know, I mean, that part wasn’t in the supplement, unfortunately. But we do have the information about referrals to other ancillary providers as part of that multidisciplinary team. So it matters. It’s a piece of the intervention. It’s just what was required per protocol versus kind of like what is patient specific, site specific, as Vicki was mentioning.

Eric 23:47

Yeah, Lynne, I’ve talked to you about. This is like there is a difference, right, between assessing someone, yourself as a physician for social work needs and then making a PRN referral versus having a social worker integrated near your clinic where they’re seeing the patients doing their assessments, managing coping. Do you feel like that that’s true for sure, Yeah.

Lynn 24:07

I think we try to do visits together with a social worker in our first assessment, even if it’s on video. And I find that when that happens, the social worker is usually able to do more integrated follow up over time, even if we don’t go on to see people together over time. I think what’s coming home to me is how every single place has its own sort of model, its own team. And that kind of speaks to the studies to look at. How do we disseminate this scarce resource? Because nobody has a perfect full team to implement, I think, any of these things fully. So when I think I just. Oh, go ahead, Vicki, it’s okay.

Vicki 24:48

No, you’re right.

Lynn 24:49

I’m changing the subject. You go, oh.

Vicki 24:51

What I was saying, the other thing that I love is that our previous studies were R1 site, right? And this is 22 sites. So this is not an MGH thing. This is a. This is a palliative care is effective in improving quality of life for patients. Right. Like in, in the outpatient setting, early outpatient setting. And that’s what I loved about it. Because even though the models are different and maybe there’s an embedded social worker or maybe the social worker sees patients at different times and the structure isn’t exactly the same, what is essentially in our common syringe works.

Eric 25:31

I’m going to play devil’s advocate. I’m going to pull back to what I remember from the stepped palliative care trial. And Alex asked the question there’s no usual care group here. There’s no. That third group. That’s the. No palliative care or palliative care. The usual palliative care would be just as needed. Palliative care, prn. Kind of like prn, Social worker. Prn. Palliative care. Should there have been a third PRN group or third control or usual care group?

Vicki 26:02

Do you want to take one more?

Eric 26:03

Alex, weren’t you gonna. Weren’t you gonna debate this with Vicki in Montreal?

Alex 26:07

Yeah, yeah, but I was waiting for the results first so that we could debate.

Lynn 26:10

Wait, what would.

Alex 26:11

I have to talk about the results before?

Eric 26:13

What would.

Vicki 26:13

Usual care.

Speaker 8 26:14

Okay.

Eric 26:15

Usual care would be usual care. You get a consult if you get a consult. But mostly you may not get consults on a lot of these people.

Alex 26:24

I guess I’ll weigh in now since you’ve called me out on this. If you look at the population who was studied in this study and the popula. Well, first, let me just reflect on what you’ve been saying. This was a tremendous undertaking. Kudos to you and kudos to all these sites. And it sounds like they got so much out of this, too. And that part of the intervention that maybe goes unrecognized in the article, but is really clear here, is the way in which this, as you said before we started podcasting, the way in which it built community and the way in which you helped each other and helped clinicians and really like.

So that is a really interesting model for how to improve and do palliative care nationally as part of a study or maybe outside of a study. The point I think we’re getting to here is that palliative care has changed a lot since that original study in New England Journal that you’re all part of that. If you look back at that population then and the treatments they received, it was almost all cytotoxic, systemic chemotherapy and radiation. And you look now at that Table 1, Characteristics of Subjects, and it’s like a third immunotherapy, a third targeted therapy. It’s like, you know, the treatments have changed. Like, you put people on these new, much better treatments, much less toxic treatments in most cases, with some exceptions, and the cancer shrinks, they start to feel a lot better. I was doing a visiting professor thing recently in Cleveland, and they were saying, now we’re not called the palliative care team. We’re called, like, the survivorship team.

Whoa. That’s pretty different. What’s happening, you know, what’s happening in outpatient palliative care? This is a new day. Can we really say have to have the goalposts moved? You know, are we the reason that the quality of life is getting better or is it something else? I don’t know. When I say we, I’m talking about palliative care because I firmly have drunk the Kool Aid.

Joe 28:17

Clearly I have two thoughts about that and I’m not going to. I absolutely see your point. And I, and I have had these thoughts myself. I mean, one thing that we were appreciative of seeing is that in both arms, whether the video or the in person arm, the improvement in quality of life did mirror what we saw in our early palliative care studies prior. And so it was a clinically meaningful improvement on the functional assessment of cancer therapy lung. That’s our primary outcome measure. It’s the same measure we used in the New England journal article. But to your other question, which is valid, cancer therapies have been changing dramatically since that original paper came out.

And so how do we think about that attribution? In preparation for the plenary that we gave on this study at the annual meeting for ASCO last year at the American Society of Clinical Oncology, I kind of, as a psychologist, did a bit of a deep dive into therapeutic trials for lung cancer just to see what they were showing with respect to quality of life improvements. Yes. With some of the immunotherapy trials, what, what we are seeing is not a dramatic increase in quality of life per se based on those trials, but buffering a decrease in quality of life relative to the control groups, whereas we are seeing an actual increase in quality of life in this current trial. So I don’t want to overstate that, but in terms of some of the data I was looking at from those different novel therapeutic trials, that’s what I was sort of gleaning is that it’s more of a buffering effect versus a dramatic improvement in quality of life.

So I hear you. You could probably make an argument maybe we still need an usual care in these future studies that this next generation of studies we’re doing. It will be a little challenging and hard pressed to get it through an IRB when the standard of care recommendation is early palliative care. So you’d have to make a solid argument to get it through a review board.

Eric 30:15

Great. Well, I think we’ve been dancing around the results. What did you find as far as this paper? Your, your primary outcome was quality of life, is that right?

Joe 30:28

Yes. At 24 weeks.

Eric 30:29

At 24 weeks, was there a difference? Were they equivalent?

Joe 30:35

They confirmed that they were equivalent. Yes, we did. There was an equivalent effect on quality of life at 24 weeks. And we were able to say, you know, pretty definitively. We had to run a bunch of different sensitivity analyses because the rate of attrition was a bit higher than we anticipated. But yes, and of course because of the pandemic, we did have some video visits in the in person arm. So we had to run some sensitivity analyses to control for that. But despite all of those, the data were pretty, pretty confirmatory and you know, whether it was either equivalence in all these sensitivities or at least non inferiority. So I think we can walk away saying we feel pretty good that these two modalities match up.

Alex 31:19

And can you say more about the magnitude of the quality of life improvement and how it was measured?

Joe 31:25

Yeah. So on the functional assessment, cancer therapy, a minimal clinically meaningful difference is roughly six points. And so for both the in person group and the video group, the improvement from baseline to 24 weeks was in excess of six points.

Eric 31:44

And in a bunch of secondary outcomes, caregiver quality of life, patient coping, patient caregiver, satisfaction with care, mood symptoms, prognostic perceptions. No difference between the two groups, right?

Joe 31:55

No differences.

Lynn 31:56

One little detail that stood out to me, which really rang true to real life, was that caregivers were actually less present during visits in the video visits.

Eric 32:06

So you see that?

Lynn 32:07

Oh, yeah, for sure. In fact, I have to often say, like, hey, who else is there with you today? You know, and invite the caregiver to come in, to come sit down.

Eric 32:17

Why do you think that is?

Alex 32:19

Because they’re not driving or.

Lynn 32:21

I think it has to do a little bit with. For some of my patients, I think it has to do with the respond that the video visit provides, the transportation. They’re not driving them. If they physically come here, it’s sort of just the natural course of things that they’ll walk into the room with the patient. Whereas many times I see caregivers kind of running around doing the dishes and stuff in the background.

Simone 32:43

I think another thing that I would add to that is that it does give the opportunity, I think, for patients to be able to have meetings with their palliative care clinician privately in a way that is often not possible when they are in person. It’s hard to find privacy, no matter. But also just to have that private space to be with your clinician. And I think that really matters for folks to be able to talk about their experience sometimes without having to worry about the impact on the family member that’s standing next to them. So I think that that is one of the benefits. It was kind of unexpected results, but I think that that may be part.

Lynn 33:21

Of why also the portability of video visits. So, like just yesterday I saw somebody while they were in their hotel room taking a trip, which is like what we want people to be able to do. So.

Alex 33:33

So I’m hearing that. On the one hand, can I. Can I just say we’re probably all relieved to find that there was equivalence, right? I see people shaking their head, yes, we’re relieved. What would we do had it been different? On the other hand, we are pointing out that there are, we do expect there to be some differences, like because the caregiver is not there as often and, you know, maybe that allows for more conversations that wouldn’t happen otherwise about things like sexual intimacy. We did a podcast about that with a region, colleagues, things like trauma, experiencing trauma or other, you know, our goals don’t align. I want to tell you now, while I have you here, doc, though they’re my caregiver, please listen to what I’m saying now. So we would expect there to be some differences, although they weren’t necessarily picked up in this study or were they?

Joe 34:26

I mean, what I find fascinating about this is the fact that caregivers attended fewer visits in the video arm versus the in person arm. A good or bad thing or both? Because on one level, you could make the argument that with the caregiver not being present, perhaps there’s a breakdown in communication. People aren’t on the same page about the goals of treatment or how they’re supporting each other in moving through the treatments, or just even caregiver understanding or awareness of everything that’s going on.

You can make the flip side argument, which is that perhaps it gives the patient and caregiver just more autonomy to decide when to have a joint visit. And that autonomy allows for different types of conversations and frankly, maybe just a more reprieve and less burden on the caregiver, given all the transportation issues, et cetera. I was reassured by the fact that we did also measure the outcomes from the caregiver perspective. So we did measure their quality of life and we did measure their coping and their distress. And thankfully, despite the fact that their participation was lower in the video visit group, their outcomes were not different across the two groups. So that was reassuring. Not only were their outcomes not different with respect to their own quality of life and distress, but also their perceptions of the patient’s curability of their cancer or the goal of treatment where you would think that communication would be a major issue.

There were no differences between groups there either in terms of their knowledge and understanding. Then lastly, satisfaction with care for the caregivers and for the patients. No differences. Despite the difference in attendance. I was reassured by those. No differences.

Vicki 36:06

I do think it’s also interesting what as clinicians we’ve learned that we ended up doing during the study. And the sites would say this for different patient populations. For example, I realized in the video arm, I would need to be intentional when I wanted the spouse to come in. Or for you guys, it’s always probably the child from Boston. For us, it’s always the child from California. Right. Like, we could say, hey, can you have your daughter from California join? Which allowed something different, but we would actually plan it ahead versus it being whenever.

I think the other piece we found was there were times when, you know, either oncology or palliative care could say, I think we need an in person visit. And there would be times that that would happen when I couldn’t get my arms around what was happening because there’d be a caregiver who I’d be like, there’s something. I can’t read it quite right. And we would do an in person visit to get our arms around what that was, or if I was worried that there were issues with technology or other kinds of things.

Eric 37:16

So is that an issue, though, with fidelity? Like, how many of the video visit folks were actually being seen in person or the opposite? Because this was happening in Covid. Right.

Vicki 37:26

Great question.

Eric 37:27

And then all of a sudden, like, we started doing all video visits. Lynn, what were you doing in Covid 2020?

Lynn 37:35

I wasn’t doing outpatient in 2020.

Eric 37:37

Oh, yeah, I forgot about that.

Lynn 37:39

I was in the hospital.

Eric 37:42

We did a massive switch to telemedicine. What happened during this study?

Lynn 37:47

There’s also the experience of, oh, I couldn’t get there today because there’s a snowstorm. Let’s switch it to video.

Joe 37:53

Yeah, we freaked out. Like, we really freaked out a lot. For many months.

Vicki 38:00

Years. It felt like years, honestly, that we freaked out. Yeah.

Joe 38:03

No, if you could. If you could design a study for which this type of pandemic would be the worst. I mean, the pandemic’s the worst, don’t get me wrong. But the worst threat to the validity of your study. Yeah, this was. This would be that study.

Simone 38:17

So precision.

Eric 38:19

But how many people switched from one group to the other? Or I guess they didn’t switch groups, but they used the other’s modality.

Joe 38:26

Yeah, we, we, we halted recruitment during the first few months of the pandemic so that people weren’t being enrolled and randomly assigned to the in person group knowing that they were going to get video visits because there, there was no choice, people had to get video visits. So among the enrolled people who were in the in person group, we were able to keep their video visits down to less than 6%.6 percentage. And so that level of contamination was not a threat. We were able to do enough per protocol and sensitivity analysis to show that that level of contamination did not threaten the validity of the study and was still confirmatory for equivalence.

Eric 39:05

Okay, I got another question. Kind of thinking forward now. So they’re equivalent as far as outcomes, but video visit, you don’t have to beg and borrow and steal rooms. You know, those rooms could be managed by oncology or somebody else who needs to see people in person. You can stay in your pajamas at home. You don’t have to drive in, you know, the commute. Should we just give up on in person palliative care consultations in the outpatient setting? Because they are equivalent from an outcomes perspective, but they’re not equivalent from just the sheer amount of time efficiency perspective. Simone, I’m going to ask you first your thoughts.

Simone 39:51

I was hoping that you were going to ask Joe, and then I put my two cents in later. But I think two things just off the top I can’t imagine, although I have no evidence to base this on, that the models that we create aren’t going to include both. And that that is also going to be some of this work that we have to do in the future is to try to figure that out, how to kind of figure out not only that by population, but by cadence. But I think in terms of thinking about how to be implementing and delivering palliative care in this changing landscape, particularly in the changing landscape of cancer care, and thinking about the different populations in terms of low or greater symptom burden, in terms of thinking about how we’re using our resources, like pulling all this together, I think ultimately we will be needing to figure out models that are individualized and that kind of pull these things together.

Like maybe we have kind of high touch palliative care in certain situations. And as part of that high touch, we’re using both in person and telemedicine visits in folks perhaps that are not needing quite the kind of heavy touch because perhaps they’re in the beginning of their disease and they are going to need kind of a lighter touch for a period. Of time. Again, some type of combination for those.

Eric 41:14

I love that because I think that’s also what Eduardo Barrera said in the editorial that’s attached to it. And he did this wonderful author in the room for JAMA about the editorial. But it really does need some individualizing. You feel like that’s the case? Joe?

Joe 41:30

Yeah.

Eric 41:31

You know, we should learn from this.

Joe 41:33

I think the good news is we’re going to continue to learn from this. So you know, we talked about the community that we established over the last seven years with this study. Now we’re kind of moving into additional analyses to answer some of these important questions. So one of the palliative care investigator clinicians from Dana Farber, Isaac Chua, he is really interested in doing some interviews with the clinicians to figure out exactly what Simone was just saying. When did the clinicians feel like in the video visit group that they just had to see the person in clinic?

Like what were the indicators for that and are there some, is there guidance that we can put out there given just the sheer volume of data and sheer number of clinicians we have in this study that we can contribute to offer those who are now training in the video visit world. And so I think there’s so much more to come in answering this question, but I don’t think there’s ever going to be a scenario where it’s exclusively video visits that just won’t exist.

Simone 42:32

I think also that it would be helpful to be looking at to some of the care that gets delivered that is indirect and outside of the clinic visit that helps to stitch these clinic visits together. I think that that is an area and I think that that is often app and or nursing run care and I think that that is an area to think about in terms of how does that contribute to what we’re seeing here and how does that contribute to what is in that palliative care syringe?

Vicki 43:02

It’s not even what happens only with the patients. It’s when the oncologists are popping in the office where the NPs are and saying hey can I talk to you about Mr. Jones and Da da da da da da. And it changes the way they think about how they should be thinking about oncology care for that patient.

Lynn 43:21

I was just going to bring us back to our battle in the beginning.

Alex 43:24

Oh, the boxing match.

Eric 43:25

The boxing match.

Alex 43:27

Two corners going in the beginning.

Lynn 43:29

When we talked in the very beginning about the in person visit that the stakeholders all said we got to do that first. I actually wonder, we said clinicians nowadays they probably would be fine with doing away with that. But I really wonder what the patient and family perspective is now, because I think that it’s changed, but I’m not sure. And it may have changed in a different way. So I’m going to go on the side of we need in person presence. I actually do my video visits here from the office, so I don’t wear pajamas. And I think we need an in person presence in the medical center, in the cancer center. Even if we’re doing video visits, we need to sort of be here to be at the table. So I’m going to go on the side of in person, huh?

Eric 44:14

Okay. In person. Even you’re doing video?

Lynn 44:18

Yeah, I’m going to say hybrid. I’ll do what, you know, what’s best for the patient in terms of how I see the patient. But I think having a presence is super important.

Eric 44:25

Vicki, you’re in a huge leadership position. What do you think about that?

Vicki 44:29

I. So one thing I think that we have not done as much, we have paid much, as much attention to as we could have, and maybe we will in the future in our studies is actually, this is really clearly in my mind, a triadic relationship. It’s the oncologist and the patient, the palliative care doctor and the nurse practitioner and the patient. And it’s the palliative care clinician and the oncology team relationship. And that relationship, I think, is key in what happens with the patient. And I think your point, Lynn, is really a good one, is that if we’re not. If we’re only at home in our jammies, we’re not there when they knock on the door to say, hey, can I talk to you about this? And I don’t. I’m on the fence about whether I should give this third line of chemotherapy or not. And that happens. It really happens.

Eric 45:19

I also noticed on page 23 in the supplement that was actually part of it, like the interaction between the palliative care team and the oncologist.

Vicki 45:29

Yeah, we did add that to our red cap form. That is true. But like, exactly what happens in those encounters, I don’t think we really know. We know that they happened.

Eric 45:38

Okay, my last question, because we’re coming close to the hour. I mean, I think this is absolutely fabulous. We’re building the evidence. Joe, you mentioned that there was this guide that you created with your co authors. Have you ever thought about publishing it so people really understand what was actually in that syringe that you taught all these 22 sites or you told them that these are the important things to do besides page 23 in the supplement.

Joe 46:07

Yeah. Are we allowed to do a little promo? Yeah, yeah. So, like, we have published. Yes. What’s in the syringes out there? You can buy it. Go on Amazon now. And.

Eric 46:18

Yeah, yeah, it’s all there. The trial protocol, like what you did in this trial?

Vicki 46:25

Well, we. It was before this, but it basically what we did. It was Joe, Jennifer, me, and Julia Jacobson, and we really looked at what have we done, Looked at our manuals that we’ve developed for all these studies, and then tried to help clinicians think about what the tasks are that they’re doing with patients over time.

Eric 46:44

And, like, coping.

Vicki 46:46

How to coping is a big part of that.

Alex 46:48

And what’s the title?

Vicki 46:50

What’s in the Syringe? I could probably pull one up.

Eric 46:53

It’s actually called What’s in the Syringe. So we will have links to the book in our show notes and we’ll have a bunch of other links to the show notes to all of our listeners. Please go to the show notes. But before we end this podcast, maybe we can get a little bit more of Adele.

Alex 47:14

(singing)

Eric 48:52

That’s a no-show, right, Lynn?

Lynn 48:55

Yeah, it’s not good for rvu.

Vicki 49:00

Can I plug HPM?

Eric 49:01

Yes. So this podcast is being published the week before AAHPM and HPNA.

Eric 49:10

What else is happening during the HPNA AAHPM meeting?

Vicki 49:15

Can I tell you how excited I am about this year’s annual assembly in Denver? I’m super excited about it. So we have several awesome keynotes. The first one on Thursday is actually going to be Krista Tippett and Lucas Johnson from on being, which is going to be fabulous. And Friday reach and step are going to be highlighted with our very own Joe Greer and Jennifer Temel and Simone Rinaldi and Laura Hansen from UNC. Toby Campbell from University of Wisconsin is going to be our MC. And we’re going to actually have a patient talking about her experience being in the video arm. So I think that’s going to be awesome.

Alex 49:55

Cool.

Vicki 49:55

And then Saturday morning, it’s going to be the top three scientific abstracts submitted to HPM.

Alex 50:01

Wow.

Vicki 50:02

Come hang out.

Eric 50:04

And don’t forget about the GeriPal Pub crawl Thursday night, Feb 6, 8:00pm.

Alex 50:09

Also to note, we are going to be doing a podcast with the abstract presenters, the Saturday plenary session. Abstract presenters as well. So look for that.

Eric 50:21

That was absolutely fabulous. Great work on the studies that you’re putting out there.

Vicki 50:26

Thank you.

Simone 50:28

Thanks so much for having us.

Eric 50:29

And thank you to all of our listeners for your continued support.

This episode is not CME eligible.