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Fernandes R, Fess EG, Sullivan S, Brack M, DeMarco T, Li D. Supportive Care for Superutilizers of a Managed Care Organization. J Palliat Med 2020; 23:1444-1451. [PMID: 32456602 PMCID: PMC7583336 DOI: 10.1089/jpm.2019.0288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Ohana Health Plan, Inc., (OHP) is one of the first managed care organizations offering supportive care services targeted to superutilizers. Bristol Hospice Hawaii, LLC, partnered with OHP to provide interdisciplinary supportive care services to home-bound OHP members. Objectives: The purpose of this study was to measure symptom relief, satisfaction, resource utilization, and cost savings associated with supportive care. Design: Prospective study. Setting: Over 12 months, 27 superutilizer members residing in the community were referred by OHP, 21 members were enrolled into supportive care. Measurements: Data were collected upon admission and repeatedly thereafter using the Edmonton Symptom Assessment Scale (ESAS) and the Missoula-Vitas Quality of Life Index (MVQOLI). The Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale was administered at discharge. Emergency department (ED) visits and hospital utilization were tracked. Results: Median age was 63 years; more than half had cardiac diagnoses. Majority of members were Hawaiian and other Pacific Islander. Median length of stay in supportive care was 90 days. Five (23%) members enrolled in hospice following supportive care. Symptom improvement occurred in pain (p < 0.0001), anxiety (p = 0.0052), and shortness of breath (p = 0.0447). This model has shown a 79.5% reduction of ED visits per thousand members and a 75% reduction of hospitalizations per thousand. Overall net savings was 36%. Discussions and documentation of end-of-life wishes increased from 23% to 85%. Conclusion: Supportive care is highly effective in reducing costs associated with superutilizers. Our experience demonstrates the effectiveness of supportive care approaches in this population through improved care and lower health care costs overall.
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Affiliation(s)
- Ritabelle Fernandes
- Division of Palliative Medicine, Department of Geriatric Medicine, John A Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA.,Bristol Hospice Hawaii, LLC, Honolulu, Hawaii, USA
| | - Ed G Fess
- Ohana Health Plan, Inc., Honolulu, Hawaii, USA
| | | | - Mona Brack
- Ohana Health Plan, Inc., Honolulu, Hawaii, USA
| | - Tara DeMarco
- Bristol Hospice Hawaii, LLC, Honolulu, Hawaii, USA
| | - Dongmei Li
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Lakin JR, Neal BJ, Maloney FL, Paladino J, Vogeli C, Tumblin J, Vienneau M, Fromme E, Cunningham R, Block SD, Bernacki RE. A systematic intervention to improve serious illness communication in primary care: Effect on expenses at the end of life. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100431. [PMID: 32553522 DOI: 10.1016/j.hjdsi.2020.100431] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/26/2020] [Accepted: 04/29/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND At a population level, conversations between clinicians and seriously ill patients exploring patients' goals and values can drive high-value healthcare, improving patient outcomes and reducing spending. METHODS We examined the impact of a quality improvement intervention to drive better communication on total medical expenses in a high-risk care management program. We present our analysis of secondary expense outcomes from a prospective implementation trial of the Serious Illness Care Program, which includes clinician training, coaching, tools, and system interventions. We included patients who died between January 2014 and September 2016 who were selected for serious illness conversations, using the "Surprise Question," as part of implementation of the program in fourteen primary care clinics. RESULTS We evaluated 124 patients and observed no differences in total medical expenses between intervention and comparison clinic patients. When comparing patients in intervention clinics who did and did not have conversations, we observed lower average monthly expenses over the last 6 ($6297 vs. $8,876, p = 0.0363) and 3 months ($7263 vs. $11,406, p = 0.0237) of life for patients who had conversations. CONCLUSIONS Possible savings observed in this study are similar in magnitude to previous studies in advance care planning and specialty palliative care but occur earlier in the disease course and in the context of documented conversations and a comprehensive, interprofessional case management program. IMPLICATIONS Programs designed to drive more, earlier, and better serious illness communication hold the potential to reduce costs. LEVEL OF EVIDENCE Prospectively designed trial, non-randomized sample, analysis of secondary outcomes.
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Affiliation(s)
- Joshua R Lakin
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA.
| | - Brandon J Neal
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Francine L Maloney
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Christine Vogeli
- Harvard Medical School, Boston, MA, USA; Partners Healthcare, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Erik Fromme
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rebecca Cunningham
- Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachelle E Bernacki
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA
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Paramanandam G, Boohene J, Tran K, Volk-Craft BE. Impact of a Hospital Community Based Palliative Care Partnership: Continuum from Hospital to Home. J Palliat Med 2020; 23:1599-1605. [PMID: 32379530 DOI: 10.1089/jpm.2020.0090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Objectives: To discuss the outcomes of a formalized care transition process for palliative care patients from the hospital to the community. Background: Patients who received inpatient palliative care services from the specialist palliative care team in the hospital or who were identified as needing community palliative care services have inadequate support on discharge. Methods: A retrospective review of the medical records of patients admitted to the community based palliative care (CBPC) program, Arizona Palliative Home Care (AZPHC) over a 12-month period (June 2018 to May 2019) was undertaken with a focus on the frequency and pattern of hospital events pre- and postadmission to the program. Patient/family satisfaction data obtained from telephone surveys were evaluated. The medical records from patients (n = 294) with advanced complex illnesses who were admitted to AZPHC from the five Honor Health Network hospitals were included in this study. Results: Of the 294 patients' records reviewed, 80% were in the 65 and older age group and had a mean length of stay on AZPHC of ∼40 days. Comparing acute care utilization pre and post AZPHC admission, there was a reduction of 68.95% at 60 days and 68.22% at 90 days. In addition, 128 avoided hospital events were recorded, and 86% of patients were very likely to recommend AZPHC to family or friends. Discussion: Collaboration between a hospital palliative care team and a CBPC program resulted in high quality transitions across care settings and reduction in acute care utilization.
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Affiliation(s)
- Gobi Paramanandam
- Arizona Palliative Care Program, Hospice of the Valley, Phoenix, Arizona, USA
| | - Jeanette Boohene
- Palliative Care, Honor Health, Scottsdale Osborn Medical Center, Scottsdale, Arizona, USA
| | - Kelvin Tran
- Hospice of the Valley, Phoenix, Arizona, USA
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Tark A, Estrada LV, Tresgallo ME, Quigley DD, Stone PW, Agarwal M. Palliative care and infection management at end of life in nursing homes: A descriptive survey. Palliat Med 2020; 34:580-588. [PMID: 32153248 PMCID: PMC7405898 DOI: 10.1177/0269216320902672] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics. AIM The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation. DESIGN This is a cross-sectional survey of nationally representative US nursing homes. SETTING/PARTICIPANTS Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation. RESULTS Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics. CONCLUSION The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.
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Affiliation(s)
- Aluem Tark
- School of Nursing, Columbia University, New York, NY, USA
| | - Leah V Estrada
- School of Nursing, Columbia University, New York, NY, USA
| | | | | | | | - Mansi Agarwal
- School of Nursing, Columbia University, New York, NY, USA
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McCarthy EP, Ogarek JA, Loomer L, Gozalo PL, Mor V, Hamel MB, Mitchell SL. Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations. JAMA Intern Med 2020; 180:385-394. [PMID: 31886827 PMCID: PMC6990757 DOI: 10.1001/jamainternmed.2019.6130] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population. OBJECTIVE To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017-before and after the introduction of national initiatives to reduce hospitalizations. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019. MAIN OUTCOMES AND MEASURES The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained. RESULTS The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%). CONCLUSIONS AND RELEVANCE The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.
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Affiliation(s)
- Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Mary Beth Hamel
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Akhtar S, Srinivasan V, Weisse C, DiSorbo P. Characterizing the Financial Value of In-Home Palliative Care for Patients, Payers, and Hospitals. Am J Hosp Palliat Care 2020; 37:196-200. [DOI: 10.1177/1049909119872486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: The holistic and multidisciplinary approach of in-home palliative care (IHPC) is known to offer high-quality and cost-effective care for patients at the end of life. However, the financial benefits of upstream IHPC programs to hospitals, patients, and payers have not been fully characterized for patients with comorbid chronic conditions. Aim: To characterize the financial benefits that upstream IHPC offers to patients with multiple chronic conditions. Methods: A structured retrospective patient record review was conducted on the number of emergency department (ED) visits, number of inpatient hospitalizations, hospital length of stay (LOS), and payments made to the hospital for all patients (N = 71) enrolled in an IHPC program between January 1, 2016, and June 30, 2016. Discharge history from each patient’s medical record was also assessed. Comparisons were drawn between patients’ LOS on IHPC and an equivalent time period prior to enrollment in IHPC. Results: After patients enrolled in IHPC, average ED and inpatient utilization declined significantly by 41% ( P = .01) and 71% ( P < .001), respectively. The payers for health-care services realized a significant decline of US$2,201 ( P < .001) in hospital payments per patient per month. Inpatient LOS was also significantly lower than expected once patients enrolled in the program ( P = .01). Conclusions: As the need for chronic disease management continues to grow, managers of health systems, managed care organizations, and home health agencies should be cognizant of the financial value that IHPC has to offer.
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Affiliation(s)
| | | | - Carol Weisse
- Psychology Department, Union College, Schenectady, NY, USA
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Courtright KR, Jordan L, Murtaugh CM, Barrón Y, Deb P, Moore S, Bowles KH, Mikkelsen ME. Risk Factors for Long-term Mortality and Patterns of End-of-Life Care Among Medicare Sepsis Survivors Discharged to Home Health Care. JAMA Netw Open 2020; 3:e200038. [PMID: 32101307 PMCID: PMC7137683 DOI: 10.1001/jamanetworkopen.2020.0038] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Despite a growing recognition of the increased mortality risk among sepsis survivors, little is known about the patterns of end-of-life care among this population. OBJECTIVE To describe patterns of end-of-life care among a national sample of sepsis survivors and identify factors associated with long-term mortality risk and hospice use. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care using national Medicare administrative, claims, and home health assessment data from 2013 to 2014. The initial and final primary analyses were conducted in July 2017 and from July to August 2019, respectively. EXPOSURES Sepsis hospital discharge and 1 or more home health assessments within 1 week. MAIN OUTCOMES AND MEASURES Outcomes were 1-year mortality among all sepsis survivors and hospitalization in the last 30 days of life, death in an acute care hospital, and hospice use among decedents. Multivariate logistic regression was used to identify factors associated with 1-year mortality and hospice use. RESULTS Among 87 581 sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care, 49 323 (56.3%) were aged 75 years or older, 69 499 (79.4%) were non-Hispanic white, and 48 472 (55.3%) were female. Among the total survivors, 24 423 (27.9%) people died within 1 year of discharge, with a median (interquartile range) survival time of 119 (51-220) days. Among these decedents, 16 684 (68.2%) were hospitalized in the last 30 days of life, 6560 (26.8%) died in an acute care hospital, and 12 573 (51.4%) were enrolled in hospice, with 5729 (45.6%) using hospice for 7 or fewer days. Several factors were associated with 1-year mortality, including a cancer diagnosis (odds ratio [OR], 3.66; 95% CI, 3.50-3.83; P < .001), multiple dependencies of activities of daily living or instrumental activities of daily living (OR, 2.80; 95% CI, 2.57-3.05; P < .001), and an overall poor health status (OR, 2.21; 95% CI, 2.01-2.44; P < .001) documented on home health assessment. Among the decedents, cancer was associated with hospice use (OR, 2.25; 95% CI, 2.11-2.41; P < .001), patients aged 85 years or older (OR, 1.49; 95% CI, 1.37-1.61; P < .001), and living in an assisted living setting (OR, 1.93; 95% CI, 1.69-2.19; P < .001). CONCLUSIONS AND RELEVANCE The findings of this study suggest that death within 1 year after sepsis discharge may be common among Medicare beneficiaries discharged to home health care. Although 1 in 2 decedents used hospice, aggressive care near the end of life and late hospice referral were common. Readily identifiable risk factors suggest opportunities to target efforts to improve palliative and end-of-life care among high-risk sepsis survivors.
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Affiliation(s)
- Katherine R. Courtright
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lizeyka Jordan
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
| | | | - Yolanda Barrón
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
| | - Partha Deb
- Department of Economics, Hunter College, The City University of New York (CUNY), New York
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Stanley Moore
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
| | - Kathryn H. Bowles
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia
| | - Mark E. Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Wittenberg E, Goldsmith J, Ferrell B, Buller H, Mendoza Y, Ragan SL. Palliative Care Communication: Outcomes From COMFORT, a Train-the-Trainer Course for Providers. Clin J Oncol Nurs 2020; 24:E1-E6. [PMID: 31961850 PMCID: PMC7271967 DOI: 10.1188/20.cjon.e1-e6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND With increasing support for the integration of palliative care and standard oncology, communication training programs are needed to teach oncology nurses and other providers about palliative care communication. OBJECTIVES This study reports on the outcomes of COMFORTTM SM Communication for Oncology Nurses, a train-the-trainer communication course to educate oncology nurses about palliative care communication and improve patient-centered communication and cancer care. METHODS 355 oncology nurses attended the two-day course. This study used 6- and 12-month follow-up data from nurses who provided feedback on the progress of these goals. FINDINGS Nurses taught an additional 9,720 oncology providers, conducted needs assessments of communication processes, and initiated institutionwide palliative care communication training. Barriers to completing outcome goals included a lack of institutional support, specifically an absence of leadership, financial backing, and dedicated time.
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Affiliation(s)
- Elaine Wittenberg
- Associate Professor, Department of Communication Studies, California State University, Los Angeles, 5151 State University Drive, Los Angeles, CA 90032
| | - Joy Goldsmith
- Professor, Department of Communication, University of Memphis
| | - Betty Ferrell
- Professor and Division Chair, Nursing Research and Education, City of Hope
| | - Haley Buller
- Research Supervisor, Nursing Research and Education, City of Hope
| | - Yesenia Mendoza
- Graduate Student, Department of Communication Studies, California State University, Los Angeles
| | - Sandra L. Ragan
- Professor Emerita, Department of Communication, University of Oklahoma
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Ornstein KA, Liu B, Schwartz RM, Smith CB, Alpert N, Taioli E. Cancer in the context of aging: Health characteristics, function and caregiving needs prior to a new cancer diagnosis in a national sample of older adults. J Geriatr Oncol 2020; 11:75-81. [PMID: 30952516 PMCID: PMC6774923 DOI: 10.1016/j.jgo.2019.03.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/25/2019] [Accepted: 03/25/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION As cancer trajectories change due to screening, earlier diagnoses, living longer with illnesses, and new successful treatments, cancer is increasingly a disease of older adults. While cancer diagnoses themselves are very stressful for patients and families, little is known about the health status, functional limitations, and social resources of older patients before they face a new cancer diagnosis. MATERIALS AND METHODS Using the National Health and Aging Trends Study (NHATS), a national survey of older Medicare beneficiaries linked to Medicare claims data, we examined the health characteristics, functional limitations and social and financial resources of older adults before a new diagnosis of lung, breast, prostate or colorectal cancer and how these factors vary by race/ethnicity. RESULTS We identified 274 community-dwelling older adults with incident cancer diagnoses: lung (30.6%), breast (20.3%), prostate (30.8%), and colorectal (18.3%) representing 1,202,920 older Medicare beneficiaries. The sample was 81% Non-Hispanic White, 10% Non-Hispanic Black, and 9% Hispanic/Other. Before diagnosis, patients had an average of three comorbidities and 29% of patients reported poor/fair health. Almost one-third were living alone, 13% received help with at least one activity of daily living (ADL), 11% had probable dementia and nearly one in ten already received financial help from family members. DISCUSSION Before an older adult has ever been diagnosed with a major cancer, many face significant health and financial challenges and are dependent on others for care. These needs vary based on cancer type and race/ethnicity and must be considered as clinicians develop individualized care plans for patients alongside caregivers.
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Affiliation(s)
- Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Bian Liu
- Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Division of Hematology/Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Rebecca M Schwartz
- Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Division of Hematology/Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Department of Occupational Medicine, Epidemiology and Prevention, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, United States of America
| | - Cardinale B Smith
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Department of Occupational Medicine, Epidemiology and Prevention, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, United States of America
| | - Naomi Alpert
- Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Emanuela Taioli
- Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Division of Hematology/Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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Suen AO, Butler RA, Arnold R, Myers B, Witteman HO, Cox CE, Argenas A, Buddadhumaruk P, Bursic A, Ernecoff NC, Shields AM, Tran DK, White DB. Developing the family support tool: An interactive, web-based tool to help families navigate the complexities of surrogate decision making in ICUs. J Crit Care 2019; 56:132-139. [PMID: 31896447 DOI: 10.1016/j.jcrc.2019.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/24/2019] [Accepted: 12/05/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Although family members of incapacitated, critically ill patients often struggle in the role of surrogate decision maker, there are no low-cost, easily-scaled interventions to address this problem. AIM OF THE STUDY To develop and pilot-test the Family Support Tool, an interactive, web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs. MATERIAL AND METHODS We used a mixed methods, user-centered process to create the Family Support Tool, including: 1) creation of a preliminary design by an expert panel; 2) engagement of a key stakeholder panel to iteratively refine the preliminary design; 3) user testing of a low-fidelity prototype of the tool by 6 former ICU surrogates; 4) creation of a web-based prototype; and 5) user testing of the web-based prototype with 14 surrogates and ICU physicians, including semi-structured interviews and quantitative measurement of usability, acceptability, and perceived effectiveness. RESULTS The initial design contained a collection of videos and exercises designed to help individuals understand the surrogate's role and think through the patient's values and preferences. Based on family stakeholders' feedback about the emotional overwhelm they experience early in an ICU stay, we redesigned the tool to be viewed in sections, with the first section focused on decreasing surrogates' emotional distress, and later sections focused on helping surrogates prepare for family meetings. Surrogates actively making decisions in the ICU judged the final tool to be highly usable (mean summary score 83.5, correlating to 95th percentile when normalized to devices of its type), acceptable (mean 4.2 +/- 0.5 out of 5), and effective (mean 4.3 +/- 0.6 out of 5). All surrogates reported the tool helped them consider goals of care and all indicated they would recommend the tool to a friend. CONCLUSIONS We successfully developed a web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs that has high potential for scalability. Surrogates judged the tool to be usable, acceptable, and effective. These data support proceeding to test the tool in a pilot randomized clinical trial.
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Affiliation(s)
- Angela O Suen
- University of Pittsburgh, School of Medicine, Department of Medicine, Division of General Internal Medicine, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, United States of America
| | - Rachel A Butler
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Robert Arnold
- University of Pittsburgh, School of Medicine, Department of Medicine, Division of General Internal Medicine, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, United States of America; University of Pittsburgh Medical Center Palliative and Supportive Institute, Iroquois Building, Suite 308, 3600 Forbes Avenue at Meyran Avenue, Pittsburgh, PA 15213, United States of America
| | - Brad Myers
- Carnegie Mellon University, School of Computer Science, Human Computer Interaction Institute, 5000 Forbes Avenue, Pittsburgh, PA 15213, United States of America
| | - Holly O Witteman
- Université Laval, Department of Family & Emergency Medicine, Bureau 4617, Pavillon Ferdinand-Vandry, 1050 Avenue de la Médecine, Quebec, QC G1V 0A6, Canada
| | - Christopher E Cox
- Duke University, School of Medicine, Department of Medicine, Division of Pulmonary & Critical Care Medicine, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Amanda Argenas
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Praewpannanrai Buddadhumaruk
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Alexandra Bursic
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Natalie C Ernecoff
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Anne-Marie Shields
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Dang K Tran
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Douglas B White
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America.
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Mann C, Aldossary F, Sullivan S. Providing Palliative Care: Oncology Nurses’ Perceptions of Their Self-Reported Abilities. Clin J Oncol Nurs 2019; 23:647-654. [DOI: 10.1188/19.cjon.647-654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Herrmann A, Carey ML, Zucca AC, Boyd LAP, Roberts BJ. Australian GPs' perceptions of barriers and enablers to best practice palliative care: a qualitative study. BMC Palliat Care 2019; 18:90. [PMID: 31672134 PMCID: PMC6824133 DOI: 10.1186/s12904-019-0478-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 10/15/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND General Practitioners (GPs) often play an important role in caring for people at the end of life. While some international studies suggest that GPs experience a number of barriers to providing palliative care, little is known about views and experiences of GPs in Australia. This study explored Australian GPs' perceptions of barriers and enablers to the provision of palliative care and provides new insights into how to implement best practice care at the end of life. METHODS This was a qualitative study using 25 semi-structured phone interviews conducted with GPs practising in metropolitan and non-metropolitan New South Wales, Australia. Data were analysed using qualitative content analysis. RESULTS GPs reported difficulties with palliative care provision due to i) the complex and often emotional nature of doctor-family-interaction; ii) a lack of evidence to guide care; and iii) the need to negotiate roles and responsibilities within the healthcare team. GPs listed a number of strategies to help deal with their workload and to improve communication processes between healthcare providers. These included appropriate scheduling of appointments, locally tailored mentoring and further education, and palliative care guidelines which more clearly outline the roles and responsibilities within multidisciplinary teams. GPs also noted the importance of online platforms to facilitate their communication with patients, their families and other healthcare providers, and to provide centralised access to locally tailored information on palliative care services. GPs suggested that non-government organisations could play an important role by raising awareness of the key role of GPs in palliative care provision and implementing an "official visitor" program, i.e. supporting volunteers to provide peer support or respite to people with palliative care needs and their families. CONCLUSIONS This study offers new insights into strategies to overcome well documented barriers to palliative care provision in general practice and help implement optimal care at the end of life. The results suggest that researchers and policy makers should adopt a comprehensive approach to improving the provision of palliative care which tackles the array of barriers and enablers identified in this study.
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Affiliation(s)
- Anne Herrmann
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308 Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308 Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305 Australia
| | - Mariko L. Carey
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308 Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308 Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305 Australia
| | - Alison C. Zucca
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308 Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308 Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305 Australia
| | - Lucy A. P. Boyd
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308 Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW 2308 Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305 Australia
| | - Bernadette J. Roberts
- Cancer Council New South Wales, 153 Dowling Street, Woolloomooloo, NSW 2011 Australia
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Transforming the Workforce for Primary Palliative Care Through a System-Wide Educational Initiative. J Nurs Adm 2019; 49:466-472. [PMID: 31490797 DOI: 10.1097/nna.0000000000000789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Palliative care (PC) is a national and global priority, yet there is insufficient knowledge regarding PC among generalist clinicians. An interdisciplinary educational initiative was implemented to enhance a hospital workforce's PC knowledge and skills. More than 1000 clinicians attended at least 1 of 27 educational offerings. Measurable gains were evident in key outcome measures including PC referrals and advanced directive documentation. Changes reflected a transformation of workforce culture and resulted in 2 national awards for improving PC.
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Electronic Health Record Mortality Prediction Model for Targeted Palliative Care Among Hospitalized Medical Patients: a Pilot Quasi-experimental Study. J Gen Intern Med 2019; 34:1841-1847. [PMID: 31313110 PMCID: PMC6712114 DOI: 10.1007/s11606-019-05169-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/11/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Development of electronic health record (EHR) prediction models to improve palliative care delivery is on the rise, yet the clinical impact of such models has not been evaluated. OBJECTIVE To assess the clinical impact of triggering palliative care using an EHR prediction model. DESIGN Pilot prospective before-after study on the general medical wards at an urban academic medical center. PARTICIPANTS Adults with a predicted probability of 6-month mortality of ≥ 0.3. INTERVENTION Triggered (with opt-out) palliative care consult on hospital day 2. MAIN MEASURES Frequencies of consults, advance care planning (ACP) documentation, home palliative care and hospice referrals, code status changes, and pre-consult length of stay (LOS). KEY RESULTS The control and intervention periods included 8 weeks each and 138 admissions and 134 admissions, respectively. Characteristics between the groups were similar, with a mean (standard deviation) risk of 6-month mortality of 0.5 (0.2). Seventy-seven (57%) triggered consults were accepted by the primary team and 8 consults were requested per usual care during the intervention period. Compared to historical controls, consultation increased by 74% (22 [16%] vs 85 [63%], P < .001), median (interquartile range) pre-consult LOS decreased by 1.4 days (2.6 [1.1, 6.2] vs 1.2 [0.8, 2.7], P = .02), ACP documentation increased by 38% (23 [17%] vs 37 [28%], P = .03), and home palliative care referrals increased by 61% (9 [7%] vs 23 [17%], P = .01). There were no differences between the control and intervention groups in hospice referrals (14 [10] vs 22 [16], P = .13), code status changes (42 [30] vs 39 [29]; P = .81), or consult requests for lower risk (< 0.3) patients (48/1004 [5] vs 33/798 [4]; P = .48). CONCLUSIONS Targeting hospital-based palliative care using an EHR mortality prediction model is a clinically promising approach to improve the quality of care among seriously ill medical patients. More evidence is needed to determine the generalizability of this approach and its impact on patient- and caregiver-reported outcomes.
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Totten AM, Fagnan LJ, Dorr D, Michaels LC, Izumi S(S, Combe A, Légaré F. Protocol for a Cluster Randomized Trial Comparing Team-Based to Clinician-Focused Implementation of Advance Care Planning in Primary Care. J Palliat Med 2019; 22:82-89. [PMID: 31486729 PMCID: PMC7366267 DOI: 10.1089/jpm.2019.0117] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction: For many patients, primary care is an appropriate setting for advance care planning (ACP). ACP focuses on what matters most to patients and ensuring health care supports patient-defined goals. ACP may involve interactions between a clinician and a patient, but for seriously ill patients ACP could be managed by a team. Methods: We are conducting a cluster randomized trial comparing team-based to clinician-focused ACP using the Serious Illness Care Program (SICP) in 42 practices recruited from 7 practice-based research networks (PBRNs). Practices were randomized to one of the two models. Patients are referred to the study after engaging in ACP in primary care. Our target enrollment is 1260 subjects. Patient data are collected at enrollment, six months and one year. Primary outcomes are patient-reported goal-concordant care and days at home. Secondary outcomes include additional patient measures, clinician/team experience, and practice-level measures of SICP implementation. Study Implementation: This trial was designed and is conducted by the Meta-network Learning and Research Center (Meta-LARC), a consortium of PBRNs focused on integrating engagement with patients, families, and other stakeholders into primary care research and practice. The trial pairs a comparative effectiveness study with implementation of a new program and is designed to balance fidelity to the assigned model with flexibility to allow each practice to adapt implementation to their environment and priorities. Our dissemination will report the results of comparing the two models and the implementation experience of the practices to create guidance for the spread of ACP in primary care.
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Affiliation(s)
- Annette M. Totten
- Department of Medical Informatics and Clinical Epidemiology, Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon
| | - Lyle J. Fagnan
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon
| | - David Dorr
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
| | - LeAnn C. Michaels
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon
| | | | - Angela Combe
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon
| | - France Légaré
- Centre de Recherche Sur Les Soins et Les Services de Première Ligne de l'Université Laval, Quebec, Canada
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Berg GD, Gurley VF. Development and validation of 15-month mortality prediction models: a retrospective observational comparison of machine-learning techniques in a national sample of Medicare recipients. BMJ Open 2019; 9:e022935. [PMID: 31315852 PMCID: PMC6661632 DOI: 10.1136/bmjopen-2018-022935] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE The objective is to develop and validate a predictive model for 15-month mortality using a random sample of community-dwelling Medicare beneficiaries. DATA SOURCE The Centres for Medicare & Medicaid Services' Limited Data Set files containing the five per cent samples for 2014 and 2015. PARTICIPANTS The data analysed contains de-identified administrative claims information at the beneficiary level, including diagnoses, procedures and demographics for 2.7 million beneficiaries. SETTING US national sample of Medicare beneficiaries. STUDY DESIGN Eleven different models were used to predict 15-month mortality risk: logistic regression (using both stepwise and least absolute shrinkage and selection operator (LASSO) selection of variables as well as models using an age gender baseline, Charlson scores, Charlson conditions, Elixhauser conditions and all variables), naïve Bayes, decision tree with adaptive boosting, neural network and support vector machines (SVMs) validated by simple cross validation. Updated Charlson score weights were generated from the predictive model using only Charlson conditions. PRIMARY OUTCOME MEASURE C-statistic. RESULTS The c-statistics was 0.696 for the naïve Bayes model and 0.762 for the decision tree model. For models that used the Charlson score or the Charlson variables the c-statistic was 0.713 and 0.726, respectively, similar to the model using Elixhauser conditions of 0.734. The c-statistic for the SVM model was 0.788 while the four models that performed the best were the logistic regression using all variables, logistic regression after selection of variables by the LASSO method, the logistic regression using a stepwise selection of variables and the neural network with c-statistics of 0.798, 0.798, 0.797 and 0.795, respectively. CONCLUSIONS Improved means for identifying individuals in the last 15 months of life is needed to improve the patient experience of care and reducing the per capita cost of healthcare. This study developed and validated a predictive model for 15-month mortality with higher generalisability than previous administrative claims-based studies.
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Lakin JR, Benotti E, Paladino J, Henrich N, Sanders J. Interprofessional Work in Serious Illness Communication in Primary Care: A Qualitative Study. J Palliat Med 2019; 22:751-763. [DOI: 10.1089/jpm.2018.0471] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Joshua R. Lakin
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Emily Benotti
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
| | - Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Natalie Henrich
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
| | - Justin Sanders
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
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Baquet-Simpson A, Spettell CM, Freeman AN, Bates AM, Paz HL, Mirsky R, Knecht DB, Brennan TA. Aetna's Compassionate Care Program: Sustained Value for Our Members with Advanced Illness. J Palliat Med 2019; 22:1324-1330. [PMID: 31180268 DOI: 10.1089/jpm.2018.0359] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: In 2004, Aetna, a national health insurer, launched the Aetna Compassionate Care Program (ACCP) targeting members diagnosed with an advanced illness with a view to increase access to palliative care and hospice services. Objective: The objective of this study is to evaluate the impact of ACCP on health care utilization and hospice enrollment among enrolled members. Methods: This was a retrospective cohort study comparing participants in ACCP to a matched control group using a propensity score method. The study group consisted of Aetna Medicare Advantage members who participated in the ACCP between January 2014 and June 2015. Potential control group members were those who were not identified by the predictive model nor were referred to the ACCP program through other means. The primary outcomes of interest were hospice use measured as percent of members electing hospice and median number of days in hospice; health care utilization and medical costs measured as rates and medical costs associated with acute inpatient admissions, emergency room, primary care, and specialty visits in the 30 and 90 days before death. Results: Participants in the ACCP program were 36% more likely to enroll in hospice (79% vs. 58%, p < 0.0001) and had reduced acute inpatient medical costs ($4169 vs. $5863, p < 0.0001) driven primarily by fewer inpatient admissions (860 vs. 1017, p < 0.0001) in the last 90 days of life. Conclusions: Advanced illness case management programs such as ACCP can improve access to hospice and improve patient outcomes while reducing unnecessary admissions in the last 90 days of life.
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Affiliation(s)
| | | | | | | | - Harold L Paz
- Aetna, a CVS Health Company, Hartford, Connecticut
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Kelley AS, Ferreira KB, Bollens-Lund E, Mather H, Hanson LC, Ritchie CS. Identifying Older Adults With Serious Illness: Transitioning From ICD-9 to ICD-10. J Pain Symptom Manage 2019; 57:1137-1142. [PMID: 30876955 PMCID: PMC11200201 DOI: 10.1016/j.jpainsymman.2019.03.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 01/02/2023]
Abstract
CONTEXT Identifying the seriously ill population is integral to improving the value of health care. Efforts to identify this population using existing data are anchored to a list of severe medical conditions (SMCs) using diagnostic codes. Published approaches have used International Classification of Diseases, Ninth Revision (ICD-9) codes, which has since been replaced by ICD-10. OBJECTIVES We translated SMCs from ICD-9 to ICD-10 using a refined code list. We aimed to test the hypothesis that people identified by ICD-9 or ICD-10 codes would have similar Medicare costs, health care utilization, and mortality. METHODS Using data from the National Health and Aging Trends Study linked to Medicare claims, we compared samples from periods using ICD-9 (2014) and ICD-10 (2016). We included participants with six-month fee-for-service Medicare data before their interview date who had an SMC identified within that period. We compared the groups' demographic, functional, and medical characteristics and followed up them for six months to compare outcomes. RESULTS Among subjects in the 2016 (ICD-10) sample, 19.9% were hospitalized, 24.6% used the emergency department, 7.2% died, and average Medicare spending totaled $9902.04 over six months of follow-up. We observed no significant differences between the 2014 and 2016 samples (P > 0.05); both samples represent 18% of Medicare fee-for-service beneficiaries. CONCLUSION Identifying the seriously ill population using currently available data requires using ICD-10 to define SMCs. Routine measurement of function, quality of life, and caregiver strain will further enhance the identification process and efficiently target palliative care services and appropriate quality measures.
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Affiliation(s)
- Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Geriatric Research Education and Clinical Centers, James J Peters VA Medical Center, Bronx, New York, USA.
| | - Katelyn B Ferreira
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura C Hanson
- Division of Geriatric Medicine Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine University of California, San Francisco, San Francisco, California, USA
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Ornstein KA, Wolff JL, Bollens-Lund E, Rahman OK, Kelley AS. Spousal Caregivers Are Caregiving Alone In The Last Years Of Life. Health Aff (Millwood) 2019; 38:964-972. [PMID: 31158025 PMCID: PMC6760240 DOI: 10.1377/hlthaff.2019.00087] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Caregiving in the last years of life is associated with increased depression and negative health outcomes for surviving spouses, many of whom are themselves in poor health. Yet it is unclear how often spouses are caregiving alone, how they differ from supported spouses, and whether lack of support affects postbereavement outcomes. We hypothesized that spouses who were solo caregivers-that is, the only caregivers (paid or unpaid) who provided assistance with a spouse's self-care or household activities-would experience more depression after bereavement than supported spouses would. Using information from the Health and Retirement Study, we found that 55 percent of the spouses of community-dwelling married people with disability were solo caregivers. Solo caregiving was even common among people who cared for spouses with dementia and those with adult children living close by. Bereavement outcomes did not differ between solo and supported caregiving spouses. Caregiving spouses are often isolated and may benefit from greater support, particularly during the final years before bereavement. While some state and federal policy proposals aim to systematically recognize and assess caregivers, further innovations in care delivery and reimbursement are needed to adequately support seriously ill older adults and their caregivers. Ultimately, the focus of serious illness care must be expanded from the patient to the family unit.
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Affiliation(s)
- Katherine A Ornstein
- Katherine A. Ornstein ( ) is an assistant professor in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, in New York City
| | - Jennifer L Wolff
- Jennifer L. Wolff is a professor of public health at Johns Hopkins University, in Baltimore, Maryland
| | - Evan Bollens-Lund
- Evan Bollens-Lund is an analyst in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Omari-Khalid Rahman
- Omari-Khalid Rahman is an analyst in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Amy S Kelley
- Amy S. Kelley is an associate professor in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
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Cross SH, Kamal AH, Taylor DH, Warraich HJ. Hospice Use Among Patients with Heart Failure. Card Fail Rev 2019; 5:93-98. [PMID: 31179019 PMCID: PMC6545999 DOI: 10.15420/cfr.2019.2.2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/26/2019] [Indexed: 12/11/2022] Open
Abstract
Despite its many benefits, hospice care is underused for patients with heart failure. This paper discusses the factors contributing to this underuse and offers recommendations to optimise use for patients with heart failure and proposes metrics to optimise quality of hospice care for this patient group.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University Durham, NC, US
| | - Arif H Kamal
- Duke Cancer Institute Durham, NC, US.,Duke Fuqua School of Business, Duke University Durham, NC, US
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University Durham, NC, US.,Margolis Center for Health Policy, Duke University Durham, NC, US.,Duke Clinical Research Institute Durham, NC, US
| | - Haider J Warraich
- Department of Medicine, Division of Cardiology, Duke University Medical Center Durham, NC, US
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Hwang J, Shen J, Kim SJ, Chun SY, Kioka M, Sheraz F, Kim P, Byun D, Yoo JW. Ten-Year Trends of Utilization of Palliative Care Services and Life-Sustaining Treatments and Hospital Costs Associated With Patients With Terminally Ill Lung Cancer in the United States From 2005 to 2014. Am J Hosp Palliat Care 2019; 36:1105-1113. [DOI: 10.1177/1049909119852082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Palliative care services and life-sustaining treatments are provided to dying patients with lung cancer in the United States. However, data on the utilization trends of palliative care services and life-sustaining treatments of dying patients with lung cancer are not available. Methods: This study was a retrospective analysis of the National Inpatient Sample data (2005-2014) and included patients with lung cancer, aged ≥ 18 years, who died in the hospitals. Claims data of palliative care services and life-sustaining treatments that contained systemic procedures, local procedures, or surgeries were extracted. Compound annual growth rates (CAGRs) using Rao-Scott correction for χ2 tests were used to determine the statistical significance of temporal utilization trends of palliative care services and life-sustaining treatments and their hospital costs. Multilevel multivariate regressions were performed to identify factors associated with hospital costs. Results: A total of 120 144 weighted patients with lung cancer died in the hospitals and 41.9% of them received palliative care services. The CAGRs of systemic procedures, local procedures, surgeries, palliative care services, and hospital cost were 3.42%, 3.48%, 6.08%, 18.5%, and 5.0% (all P < .001), respectively. Increased hospital cost was attributed to systemic procedures (50.6%), local procedures (74.4%), and surgeries (68.5%; all P < .001), respectively. Palliative care services were related to decreasing hospital costs by 28.6% ( P < .001). Conclusion: The temporal trends of palliative care services indicate that their utilization has increased gradually. Palliative care services were associated with reduced hospital costs. However, life-sustaining treatments were associated with increased hospital costs.
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Affiliation(s)
- Jinwook Hwang
- Department of Cardiovascular and Thoracic Surgery, Korea University Medical Center, Ansan Hospital, Ansan, Gyeonggi-do, South Korea
- Department of Health Care Administration and Policy, School of Community Health Science, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Jay Shen
- Department of Health Care Administration and Policy, School of Community Health Science, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Sun Jung Kim
- Department of Health Administration and Management, Soonchunhyang University, Asan, Chungcheongnam-do, South Korea
| | - Sung-Youn Chun
- Department of Health Care Administration and Policy, School of Community Health Science, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Mutsumi Kioka
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Faizan Sheraz
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Pearl Kim
- Department of Health Care Administration and Policy, School of Community Health Science, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - David Byun
- Department of Medicine, Southern Nevada Veterans Affairs Health System, North Las Vegas, NV, USA
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
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74
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Lakin JR, Brannen EN, Bernacki RE, Jones E. A Curriculum in Quality Improvement for Interprofessional Palliative Care Trainees. Am J Hosp Palliat Care 2019; 37:41-45. [PMID: 31096756 DOI: 10.1177/1049909119850794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION A structured and intentional approach to quality improvement is critical for clinicians specializing in palliative care and is a required component of training programs. METHODS We present a multimodal, comprehensive curriculum for teaching quality improvement to interdisciplinary trainees in palliative care. RESULTS The curriculum consists of 4 sessions, one and half hours long a piece, that focus on the purpose and practice of quality improvement and guide learners through a team-based project implementation experience. Course assessments demonstrate satisfaction with the course and improvement in targeted skills, knowledge, and attitudes. DISCUSSION Several key learnings stand out from our experience with this curriculum as central to the experience of students: project work completed as interdisciplinary teams, varying teaching methodologies over a longitudinal curriculum, and the opportunity for formal presentation of their work.
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Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Elise N Brannen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Emma Jones
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Pediatric Advanced Care Team (PACT), Boston Children's Hospital, Boston, MA, USA
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75
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Fricker ZP, Serper M. Current Knowledge, Barriers to Implementation, and Future Directions in Palliative Care for End-Stage Liver Disease. Liver Transpl 2019; 25:787-796. [PMID: 30758901 DOI: 10.1002/lt.25434] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/10/2019] [Indexed: 02/07/2023]
Abstract
End-stage liver disease (ESLD) is associated with a high degree of morbidity and mortality as well as symptom burden. Despite this, the rate of consultation with palliative care (PC) providers remains low, and invasive procedures near the end of life are commonplace. Studies show that involvement of PC providers improves patient satisfaction, and evidence from other chronic diseases demonstrates reduced costs of care and potentially increased survival. Better integration of PC is imperative but hindered by patient and provider misconceptions about its role in the care of patients with ESLD, specifically among candidates for liver transplantation. Additionally, reimbursement barriers and lack of provider knowledge may contribute to PC underutilization. In this review, we discuss the benefits of PC in ESLD, the variability of its delivery, and key stakeholders' perceptions about its use. Additionally, we identify barriers to more widespread PC adoption and highlight areas for future research.
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Affiliation(s)
- Zachary P Fricker
- Division of Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marina Serper
- Division of Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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76
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Liu X, Shen JJ, Kim P, Kim SJ, Ukken J, Choi Y, Hwang IC, Lee JH, Chun SY, Hwang J, Choi H, Yeom H, Lee YJ, Yoo JW. Trends in the Utilization of Life-Sustaining Procedures and Palliative Care Consultation Among Dying Patients With Advanced Chronic Pancreas Illnesses in US Hospitals: 2005 to 2014. J Palliat Care 2019; 34:232-240. [PMID: 30767641 DOI: 10.1177/0825859719827313] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIM Pancreas cancer continues to carry a poor prognosis. Hospitalized patients with advanced chronic pancreatic illnesses increasingly receive palliative care due to its perceived clinical benefits. Meanwhile, a growing proportion of elderly patients are reportedly receiving life-sustaining procedures. Temporal trends in the utilization of life-sustaining procedures and palliative care consultation among dying patients with advanced chronic pancreatic illnesses in US hospitals were examined. METHODS AND MATERIALS A serial, cross-sectional analysis was carried out using the National Inpatient Sample Database. Decedents 18 years and older with a principal diagnosis of pancreas cancer or other advanced chronic pancreatic illnesses from 2005 through 2014. The compound annual growth rates (CAGRs) and Cochrane-Armitage correction of χ2 statistic were used. The receipt of life-sustaining systemic procedures, intra-abdominal local procedures and surgeries, and palliative care consultation were examined. Multilevel multivariate logistic regressions were performed to examine the association of various procedures with the utilization of palliative care consultation. RESULTS Among 77 394 183 hospitalizations, 29 515 patients were examined. The CAGRs of systemic procedures, intra-abdominal procedures, surgeries, and palliative care were -4.19% (P = .008), 2.17%, -1.40%, and 14.03% (P < .001), respectively. The receipt of systemic procedures (odds ratio [OR] = 2.40, 95% confidence interval [CI], 2.08-2.74), local intra-abdominal procedures (OR = 1.46, 95% CI, 1.27-1.70), and surgeries (OR = 2.51, 95% CI, 2.07-3.05) was associated with palliative care consultation (Ps < .001). CONCLUSIONS Among adults with pancreatic cancer or other advanced chronic pancreatic illnesses in the US hospitals from 2005 to 2014, the utilization of life-sustaining systemic procedures decreased while the prevalence of palliative care consultation increased.
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Affiliation(s)
- Xibei Liu
- Department of Medicine, University of Arizona College of Medicine, Tuscon, AZ, USA
| | - Jay J Shen
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Pearl Kim
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Sun Jung Kim
- Department of Health Administration and Management, Soon Chun Hyang University, Asan, Chungcheongnam-do, Korea
| | - Johnson Ukken
- University of Nevada Reno School of Medicine, Reno, NV, USA
| | - Younseon Choi
- Department of Family Medicine, Korea University of College of Medicine, Seoul, Korea
| | - In Choel Hwang
- Department of Family Medicine, Gachon University College of Medicine, Inchon, Korea
| | - Jae-Hoon Lee
- Department of Family Medicine, University of Nevada, Las Vegas
| | - Sung-Youn Chun
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Jinwook Hwang
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Haneul Choi
- Honors College, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Hyeyoung Yeom
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Yong-Jae Lee
- Department of Family Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
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77
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Modes ME, Engelberg RA, Downey L, Nielsen EL, Curtis JR, Kross EK. Did a Goals-of-Care Discussion Happen? Differences in the Occurrence of Goals-of-Care Discussions as Reported by Patients, Clinicians, and in the Electronic Health Record. J Pain Symptom Manage 2019; 57:251-259. [PMID: 30391656 PMCID: PMC6348015 DOI: 10.1016/j.jpainsymman.2018.10.507] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 01/06/2023]
Abstract
CONTEXT Goals-of-care discussions are associated with improved end-of-life care for patients and therefore may be used as a process measure in quality improvement, research, and reimbursement programs. OBJECTIVES To examine three methods to assess occurrence of a goals-of-care discussion-patient report, clinician report, and documentation in the electronic health record (EHR)-at a clinic visit for seriously ill patients and determine whether each method is associated with patient-reported receipt of goal-concordant care. METHODS We conducted a secondary analysis of a multicenter cluster-randomized trial, with 494 patients and 124 clinicians caring for them. Self-reported surveys collected from patients and clinicians two weeks after a clinic visit assessed occurrence of a goals-of-care discussion. Documentation of a goals-of-care discussion was abstracted from the EHR. Patient-reported receipt of goal-concordant care was assessed by survey two weeks after the visit. RESULTS Fifty-two percent of patients reported occurrence of a goals-of-care discussion at the clinic visit; clinicians reported occurrence of a discussion at 66% of visits. EHR documentation occurred in 42% of visits (P < 0.001 for each compared with other two). Patients who reported occurrence of a goals-of-care discussion at the visit were more likely to report receipt of goal-concordant care than patients who reported no discussion (β 0.441, 95% CI 0.190-0.692; P = 0.001). Neither occurrence of a discussion by clinician report nor by EHR documentation was associated with goal-concordant care. CONCLUSION Different approaches to assess goals-of-care discussions give differing results, yet each may have advantages. Patient report is most likely to correlate with patient-reported receipt of goal-concordant care.
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Affiliation(s)
- Matthew E Modes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA; Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA.
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78
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Courtright KR, O'Connor NR. Towards Scalable Hospital-Based Palliative Care: Challenges and Opportunities for Hospitalists. J Hosp Med 2018; 13:881-882. [PMID: 30496332 DOI: 10.12788/jhm.3118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Katherine R Courtright
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Palliative and Hospice Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nina R O'Connor
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Palliative and Hospice Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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79
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Chen CY, Naessens JM, Takahashi PY, McCoy RG, Borah BJ, Borkenhagen LS, Kimeu AK, Rojas RL, Johnson MG, Visscher SL, Cha SS, Thorsteinsdottir B, Hanson GJ. Improving Value of Care for Older Adults With Advanced Medical Illness and Functional Decline: Cost Analyses of a Home-Based Palliative Care Program. J Pain Symptom Manage 2018; 56:928-935. [PMID: 30165123 DOI: 10.1016/j.jpainsymman.2018.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 01/07/2023]
Abstract
CONTEXT Identifying high-value health care delivery for patients with clinically complex and high-cost conditions is important for future reimbursement models. OBJECTIVES The objective of this study was to assess the Medicare reimbursement savings of an established palliative care homebound program. METHODS This is a retrospective cohort study involving 50 participants enrolled in a palliative care homebound program and 95 propensity-matched control patients at Mayo Clinic in Rochester, Minnesota, between September 1, 2012, and March 31, 2013. Total Medicare reimbursement was compared in the year before enrollment with the year after enrollment for participants and controls. RESULTS No significant differences were observed in demographic characteristics or prognostic indices between the two groups. Total Medicare reimbursement per program participant the year before program enrollment was $16,429 compared with $14,427 per control patient, resulting in $2004 higher charges per program patient. In 12 months after program enrollment, mean annual payment was $5783 per patient among participants and $22,031 per patient among the matched controls. In the second year, the intervention group had a decrease of $10,646 per patient; the control group had an increase of $7604 per patient. The difference between the participant group and control group was statistically significant (P < 0.001) and favored the palliative care homebound program enrollees by $18,251 (95% CI, $11,268-$25,234). CONCLUSION The Mayo Clinic Palliative Care Homebound Program reduced annual Medicare expenditures by $18,251 per program participant compared with matched control patients. This supports the role of home-based palliative medicine in delivering high-value care to high-risk older adults.
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Affiliation(s)
- Christina Y Chen
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - James M Naessens
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA; Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul Y Takahashi
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rozalina G McCoy
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA; Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Bijan J Borah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA; Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ashley K Kimeu
- Certified Nurse Practitioners, Mayo Clinic, Rochester, Minnesota, USA
| | - Ricardo L Rojas
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Matt G Johnson
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sue L Visscher
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephen S Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Gregory J Hanson
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA; Mayo Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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80
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Iyer AS, Benzo RP, Bakitas MA. Easing the Tension Between Palliative Care and Intensive Care in Chronic Obstructive Pulmonary Disease. J Palliat Care 2018; 33:123-124. [PMID: 29902961 DOI: 10.1177/0825859718782505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anand S Iyer
- 1 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,2 Health Services, Outcomes, and Effectiveness Research Training Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roberto P Benzo
- 3 Division of Pulmonary and Critical Care Medicine, Mindful Breathing Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Marie A Bakitas
- 4 Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,5 School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
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81
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DiLello LC, Mulvihill K, Carpini JD, Shah R, Hermanowski J, Chaubey D. Content Validation of Advanced Illness Criteria of a Palliative Care Screening Tool. J Palliat Med 2018; 21:1604-1608. [DOI: 10.1089/jpm.2017.0703] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Lauren C. DiLello
- Departments of Medicine and Research, Western Connecticut Health Network, Danbury Hospital, Danbury, Connecticut
| | - Karen Mulvihill
- Departments of Medicine and Research, Western Connecticut Health Network, Danbury Hospital, Danbury, Connecticut
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | | | - Riddhi Shah
- Departments of Medicine and Research, Western Connecticut Health Network, Danbury Hospital, Danbury, Connecticut
| | - Julia Hermanowski
- Departments of Medicine and Research, Western Connecticut Health Network, Danbury Hospital, Danbury, Connecticut
| | - Damanjeet Chaubey
- Departments of Medicine and Research, Western Connecticut Health Network, Danbury Hospital, Danbury, Connecticut
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont
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82
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Shah UK, Miller EG, Levy C. Palliation in pediatric otorhinolaryngology. Int J Pediatr Otorhinolaryngol 2018; 113:22-25. [PMID: 30173990 DOI: 10.1016/j.ijporl.2018.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 07/09/2018] [Accepted: 07/09/2018] [Indexed: 11/18/2022]
Abstract
Palliation in pediatric otorhinolaryngology is a rarely discussed but important aspect of care. This review encapsulates current thinking on pediatric palliative care (PC) and demonstrates, through one case, the impact of integrating PC into clinical care. We encourage early consideration of pediatric palliative care approaches for children with complex otorhinolaryngologic disorders.
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Affiliation(s)
- Udayan K Shah
- Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
| | - Elissa G Miller
- Division of Palliative Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Carly Levy
- Division of Palliative Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
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83
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Voumard R, Rubli Truchard E, Benaroyo L, Borasio GD, Büla C, Jox RJ. Geriatric palliative care: a view of its concept, challenges and strategies. BMC Geriatr 2018; 18:220. [PMID: 30236063 PMCID: PMC6148954 DOI: 10.1186/s12877-018-0914-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 09/10/2018] [Indexed: 11/18/2022] Open
Abstract
In aging societies, the last phase of people’s lives changes profoundly, challenging traditional care provision in geriatric medicine and palliative care. Both specialties have to collaborate closely and geriatric palliative care (GPC) should be conceptualized as an interdisciplinary field of care and research based on the synergies of the two and an ethics of care. Major challenges characterizing the emerging field of GPC concern (1) the development of methodologically creative and ethically sound research to promote evidence-based care and teaching; (2) the promotion of responsible care and treatment decision making in the face of multiple complicating factors related to decisional capacity, communication and behavioural problems, extended disease trajectories and complex social contexts; (3) the implementation of coordinated, continuous care despite the increasing fragmentation, sectorization and specialization in health care. Exemplary strategies to address these challenges are presented: (1) GPC research could be enhanced by specific funding programs, specific patient registries and anticipatory consent procedures; (2) treatment decision making can be significantly improved using advance care planning programs that include adequate decision aids, including those that address proxies of patient who have lost decisional capacity; (3) care coordination and continuity require multiple approaches, such as care transition programs, electronic solutions, and professionals who act as key integrators.
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Affiliation(s)
- R Voumard
- Service of Palliative and Supportive Care, Department of Medicine, Lausanne University Hospital, Avenue Pierre-Decker 5, CH-1011, Lausanne, Switzerland
| | - E Rubli Truchard
- Geriatric Palliative Care, Department of Medicine, Lausanne University Hospital, Avenue Pierre-Decker 5, CH-1011, Lausanne, Switzerland.,Service of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, Lausanne University Hospital, Chemin de Mont-Paisible 16, CH-1011, Lausanne, Switzerland
| | - L Benaroyo
- Clinical Ethics Unit and Institute of Humanities in Medicine, Faculty of Biology and Medicine, University of Lausanne, Avenue de Provence 82, CH-1011, Lausanne, Switzerland
| | - G D Borasio
- Service of Palliative and Supportive Care, Department of Medicine, Lausanne University Hospital, Avenue Pierre-Decker 5, CH-1011, Lausanne, Switzerland
| | - C Büla
- Service of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, Lausanne University Hospital, Chemin de Mont-Paisible 16, CH-1011, Lausanne, Switzerland
| | - R J Jox
- Service of Palliative and Supportive Care, Department of Medicine, Lausanne University Hospital, Avenue Pierre-Decker 5, CH-1011, Lausanne, Switzerland. .,Geriatric Palliative Care, Department of Medicine, Lausanne University Hospital, Avenue Pierre-Decker 5, CH-1011, Lausanne, Switzerland. .,Clinical Ethics Unit and Institute of Humanities in Medicine, Faculty of Biology and Medicine, University of Lausanne, Avenue de Provence 82, CH-1011, Lausanne, Switzerland.
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84
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Abstract
OBJECTIVE To describe palliative care integration into oncology, including several models that facilitate this integration, important considerations when initiating a program, special oncologic populations that would benefit from palliative care, and challenges to consider. DATA SOURCES Palliative care and oncology literature over the past decade. CONCLUSION Multiple models exist to facilitate the integration of palliative care based on the needs of the providers or payers. There are several special populations that would benefit from early integration of palliative care. IMPLICATIONS FOR NURSING PRACTICE Nurses play a critical role in identifying patients, providing early primary palliative care, and facilitating collaborative relationships with and referring to specialist palliative care.
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85
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Curtis JR, Downey L, Back AL, Nielsen EL, Paul S, Lahdya AZ, Treece PD, Armstrong P, Peck R, Engelberg RA. Effect of a Patient and Clinician Communication-Priming Intervention on Patient-Reported Goals-of-Care Discussions Between Patients With Serious Illness and Clinicians: A Randomized Clinical Trial. JAMA Intern Med 2018; 178:930-940. [PMID: 29802770 PMCID: PMC6145723 DOI: 10.1001/jamainternmed.2018.2317] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/07/2018] [Indexed: 12/20/2022]
Abstract
Importance Clinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication. Objective To evaluate the efficacy of a patient-specific preconversation communication-priming intervention (Jumpstart-Tips) targeting both patients and clinicians and designed to increase goals-of-care conversations compared with usual care. Design, Setting, and Participants Multicenter cluster-randomized trial in outpatient clinics with physicians or nurse practitioners and patients with serious illness. The study was conducted between 2012 and 2016. Interventions Clinicians were randomized to the bilateral, preconversation, communication-priming intervention (n = 65) or usual care (n = 67), with 249 patients assigned to the intervention and 288 to usual care. Main Outcomes and Measures The primary outcome was patient-reported occurrence of a goals-of-care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals-of-care conversation in the medical record and patient-reported quality of communication (Quality of Communication questionnaire [QOC]; 4-indicator latent construct) at 2 weeks, as well as patient assessments of goal-concordant care at 3 months and patient-reported symptoms of depression (8-item Patient Health Questionnaire; PHQ-8) and anxiety (7-item Generalized Anxiety Disorder survey; GAD-7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for confounders. Results We enrolled 132 of 485 potentially eligible clinicians (27% participation; 71 women [53.8%]; mean [SD] age, 47.1 [9.6] years) and 537 of 917 eligible patients (59% participation; 256 women [47.7%]; mean [SD] age, 73.4 [12.7] years). The intervention was associated with a significant increase in a goals-of-care discussion at the target visit (74% vs 31%; P < .001) and increased medical record documentation (62% vs 17%; P < .001), as well as increased patient-rated quality of communication (4.6 vs 2.1; P = .01). Patient-assessed goal-concordant care did not increase significantly overall (70% vs 57%; P = .08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = .03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months. Conclusions and Relevance This intervention increased the occurrence, documentation, and quality of goals-of-care communication during routine outpatient visits and increased goal-concordant care at 3 months among patients with stable goals, with no change in symptoms of anxiety or depression. Understanding the effect on subsequent health care delivery will require additional study. Trial Registration ClinicalTrials.gov identifier: NCT01933789.
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Affiliation(s)
- J. Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Anthony L. Back
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
| | - Elizabeth L. Nielsen
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Sudiptho Paul
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Alexandria Z. Lahdya
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Patsy D. Treece
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Priscilla Armstrong
- Community Advisory Board, Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ronald Peck
- Community Advisory Board, Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
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86
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Life-Sustaining Procedures, Palliative Care Consultation, and Do-Not Resuscitate Status in Dying Patients With COPD in US Hospitals. J Palliat Care 2018; 33:159-166. [DOI: 10.1177/0825859718777375] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aim: Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in US hospitals. We examined temporal trends and the impact of palliative care on the use of life-sustaining procedures in this population. Materials and Methods: A retrospective nationwide cohort analysis was performed using weighted National Inpatient Sample (NIS) data obtained from 2010 to 2014. Decedents ≥18 years of age at the time of death and with a principal diagnosis of COPD were included. We examined the receipt of life-sustaining procedures, defined as1 ventilation (intubation, mechanical ventilation, and noninvasive ventilation),2 vasopressor use (infusion and intravascular monitoring),3 nutrition (enteral and parenteral infusion of concentrated nutrition),4 dialysis, and5 cardiopulmonary resuscitation as well as palliative care consultation and do not resuscitate (DNR). We used compound annual growth rates (CAGRs) and the Rao-Scott correction of the χ2 statistic to determine the statistical significance of temporal trends of life-sustaining procedures, palliative care utilization, and DNR status. Results: Among 37 312 324 hospitalizations, 38 425 patients were examined. The CAGRs of life-sustaining procedures were 6.61% and −9.73% among patients who underwent multiple procedures and patients who did not undergo any procedure, respectively (both P < .001). The CAGRs of palliative consultation and DNR were 5.25% and 36.62%, respectively (both P < .001). Conclusions: Among adults with COPD dying in US hospitals between 2010 and 2014, the utilization of life-sustaining procedures, palliative care, and DNR status increased.
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87
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Kurella Tamura M, O'Hare AM, Lin E, Holdsworth LM, Malcolm E, Moss AH. Palliative Care Disincentives in CKD: Changing Policy to Improve CKD Care. Am J Kidney Dis 2018; 71:866-873. [PMID: 29510920 DOI: 10.1053/j.ajkd.2017.12.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/14/2017] [Indexed: 01/03/2023]
Abstract
The dominant health delivery model for advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States, which focuses on provision of dialysis, is ill-equipped to address many of the needs of seriously ill patients. Although palliative care may address some of these gaps in care, its integration into advanced CKD care has been suboptimal due to several health system barriers. These barriers include uneven access to specialty palliative care services, underdeveloped models of care for seriously ill patients with advanced CKD, and misaligned policy incentives. This article reviews policies that affect the delivery of palliative care for this population, discusses reforms that could address disincentives to palliative care, identifies quality measurement issues for palliative care for individuals with advanced CKD and ESRD, and considers potential pitfalls in the implementation of new models of integrated palliative care. Reforming health care delivery in ways that remove policy disincentives to palliative care for patients with advanced CKD and ESRD will fill a critical gap in care.
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Affiliation(s)
- Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA; Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
| | - Ann M O'Hare
- Division of Nephrology, University of Washington School of Medicine and VA Puget Sound Healthcare System, Seattle, WA
| | - Eugene Lin
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA; Centers for Health Policy, Stanford University School of Medicine, Palo Alto, CA; Primary Care Outcomes Research, Stanford University School of Medicine, Palo Alto, CA
| | - Laura M Holdsworth
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Elizabeth Malcolm
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Alvin H Moss
- Sections of Nephrology, West Virginia University School of Medicine, Morgantown, WV; Supportive Care, West Virginia University School of Medicine, Morgantown, WV
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88
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Ellington L, Clayton MF, Reblin M, Donaldson G, Latimer S. Communication among cancer patients, caregivers, and hospice nurses: Content, process and change over time. PATIENT EDUCATION AND COUNSELING 2018; 101:414-421. [PMID: 28964559 PMCID: PMC5857410 DOI: 10.1016/j.pec.2017.09.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/08/2017] [Accepted: 09/22/2017] [Indexed: 05/21/2023]
Abstract
OBJECTIVE First, to describe communication of home hospice nurse visits to cancer patient-caregiver dyads. Second, to assess change in communication related to domains of care over the course of visits. METHODS Multi-site prospective observational longitudinal study of audio-recorded home hospice visits (N=537 visits; 101 patient-caregiver dyads; 58 nurses). Communication was coded using the Roter Interaction Analysis System to describe content and process. Conversation representing three care domains (physical, psychosocial/daily life, and emotional) was calculated from RIAS categories across speakers and analyzed to assess change in communication over time. RESULTS On average, nurses spoke 54% of total utterances, caregivers 29%, and patients 17%. For all participants, the predominant conversational focus was on physical care. Linear mixed effects models indicated that combined participant emotional talk showed a small systematic decrease over time; however, the results for all domains indicated variability unexplained by time or speaker effects. CONCLUSIONS Home hospice conversations are predominantly focused on physical care. Systematic change in communication versus responsiveness to the dynamic effects of patient death and family response over time are discussed. PRACTICE IMPLICATIONS Communication strategies already in use by hospice nurses could be leveraged and expanded upon to better facilitate family competence and confidence.
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Affiliation(s)
- Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, USA
| | | | - Maija Reblin
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, USA.
| | - Gary Donaldson
- College of Nursing, University of Utah, Salt Lake City, USA
| | - Seth Latimer
- College of Nursing, University of Utah, Salt Lake City, USA
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89
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Cassel JB, Bowman B, Rogers M, Spragens LH, Meier DE. Palliative Care Leadership Centers Are Key To The Diffusion Of Palliative Care Innovation. Health Aff (Millwood) 2018; 37:231-239. [DOI: 10.1377/hlthaff.2017.1122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- J. Brian Cassel
- J. Brian Cassel is an assistant professor of hematology, oncology, and palliative care at Virginia Commonwealth University, in Richmond
| | - Brynn Bowman
- Brynn Bowman is vice president of education at the Center to Advance Palliative Care, in New York City
| | - Maggie Rogers
- Maggie Rogers is a senior research associate at the Center to Advance Palliative Care
| | - Lynn H. Spragens
- Lynn H. Spragens is CEO of Spragens & Associates, in Durham, North Carolina
| | - Diane E. Meier
- Diane E. Meier is a professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai, in New York City
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90
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Courtright KR, Cassel JB, Halpern SD. A Research Agenda for High-Value Palliative Care. Ann Intern Med 2018; 168:71-72. [PMID: 29132161 PMCID: PMC6476178 DOI: 10.7326/m17-2164] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Katherine R Courtright
- From Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, and Virginia Commonwealth University, Richmond, Virginia
| | - J Brian Cassel
- From Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, and Virginia Commonwealth University, Richmond, Virginia
| | - Scott D Halpern
- From Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, and Virginia Commonwealth University, Richmond, Virginia
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91
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Teno JM, Montgomery R, Valuck T, Corrigan J, Meier DE, Kelley A, Curtis JR, Engelberg R. Accountability for Community-Based Programs for the Seriously Ill. J Palliat Med 2017; 21:S81-S87. [PMID: 29195052 DOI: 10.1089/jpm.2017.0583] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Innovation is needed to improve care of the seriously ill, and there are important opportunities as we transition from a volume- to value-based payment system. Not all seriously ill are dying; some recover, while others are persistently functionally impaired. While we innovate in service delivery and payment models for the seriously ill, it is important that we concurrently develop accountability that ensures a focus on high-quality care rather than narrowly focusing on cost containment. The Gordon and Betty Moore Foundation convened a meeting of 45 experts to arrive at guiding principles for measurement, create a starter measurement set, specify a proposed definition of the denominator and its refinement, and identify research priorities for future implementation of the accountability system. A series of articles written by experts provided the basis for debate and guidance in formulating a path forward to develop an accountability system for community-based programs for the seriously ill, outlined in this article. As we innovate in existing population-based payment programs such as Medicare Advantage and develop new alternative payment models, it is important and urgent that we develop the foundation for accountability along with actionable measures so that the healthcare system ensures high-quality person- and family-centered care for persons who are seriously ill.
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Affiliation(s)
- Joan M Teno
- 1 Department of Gerontology and Geriatrics, University of Washington , Seattle, Washington
| | | | | | - Janet Corrigan
- 4 Gordon and Betty Moore Foundation , Palo Alto, California
| | - Diane E Meier
- 5 Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics, Mount Sinai School of Medicine , New York, New York
| | - Amy Kelley
- 6 Brookdale Department of Geriatrics, Icahn School of Medicine at Mount Sinai , New York, New York; James J. Peters VA, Bronx, New York
| | - J Randall Curtis
- 2 Pulmonary and Critical Care Medicine, University of Washington , Seattle, Washington
| | - Ruth Engelberg
- 2 Pulmonary and Critical Care Medicine, University of Washington , Seattle, Washington
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92
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Curtis JR, Sathitratanacheewin S, Starks H, Lee RY, Kross EK, Downey L, Sibley J, Lober W, Loggers ET, Fausto JA, Lindvall C, Engelberg RA. Using Electronic Health Records for Quality Measurement and Accountability in Care of the Seriously Ill: Opportunities and Challenges. J Palliat Med 2017; 21:S52-S60. [PMID: 29182487 DOI: 10.1089/jpm.2017.0542] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND As our population ages and the burden of chronic illness rises, there is increasing need to implement quality metrics that measure and benchmark care of the seriously ill, including the delivery of both primary care and specialty palliative care. Such metrics can be used to drive quality improvement, value-based payment, and accountability for population-based outcomes. METHODS In this article, we examine use of the electronic health record (EHR) as a tool to assess quality of serious illness care through narrative review and description of a palliative care quality metrics program in a large healthcare system. RESULTS In the search for feasible, reliable, and valid palliative care quality metrics, the EHR is an attractive option for collecting quality data on large numbers of seriously ill patients. However, important challenges to using EHR data for quality improvement and accountability exist, including understanding the validity, reliability, and completeness of the data, as well as acknowledging the difference between care documented and care delivered. Challenges also include developing achievable metrics that are clearly linked to patient and family outcomes and addressing data interoperability across sites as well as EHR platforms and vendors. This article summarizes the strengths and weakness of the EHR as a data source for accountability of community- and population-based programs for serious illness, describes the implementation of EHR data in the palliative care quality metrics program at the University of Washington, and, based on that experience, discusses opportunities and challenges. Our palliative care metrics program was designed to serve as a resource for other healthcare systems. DISCUSSION Although the EHR offers great promise for enhancing quality of care provided for the seriously ill, significant challenges remain to operationalizing this promise on a national scale and using EHR data for population-based quality and accountability.
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Affiliation(s)
- J Randall Curtis
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington.,3 Department of Bioethics and Humanities, University of Washington , Seattle, Washington
| | - Seelwan Sathitratanacheewin
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Helene Starks
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,3 Department of Bioethics and Humanities, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington
| | - Robert Y Lee
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Erin K Kross
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Lois Downey
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - James Sibley
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,5 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - William Lober
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,5 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - Elizabeth T Loggers
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,6 Seattle Cancer Care Alliance , Seattle, Washington.,7 Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - James A Fausto
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington
| | - Charlotta Lindvall
- 8 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Ruth A Engelberg
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
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