Financial challenges are a significant issue navigated by family caregivers of individuals across the lifespan due to employment challenges and costs of caregiving, yet there are no scoping reviews to summarise financial interventions for family caregivers. The purpose of this scoping review is to understand the nature and effect of financial interventions for family caregivers. This study used the Arksey and O'Malley framework to conduct a scoping review. A systematic search for articles across multiple databases and grey literature was conducted. Articles published from 1997 to September 2024 were included for the review. After the title, abstract and full-text review, 11 studies of 2774 remained for data extraction. Data from articles were extracted and summarised for financial intervention nature, scope, measurement, effect and health system context. Ten articles and one dissertation synthesising findings from randomised controlled trials, quasi-experiments and one natural experiment were included. Financial interventions ranged from embedded supports in larger programmes (n=8) to stand-alone initiatives (n=3) across diverse health conditions and economic contexts. Some studies noted improvements in mental health, caregiver preparedness and cost-effectiveness. Direct measurement of income or perceived financial well-being was not assessed as an outcome. Findings suggest diverse approaches for financial interventions with an opportunity for more direct assessment of financial outcomes. Palliative care team members can use these findings to build interventions and initiatives that address the financial needs of family caregivers.

INTRODUCTION:Rural-dwelling older adults with cancer have limited access to palliative care and face barriers in coordinating palliative care with cancer care. This study aimed to identify barriers and facilitators to care coordination in the palliative care referral and care delivery process for rural-dwelling older adults with cancer from the perspectives of palliative care and oncology healthcare professionals (HCPs). MATERIALS AND METHODS:We conducted focus groups and dyadic semi-structured interviews with palliative care and oncology HCPs. Participants were recruited from clinics within large academic health systems (n = 14) and rural non-affiliated practices (n = 11) in Colorado. We analyzed interviews guided by a reflexive thematic analysis approach. RESULTS:Five themes emerged; within each theme specific barriers and facilitators were identified: (1) Tension of different practice styles delays palliative care referral for rural older adults; (2) Limited capacity prevents early palliative care integration for older adults in rural areas; (3) Structured communication pathways can facilitate coordinated care for older rural adults; (4) Competing influences of rural cultural context on older adults' palliative and oncologic care coordination; and (5) Telehealth has "come a long way," offering more opportunities for rural older adults to receive effective care coordination. Participants also shared insights on intervention strategies targeting barriers to coordinating palliative care with cancer care for rural-dwelling older adults with cancer. DISCUSSION:The identified barriers and facilitators suggest intervention targets to improve care coordination between palliative care and cancer care for rural-dwelling older adults at the health system, provider, and patient levels.

Objective: The objective of this study was to examine the association between portal use and end-of-life (EOL) outcomes in the last year of life.Methods: A retrospective cohort (n = 6,517) study at Kaiser Permanente Colorado among adults with serious illness deceased between January 1, 2016, and June 30, 2019. Portal use was categorized into engagement types: no use, nonactive, active without a provider, and active with a provider. EOL outcomes were hospitalizations in the month before death, last-year advance directive completion, and hospice use. Association between EOL outcomes and levels of portal use was assessed using chi 2 statistics and generalized linear models.Results: Higher portal engagement types were associated with higher rates of hospitalizations (p = 0.0492), advance directive completion (p = 0.0226), and hospice use (p = 0.0070).Conclusion: Portal use in the last year of life was associated with increases in a poor EOL outcome, hospitalizations, and beneficial EOL outcomes, advance directives, and hospice care.

Biomedical research has advanced medicine but also contributed to widening racial and ethnic health inequities. Despite a growing acknowledgment of the need to incorporate anti-racist objectives into research, there remains a need for practical guidance for recognizing and addressing the influence of ingrained practices perpetuating racial harms, particularly for general internists. Through a review of the literature, and informed by the Research Lifecycle Framework, this position statement from the Society of General Internal Medicine presents a conceptual framework suggesting multi-level systemic changes and strategies for researchers to incorporate an anti-racist perspective throughout the research lifecycle. It begins with a clear assertion that race and ethnicity are socio-political constructs that have important consequences on health and health disparities through various forms of racism. Recommendations include leveraging a comprehensive approach to integrate anti-racist principles and acknowledging that racism, not race, drives health inequities. Individual researchers must acknowledge systemic racism’s impact on health, engage in self-education to mitigate biases, hire diverse teams, and include historically excluded communities in research. Institutions must provide clear guidelines on the use of race and ethnicity in research, reject stigmatizing language, and invest in systemic commitments to diversity, equity, and anti-racism. National organizations must call for race-conscious research standards and training, and create measures to ensure accountability, establishing standards for race-conscious research for research funding. This position statement emphasizes our collective responsibility to combat systemic racism in research, and urges a transformative shift toward anti-racist practices throughout the research cycle.

Ensuring an adequate supply of physicians is paramount in securing the future of healthcare. To do so, accurate physician workforce predictions are needed to inform policymakers. However, the United States lacks such predictions from reliable sources. Several non-governmental organizations have actively been involved in attempting to quantify workforce needs, but they often employ opaque methodologies and are deeply conflicted, leading to potentially unreliable or biased results. Moreover, while federal and state entities invest approximately 15 billion annually in graduate medical education (GME) payments, they have very little control over how the funding is used to shape the future physician workforce. In this article, we review physician workforce predictions from both an international and a domestic perspective and finally discuss how the creation of an apolitical, data-driven, expert-led panel at the federal level with sufficient authority to influence broader workforce policy is the optimal solution for ensuring an adequate supply of physicians for generations to come.

Objectives Despite common use of palliative care screening tools in other settings, the performance of these tools in the nursing home has not been well established; therefore, the purpose of this review is to (1) identify palliative care screening tools validated for nursing home residents and (2) critically appraise, compare, and summarize the quality of measurement properties. Design Systematic review of measurement properties consistent with Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. Settings and participants Embase (Ovid), MEDLINE (PubMed), CINAHL (EBSCO), and PsycINFO (Ovid) were searched from inception to May 2022. Studies that (1) reported the development or evaluation of a palliative care screening tool and (2) sampled older adults living in a nursing home were included. Methods Two reviewers independently screened, selected, extracted data, and assessed risk of bias. Results We identified only 1 palliative care screening tool meeting COSMIN criteria, the NECesidades Paliativas (NEC-PAL, equivalent to palliative needs in English), but evidence for use with nursing home residents was of low quality. The NEC-PAL lacked robust testing of measurement properties such as reliability, sensitivity, and specificity in the nursing home setting. Construct validity through hypothesis testing was adequate but only reported in 1 study. Consequently, there is insufficient evidence to guide practice. Broadening the criteria further, this review reports on 3 additional palliative care screening tools identified during the search and screening process but which were excluded during full-text review for various reasons. Conclusion and Implications Given the unique care environment of nursing homes, we recommend future studies to validate available tools and develop new instruments specifically designed for nursing home use. In the meantime, we recommend that clinicians consider the evidence presented here and choose a screening instrument that best meets their needs.

Results.Of 35,886 outpatients included in the analysis, 9,700 (27%) had a provider launch their "Patient Values Tab."Of 10,055 inpatients included in the analysis, 4,517 (45%) had a provider launch their "Patient Values Tab." Patterns of adoption varied by provider role, with 67% of chaplains, 77% of social workers, 49% of advanced practice providers, 32% of nurses, and 27% of attending physicians launching the "Patient Values Tab" for at least one patient; this was consistent across outpatient and inpatient cohorts. Conclusion. Patterns of adoption of an innovative"Patient Values Tab" EHR feature varied across clinical contexts and provider roles.Ongoing research is exploring factors that impede/facilitate adoption at the level of the patient, provider, and clinical context to inform strategies to enhance/sustain adoption.

Abstract Examining end-of-life (EOL) patient outcomes associated with patient portal use will help identify benefits and barriers of portal use during EOL care. The primary objective of this retrospective cohort study was to assess the association between EOL outcomes and patient portal use among a cohort (N=6,517) of deceased patients (18+ years old) in the last 12 months of life within Kaiser Permanente Colorado (KPCO). Outcomes including 1) number of hospitalizations in the last 30 days of life, 2) having documented advance directive before death, and 3) dying in hospice were investigated by levels of patient portal use (no use, non-active use, active use without provider, and active use with a provider) for the first six months of the last year of life. A generalized linear model with Poisson distribution, a log link and an offset to account for person-days of follow-up was used to estimate rates of hospitalizations in the last 30 days. Logistic regression was used to estimate advance directive and death in hospice outcomes. Patient portal use appeared to be associated with beneficial EOL outcomes such as advance care planning (P = 0.0226) and dying in hospice (P = 0.0070). Hospitalizations were greater with higher levels of patient portal use (P = 0.0492), suggesting that patients/caregivers may have used patient portals for disease related information and accessing health services during times of need. More research is needed to leverage patient portal use to intentionally engage, educate and guide patients with serious illness and approaching EOL.

Background: Little is known about how local area hospice capacity and staffing levels impact hospice use in urban versus rural areas. Objectives: To examine the association between local hospice capacity and staffing levels and hospice use in the context of rural disparities in hospice use, among a sample of patients with metastatic breast cancer. Design: A retrospective cohort study using Surveillance Epidemiology End-Results (SEER)-Medicare linked data 2000-2010, Medicare Provider of Service files, and Census 2000 U.S. Zip Code Tabulation Areas files. Setting: Use of Medicare-certified hospice programs among older adults with metastatic breast cancer residing in one of the SEER program cancer registries designated by National Cancer Institute in the United States. Measurements: Measurements of geographic access to hospices include urban/rural characteristics of patient residence and driving time from the nearest Medicare-certified hospice headquarter. Measurements of local-area hospice capacity and staffing levels include per capita number of Medicare-certified hospice programs and full-time employees among older adults within a predefined radius. Results: Among the study population (N = 5418), remote and suburban areas were negatively associated with hospice use. Lower hospice use in remote and suburban areas was associated with fewer per capita number of Medicare-certified hospice program employees in local areas ≥70-minute driving radius (p = 0.0042), while per capita number of Medicare-certified hospice programs in local areas showed no impact. Conclusion: For older patients with metastatic breast cancer, availability of hospice staff, rather than driving distance or the number of hospice agencies, may limit hospice use in remote and suburban areas.

Palliative care nurses are key members of the health care team and provide support to patients and their families navigating chronic and life-limiting illness. Financial burden is an issue inherent to chronic illness, yet has not been fully addressed in family caregivers. The purpose of this article is to (1) provide a case study of a family caregiver navigating chronic illness with her daughter and the associated financial and employment consequences and (2) review the nursing ethical, policy, and practice implications of financial burden for family caregivers. The ethical implications of financial burden in family caregivers relate to health equity and health outcomes for both the patient and family caregiver in treatment access and quality. The policy implications include state and federal policies related to caregiver compensation and support and family medical leave. Palliative care nurses play an integral role in addressing caregiver financial burden through assessment, education, referral, and policy support. Family caregivers are essential to the palliative care team, and palliative care nurses have the opportunity to lead initiatives to support the financial well-being of family caregivers in practice, research, and policy settings.

Introduction There are 53 million caregivers in the USA providing informal care for individuals with chronic illnesses. These caregivers contribute significantly to the healthcare system, yet they may experience adverse consequences due to caregiving, including financial burden. The purpose of this scoping review is to fill a research gap on understanding the nature and effect of financial interventions for family caregivers. Methods and analysis This study will use the Arksey and O'Malley scoping review framework to systematically search for articles in MEDLINE, PubMed, CINAHL Complete, Cochrane Library, PsycINFO, Dissertations & Theses Global, and Web of Science during April 2022. Articles published from 1997 to the present will be included for the review. Data from articles will be extracted and summarised for financial intervention nature, scope, measurement, effect and health system context. Ethics and dissemination This study does not include human subjects; therefore, no ethical review will be undertaken. Findings will be disseminated in scholarly journals and at caregiving and ageing conferences, such as the Gerontological Society of America.

Subgroup analysis is designed to evaluate whether an intervention has differing effects according to baseline characteristics of participants in clinical trials. This approach can help identify subgroups of patient populations, within a single trial or across multiple trials (meta-analysis), that may benefit from the intervention or can be hypothesis-generating for future trials. Properly prespecified subgroup analyses can increase the effect size of subgroups and the legitimacy of P-values in determining significance and hypothesis testing. However, many pitfalls and limitations exist and must be recognized, including post hoc data-generating, multiple testing, selective reporting, and insufficient sample size. Failure to account for these limitations could lead to erroneous interpretations that adversely impact clinical decision-making. This review will provide a general overview, best practices, and pitfalls to avoid for investigators involved in the design, conduct, or interpretation of subgroup analyses.

Few studies have assessed prescription opioid supply preceding death in individuals dying from unintentional prescription opioid overdoses, or described the characteristics of these individuals, particularly among Veterans.To describe the history of prescription opioid supply preceding prescription opioid overdose death among Veterans.In a national cohort of Veterans who filled ≥1 opioid prescriptions from the Veterans Health Administration (VA) or Medicare Part D during 2008–2013, we identified deaths from unintentional or undetermined-intent prescription opioid overdoses in 2012–2013. We captured opioid prescriptions using both linked VA and Part D data, and VA data only.Among 1181 decedents, 643 (54.4%) had prescription opioid supply on the day of death, and 735 (62.2%) within 30 days based on linked data, compared to 40.1% and 46.7%, respectively, using VA data alone. Decedents with prescription opioid supply were significantly older and less likely to have alcohol or illicit drugs as co-occurring substances involved in the overdose. Using linked data, 241 (20.4%) decedents lacked prescription opioid supply within a year of death.Many VA patients who die from prescription opioid overdose receive opioid prescriptions outside VA or not at all. It is important to supplement VA with non-VA data to more accurately measure prescription opioid exposure and improve opioid medication safety.

Appalachia is a largely rural, mountainous, poor and underserved region of the United States. Adherence to adjuvant endocrine therapy among Appalachian women with breast cancer is suboptimal.To explore small-area geographic variations and clustering patterns of breast cancer patient adherence to adjuvant endocrine therapy and associated factors in Appalachia.In this retrospective study, we analyzed Medicare claims data linked with cancer registries from four Appalachian states (PA, OH, KY, and NC) in 2006–2008. We included adult women who were diagnosed with stage I–III, hormone-receptor positive, primary breast cancer and who newly started adjuvant endocrine therapy after the primary treatment for breast cancer. Hot spot analysis was conducted to explore geographic variations in adjuvant endocrine therapy adherence. Geographically weighted logistic regression (GWLR) was used to examine whether the impacts of factors associated with adherence varied across the region.Breast cancer patients living in PA and OH showed higher adherence to adjuvant endocrine therapy than those living in KY and NC. We identified clusters of high adherence in most of PA but poor adherence in Erie County, PA and in Buncombe, Transylvania, Henderson, and Polk Counties, NC. Adherence to adjuvant endocrine therapy was significantly associated with the Health Professional Shortage Area designation, catastrophic coverage, dual-eligibility status of Medicaid and Medicare, adjuvant endocrine therapy drug class, and side effects. And among these factors, the impacts of dual-eligibility status and the use of pain medications to treat side effects on adherence were more pronounced in KY and NC than in PA.There were significant geographic disparities in adherence to adjuvant endocrine therapy in the Appalachian counties in PA, OH, KY, and NC. This study explored these geographic areas with poor adherence as well as geographically varying effects of predictors on adherence; our results may provide more localized information that may be used to improve adjuvant therapy use and breast cancer care in these high-risk and underserved areas.

To meet the needs of an aging population who often have multiple chronic conditions, interprofessional care is increasingly adopted by patient-centred medical homes and Accountable Care Organisations to improve patient care coordination and decrease costs in the United States, especially in underserved areas with primary care workforce shortages. In this cross-sectional survey across multiple clinical settings in an underserved area, healthcare providers perceived overall outcomes associated with interprofessional care teams as positive. This included healthcare providers' beliefs that interprofessional care teams improved patient outcomes, increased clinic efficiency, and enhanced care coordination and patient follow-up. Teams with primary care physician available each day were perceived as better able to coordinate care and follow up with patients (p = .031), while teams that included clinical pharmacists were perceived as preventing medication-associated problems (p < .0001). Healthcare providers perceived the interprofessional care model as a useful strategy to improve various outcomes across different clinical settings in the context of a shortage of primary care physicians.

Significant age-related variation in chemotherapy use has been observed among elderly patients with metastatic breast cancer (MBC), which may be partly attributable to geographic access factors such as local area physician practice culture and local health care system capacity. The purpose of the paper was to examine how age may modify the effect of geographic access on chemotherapy use in elderly patients with MBC. This was a retrospective cohort study based on the surveillance, epidemiology, and end results-Medicare-linked database of 1992-2002. Chemotherapy use was defined as at least one chemotherapy-related claim within 6-month post-diagnosis. Geographic access to cancer care was measured by four variables: patient travel time to the nearest oncologist practice, local area per capita number of oncologists, local area per capita number of hospices, and local area chemotherapy rate. Using multivariate logistic regression model, both aggregate models with interaction terms and subgroup analyses were conducted. Among 4,533 elderly with MBC, 30.16 % used chemotherapy. Chemotherapy use decreased with age. Both the aggregate model with interaction terms and the subgroup analysis showed that local area chemotherapy rate was positively associated with chemotherapy use (P = .0004 in the whole group; in the subgroup analyses, P < .0001, P = .0006, P = .0006, P = .18, P = .026, respectively). In addition, subgroup analysis showed that, among patients aged 85+ years old, local area oncologist supply was negatively associated with chemotherapy use (P = .028). The impact of geographic access to cancer care is the greatest among the oldest group, for whom the clinical evidence is the least certain.

PurposeTo estimate travel distance and time for US hemodialysis patients and to compare travel of rural versus urban patients.MethodsDialysis patient residences were estimated from ZIP code-level patient counts as of February 2011 allocated within the ZIP code proportional to census tract-level population, obtained from the 2010 US Census. Dialysis facility addresses were obtained from Medicare public-use files. Patients were assigned to an original and replacement facility, assuming patients used the facility closest to home and would select the next closest facility as a replacement, if a replacement facility was required. Driving distances and times were calculated between patient residences and facility locations using GIS software.FindingsThe mean one-way driving distance to the original facility was 7.9 miles; for rural patients average distances were 2.5 times farther than for urban patients (15.9 vs 6.2 miles). Mean driving distance to a replacement facility was 10.6 miles, with rural patients traveling on average 4 times farther than urban patients to a replacement facility (28.8 vs 6.8 miles).ConclusionRural patients travel much longer distances for dialysis than urban patients. Accessing alternative facilities, if required, would greatly increase rural patient travel, while having little impact on urban patients. Increased travel could have clinical implications as longer travel is associated with increased mortality and decreased quality of life.

BACKGROUND:Payments for red blood cell (RBC) transfusions are separate from US Medicare bundled payments for dialysis-related services and medications. Our objective was to examine the economic burden for payers when chronic dialysis patients receive outpatient RBC transfusions.METHODS:Using Truven Health MarketScan® data (1/1/02-10/31/10) in this retrospective micro-costing economic analysis, we analyzed data from chronic dialysis patients who underwent at least 1 outpatient RBC transfusion who had at least 6 months of continuous enrollment prior to initial dialysis claim and at least 30 days post-transfusion follow-up. A conceptual model of transfusion-associated resource use based on current literature was employed to estimate outpatient RBC transfusion payments. Total payments per RBC transfusion episode included screening/monitoring (within 3 days), blood acquisition/administration (within 2 days), and associated complications (within 3 days for acute events; up to 45 days for chronic events).RESULTS:A total of 3283 patient transfusion episodes were included; 56.4% were men and 40.9% had Medicare supplemental insurance. Mean (standard deviation [SD]) age was 60.9 (15.0) years, and mean Charlson comorbidity index was 4.3 (2.5). During a mean (SD) follow-up of 495 (474) days, patients had a mean of 2.2 (3.8) outpatient RBC transfusion episodes. Mean/median (SD) total payment per RBC transfusion episode was $854/$427 ($2,060) with 72.1% attributable to blood acquisition and administration payments. Complication payments ranged from mean (SD) $213 ($168) for delayed hemolytic transfusion reaction to $19,466 ($15,424) for congestive heart failure.CONCLUSIONS:Payments for outpatient RBC transfusion episodes were driven by blood acquisition and administration payments. While infrequent, transfusion complications increased payments substantially when they occurred.