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Disease Attributes

Early palliative care consultation for ED patients with advanced cancer.

Care as usual, may or may not receive palliative care consultation

Patients will have symptoms assessed, have goals of care discussion with family and team present, and surrogate designated, as well as coordination of care and home services.

Early palliative care consultation

Standard care as usual which may or may not include palliative care consultation

Care as usual

Corita Grudzen, MD, MSHS

The purpose of this study is to: 1) identify the palliative care needs of Emergency Department patients with advanced cancer, and determine if these needs can be rapidly assessed in the ED; 2) determine whether early palliative care consultation improves survival, quality of life and other burdensome symptoms and decreases utilization as compared to usual care.

As the population ages, the number of individual living with cancer will continue to rise, and the number of Emergency Department (ED) visits for this population will continue to increase. Cancer patients visit EDs because symptoms, such as pain or vomiting, can't be controlled at home, in an assisted living facility, or in their provider's office. The ED is often the only place that can provide the necessary treatments as well as immediate access to technologically advanced testing for those with cancer. However, palliative care (PC) services, such as relief of burdensome symptoms), attention to spiritual or social concerns, and establishing goals of care, is not standard care in the ED outside of a few medical centers. Most patients do not have well-defined goals of care, and are often subjected to painful and marginally effective tests and procedures, not because they are consistent with their goals but because it is less time-consuming than discussing other options and has less perceived legal risk. Until recently little emphasis has been placed on education, research, or guidelines for the delivery of PC services in this important setting. While emergency providers could provide some of these services themselves, knowledge and skills regarding PC as well as staffing are currently inadequate to provide comprehensive services. In addition to further decreasing days spent in the hospital and health care costs, consultation by a PC team for ED cancer patients might also reduce pain and other symptoms, aid in complex medical decision-making regarding testing and treatments, and facilitate transfer to hospice or home with visiting nurse services. To enable PC consultation for ED cancer patients, the investigators will first determine who could benefit from emergent consultation, what services they need, and what characteristics of emergency providers and hospitals are preventing them from being offered. To determine what affect PC consultation for patients with advanced cancer has on symptoms, discussions with patients and families about goals of care, and how long patients spend in the ED, the investigators will then randomly assign 200 ED cancer patients to targeted PC consultation versus usual or standard care.

Emergency Department-Based Palliative Care for Advanced Cancer Patients

Comparison of life and quality of mental health from baseline to 6 weeks and 12 weeks.

Costs per day during incident admission and total cost of entire incident hospital stay

Number of days hospitalized for incident admission: i.e., date of admission and date of discharge, difference between those two dates.

Survival days from day of enrollment to day of death or study termination

American Cancer Society, Inc.

Icahn School of Medicine at Mount Sinai

Respiratory Tract (Lung and Bronchial) Diseases

Heart and Blood Diseases

Nutritional and Metabolic Diseases

Digestive System Diseases

Rare Diseases

Pleural Effusion

Fibrosis

Pulmonary Atelectasis

Multiple Pulmonary Nodules

Cardiomegaly

Calcinosis

Pneumothorax

Pneumoperitoneum

Pulmonary Fibrosis

Solitary Pulmonary Nodule

Pleural Diseases

Respiratory Tract Diseases

Lung Diseases

Lung Neoplasms

Respiratory Tract Neoplasms

Thoracic Neoplasms

Peritoneal Diseases

Gastrointestinal Diseases

Lung Diseases, Interstitial

Heart Diseases

Hypertrophy

Pathological Conditions, Anatomical

Chronic Graft Versus Host Disease

Acute Graft Versus Host Disease

Reader Selection: 30 readers will be selected from the following five clinical specialty groups:

* emergency medicine (ED)
* adult intensive care (ICU)
* adult general medicine (AGM)
* radiographers (Rad)
* general radiologists

Each specialty group consists of 6 members of ranked seniority. For the physicians this consists of:

* Two 'Juniors' (Foundation Year 1 - Specialty Training 2 years)
* Two 'Middle Grades' (Registrar from Specialty Training 3 to 6 years)
* Two Consultants

For the radiographers, this consists of:

* Two 'Junior/Newly qualified radiographers' (up to 18 months experience post qualification)
* Two 'Mid-experience radiographers' (approx. 3 years' experience)
* Two 'Reporting radiographers' (5+ years' experience)

Two consultant thoracic radiologists. A third senior thoracic radiologist's opinion (\>20 years experience) will undertake arbitration.

The reading will be done remotely via the Report and Image Quality Control site (www.RAIQC.com), an online platform allowing medical imaging viewing and reporting. Participants can work from any location, but the work must be done from a computer with internet access. For avoidance of doubt, the work cannot be performed from a phone or tablet.

The project is divided into two phases and participants are required to complete both phases. The estimated total involvement in the project is up to 20-24 hours.

Phase 1: Time allowed: 2 weeks

- Review 500 chest X-rays and express a clinical opinion through a structured reporting template (multiple choice, no open text required).

Rest/washout period of 2 weeks.

Phase 2 - Time allowed: 2 weeks

- Review 500 chest X-rays together with an AI report for each case and express your clinical opinion through the same structured reporting template used in Phase A.

Cases reading

Two consultant thoracic radiologists will independently review the images to establish the 'ground truth' findings on the CXRs, where a consensus is reached this will then be used as the reference standard. In the case of disagreement, a third senior thoracic radiologist's opinion (\>20 years experience) will undertake arbitration. A difficulty score will be assigned to each abnormality by the ground truthers using a 4-point Likert scale (1 being easy/obvious to 4 being hard/poorly visualised).

Ground truthing

This study has been added as a sub study to the Simulation Training for Emergency Department Imaging 2 study (ClinicalTrials.gov ID NCT05427838).

The Lunit INSIGHT CXR is a validation study that aims to assess the utility of an Artificial Intelligence-based (AI) chest X-ray (CXR) interpretation tool in assisting the diagnostic accuracy, speed, and confidence of a varied group of healthcare professionals. The study will be conducted using 500 retrospectively collected inpatient and emergency department CXRs from two United Kingdom (UK) hospital trusts. Two fellowship trained thoracic radiologists will independently review all studies to establish the ground truth reference standard. The Lunit INSIGHT CXR tool will be used to analyze each CXR, and its performance will be measured against the expert readers. The study will evaluate the utility of the algorithm in improving reader accuracy and confidence as measured by sensitivity, specificity, positive predictive value, and negative predictive value. The study will measure the performance of the algorithm against ten abnormal findings, including pulmonary nodules/mass, consolidation, pneumothorax, atelectasis, calcification, cardiomegaly, fibrosis, mediastinal widening, pleural effusion, and pneumoperitoneum. The study will involve readers from various clinical professional groups with and without the assistance of Lunit INSIGHT CXR. The study will provide evidence on the impact of AI algorithms in assisting healthcare professionals such as emergency medicine and general medicine physicians who regularly review images in their daily practice.

AI Assisted Detection of Chest X-Rays

Utility of an AI-based CXR Interpretation Tool in Assisting Diagnostic Accuracy, Speed, and Confidence of Healthcare Professionals: a Study Using 500 Retrospectively Collected Inpatient and Emergency Department CXRs From Two UK Hospital Trusts

Evaluation of the Lunit INSIGHT CXR algorithm will be performed comparing it to the reference standard in order to determine sensitivity.

Evaluation of the Lunit INSIGHT CXR algorithm will be performed comparing it to the reference standard in order to determine specificity.

Evaluation of the Lunit INSIGHT CXR algorithm will be performed comparing it to the reference standard. Continuous probability score from the algorithm will be utilized for the ROC analyses, while binary classification results with a predefined operating cut-off will be used for evaluation of sensitivity, specificity, positive predictive value, and negative predictive value.

The study will include two sessions (with and without AI overlay), with all 30 readers reviewing all 500 CXR cases each time separated by a washout period to mitigate recall bias. The cases will be randomised between the two reads and for every reader.

Mean time taken to review a scan, with vs without AI assistance.

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Emergency Department-Based Palliative Care for Advanced Cancer Patients	NCT01358110	Advanced Cancer Metastatic Canc...	Early palliativ... Care as usual	18 Years -	Icahn School of Medicine at Mount Sinai
AI Assisted Detection of Chest X-Rays	NCT06075836	Pulmonary Nodul... Pulmonary Nodul... Pulmonary Conso... Pneumothorax Pneumothorax; A... Atelectasis Pulmonary Calci... Cardiomegaly Fibrosis Lung Pleural Effusio... Pleural Effusio... Pneumoperitoneu...	Cases reading Ground truthing	-	Oxford University Hospitals NHS Trust
AI Assisted Detection of Chest X-Rays	NCT06075836	Pulmonary Nodul... Pulmonary Nodul... Pulmonary Conso... Pneumothorax Pneumothorax; A... Atelectasis Pulmonary Calci... Cardiomegaly Fibrosis Lung Pleural Effusio... Pleural Effusio... Pneumoperitoneu...	Cases reading Ground truthing	-	Oxford University Hospitals NHS Trust

Spots Global Cancer Trial Database for emergency medicine