Karl A Lorenz

University of Alabama at Birmingham, Birmingham, Alabama, United States

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Publications (113)453.41 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: We built a web-based, interactive, self-directed learning module about end-of-life care. Objective: The study objective was to develop an online module about end-of-life care targeted at surgeons, and to assess the effect of the module on attitudes towards and knowledge about end-of-life care. Methods: Informed by a panel of experts in supportive care and educational assessment, we developed an instrument that required approximately 15 minutes to complete. The module targets surgeons, but is applicable to other practitioners as well. We recruited general surgeons, surgical subspecialists, and medical practitioners and subspecialists from UCLA and the GLA-VA (N=114). We compared pre- and post-intervention scores for attitude and knowledge, then used ANOVA to compare the pre- and postmodule means for each level of the covariate. We performed bivariable analyses to assess the association of subject characteristic and change in score over time. We ran separate analyses to assess baseline and change scores based on the covariates we had selected a priori. Results: Subjects improved meaningfully in all five domains of attitude and in each of the six knowledge items. Individuals younger than 30 years of age had the greatest change in attitudes about addressing pain, addressing end-of-life goals, and being actively involved as death approached; they also had the most marked improvement in total knowledge score. Having a family member die of cancer within the last five years or a personal experience with palliative care or hospice were associated with higher change scores. Conclusions: A web-based education module improved surgical and medical provider attitudes and knowledge about end-of-life care.
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    ABSTRACT: Calls for improvement in end-of-life care have focused attention on the management of pain and other troubling symptoms at the end of life. To describe changes in pain intensity and symptom prevalence during the last year of life from 1998 to 2010. Observational study. The HRS (Health and Retirement Study), a nationally representative longitudinal survey of community-dwelling U.S. residents aged 51 years or older. 7204 HRS participants who died while enrolled in the study and their family respondents. Proxy-reported pain during the last year of life and other symptoms for at least 1 month during the last year of life. Trends in pain intensity and symptom prevalence were analyzed for all decedents and within the categories of sudden death, cancer, congestive heart failure or chronic lung disease, and frailty. Between 1998 and 2010, proxy reports of the prevalence of any pain increased for all decedents from 54.3% (95% CI, 51.6% to 57.1%) to 60.8% (CI, 58.2% to 63.4%), an increase of 11.9% (CI, 3.1% to 21.4%). Reported prevalences of depression and periodic confusion also increased for all decedents by 26.6% (CI, 14.5% to 40.1%) and 31.3% (CI, 18.6% to 45.1%), respectively. Individual symptoms increased in prevalence among specific decedent categories, except in cancer, which showed no significant changes. The prevalence of moderate or severe pain did not change among all decedents or in any specific decedent category. Use of proxy reports and limited information about some patient and surrogate variables. Despite national efforts to improve end-of-life care, proxy reports of pain and other alarming symptoms in the last year of life increased from 1998 to 2010. National Institute of Nursing Research.
    Annals of internal medicine 02/2015; 162(3):175-83. DOI:10.7326/M13-1609 · 16.10 Impact Factor
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    ABSTRACT: Increasing interest in end-of-life care has resulted in many tools to measure the quality of care. An important outcome measure of end-of-life care is the family members' or caregivers' experiences of care. To evaluate the instruments currently in use to inform next steps for research and policy in this area. We conducted a systematic review of PubMed, PsycINFO, and PsycTESTS® for all English-language articles published after 1990 using instruments to measure adult patient, family, or informal caregiver experiences with end-of-life care. Survey items were abstracted and categorized into content areas identified through an iterative method using three independent reviewers. We also abstracted information from the most frequently used surveys about the identification of proxy respondents for after-death surveys, the timing and method of survey administration, and the health care setting being assessed. We identified 88 articles containing 51 unique surveys with available content. We characterized 14 content areas variably present across the 51 surveys. Information and care planning, provider care, symptom management, and overall experience were the most frequent areas addressed. There was also considerable variation across the surveys in the identification of proxy respondents, the timing of survey administration, and in the health care settings and services being evaluated. This review identified several comprehensive surveys aimed at measuring the experiences of end-of-life care, covering a variety of content areas and practical issues for survey administration. Future work should focus on standardizing surveys and administration methods so experiences of care can be reliably measured and compared across care settings. Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
    Journal of Pain and Symptom Management 12/2014; DOI:10.1016/j.jpainsymman.2014.10.018 · 2.74 Impact Factor
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    ABSTRACT: Abstract Background: Palliative care and preparation for liver transplantation are often perceived as conflicting for patients with end-stage liver disease (ESLD). We sought to improve both simultaneously through a case finding and care coordination quality improvement intervention. Methods: We identified patients with cirrhosis using validated ICD-9 codes and screened them for ESLD by assessing medical records at a VA hospital for either a model for end-stage liver disease (MELD) ≥14 or a diagnosis of hepatocellular carcinoma (HCC) between October 2012 and January 2013. A care coordinator followed veterans from the index hospitalization through April 2013 and encouraged treating physicians to submit liver transplant evaluation consults for all veterans with a MELD ≥14 and palliative care consults for all veterans with a MELD ≥20 or inoperable HCC. Results: We compared rates of consultation for 49 hospitalized veterans and compared their outcomes to 61 pre-intervention veterans. Veterans were more likely to be considered for liver transplantation (77.6% versus 31.1%, p<0.001) and receive palliative care consultation during the intervention period, although the latter finding did not reach statistical significance (62.5% versus 47.1%, p=0.38). Conclusions: Active case finding improved consideration for liver transplantation without decreasing palliative care consultation.
    Journal of Palliative Medicine 12/2014; DOI:10.1089/jpm.2014.0265 · 2.06 Impact Factor
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    ABSTRACT: Background:Composite measures are useful for distilling quality data into summary scores; yet, there has been limited use of composite measures for cancer care.Objective:Compare multiple approaches for generating cancer care composite measures and evaluate how well composite measures summarize dimensions of cancer care and predict survival.Study Design:We computed hospital-level rates for 13 colorectal, lung, and prostate cancer process measures in 59 Veterans Affairs hospitals. We computed 4 empirical-factor (based on an exploratory factor analysis), 3 cancer-specific (colorectal, lung, prostate care), and 3 care modality-specific (diagnosis/evaluation, surgical, nonsurgical treatments) composite measures. We assessed correlations among all composite measures and estimated all-cause survival for colon, rectal, non-small cell lung, and small cell lung cancers as a function of composite scores, adjusting for patient characteristics.Results:Four factors emerged from the factor analysis: nonsurgical treatment, surgical treatment, colorectal early diagnosis, and prostate treatment. We observed strong correlations (r) among composite measures comprised of similar process measures (r=0.58-1.00, P<0.0001), but not among composite measures reflecting different care dimensions. Composite measures were rarely associated with survival.Conclusions:The empirical-factor domains grouped measures variously by cancer type and care modality. The evidence did not support any single approach for generating cancer care composite measures. Weak associations across different care domains suggest that low-quality and high-quality cancer care delivery may coexist within Veterans Affairs hospitals.
    Medical Care 11/2014; 53(1). DOI:10.1097/MLR.0000000000000257 · 2.94 Impact Factor
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    ABSTRACT: We partnered with patients, families, and palliative care clinicians to develop an integrated urology-palliative care clinic for patients with metastatic cancer. We assessed clinician satisfaction with a multidisciplinary palliative care clinic model.
    The American journal of hospice & palliative care 10/2014; DOI:10.1177/1049909114555156
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    ABSTRACT: Early and repeated patient-provider conversations about advance care planning (ACP) are now widely recommended. We sought to characterize barriers and strategies for realizing an iterative model of ACP patient-provider communication.
    The American journal of hospice & palliative care 07/2014; DOI:10.1177/1049909114541513
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    ABSTRACT: Patient-reported data may provide valuable information for oncology quality measurement. We evaluated applying patient-reported data from the Cancer Care Outcomes Research and Surveillance Consortium national study to quality indicators addressing supportive oncology domains. We analyzed surveys including validated instruments for symptoms and care planning from 4,174 patients newly diagnosed with lung or colorectal cancer. We adapted existing supportive oncology indicators for use with patient-reported data from Cancer Quality-ASSIST and the American Society of Clinical Oncology Quality Oncology Practice Initiative. Where feasible, we examined indicators using medical record data for comparison purposes. Using patient-reported data, the percentage of patients meeting indicator criteria for screening ranged from 74% (significant depressive symptoms) to 93% (pain, nausea/vomiting). The percentage meeting indicator criteria for symptom treatment ranged from 73% (significant depressive symptoms) to 99% (nausea/vomiting). Symptom severity did not affect the results. Using medical record data, the percentage meeting indicator criteria varied between 4% (significant depressive symptoms) and 23% (pain). For information and care planning, 44% met criteria for discussion about resuscitation and 32% for hospice discussion using survey data. Using medical record data, 11% met criteria for goals-of-care discussion in intensive care and 46% for hospice/pain management/palliative care referral before death. Quality of care for symptoms measured using patient self-report was higher than when including medical record data. Use of patient-reported and medical record data allowed measurement of different perspectives on care planning indicators. Patient-reported data provide a complementary, patient-centered perspective on the quality of supportive oncology care.
    Journal of Oncology Practice 03/2014; DOI:10.1200/JOP.2013.001237
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    ABSTRACT: Abstract Background: Increasing emphasis in performance-based payment, public reporting, and quality improvement (QI) has led to widespread interest in measuring and improving the quality of care. By 2014, hospice programs will be required to report quality data to the federal government or incur financial penalties. With this increased interest in quality reporting comes an opportunity to develop informatics tools to capture data that reflect the complex practices involved in palliative care (PC). Therefore, there is a need to disseminate information on developing tools that facilitate capturing data and fostering improved performance. The Veterans Health Care Administration, a national leader in health information technology (HIT) and PC, established the Quality Improvement Resource Center (QuIRC) to develop innovative HIT tools to standardize and improve PC practices throughout the 153 Department of Veterans Affairs (VA) medical centers nationwide. Objective: The aim of the paper is to describe the development of the Palliative Care-National Clinical Template (PC-NCT) for documenting initial PC consults. Results: Domains of quality of life provided the foundation for this template. Principles of user-centered informatics design guided development activities. A national consensus panel of PC experts prioritized quality indicators as targets for QI. An interdisciplinary team of PC providers identified desired aspects of template functionality. QuIRC balanced PC providers' desired aspects of functionality against the feasibility within the VA HIT system. Formal pilot and usability testing contributed to numerous iterations of the PC-NCT currently piloted in five geographically distributed sites. Conclusion: This paper presents a robust approach to developing an informatics tool for PC practice. Data collected via the PC-NCT will bring variations in current practice into view and assist in directing resources at "important targets" for QI. Although the development of HIT tools to quantify PC practice is complex, there is enormous potential to improve the quality of care for patients and families facing serious illnesses.
    Journal of palliative medicine 02/2014; 17(3). DOI:10.1089/jpm.2013.0288 · 1.84 Impact Factor
  • Journal of Pain and Symptom Management; 02/2014
  • Journal of Pain and Symptom Management 02/2014; 47(2):453-454. DOI:10.1016/j.jpainsymman.2013.12.208 · 2.74 Impact Factor
  • Journal of Pain and Symptom Management 02/2014; 47(2):508. DOI:10.1016/j.jpainsymman.2013.12.187 · 2.74 Impact Factor
  • Journal of Pain and Symptom Management 02/2014; 47(2):410-411. DOI:10.1016/j.jpainsymman.2013.12.064 · 2.74 Impact Factor
  • Journal of Pain and Symptom Management 02/2014; 47(2):502-503. DOI:10.1016/j.jpainsymman.2013.12.178 · 2.74 Impact Factor
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    ABSTRACT: Abstract Background: People with chronic heart failure (HF) suffer from numerous symptoms that worsen quality of life. The CASA (Collaborative Care to Alleviate Symptoms and Adjust to Illness) intervention was designed to improve symptoms and quality of life by integrating palliative and psychosocial care into chronic care. Objective: Our aim was to determine the feasibility and acceptability of CASA and identify necessary improvements. Methods: We conducted a prospective mixed-methods pilot trial. The CASA intervention included (1) nurse phone visits involving structured symptom assessments and guidelines to alleviate breathlessness, fatigue, pain, or depression; (2) structured phone counseling targeting adjustment to illness and depression if present; and (3) weekly team meetings with a palliative care specialist, cardiologist, and primary care physician focused on medical recommendations to primary care providers (PCPs, physician or nurse practioners) to improve symptoms. Study subjects were outpatients with chronic HF from a Veteran's Affairs hospital (n=15) and a university hospital (n=2). Measurements included feasibility (cohort retention rate, medical recommendation implementation rate, missing data, quality of care) and acceptability (an end-of-study semi-structured participant interview). Results: Participants were male with a median age of 63 years. One withdrew early and there were <5% missing data. Overall, 85% of 87 collaborative care team medical recommendations were implemented. All participants who screened positive for depression were either treated for depression or thought to not have a depressive disorder. In the qualitative interviews, patients reported a positive experience and provided several constructive critiques. Conclusions: The CASA intervention was feasible based on participant enrollment, cohort retention, implementation of medical recommendations, minimal missing data, and acceptability. Several intervention changes were made based on participant feedback.
    Journal of palliative medicine 12/2013; 17(2). DOI:10.1089/jpm.2013.0143 · 1.84 Impact Factor
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    ABSTRACT: Historically, hospice use by veterans has lagged behind that of non-veterans. Little is known about hospice use by veterans at a population level. To determine whether veteran and non-veteran hospice users differ by demographics, primary diagnosis, location of care, and service utilization. Using the 2007 National Home and Hospice Care Survey, we identified 483 veteran and 932 non-veteran male hospice users representing 287,620 hospice enrollees nationally. We used chi-square and t-tests to compare veterans and non-veterans by demographic characteristics, primary diagnosis, and location of hospice care. We used multivariate regression to assess for differences in hospice diagnosis and location of care, adjusting for demographic and clinical factors. We also compared length of stay and number of visits by hospice personnel between veterans and non-veterans using multivariate regression. Veteran hospice users were older than non-veterans (77.0 vs. 74.3 years, P = 0.02) but did not differ by other demographics. In adjusted analyses, cancer was a more common primary diagnosis among veterans than non-veterans (56.4% vs. 48.4%; P = 0.02), and veteran hospice users were more likely than non-veterans to receive hospice at home (68.4% vs. 57.6%; P = 0.007). The median adjusted length of stay and number of nurse or social worker visits did not differ by veteran status (all P > 0.10), but veterans received fewer home health aide visits than non-veterans (one every 5.3 days vs. one every 3.7 days; P = 0.002). Although veteran and non-veteran hospice users were similar on most demographic measures, important differences in hospice referral patterns and utilization exist.
    Journal of pain and symptom management 11/2013; 48(1). DOI:10.1016/j.jpainsymman.2013.08.013 · 2.42 Impact Factor
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    ABSTRACT: IMPORTANCE Characterizing the quality of supportive cancer care can guide quality improvement. OBJECTIVE To evaluate nonhospice supportive cancer care comprehensively in a national sample of veterans. DESIGN, SETTING, AND PARTICIPANTS Using a retrospective cohort study design, we measured evidence-based cancer care processes using previously validated indicators of care quality in patients with advanced cancer, addressing pain, nonpain symptoms, and information and care planning among 719 veterans with a 2008 Veterans Affairs Central Cancer Registry diagnosis of stage IV colorectal (37.0%), pancreatic (29.8%), or lung (33.2%) cancer. MAIN OUTCOMES AND MEASURES We abstracted medical records from diagnosis for 3 years or until death among eligible veterans (lived ≥30 days following diagnosis with ≥1 Veterans Affairs hospitalization or ≥2 Veterans Affairs outpatient visits). Each indicator identified a clinical scenario and an appropriate action. For each indicator for which a veteran was eligible, we determined whether appropriate care was provided. We also determined patient-level quality overall and by pain, nonpain symptoms, and information and care planning domains. RESULTS Most veterans were older (mean age, 66.2 years), male (97.2%), and white (74.3%). Eighty-five percent received both inpatient and outpatient care, and 92.5% died. Overall, the 719 veterans triggered a mean of 11.7 quality indicators (range, 1-22) and received a mean 49.5% of appropriate care. Notable gaps in care were that inpatient pain screening was common (96.5%) but lacking for outpatients (58.1%). With opioids, bowel prophylaxis occurred for only 52.2% of outpatients and 70.5% of inpatients. Few patients had a timely dyspnea evaluation (15.8%) or treatment (10.8%). Outpatient assessment of fatigue occurred for 31.3%. Of patients at high risk for diarrhea from chemotherapy, 24.2% were offered appropriate antidiarrheals. Only 17.7% of veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63.7% had timely discussion of goals following intensive care unit admission. Most decedents (86.4%) were referred to palliative care or hospice before death. Single- vs multiple-fraction radiotherapy should have been considered in 28 veterans with bone metastasis, but none were offered this option. CONCLUSIONS AND RELEVANCE These care gaps reflect important targets for improving the patient and family experience of cancer care.
    JAMA Internal Medicine 10/2013; 173(22). DOI:10.1001/jamainternmed.2013.10797 · 13.25 Impact Factor
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    ABSTRACT: Research has demonstrated that limited dialogue in end-of-life (EOL) care can negatively impact decision-making and place of death. Furthermore, when vulnerable populations are faced with EOL cancer care, they experience issues resulting from previous gaps in services attributed to sociocultural and economic issues that influence EOL care. These conditions place an additional burden on disadvantaged populations which can cause distress, especially as disparate conditions continue to persist. Little is known about Latinos' psychosocial concerns that lead to distress in EOL care. The objective of this study is to explore Latinas' experiences with life-limiting cancer conditions to identify the EOL care concerns that impact their dying experience. This study used a phenomenological approach to explore the EOL care concerns of 24 Latinas receiving treatment for metastatic cancers in a public sector healthcare system in Los Angeles, California. In-depth interviews were recorded and transcribed, and qualitative analysis was performed using Atlas.ti software.
    OMEGA--Journal of Death and Dying 08/2013; 67(1-2):167-74. DOI:10.2190/OM.67.1-2.t · 0.44 Impact Factor
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    ABSTRACT: Physician Orders for Life-Sustaining Treatment (POLST) is a tool to document and ensure continuity of end-of-life treatment decisions across healthcare settings that became a legal document in California in January 2009. Hospitals were surveyed to evaluate factors associated with uptake of this intervention and whether a grassroots community coalition intervention facilitated dissemination. A mail and telephone survey of all acute care hospitals in California was conducted between August 2011 and January 2012, and community coalition reports of interaction with hospitals and hospital characteristics from the California Office of Statewide Planning and Development and Census ZIP Code Tabulation Areas were analyzed. Of 349 hospitals, 286 (81.9%) responded to the survey. Sixty-five percent of hospitals had a policy about POLST, 87% had available blank POLST forms, 84% had educated staff, and 94% reported handling POLST properly in the emergency department and on admission. In multivariable analyses, hospitals in poor areas and for-profit (vs nonprofit) hospitals were less likely to stock blank POLST forms and to have educated staff, and hospitals with community coalition interaction and in wealthier areas were more likely to handle POLST forms correctly. Although POLST is widely used in California, a significant minority of hospitals remain unprepared 3 years after implementation. Efforts to improve implementation should emphasize dissemination in poorer areas and in for-profit hospitals.
    Journal of the American Geriatrics Society 07/2013; 61(8). DOI:10.1111/jgs.12367 · 4.22 Impact Factor
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    ABSTRACT: This research explores health care professionals' understanding of the problems that arise in managing a terminal condition impacting the Latino population and conceptualizes the components of patient advocacy that address gaps in end-of-life care for patients and their family members. Limited research exists regarding patient advocacy from the perspectives of health care providers working with vulnerable Latino populations utilizing a public sector health care system. Forty-six semi-structured interviews were conducted with providers from different disciplines including medicine, nursing, social work, and chaplaincy. Although roles and responsibilities vary among health providers, it is imperative that all providers become aware of the need for patient advocacy. Doing so is not only in the best interest of vulnerable Latino populations but also has overarching financial benefits and positive outcomes for patients, administrators, and public health care systems. Social workers are the ideal professionals to assume leadership roles and share their knowledge of how to advocate effectively for the most vulnerable populations.
    Social Work in Health Care 07/2013; 52(6):558-77. DOI:10.1080/00981389.2013.779359 · 0.62 Impact Factor

Publication Stats

2k Citations
453.41 Total Impact Points


  • 2014
    • University of Alabama at Birmingham
      • School of Nursing
      Birmingham, Alabama, United States
  • 2002–2014
    • VA Greater Los Angeles Healthcare System
      Los Angeles, California, United States
  • 2001–2013
    • University of California, Los Angeles
      • • Department of Urology
      • • Division of General Internal Medicine and Health Services Research
      • • School of Nursing
      Los Ángeles, California, United States
  • 2011
    • The Harvard Drug Group
      Ливония, Michigan, United States
  • 2010
    • California State University, Long Beach
      • School of Nursing
      Long Beach, California, United States
  • 2009–2010
    • RAND Corporation
      Santa Monica, California, United States
    • Kaiser Permanente
      Oakland, California, United States
    • CSU Mentor
      Long Beach, California, United States
  • 2008
    • Northwestern University
      • Feinberg School of Medicine
      Evanston, IL, United States
  • 2005–2008
    • Johns Hopkins University
      Baltimore, Maryland, United States