Non-Hispanic Black-White disparities in pain and pain management among newly admitted nursing home residents with cancer

Background: Racial disparities in pain management persist across health care settings and likely extend into nursing homes. No recent studies have evaluated racial disparities in pain management among residents with cancer in nursing homes at time of admission. Methods: Using a cross-sectional study design, we compared reported pain and pain management between non-Hispanic White and non-Hispanic Black newly admitted nursing home residents with cancer (n=342,920) using the de-identified Minimum Data Set version 3.0. Pain management strategies included the use of scheduled analgesics, pro re nata analgesics, and non-pharmacological methods. Presence of pain was based on self-report when residents were able, and staff report when unable. Robust Poisson models provided estimates of adjusted prevalence ratios (aPR) and 95% CIs for reported pain and pain management strategies. Results: Among nursing home residents with cancer, ~60% reported pain with non-Hispanic Blacks less likely to have both self-reported pain (aPR [Black versus White]: 0.98, 95% CI: 0.97-0.99) and staff-reported pain (aPR: 0.89, 95% CI: 0.86-0.93) documentation compared with Non-Hispanic Whites. While most residents received some pharmacologic pain management, Blacks were less likely to receive any compared with Whites (Blacks: 66.6%, Whites: 71.1%; aPR: 0.98, 95% CI: 0.97-0.99), consistent with differences in receipt of non-pharmacologic treatments (Blacks: 25.8%, Whites: 34.0%; aPR: 0.98, 95 CI%: 0.96-0.99). Conclusion: Less pain was reported for Black compared with White nursing home residents and White residents subsequently received more frequent pain management at admission. The extent to which unequal reporting and management of pain persists in nursing homes should be further explored

Validation of a Predictive Model for Survival in Patients With Advanced Cancer: Secondary Analysis of RTOG 9714.

BackgroundThe objective of this study was to validate a simple predictive model for survival of patients with advanced cancer.MethodsPrevious studies with training and validation datasets developed a model predicting survival of patients referred for palliative radiotherapy using three readily available factors: primary cancer site, site of metastases and Karnofsky performance score (KPS). This predictive model was used in the current study, where each factor was assigned a value proportional to its prognostic weight and the sum of the weighted scores for each patient was survival prediction score (SPS). Patients were also classified according to their number of risk factors (NRF). Three risk groups were established. The Radiation Therapy and Oncology Group (RTOG) 9714 data was used to provide an additional external validation set comprised of patients treated among multiple institutions with appropriate statistical tests.ResultsThe RTOG external validation set comprised of 908 patients treated at 66 different radiation facilities from 1998 to 2002. The SPS method classified all patients into the low-risk group. Based on the NRF, two distinct risk groups with significantly different survival estimates were identified. The ability to predict survival was similar to that of the training and previous validation datasets for both the SPS and NRF methods.ConclusionsThe three variable NRF model is preferred because of its relative simplicity

Black-White Disparities in Pain Management among Nursing Home Residents with Cancer

Background: Racial disparities in pain management persist across healthcare settings and likely extend into nursing homes. No studies to-date have thoroughly evaluated racial disparities in cancer pain management in this setting. Methods: Using a cross-sectional study design, we compared reported pain and pharmacological pain management between non-Hispanic White and Black newly admitted nursing home residents with cancer (n=113,765) using the Minimum Data Set version 3.0. Pain management strategies considered included: use of scheduled analgesics, pro re nata analgesics, and non-pharmacological methods. Presence of pain was based on self-report when residents were able to, or by staff. Logistic models provided estimates of odds ratios for pain management strategies adjusted for resident factors. Results: Among nursing home residents with cancer, nearly one-third reported pain with estimates similar in Black (32.4%) and White (32.8%) residents. Estimates of pain frequency and intensity were also similar by race. While most residents received scheduled pharmacologic pain management, Whites had greater odds of receiving it than Blacks (Whites: 72.8%, Blacks: 69.3%, adjusted odds ratio Black vs. White (aOR): 0.92; 95% confidence interval (CI): 0.88-0.96). Pro re nata analgesic use was more common in Whites than Blacks (Whites: 40.1%, Blacks: 38.5%, aOR: 0.78; 95% CI: 0.75-0.81) as were non-pharmacologic approaches (Whites: 33.1%, Blacks: 25.3%, aOR: 0.70; 95 CI%: 0.67-0.73). Conclusions: While reporting of pain was similar for Black and White nursing home residents, White residents received more frequent pain management at admission. The extent to which unequal management of pain persists in nursing homes should be further explored

Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life

Purpose of Review: To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL). Recent Findings: We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators. Summary: EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind

Prevalence of Pain on Admission by Level of Cognitive Impairment in Nursing Homes

Purpose: To provide contemporary estimates of pain by level of cognitive impairment among US nursing home residents without cancer. Methods: Newly admitted US nursing home residents without cancer assessed with the Minimum Data Set 3.0 at admission (2010-2016) were eligible (n=8,613,080). The Cognitive Function Scale was used to categorize level of cognitive impairment. Self-report or staff-assessed pain was used based on a 5-day look-back period. Estimates of adjusted prevalence ratios (aPR) were derived from modified Poisson models. Results: Documented prevalence of pain decreased with increased levels of cognitive impairment in those who self-reported pain (68.9% no/mild, 32.9% severe) and those with staff-assessed pain (50.6% no/mild, 37.2% severe staff-assessed pain). Relative to residents with no/mild cognitive impairment, pharmacologic pain management was less prevalent in those with severe cognitive impairment (self-reported: 51.3% severe vs 76.9% in those with no/mild; staff assessed: 52.0% severe vs 67.7% no/mild). Conclusion: Pain was less frequently documented in those with severe cognitive impairment relative to those with no/mild impairments. Failure to identify pain may result in untreated or undertreated pain. Interventions to improve evaluation of pain in nursing home residents with cognitive impairment are needed

Effect of a Multidisciplinary Team Approach to Eradicate Central Line Associated Blood-Stream Infections (CLABSI)

Introduction: CLABSI remains a significant problem in the intensive care unit. Hypothesis: A multimodal approach for the insertion and care of CVC will prevent CLABSI. Methods: A Critical Care Operations Committee was formed to transform care in 8 intensive care units (ICU) in an academic medical center in 9/2004. One goal was to reduce CLABSI. Using evidence based medicine, a clinical practice guideline was developed that incorporated the use of maximum barrier precautions, chlorhexidine skin preparation, avoidance of the femoral insertion site, dedicated catheter cart, a check list, the tracking of high risk CVC, anti-septic or antimicrobial impregnated catheters, a recommendation to use ultrasound guidance when inserting CVC in the internal jugular vein, daily determination of the need for the CVC and treatment of CLABSI as a critical event.CLABSI were adjudicated by the hospital epidemiologist and CVC days were tracked. Rates of CLABSI were followed from 9/2004 through 7/2011. The Spearman correlation coefficient was used for statistical evaluation. A p Results: CLABSI rates (per 1000 catheter-days) declined dramatically from 2004 to 2011 (p Conclusions: A multimodal approach to CVC insertion and care reduces CLABSI by over 90%. Our ultimate goal is the complete eradication of CRBSI in our institution

Eliciting the child's voice in adverse event reporting in oncology trials: Cognitive interview findings from the Pediatric Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events initiative: Reeve et al.

Adverse event (AE) reporting in oncology trials is required, but current practice does not directly integrate the child’s voice. The Pediatric Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) is being developed to assess symptomatic AEs via child/adolescent self-report or proxy-report. This qualitative study evaluates the child’s/adolescent’s understanding and ability to provide valid responses to the PRO-CTCAE to inform questionnaire refinements and confirm content validity

Enhanced Software for Scheduling Space-Shuttle Processing

The Ground Processing Scheduling System (GPSS) computer program is used to develop streamlined schedules for the inspection, repair, and refurbishment of space shuttles at Kennedy Space Center. A scheduling computer program is needed because space-shuttle processing is complex and it is frequently necessary to modify schedules to accommodate unanticipated events, unavailability of specialized personnel, unexpected delays, and the need to repair newly discovered defects. GPSS implements constraint-based scheduling algorithms and provides an interactive scheduling software environment. In response to inputs, GPSS can respond with schedules that are optimized in the sense that they contain minimal violations of constraints while supporting the most effective and efficient utilization of space-shuttle ground processing resources. The present version of GPSS is a product of re-engineering of a prototype version. While the prototype version proved to be valuable and versatile as a scheduling software tool during the first five years, it was characterized by design and algorithmic deficiencies that affected schedule revisions, query capability, task movement, report capability, and overall interface complexity. In addition, the lack of documentation gave rise to difficulties in maintenance and limited both enhanceability and portability. The goal of the GPSS re-engineering project was to upgrade the prototype into a flexible system that supports multiple- flow, multiple-site scheduling and that retains the strengths of the prototype while incorporating improvements in maintainability, enhanceability, and portability