Karl A Lorenz

United States Department of Veterans Affairs, Бедфорд, Massachusetts, United States

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Publications (135)546.27 Total impact

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    Preview · Article · Jan 2016 · American Journal of Critical Care
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    ABSTRACT: Background: Unlike Medicare, the Veterans Health Administration (VA) health care system does not require veterans with cancer to make the "terrible choice" between receipt of hospice services or disease-modifying chemotherapy/radiation therapy. For this report, the authors characterized the VA's provision of concurrent care, defined as days in the last 6 months of life during which veterans simultaneously received hospice services and chemotherapy or radiation therapy. Methods: This retrospective cohort study included veteran decedents with cancer during 2006 through 2012 who were identified from claims with cancer diagnoses. Hospice and cancer treatment were identified using VA and Medicare administrative data. Descriptive statistics were used to characterize the changes in concurrent care, hospice, palliative care, and chemotherapy or radiation treatment. Results: The proportion of veterans receiving chemotherapy or radiation therapy remained stable at approximately 45%, whereas the proportion of veterans who received hospice increased from 55% to 68%. The receipt of concurrent care also increased during this time from 16.2% to 24.5%. The median time between hospice initiation and death remained stable at around 21 days. Among veterans who received chemotherapy or radiation therapy in their last 6 months of life, the median time between treatment termination and death ranged from 35 to 40 days. There was considerable variation between VA medical centers in the use of concurrent care (interquartile range, 16%-34% in 2012). Conclusions: Concurrent receipt of hospice and chemotherapy or radiation therapy increased among veterans dying from cancer without reductions in the receipt of cancer therapy. This approach reflects the expansion of hospice services in the VA with VA policy allowing the concurrent receipt of hospice and antineoplastic therapies. Cancer 2015. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.
    No preview · Article · Dec 2015 · Cancer
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    ABSTRACT: Family meetings can be challenging, requiring a range of skills and participation. We sought to identify tools available to aid the conduct of family meetings in palliative, hospice, and intensive care unit settings. We systematically reviewed PubMed for articles describing family meeting tools and abstracted information on tool type, usage, and content. We identified 16 articles containing 23 tools in 7 categories: meeting guide (n = 8), meeting planner (n = 5), documentation template (n = 4), meeting strategies (n = 2), decision aid/screener (n = 2), family checklist (n = 1), and training module (n = 1). We found considerable variation across tools in usage and content and a lack of tools supporting family engagement. There is need to standardize family meeting tools and develop tools to help family members effectively engage in the process. © The Author(s) 2015.
    No preview · Article · Jul 2015 · The American journal of hospice & palliative care
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    ABSTRACT: Early patient-physician care planning discussions may influence the intensity of end-of-life (EOL) care received by veterans with advanced cancer. The study objective was to evaluate the association between medical record documentation of patient-physician care planning discussions and intensity of EOL care among veterans with advanced cancer. This was a retrospective cohort study. Subjects were 665 veteran decedents diagnosed with stage IV colorectal, lung, or pancreatic cancer in 2008, and followed till death or the end of the study period in 2011. We estimated the effect of patient-physician care planning discussions documented within one month of metastatic diagnosis on the intensity of EOL care measured by receipt of acute care, intensive interventions, chemotherapy, and hospice care, using multivariate logistic regression models. Veterans in our study were predominantly male (97.1%), white (74.7%), with an average age at diagnosis of 66.4 years. Approximately 31% received some acute care, 9.3% received some intensive intervention, and 6.5% had a new chemotherapy regimen initiated in the last month of life. Approximately 41% of decedents received no hospice or were admitted within three days of death. Almost half (46.8%) had documentation of a care planning discussion within the first month after diagnosis and those who did were significantly less likely to receive acute care at EOL (OR: 0.67; p=0.025). Documented discussions were not significantly associated with intensive interventions, chemotherapy, or hospice care. Early care planning discussions are associated with lower rates of acute care use at the EOL in a system with already low rates of intensive EOL care.
    Full-text · Article · Jul 2015 · Journal of palliative medicine
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    ABSTRACT: Long-term care hospitals are postacute care facilities for patients requiring extended hospital-level care. These facilities are reimbursed by Medicare under a prospective payment system with a short-stay outlier policy, which results in substantially lower payments for patients discharged before a diagnosis-related group-specific short-stay threshold. Using Medicare data, we examined the impact of the short-stay policy on lengths-of-stay and Medicare reimbursement among patients in long-term care hospitals who require prolonged mechanical ventilation. After accounting for case-mix and facility-level differences, we found that discharges for reasons other than death in the period 2005-10 were most likely to occur on the day of or immediately after the short-stay threshold; this held true regardless of facility ownership. In contrast, live discharges in 2002-the year before the prospective payment system started phasing out cost-based payment-were evenly distributed around the day that later became the short-stay threshold. Our findings confirm that the short-stay outlier payment policy created a strong financial incentive for long-term care hospitals to time patient discharges to maximize Medicare reimbursement. The results suggest that the new very-short-stay policy implemented in December 2012 could have a similar effect. Project HOPE—The People-to-People Health Foundation, Inc.
    No preview · Article · Jun 2015 · Health Affairs

  • No preview · Conference Paper · Apr 2015
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    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.
    No preview · Article · Mar 2015 · Journal of Palliative Medicine
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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.
    No preview · Article · Feb 2015 · Annals of internal medicine
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    ABSTRACT: Objectives To determine the perspectives of seriously ill individuals on reasons for 30-day hospital readmission.DesignA prospective qualitative study was conducted employing individual interviews conducted at bedside.SettingDepartment of Veterans Affairs Greater Los Angeles Healthcare System.ParticipantsSeriously ill individuals with heart failure or cancer receiving inpatient palliative care and readmitted to the hospital within 30 days of hospital discharge were recruited to participate. Nine were interviewed.MeasurementsA semistructured interview protocol was used to elicit participant perspectives on readmission causes.ResultsAll participants were male and had a mean age of 70.1 ± 9.5. Participants were ethnically diverse (three African Americans, three Caucasians, three Hispanic or mixed ethnic background). Six lived alone, and four did not have caregiver support. Qualitative analysis of transcripts revealed three themes relating to reasons for hospital readmission: lack of caregiver support and motivation to provide self-care, acceptance of condition and desire for aggressive care, and access to care and poor quality of care.Conclusion Participants identified potentially avoidable reasons for hospital readmission as well as causes that require rethinking regarding how community support is targeted and delivered. Participant preference for aggressive care, inability to provide self-care, and lack of caregiver support suggest the need for new and innovative mechanisms to support seriously ill community-dwelling individuals.
    Full-text · Article · Feb 2015 · Journal of the American Geriatrics Society
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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.
    Full-text · Article · Dec 2014 · Journal of Pain and Symptom Management
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    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.
    No preview · Article · Dec 2014 · Journal of Palliative Medicine
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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.
    No preview · Article · Nov 2014 · Medical Care
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    ABSTRACT: Background: 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. Methods: We conducted semi-structured interviews with 18 clinicians who practice in our integrated clinic. We analyzed transcripts using a multistage, cutting-and-sorting technique in an inductive approach based on grounded theory analysis. Finally, we administered a validated physician job satisfaction survey. Results: Clinicians found that referring a patient to palliative care in the urology clinic was feasible and appropriate. Patients were receptive to supportive care, and clinicians perceived that quality of care improved following the intervention. Conclusion: An integrated, patient-centered model for individuals with advanced urologic malignancies is feasible and well received by practitioners.
    No preview · Article · Oct 2014 · The American journal of hospice & palliative care
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    ABSTRACT: Morbidity related to cancer and its treatment remains a significant source of human suffering and a challenge to the delivery of high-quality care. To develop and apply quality indicators to evaluate quality of supportive care for advanced lung cancer in the Veterans Health Administration (VHA) and examine facility-level predictors of quality. We evaluated supportive care quality using 12 quality indicators. Data were taken from VHA electronic health records for incident lung cancer cases occurring during 2007. Organizational characteristics of 111 VHA facilities were examined for association with receipt of care. Not all supportive care was evaluated. Care processes identified as present at facilities may not have been applied to cohort patients. Facility-level results may be influenced by errors in attributing a patient's care to the correct facility. Quality indicators for supportive cancer care can be developed and applied in large evaluations using electronic health record review. This study confirmed high-quality supportive care, while identifying significant facility-level variation in VHA. ©2014 Frontline Medical Communications.
    No preview · Article · Oct 2014
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    ABSTRACT: Background: 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. Methods: A total of 2 multidisciplinary focus groups and 3 semistructured interviews with 20 providers at a large Veterans Affairs medical center. Thematic analysis was employed to identify salient themes. Results: Barriers included variation among providers in approaches to ACP, lack of useful information about patient values to guide decision making, and ineffective communication between providers across settings. Strategies included eliciting patient values rather than specific treatment choices and an increased role for primary care in the ACP process. Conclusions: Greater attention to connecting providers across the continuum, maximizing the potential of the electronic health record, and linking patient experiences to their values may help to connect ACP communication across the continuum.
    No preview · Article · Jul 2014 · The American journal of hospice & palliative care
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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.
    Full-text · Article · Mar 2014 · Journal of Oncology Practice
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    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.
    Full-text · Article · Feb 2014 · Journal of palliative medicine
  • Daniella Meeker · Joanne Lynn · Duncan Leaf · Karl Lorenz

    No preview · Article · Feb 2014 · Journal of Pain and Symptom Management

  • No preview · Article · Feb 2014 · Journal of Pain and Symptom Management

  • No preview · Article · Feb 2014 · Journal of Pain and Symptom Management

Publication Stats

2k Citations
546.27 Total Impact Points


  • 2015
    • United States Department of Veterans Affairs
      Бедфорд, Massachusetts, United States
  • 2009-2015
    • Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
      Torrance, California, United States
    • CSU Mentor
      Long Beach, California, United States
  • 2002-2015
    • VA Greater Los Angeles Healthcare System
      Los Ángeles, California, United States
  • 2003-2014
    • University of California, Los Angeles
      • • School of Nursing
      • • Division of General Internal Medicine and Health Services Research
      Los Ángeles, California, 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
  • 2008
    • Johns Hopkins University
      Baltimore, Maryland, United States